Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0239, written 10 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 | 10 Jul 2023 |
|---|---|
| Reference | 2023-0239 |
| Deceased | Christian Tuvi |
| Coroner | Andrew Harris |
| Coroner area | London Inner (South) |
| Category | Other 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 1. CORONER I am Andrew Harris, Senior Coroner, London Inner South jurisdiction 2. CORONER’S LEGAL POWERS I make these reports under paragraph 7, Schedule 5, Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3. INQUEST On 18th September 2019 the death of Mr Christian Kwame Tuvi , an escalator cleaner aged 44, in Waterloo Station was reported to the coroner by the British Transport Police. A forensic autopsy was conducted. An inquest was opened on 30th September 2019, and was suspended under CJA schedule 1(1). It was extended, due to the ongoing criminal investigation. On 1st March 2022, BTP informed the coroner that there were to be no charges and that the matter was then referred to the Office for Road and Rail. The senior coroner resumed his investigation. The inquest did not engage Article 2 ECHR. On 16th June 2023, the jury returned a narrative Record of Inquest The medical cause of death was 1a blunt force (crash) trauma to the chest 1b Movement of the travellator while Mr Tuvi was in the gap. 4. CIRCUMSTANCES OF THE DEATH The jury concluded that there was an inadequate briefing to the cleaners, omitting the form of communication to be used, a failure to complete a site specific risk assessment, and a failure to give an audible warning that the travellator was about to be moved. The jury found that two other matters contributed to the death: failure of the person in charge to plug the inching pendant into the closest port to the gap being cleaned and an acceptance of variation and non- compliance with the established method statement not being corrected. 5. THE CORONER’S MATTER OF CONCERN The ORR informed the coroner that in 2020 an improvement notice was served on Cleshar Cleaners, requiring them to provide a safe system of work for communicating the movement of the conveyor which does not rely solely on verbal communication. Cleshar has appealed the Improvement Notice and the Employment Tribunal have stayed the notice until 2024. Although the improvement notice is under appeal Cleshar has made some changes to improve their safe system of work. These included a padlock for the operative to place on the nearest isolator switch before entering the gap, pressing the stop button in, KONE discussing with Cleshar where the gap is to be left prior to handing over control of the machine and the risk assessment and method statement now identify the need for a middle person to relay messages. The improvements that Cleshar made have allowed them to resume the deep clean of Waterloo moving walkway. However, the TfL familiarisation training for working in a plant room no longer provides inching as part of the course. TfL expects their contractors to provide inching training for their operatives. Without the evidence of competence to inch the machine the isolation/inching function remains with KONE as a temporary solution. It is unclear why this cannot be a permanent solution. I heard from witnesses that it would be safer for engineers, who are present during deep cleans, to operate the movements of the travellator, but I was told that it would lead to a lack of clarity as to who was in charge. This seems not to be insoluble given different contractors with different employees is a norm on building sites working safely under HSE rules across the country. More likely there are undisclosed issues perhaps related to assumption of responsibility for risk or financial considerations which explain the resistance. The inquest heard that prior to the accident, cleaners would attend a TfL training course with a signed form which TfL observed was a certificate of competence to inch and operate the controls of the travellator. But the issuing manager and cleaners thought that the TfL course provided that training. The withdrawal of that training and the inability to find another training facility, has led to the cleaners not being trained and so not permitted to operate the travellator. Cleshar Cleaners management have not in the past assessed their cleaners for competence to inch and there is no agreed standard of competence. Concerns were expressed in the inquest that most of the cleaners did not have English as their first language and that the risk assessment method statement was a huge technical document, with which the cleaners were not familiar and they all required training in the whole method of work, and not just the person in charge. MY CONCERN and reason for reporting this matter to the minister and not just the regulator and contractors, is that nearly four years have passed and there remains an impasse between the organizations as to whom should train whom, and the competence required to operate the travellator whilst it is being cleaned. It seems that TfL has the power to produce a resolution, but is leaving matters to others to resolve. It is hard not to conclude that there is corporate reluctance to assume risk for an important public service. The regulatory bodies and contractors in the supply chain have allowed this matter to remain unresolved for an unacceptable length of time and there may be a system failure in the allocation of responsibilities and powers in the process of contracting for cleaning escalators. ________________________________________________________ This REPORT IS BEING SENT TO: 6. 1. The Rt. Hon Mark Harper, The Secretary of State for Transport, Department of Transport, Zone 1/18 Great Minister House, 33 Horseferry Road, London, SW1P 4DR 2. , Chief Executive of Office for Road & Rail, 25 Cabot Square, London, E14 4QZ 7. ACTION SHOULD BE TAKEN The public cannot be assured that the lessons have been learnt from this tragedy unless the redesigned improved system of work for cleaners is implemented with appropriate training and leadership in a permanent sustainable contracting system. These matters remain in dispute and may need political and regulatory enforcement. 8. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by September 4th, 2023. I, the coroner, may extend the period. If you require any further information or assistance about the case, please contact the case officer, and coroner paralegal, 9. COPIES and PUBLICATION The report is copied to Transport for London (TfL), Cleshar Cleaning Services Ltd (Cleshar) and Kone Plc. as these organizations need to know of the report to the Department and Regulator seeking review of the contractual process or directions to resolve the impasse between them, to ensure that a permanent solution is found that secures the minimization of risks of deaths in cleaning moving walkways and escalators. It is also sent to the other interested persons: representing family from Simpson Millar Solicitors. representing from Keoghs Solicitors. I have sent a copy of my report to the following interested persons: for Transport for London. for Cleshar of BCL Solicitors LLP. for Kone Plc from Walker Morris Solicitors. for Office of Road and Rail. I will also be sending a copy of my report to British Transport Police for information. I am also under a duty to send the Chief Coroner a copy of your response. He 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. 10. [DATE] [SIGNED BY SENIOR CORONER] Monday 10th July, 2023 A N G Harris
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.
Dr Andrew Harris HM Senior Coroner London Inner South HM Coroners Court 1 Tennis Street Southwark London SE1 1YD From the Secretary of State The Rt Hon Mark Harper MP Great Minster House 33 Horseferry Road London SW1P 4DR 4 September 2023 Dear Dr Harris, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS: MR CHRISTIAN KWAME TUVI, Thank you for your Report dated Monday 10 July 2023, following the inquest into the tragic death of Mr Tuvi at Waterloo Underground Station on 18 September 2019. I note that you consider there is an unresolved matter relating to the provision of training and assessment of competence to operate travellators safely during cleaning, which you have raised with me and with the Chief Executive of the Office of Rail and Road, as you consider that this may need political and regulatory enforcement to address. I am responding to you in accordance with the Coroners (Investigations) Regulations 2013. As you will be aware, my Department has limited powers to intervene formally in transport safety matters, which are the responsibility of the Office of Rail and Road in its capacity as the independent Rail Safety Regulator. Furthermore, my Department does not have powers to intervene in London Underground Limited’s day-to-day operations or processes, for which it is separately accountable to the London Mayor as a subsidiary of TfL. Nonetheless, I asked my officials to investigate this matter and to report to me. My officials have spoken to the Office of Rail and Road safety inspectors, who have been in regular contact with London Underground Limited throughout their investigation. I understand that London Underground Limited has now reached agreement with its contractors over where permanent responsibility should lie for operating its escalators during maintenance and cleaning and is in the process of agreeing safe systems of work before work resumes. The Office of Rail and Road has confirmed that it is satisfied that this will be a safe and effective solution to the specific concerns you raise in your Report. I am assured that London Underground Limited intends to write to you very shortly with details of the arrangements it has agreed with its contractors to ensure that these concerns are fully resolved. Thank you once again for taking the time to raise this important matter with me, and I trust that my officials have been able to assist in ensuring a satisfactory and permanent resolution. I am copying this letter to in the Office of Rail and Road. Yours sincerely, The Rt Hon Mark Harper MP SECRETARY OF STATE FOR TRANSPORT Copy: , Chief Executive Officer, Office of Rail and Road
12 September 2023
Dr Andrew Harris
HM Senior Coroner
London Inner South HM Coroners Court
1 Tennis Street
Southwark
London
SE1 1YD
Dear Dr Harris,
Chief Operating Officer
Transport for London
Palestra
1 97 Blackfriars Road
London
SE1 8NJ
Death of Christian Tuvi at Waterloo station on 18 September 2019:
Prevention of Future Deaths (PFD) report
Following your inquest into the tragic death of Christian Tuvi, which took place
between 5-16 June 2023, you issued a Prevention of Future Deaths (PFD) report
addressed to the Secretary of State for Transport and the Office of Rail and Road
(ORR). Your concerns related to the arrangements for training of inching
activities on escalators and moving walks on the London Underground (LU)
network, in particular clarity on responsibilities.
I am aware that the Secretary of State for Transport has responded to you and
noted that we would write to you with details of the arrangements we have put in
place with our contractors to ensure that your concerns have been fully resolved.
We have also been in regular discussions with the ORR about this issue and
have given them assurance that we have addressed and resolved this issue. I
have set out the steps we have taken below.
You will remember that KONE plc (KONE) agreed at the inquest that training of
their staff, or any suppliers who work for them, was their responsibility.
In light of the report, we have discussed the training of inching activities with
KONE. KONE has informed us that, having considered the relevant work
arrangements, they have decided, in consultation with Cleshar Contract Services
Ltd (Cleshar), to continue permanently with the current temporary working
arrangements i.e. KONE engineers will undertake all inching activities on LU’s
moving walks and escalators, which they are contracted to maintain and clean,
so Cleshar operatives can clean the machines. KONE engineers are assessed
and deemed competent against the National Vocational Qualification (NVQ)
Level 3 for escalator maintenance which includes inching. KONE consider that
this is a clear and safe way forward to ensure that they meet their responsibility
for the cleaning of these assets.
We are currently working with KONE to ensure that their Safe Systems of Work,
as well as Cleshar’s, have been updated to reflect these new arrangements. We
want to ensure that, given the two parties are involved in an intrusive clean, the
Safe Systems of Work are clear on who is always in control of the machine. We
plan to complete this review with KONE by 29 September 2023.
Thank you for your report and I hope that my response addresses the important
concerns that it raises on escalator maintenance and training responsibilities.
I am grateful for the opportunity to update you and have copied my response to
the ORR.
If you have any further questions, please do not hesitate to contact me.
Yours sincerely
Chief Operating Officer
Transport for London
cc:
, HM Deputy Chief Inspector of Railways, Office of Rail and Road.
, Commissioner for Transport, TfL.
, Chief Safety Health & Environment Officer, TfL.
, Principal Lawyer, TfL.
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