Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0233, written 7 Jul 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Jul 2023 |
|---|---|
| Reference | 2023-0233 |
| Deceased | David Lyth |
| Coroner | Charlotte Keighley |
| Coroner area | Cheshire |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 3D Trans 2 Health and Safety Executive 1 CORONER I am Charlotte KEIGHLEY, Assistant Coroner for the coroner area of Cheshire 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 10 December 2021 I commenced an investigation into the death of David Alan LYTH aged 45. The investigation concluded at the end of the inquest on 27 June 2023. The conclusion of the inquest was that: On 30 November 2021 at 3D Trans Shell Green Industrial Estate, Widnes, David Alan Lyth became trapped between two trailers resulting in asphyxia. From the evidence presented the rollaway could only have occurred from neither the unit and the trailer brake not being applied. 4 CIRCUMSTANCES OF THE DEATH On the 30th November 2021 David Lyth had been working for 3D Trans Limited through a driving agency. That day he had complained of an issue with the air cables on his trailer and had been advised to collect a new trailer from the 3D Trans Limited yard. As he coupled up to a new trailer, the trailer started to roll back and he put his arms out to stop it and became trapped between two HGV trailers. When he was found, he was unresponsive and was taken to Whiston Hospital where his death was confirmed. 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: (brief summary of matters of concern) (1) involving drivers working for 3D Trans Ltd:- I received evidence that since 2020, there have been four rollaway incidents An incident causing damage to a fence between the 17th September 2020 and the a. 9th October 2020; b. c. d. An incident leading to the death of Mr Lyth on the 30th November 2021; An incident on the 15th November 2022; An incident on the 12th June 2023. Regulation 28 – After Inquest Document Template Updated 30/07/2021 I acknowledge that these incidents involve different circumstances and that only one resulted in a fatality. (2) I received evidence that following each of the incidents, refresher training was provided and various measures were put in place at the yard to physically prevent the vehicles or trailers rolling away. In addition to this, signage has been placed on the tractor and trailer units to serve as a reminder to drivers of the importance of securing the parking brakes on the tractor and trailer units. I have concerns regarding the provision of regular and periodic training for all drivers in respect of coupling and uncoupling procedures. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) 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 September 01, 2023. 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 3D Trans I have also sent it to 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. 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: 07/07/2023 Regulation 28 – After Inquest Document Template Updated 30/07/2021 Charlotte KEIGHLEY Assistant Coroner for Cheshire Regulation 28 – After Inquest Document Template Updated 30/07/2021
2 responses 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.
TRAINS HM Assistant Coraner for Chesnire Charlotte Ketghley 13-07-2023 Dear Coroner Re. Resulation 28 Report to Prevent Deaths We write with reference to your Regulation 28 report which was issued to 3D Trans Limited in connection with the death of Mr David Lyth on 30 November 2021 We can confirm that the company has naw strengthened its training programme to ensure that all drivers receive quarterly refresher training against the company 5 coupling and uncoupling procedure, to include reviewing the written procedures, watching a video and completing a test to confirm their understanding. These records will be retained by the company fora minimum of two years We trust that this amendment is sufficient to satisfy the report Issued, but please do not hesitate to contact us should you require any additional information. Kindest Regards. Director Director 3D Trans Limited, Thompson Building, Shell Green Ind. Estate, Widnes WAS OFZ Company Reg: 9397135 VAT: 221-944-128 ES Idtranalimited ¢o uk
Health and Safety Executive FOD Ops Unit 1-3 FOD Ops Unit 2 Group 7 Bootle - Redgrave Court BLK 1 FLR G Merton Road Bootle MER L20 7HS Tel: Fax: http://www.hse.gov.uk/ Head of Operations Ms Charlotte Keighley HM Assistant Coroner Cheshire By E mail to Reference Date 22 September 2023 Dear HM Coroner Keighley Preven(cid:415)on of Future Deaths Report - A(cid:332)er Inquest LYTH D A 30112021 Thank you for your letter and Regulation 28 report to prevent future deaths issued following the inquest into the death of David Lyth. You asked the Health and Safety Executive (HSE) to consider your concerns regarding the provision of regular and periodic training for all drivers in respect of coupling and uncoupling procedures. It may be helpful to provide some background: the general duty under the Health and Safety at Work etc. Act 1974 is to ensure employees health, safety and welfare at work. This legislation is not prescriptive but is goal setting. It is for the employer to consider the risks specific to their business and then take appropriate steps to control those risks. To assist employers with that process, HSE produces extensive free guidance on managing risk, some of which is industry specific. For example, HSE worked closely with the haulage industry and other regulators to investigate the reasons for unintended vehicle movement and subsequently produced specific guidance in 2013, please see safe-coupling-guide.pdf. This guidance provides practical advice for employers to help them manage the risks of coupling and uncoupling articulated vehicles. HSE produced further guidance on transport safety in 2014; this guidance is aimed at all industries and also provides practical measures for coupling and uncoupling, please see Workplace transport safety - A guide to workplace transport safety (hse.gov.uk) As part of their consideration of risk in the business, employers should identify suitable risk controls and provide appropriate training and information to their employees to enable them to carry out their jobs safely, as well as an appropriate level of supervision/review to ensure that processes are followed consistently and that any issues are quickly identified and resolved. It is, for this reason, the employer’s responsibility to decide on the intervals for any refresher training. Whatever system the employer chooses to implement to manage risk, they should review it regularly to make sure it is up to date and still relevant. HSE continues to work closely with the industry in this area and we will engage with key stakeholders to remind them of the need to manage risk when coupling and uncoupling articulated vehicles. In relation to 3D Trans Ltd, HSE has conducted a further Inspection of the company since the inquest, and we are satisfied with the measures the company have put in place regarding training and monitoring and supervision for their drivers in respect of safe coupling and uncoupling procedures. Yours Sincerely HM Principal Inspector of Health and Safety 2
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