Adam Brunskill

Regulation 28 report to Coroner to 
prevent future deaths    

Deceased – Adam Joseph Brunskill 

To: Joanne Lees 

HM Area Coroner  for the Black Country 

Black Country Coroner’s  Court, Jack Judge House, Halesowen  Street, Oldbury B69 2AJ 

HM Inspector  of Health  & Safety 

19 Ridgeway, Quinton  Business  Park, Birmingham B32 1AL 

CDM Regulations 

I’m sure  the Coroner is aware of the Construction  (Design  and Management)  Regulations  2015, 
but other readers  of this  document may find a short  precis useful, as this  is the main piece of 
health  & safety legislation  governing  construction  sites: 

These  regulations,  amongst many other things,  define the roles  and duties  of those  involved in a 
construction  project. The Client  must appoint  in writing a Principal  Designer  (PD) and a Principal 
Contractor (PC). They are responsible  for health  and  safety during  the pre-construction  phase 
and the construction  phase  respectively.   

The PD may themselves  engage  Designers  (architects,  structural  engineers,  surveyors for 
example), and the PC will engage  Contractors  (often known as subcontractors) 

In the construction  phase,  the PC is basically  the site manager.  They control and  are responsible 
for what happens  on site.  Of course, Contractors  have duties  and responsibilities  as well,  but 
overall responsibility  lies  with the appointed  PC for planning,  managing  and monitoring  health  & 
safety. 

Further  details  can be found in the regulations  themselves  at 
https://www.legislation.gov.uk/uksi/2015/51/contents/made   

1 

   
 
 Roles and responsibilities on this site 

The construction  industry  is commonly a gig economy. On a typical site, most individuals  are 
nominally  self employed in that they may well do their  own taxes, but they are managed and 
monitored  by the Contractor or PC who engaged  them.   

On this  site, the PC was Proclad Developments  Ltd. The  Contractor in question  was Wayne 
Clarey Roofing & Cladding  Ltd. The company consists  of
commonly uses.  He provided  what is known as a “labour  only” contract. He worked  full time for 
Proclad. His workers worked full time for him. Wayne Clarey Roofing and  Cladding  Ltd do not 
determine  the risk assessments  or method statements,  and  are not part of the process,  they are 
given these  as instructions  by Proclad. Wayne Clarey Roofing and  Cladding  Ltd do not decide on 
access arrangements  or safety precautions,  Proclad do. Proclad decided  what was needed  and 
booked the scaffolding. 
 and his workers  were arguably employees  of Proclad in all  but 
name, in terms of managing  their work. The revised  Contract For Services document from 
Proclad seeks to alter or clarify this  relationship,  in ways addressed  below. 

, and the workers he 

Work at height 

The Work at Height Regulations  2005 regulation  6(3) states  that   

“(3) Where work is carried out at height, every employer shall take suitable and sufficient measures to prevent, s o far as is 
reasonably practicable, any person falling a distance liable to cause personal injury ”  

The Work at Height Regulations  2005 regulation  9 states  that  

“9.—(1) Every employer shall ensure that no person at work passes across or near, or works on, from or near, a frag i l e  

surface where it is reasonably practicable to carry out work safely and under appropriate ergonomic conditions withou t h i s 

doing so. 

(2) Where it is not reasonably practicable to carry out work safely and under appropriate ergonomic condition s w i th o u t 

passing across or near, or working on, from or near, a fragile surface, every employer shall — 

(a)ensure, so far as is reasonably practicable, that suitable and sufficient platforms, coverings, guard rails or similar means 

of support or protection are provided and used so that any foreseeable loading is supported by such supports or borne by 

such protection; 

(b)where a risk of a person at work falling remains despite the measures taken under the preceding provisions of this 

regulation, take suitable and sufficient measures to minimise the distances and consequences of his fall. ” 

The dutyholder  responsible  for ensuring  that  roof workers are prevented  from falling  through  the 
fragile roof to the floor below is the Principal  Contractor. 

2 

 
 
 
 
 Coroner’s concerns and action taken or proposed 

The MATTERS OF CONCERN are as follows.  –  

(1) The Coroner heard at inquest that Adam had been employed by Wayne Clarey Roofing and 
Cladding to work on a roof with no prior experience of working on a roof and no CSCS card nor 
had he completed a mandatory one-day Health & Safety course; 

It is important to make clear HSE’s view that regardless of his experience or inexperience, Adam 
Brunskill’s death should have been prevented, not by training, but by the risk assessor recognising the 
fragile nature of the rooflights during their risk assessment, and by the  consequent management of that 
risk. This could have been by means of avoiding the risk with collective means or personal means, by 
barriers or coverings, and by netting below to minimise the consequences of a fall through the fragile 
surfaces. The fall from roof to floor should not have been possible. 

Whilst we do not believe that lack of training was the main cause of the accident, and believe that 
everyone must start somewhere, we do of course believe that health & safety training and awareness is 
important, that the CSCS card system is the industry established system, and fully agree with the Coroner 
that requiring this concern be addressed is important in the drive to prevent future deaths.  

The Principal Contractor Proclad have recognised that their control of training for workers on sites should 
be improved. They have revised their Contract For Services document to state that subcontractors on site 
must ensure that they, and any other persons they bring on site, are trained to a minimum of CSCS card 
holder, with the 1 day health & safety course. 

(2) On day 13/7/20 and 14/7/20 there was no evidence of a designated supervisor responsible for 
Adam on site and/or responsible for Adam’s practical on the job training; 

Similarly, whilst we do not believe that lack of a designated supervisor led to Adam’s death, as it should 
have been prevented by physically stopping a fall from the roof to the floor below, we agree with the 
Coroner in this matter as well that future deaths may be prevented by improvements in supervision.  

Proclad, as the Principal Contractor, have revised their Contract For Services document to state that 
subcontractors must appropriately supervise their workers, taking into account their experience, and 
ensure that additional steps are taken to provide support and supervision to inexperienced staff.  

 has said that he will not consider using inexperienced workers again.  

(3) The Coroner did hear in evidence that one of the Principal Contractors who provided regular 
work to Wayne Clarey Roofing and Cladding would undertake to train any future unqualified 
 and provide access to an accredited training qualification and training 
employees of 
matrix.  The Coroner also heard that 
 had legal responsibilities under the Health & Safety 
at Work Act and the Construction (Design and Management) Regulations 2015. However, there was 
no evidence of any clear designated structured training programme in place by 
Roofing and Cladding for new and/or unqualified employees; 

Proclad have previously paid for the training of employees of Wayne Clarey Roofing & Cladding Ltd, such 
as SSSTS (Site Supervisor Safety Training Scheme, the industry standard course), first aid and IPAF 
(International Powered Access Federation, the industry standard course to use scissor lifts, cherry pickers 
etc). 

In their revised Contract For Services document, Proclad state that they are happy to provide support to 
subcontractors in facilitating training for workers, and to grant access to their training matrix systems. 
Wayne Clarey Roofing & Cladding Ltd will use this arrangement. 

3 

 
 
 (4) The Coroner did hear in evidence that one of the Principal Contractors who  provided regular 
work to Wayne Clarey Roofing and Cladding would undertake to train any future unqualified 
 and provide access to an accredited training qualification and training 
employees of 
matrix.  The Coroner also heard that 
 had legal responsibilities under the Health & Safety 
at Work Act and the Construction (Design and Management) Regulations 2015. However, there was 
no evidence of any clearly identifiable supervisor and/or supervisory arrangements in place by 
Wayne Clarey Roofing and Cladding for new and/or unqualified employees; 

In their revised Contract For Services document, Proclad state that their subcontractors must 
appropriately supervise their workers.  

 and one of his workers had SSSTS, which is an appropriate level of supervisory training for 

them, for a team of four, including deputising cover if 

 was not on site.  

(5) The Coroner did hear in evidence that one of the Principal Contractors who provided regular 
work to Wayne Clarey Roofing and Cladding would undertake to train any future unqualified 
 and provide access to an accredited training qualification and training 
employees of 
matrix.  The Coroner also heard that 
 had legal responsibilities under the Health & Safety 
at Work Act and the Construction (Design and Management) Regulations 2015. However, there was 
no evidence of any appraisal system in place by Wayne Clarey Roofing and Cladding.  

In their revised Contract For Services document, Proclad state that their training matrix system will be 
available to subcontractors. As Wayne Clarey Roofing & Cladding Ltd continue to work full time for 
Proclad, and they fully use their systems, this will include appraisals and training needs analysis.  

Conclusions 

It appears  that Proclad have appropriate  systems in place, which they are extending  to their 
subcontractors  where appropriate,  including  Wayne Clarey Roofing & Cladding  Ltd 

HSE investigations  are completed, and  reported  to my line manager for consideration  of any 
further action to be taken. 

Signed    

Name 

Date   

,  HM Inspector of Health  & Safety  

27th October 2021 

4

R Metcalf Ltd Solicitors

Felling
Tyne and Wear
NE10 OJP

The Black Country Coroner's Court

Jack Judge House Your Ref:

Halesowen Street

Oldbury Date: 19” August 2021

B69 2AJ

Dear Sirs

Re: INQUEST INTO THE DEATH OF ADAM BRUNSKILL
PREVENTING FUTURE DEATHS REPORT

We write further to the inquest into the death of Adam Brunskill and following receipt of the ‘Preventing
Future Deaths’ Report.

On behalf of Wayne Clarey, we wish to state that he believes there has been a fundamental
misunderstanding of his evidence given on the last day of the inquest. So that there can be no
misunderstanding, we can confirm that [Knew Adam Brunskill quite well because of the rugby
coaching that Mr Clarey carries out for his home club. He was approached by Adam's mother who said
that he could not find a job anywhere and would @s a favour, take him on and train him in
roofing. After Adam's first day at work, he rang his mother and sister and said he was really enjoying
working with the men in the job as a labourer.

When questioned about future trainees [ME :otes that he would never put himself in the position
of having a new trainee as he could not, in all conscience, take on anyone again because of the
accidental death of Adam. Therefore we restrict ourselves to the hetical situation of a new trainee
unskilled being placed on an induction course under supervision. would insist that any trainee
would have to have the mandatory card and undertake the health and safety course. Also, as 99.9%
of his work is with Pro-Ciad, he would ensure that he would make himself available to use their training
and also set out a full training schedule with checks by both himself and Pro-Clad. In relation to new
workers with experience, again he would make sure that he adopted the Pro-Clad training structure.
This in essence is already being undertaken by [NMJ and his second-in-command both
of them have obtained extra skills which entail an outside body attending and watching them at their
work and assessing their skills. This is a clearly defined set of proposals by EEN for a situation
that will never happen for a trainee without experience. It is part and parcel of the way that he works
and his company works very closely with Pro-clad.

R Metcalf Limited No 11956128
Authorised and Regulated by the Solicitors Regulation Authonty No. 662810

Ne

The relationship between Pro-clad and Wayne Clarey Roofing has strengthened since the tragic
situation which means that any future jobs will have a much higher standard of safety measures in place

with more rigorous supervision by both Pro-clad and himself
We hope that what has been written will be ac: @S a genuine attempt to answer the concems of
the Coroner. It should also be stated that land his staff have fully cooperated with the HSE

from the beginning of this incident right up to the inquest and they will continue to offer any assistance
necessary to the HSE to safeguard lives. The impact on the family has obviously been immense but it
has also been a tragedy for

Yours faithfully

R Metoatf Limited No 11056128
Authorised and Regulated by the Solicitors Regulation Authonty No. 662810

R Metcalf Ltd Solicitors

Design Works
William Street
Felling

Tyne and Wear
NE10 OJP

HM Coroner

The Black Country Coroner's Court
Jack Judge House Your Ref

Halesowen Street

Oldbury Date 4" October 2021
B69 2AJ

Dear Sirs
Re: REGULATION 28 : REPORT TO PREVENT FUTURE DEATHS
Further to your email of 3° October, we wish to confirm the following

1 Since the inquest, Wayne Clarey Roofing has been using a clear designated structured training
programme for new and /or unqualified employees. It is the Pro-Ciad training structure. It was

stated at the inquest by NNN that [Ns an employee of Pro-Clad as 99% of
his work is cared out for Pro-Clad.

Ne

The 2 supervisors ore >< This was confirmed in the inquest by

both men.

ww

appraises the workers on a daily basis and recommends them for further
qualification which is tested by outside agencies whilst they are at work

For completeness, the above was put into place immediately following the inquest and we would
therefore be grateful if you could confirm that our obligation to respond to the Regulation 28 Notice has
now been complied with. Would you also confirm if the HSE have responded to the Notice.

Yours faithfully

R Meteaf Limited No 11956128

Authorised and Regulated by the Sollotors Regulation Authority No. 682810

Regulations