Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0257, written 8 May 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2024 |
|---|---|
| Reference | 2024-0257 |
| Deceased | Sean O’Connor |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| 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: Prevention of Future Deaths report
Sean Patrick O’CONNOR (died 24.11.21)
THIS REPORT IS BEING SENT TO:
1.
Chief Executive Officer
Canary Wharf Management Limited (CWML)
One Canada Square
Canary Wharf
London E14 5AB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 2 December 2021, one of my assistant coroners, Sarah Bourke,
commenced an investigation into the death of Sean O’Connor aged 34
years. The investigation concluded at the end of the inquest on 1 May
2024. The jury made a determination at inquest of death by accident.
4
CIRCUMSTANCES OF THE DEATH
On 24 November 2021, shortly after 10am, Mr O’Connor was
electrocuted as a result of contact with a heat pump flow switch terminal,
during the course of work at Columbus House 7 Westferry Circus,
London. He was a Mitsubishi employee changing the flow switch.
His medical cause of death was:
1a electrocution.
1
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
I heard evidence at inquest that, as he was regarded as a lone worker,
Sean O’Connor could and, according to the risk assessment method
statement (RAMS), should have asked a CWML colleague to come to
check on him during the day. He did not ask for such a check and,
although a CWML employee thought of doing so, that person was busy
and so did not.
Whilst such a check is likely to have taken place too late in the day to
have changed the outcome for Mr O’Connor, that might be different for
another lone worker.
Several witnesses gave evidence that discussions take place with every
worker coming on site as a matter of routine, covering such matters as
where the worker is meant to be located, the exact nature of the job and
so forth. The CWML director who gave evidence at inquest agreed with
me that it would be a straight forward matter to include within that as a
point always for brief discussion, whether any checks are required during
the day. In this way, if the operative forgets to ask, the discussion can
act as a reminder.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you 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 15 July 2024. 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
2
I have sent a copy of my report to the following.
, wife of Sean O’Connor
•
•
• Mitsubishi Electric
• The London Borough of Tower Hamlets
• HHJ Thomas Teague QC, the Chief Coroner of England & Wales
, parents of Sean O’Connor
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 other 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.
9
DATE SIGNED BY SENIOR CORONER
08.05.24 ME Hassell
3
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.
C A N A R Y W H A R F M A N A G E M E N T 11th July 2024 Senior Coroner Inner North London St Pancras Coroner’s Court Camley Street N1C4PP Dear Madam, Inquest into the death of Sean O’Connor We refer to the report made following the Inquest into Mr O'Connor's death in which you raised some concerns about the arrangements for lone workers employed by independent contractors whilst on the Canary Wharf Estate. We have reviewed the company's procedures for lone workers. Currently, contractors are required to obtain a Work Authorisation (WA)1 or permit to work (PtW) depending on the nature of the work to be undertaken. Where works are undertaken under a PtW, these are subject to spot checks. Spot checks may also occur when works are performed under a WA. CWML’s approach to facilitating access to its premises by independent contractors reflects what it understands to be recognised practice. CWML is not aware of any concerns raised by contractors (including Mitsubishi) before the incident involving Mr O'Connor. The existing CWML system prioritises checks based on risk (higher risk works requiring a PtW involve mandatory checks and are rarely performed by lone workers). CWML is mindful of the need to avoid potentially undermining the strengths of the system by diverting resource away from higher risk works. Notwithstanding the above, and as part of a process of continuous improvement, CWML has decided to trial a new feature to apply to WA, beginning July 2024. The arrangements will include: (cid:127) When applying for work authorisation involving lone working, a mandatory prompt now appears on the system which asks the contractor if a welfare check is required. If a check is requested, it will be conducted either by the person requesting the work on behalf of CWML or another competent CWML employee. (cid:127) (cid:127) The check / visit must be recorded in the system. 1 A Work Authorisation is now called an Access Permit but for ease we will refer to it as a WA in this letter. CANARY WHARF MANAGEMENT LIMITED, ONE CANADA SQUARE, CANARY WHARF, LONDON E14 5AB Canary Wharf Management Limited is a member of the Canary Wharf Group of companies. Registered in England and Wales No. 2067510 ISO 14001 ISO 9001 OHSAS 1B001 iSOQAR db. V tew Cert No. 11016 For the avoidance of doubt, these steps are in addition to the existing procedure which allows for ad hoc checks on lone workers, as has always been the case. These arrangements will apply in addition to the independent contractors' procedures for lone working. The trial is intended to run for 6 months at the end of which CWML will review the results, consider their effectiveness and decide whether to implement some or all of the trial or make any further changes. In addition to the above, CWML will be updating the Contractor Handbook and the Lone Working Policy to apply to contractors. Yours faithfully Canary Wharf Management Limited
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