Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0296, written 26 Sep 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 26 Sep 2022 |
|---|---|
| Reference | 2022-0296 |
| Deceased | Zachariah Richardson |
| Coroner | Jacqueline Lake |
| Coroner area | Norfolk |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Lincs Firewood Co Ltd and DD Dodds and Son Ltd The Plantation Rowdyke Wyberton Boston PE21 7AQ 1 CORONER I am Jacqueline Lake, Senior Coroner for the coroner area of Norfolk 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 30 October 2020 I commenced an investigation into the death of Zachariah Nathaniel RICHARDSON aged 18. The investigation concluded at the end of the inquest on 23 September 2022. The medical cause of death was: Compression Asphyxia 1a) 1b) 1c) 2) The conclusion of the inquest was: Accidental Death. 4 CIRCUMSTANCES OF THE DEATH Mr Richardson started working for Lincs Firewood on 6 October 2020. He completed a two day practical and theoretical training course on operating forklift trucks (FLTs) on 18 October 2020. On 24 October 2020 Mr Richardson went to DD Dodds and Son’s Elm Farm Site to help tidy up the site. He was alone from approximately 15.51 hours until 17.13 hours. At approximately 17.16 hours Mr Richardson was found trapped between a FLT and a wall. Mr Richardson suffered fatal injuries and was declared dead at the scene. 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: Regulation 28 – After Inquest Document Template Updated 30/07/2021 1. Evidence was heard at the inquest that Mr Richardson, aged 18 years, had joined Lincs Firewood some 18 days prior to his death and had undergone training to use a FLT some 6 days prior to his death. He was left alone on a site for approximately 1 hour 20 minutes, which he had visited on one occasion a few days prior to his death. 2. The evidence was that the FLTs at the Elm Farm site were seven months overdue for the annual Thorough Examination and had not undergone a service since February 2019. The seat safety switch device on the FLTs had been defeated at some point prior to the incident. The seat safety switch device on one of the FLTs was defective 3. Evidence was heard at the inquest that a Health and Safety Consultant visited the sites at Lincs Firewood and Dodds and Son in October and November 2020, following Mr Richardson’s death. The Consultant found there was little understanding of the importance of health and safety because there were no systems in place although working on high risk machinery. The perception of risk was found to be “poor” and “no one had taken the time or understood the importance to become competent in health and safety prior to the incident” 4. As at the time of making the Report in September 2021, no feedback had been received disagreeing with or challenging any of the findings in the Report 5. An email dated 11 November 2020 from Boston District Council to Health and Safety Executive referred to a visit made to the site that day which found “Refusal to accept the nature of the goods in the yard presents a leptospirosis risk but agreed to issue pocket cards!” and “Some doubt as to the interpretation of the LOLER regs” [which applied to the use and operation of the machinery on site]. 6. As at the date of the inquest, some 23 months following Mr Richardson’s death, no evidence was heard as to any changes which had been made with regard to health and safety at either Lincs Firewood or DD Dodds and Son 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisations have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by November 21, 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons , Parents Breckland District Council I have also sent it to Health and Safety Executive Boston District Council RoSPA who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. Regulation 28 – After Inquest Document Template Updated 30/07/2021 The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 26 September 2022 Jacqueline LAKE Senior Coroner for Norfolk Norfolk Coroner Service County Hall Martineau Lane Norwich NR1 2DH Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Your Ref: 21 November 2022 PRIVATE AND CONFIDENTIAL Mrs J Lake Senior Coroner for Norfolk Norfolk Coroner Service County Hall Martineau Lane Norwich NR1 2DH Dear Sirs Our Client Matter Date of Incident : Lincs Firewood Company Ltd & D D Dodd & Son Ltd : Regulation 28 Prevention of Future Deaths Report - Response : 24 October 2020 We act for Lincs Firewood Company Ltd and DD Dodd & Son Ltd (together “the Companies”), who were Interested Parties in the Inquest into the Death of Mr Zach Richardson, concluding on 23 September 2022. On 26 September the Senior Coroner for Norfolk made a report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 (“the PFD Report”). The Companies are aware that they must respond to the PFD Report. In doing so, they are required as per Regulation 29(1) of the Coroner (Investigation) Regulations 2013, to:- a) Provide details of any action that has been taken, or which it is proposed will be taken in response to the report, or otherwise and set out a timetable of the action taken or proposed to be taken; or b) Provide an explanation as to why no action is proposed. PFD Report – Box 5 This letter is submitted as both the Companies definitive response to the PFD Report. It will address the Coroner’s concerns, as set out in Box 5 of the PFD Report which were:- 1. Evidence was heard at the inquest that Mr Richardson, aged 18 years, had joined Lincs Firewood some 18 days prior to his death and had undergone training to use a FLT some 6 days prior to his death. He was left alone on a site for approximately 1 hour 20 minutes, which he had visited on one occasion a few days prior to his death. DAC Beachcroft Claims Ltd Portwall Place Portwall Lane Bristol BS1 9HS UK (Sat Nav postcode: BS1 6NA) dir tel: +44 (0) 117 918 2117 tel: +44 (0) 117 918 2000 fax: +44 (0) 117 918 2100 email: cstephens@dacbeachcroft.com DX 7846 Bristol 1 DAC Beachcroft Claims - part of DAC Beachcroft, an international law firm DAC Beachcroft Claims Limited is a limited company registered in England and Wales (registration number 04218278) which is authorised and regulated by the Solicitors Regulation Authority (authorisation number 509760). A list of the directors is available for inspection at our registered office: Portwall Place, Portwall Lane, Bristol BS1 9HS, UK (Sat Nav postcode: BS1 6NA). Please read our DAC Beachcroft group privacy policy at www.dacbeachcroft.com. 2. The evidence was that the FLTs at the Elm Farm site were seven months overdue for the annual Thorough Examination and had not undergone a service since February 2019. The seat safety switch device on the FLTs had been defeated at some point prior to the incident. The seat safety switch device on one of the FLTs was defective. 3. Evidence was heard at the inquest that a Health and Safety Consultant visited the sites at Lincs Firewood and Dodds and Son in October and November 2020, following Mr Richardson’s death. The Consultant found there was little understanding of the importance of health and safety because there were no systems in place although working on high risk machinery. The perception of risk was found to be “poor” and “no one had taken the time or understood the importance to become competent in health and safety prior to the incident”. 4. As at the time of making the Report in September 2021, no feedback had been received disagreeing with or challenging any of the findings in the Report. 5. An email dated 11 November 2020 from Boston District Council to Health and Safety Executive referred to a visit made to the site that day which found “Refusal to accept the nature of the goods in the yard presents a leptospirosis risk but agreed to issue pocket cards!” and “Some doubt as to the interpretation of the LOLER regs” [which applied to the use and operation of the machinery on site]. 6. As at the date of the inquest, some 23 months following Mr Richardson’s death, no evidence was heard as to any changes which had been made with regard to health and safety at either Lincs Firewood or DD Dodds and Son Response Lone Working at the DD Dodd & Son Yard The incident occurred at the DD Dodd & Son yard at Elm Farm. The Company made the decision shortly after the accident to consolidate all its activities to the main site in Boston. The Elm Farm yard is no longer rented and all DD Dodd & Son activities are now managed and supervised from the main site in Boston, alongside the activities of Lincs Firewood. Thorough Examination and Servicing of Plant All new lifting equipment (i.e. purchased in 2021) is under a service agreement with G & J Peck Ltd, which covers regular servicing (as per operational hours) and annual thorough examinations. The plant under this servicing agreement is connected to a ‘Live Link’ system, whereby the machine’s operational parameters are automatically uploaded to an online log, which can be accessed and viewed at any time. As well as capturing live service hours and vehicle performance, the log automatically records driver behaviour, application of the parking brake and use of the seatbelt. The Companies regularly access this log to audit the employees’ operational performance and to identify non-compliance. This allows the Companies to quickly react and provide further training / briefing as required. Page 2 of 6 The Live Link system automatically informs G & J Peck Ltd when the service-hours indicate a service is need. It also records the last thorough examination and again informs G & J Peck Ltd when the next is required. All other lifting equipment (pre-2021) owned by the Companies is subject to 6-monthly servicing and annual thorough examinations organised through Phil Limb Agri Services Ltd. This company carries out all servicing and ad hoc repairs to the machinery. Thorough examinations are carried out by M- Tec Engineering, organised through Phil Limb Agri Services. Required servicing and thorough examinations are tracked using a matrix, which displays the plant serial number (for identification purposes), last service date, last through examination date, next through examination date and the details of the service engineer overseeing the plant’s maintenance, together with their contact details. Health and Safety (“H&S”) External Assistance The Companies remain in contract with health and safety consultants Avensure Limited. This contract includes the following services:- An annual visit to the Boston site to audit the Companies’ operations The provision of a summary report, together with recommendations following the audit Access to a H&S management system and documentation, including for example, H&S policy statements, risk assessment guidance and general guidance notes Regular legislation updates Online e-learning H&S programmes Unlimited email and telephone support + 24 hour access to an expert H&S Team The Companies were also subject to a risk improvement audit by their insurer in August 2022. It can be confirmed that this audit found no concerns with:- The risk assessment process or implementation of control measures The servicing and through examination of lifting equipment The servicing and maintenance of other machinery The training, competence or supervision of employees Internal The Companies have invested heavily in improving their health and safety management. They have appointed an employee to act as H&S Coordinator, which is a dedicated full-time role. To equip this employee with the skills and knowledge necessary to meet this responsibility they were funded to complete the IOSH Managing Safely qualification, becoming certified in June 2021. To complement their knowledge they have also completed health and safety courses covering:- Risk assessment H&S Basics + H&S for Managers and Supervisors Page 3 of 6 Fire warden training COSHH Accident reporting LOLER Risk Assessment and Toolbox Talks The engagement of Avensure, together with the appointment and qualification of a H&S Coordinator has ensured that the Companies assess and identify risks and hazards, implementing robust control measures. Task specific risk assessments are available and all employees have been consulted on their findings and briefed on their content. Risk assessments are subject to annual review, or sooner should a material change occur with a process, procedure or piece of machinery. Overview of Health and Safety Management The Companies hope that the Coroner is reassured by the health and safety management scheme in place, which can be summarised as follows:- There is a company H&S policy and statement which is reviewed annually The Companies have simplified their operations, resulting in the consolidation of all activities to a single site – the Boston site Operations at the Boston site have been reassessed and suitable and sufficient risk assessments have been revised, implemented and briefed to all employees Toolbox talks are held to brief employees on changes to the risk assessments when necessary A dedicated full-time H&S Coordinator has been appointed There remains a dedicated Yard Manager to oversee / supervise all site operations The employee induction process has been made more robust and includes a review of all relevant safety documentation, including risk assessments A revised, comprehensive Employee Handbook, setting out the Companies policies has been issued to all employees Employee Training Induction The Coroner has seen, from the disclosure provided, that Mr Richardson as an employee of Lincs Firewood was subject to a full induction. This is and was standard practice for all new employees. The induction covers, policies, procedures, safe working and risk assessments and are signed off by both the new employee and the employee carrying out the induction. One-to-One Training As is standard industry practice, much of the training after induction is delivered one-to-one, led by the experienced management team. Machine specific training matrixes are in place which ensure employees learn how to operate static machinery safely and in compliance with company procedure. Common training objectives listed in the training matrixes include:- Page 4 of 6 A review of the risk assessment applicable to the machine Briefing on pre-operational checks – including location of check forms and company policy on their return Overview of controls Common faults and safe resolutions Sensors Daily maintenance General husbandry – best practice External Training Where applicable, employees are subject to externally delivered and assessed courses. Without a formally assessed qualification employees are not authorised to operate moving plant. The Companies operate an ‘Authorisation to Operate a …’ system. Only once they have attended a course, been assessed as competent and the Companies have been notified of their passing by the examiner, will an authorisation be issued for use of that plant. This authorisation sits on the employees personnel file and details the plant they are authorised to use, any attachments applicable to that plant and the areas on site that such authorisation extends. The Companies reserve the right to withdrawn authorisation at any time. The Companies have provided funding for employees to attend the following externally accessed courses to ensure their competence and statutory compliance (subject to role relevance):- IPAF – mobile vertical 3a – scissor lift IPAD – mobile boom 3b Lift truck operator (forklifts) Lift truck (rough terrain telescopic material handler) Crane operator Telescopic handler Plant and vehicle marshal training Chainsaw maintenance and cross-cutting Emergency first aid at work & AED Driver Certificate of Professional Competence – in relation to the Operator’s Licence regime Operator Licence Awareness – in relation to the Operator’s Licence regime IOSH Managing Safely – for H&S Coordinator Health and Safety Training To complement the task-specific and externally assessed training, the Companies have implemented a suite of health and safety modules which dove-tail with the safe working procedures. Subject to role, employees will complete courses in:- Risk assessment H&S Basics & Essentials H&S for Managers & Supervisors Fire warden training Manual handling Page 5 of 6 Display screen equipment Lone working in the work place COSHH Ladder safety Working at height Accident reporting Hand / arm vibration awareness LOLER Conclusion The procedures set out above were either already in place at the time of the incident, or have been enhanced since. There were legal reasons why it was not appropriate for the Companies to give evidence on its pre and post-incident health and safety and training procedures during the Inquest. The Companies appreciate health and safety is an ongoing duty and can confirm that these procedures will be reviewed regularly and built upon to ensure they remain effective and compliant in managing health and safety. Finally, the Companies and its director wish to again extend their deepest sympathies to Mr Richardson’s family and friends. He was a well-liked and valued employee, and his loss felt by everyone. Yours faithfully For DAC Beachcroft Claims Ltd Page 6 of 6
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