Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0385, written 18 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jul 2024 |
|---|---|
| Reference | 2024-0385 |
| Deceased | Tony Williams |
| Coroner | Jacqueline Devonish |
| Coroner area | Cheshire |
| 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 NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Health and Safety Executive 1 CORONER I am Jacqueline DEVONISH, Senior 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 2020 I commenced an investigation into the death of Tony WILLIAMS aged 45. The investigation concluded at the end of the inquest on 15 July 2024. The conclusion of the inquest was that the death was a Misadventure. 4 CIRCUMSTANCES OF THE DEATH On 2 December 2020, Tony Williams, an HGV driver for hay to at experienced in the strapping and loading of Hesston bales. Three bales were loaded width ways, the opposite direction to the rest of the bales, on the back end of the vehicle. , was delivering bales of in Cheshire. Thirty-three hay bales were loaded onto the 45ft HGV in Suffolk by the farm director in the presence of Mr Williams, who was On the journey from Suffolk, somewhere along the route an ANPR camera had caught an image of hay overhanging the back of the vehicle. When arriving at , with the assistance of a banksman, Mr Williams reversed down road with a known slope comparable to a wheelchair ramp. Mr Williams was witnessed by a Farmhand unstrapping the load when the three width ways bales fell from the back. Two of which fell on top of Mr Williams. a public domain The Farmhand who witnessed the unstrapping, removed the bales from Mr Williams with his telehandler and administered CPR with guidance from the ambulance service operator. When the ambulance arrived advanced life saving measures were administered to no avail. He was pronounced dead at the scene at 11:01 hours. 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: The configurations for safely loading bales widthways, on a slope of 4.5 degrees and utilising crisscross strapping were considered in evidence. HSE produced laser measurements and images identifying the centre of gravity and risks associated with unloading overhanging bales on a slope when the most rearward bales are loaded widthways. HSE concluded that the accident would not have occurred if Mr Williams had not unloaded with the overhang facing downhill. Regulation 28 – After Inquest Document Template Updated 30/07/2021 It became apparent that there were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales. 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 10, 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. COPIES and PUBLICATION 8 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons I have also sent it to Mr William’s family, Liverpool University, and , 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: 18/07/2024 Jacqueline DEVONISH Senior Coroner for Cheshire 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.
Health and Safety Executive INVESTIGATION DIVISION Steve Parncutt INV UNIT 2 HEAD OF OPS - P Bootle - Redgrave Court Merton Road Bootle MER L20 7HS Tel: Line Manager Sarah Jardine HM Senior Coroner Jacqueline Devonish Cheshire Coroner's Service Museum Street Warrington WA1 1JX Reference Date 6th September 2024 Dear HM Senior Coroner Devonish PREVENTION OF FUTURE DEATHS REPORT – TONY WILLIAMS Thank you for your email and attached Regulation 28 “Report to prevent future deaths” dated 18/07/2024. The report outlines matters of concern arising from the inquest into the death of Mr Tony Williams. Mr in Cheshire on 2nd December Williams was killed while unloading bales from a trailer at 2020. I am the Health and Safety Executive’s (HSE) Head of Operations covering the area of Great Britain (GB) in which the incident occurred. In providing this response I have consulted with the team that sets HSE operational policy in relation to safe work with bales, and the team responsible for HSE operational policy in relation to transport. You raise the following MATTERS OF CONCERN in your report: It became apparent that there were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales”. Background HSE recognise that unstable loads present a serious risk of harm. Vehicle loading, unloading and load securing cross over two areas of legislation: road traffic, which is enforced by the Driver & Vehicle Standards Agency (DVSA) and police forces, and workplace safety which is enforced by HSE and local authorities. In this response, although I have made reference to some DVSA guidance, I will address the workplace safety aspect as other agencies are better placed to address any concerns regarding how material is transported by road. Your concerns for HSE to address Health and safety legislation is goal setting in its nature, rather than prescriptive. The Health and Safety at Work etc. Act 1974 and Regulations made under it require employers to assess the risk from work operations, including working with bales, and provide control measures to reduce these risks, so far as is reasonably practicable. To assist employers and provide a framework for compliance with the law, HSE produce guidance for industry to follow. In relation to working with bales in agriculture, HSE produced publication INDG125(rev 3) “Safe working with bales from our website at: https://www.hse.gov.uk/pubns/indg125.pdf. Whilst there is guidance on safe working with bales in other HSE publications, such as “Farmwise” and “What a good farm looks like” (both available free from the HSE website), INDG125 is HSE’s primary guidance document for the safe loading and stacking of bales. In addressing your concerns, this reply will focus predominantly on INDG125. in agriculture” which is available free Bales and the trailers on which they are transported, may be of a range of shapes and sizes. INDG125 must therefore contain sufficient information to be useful to duty holders such that they can plan for safe operation of activities, but also be broad and flexible enough to reflect the variations. The guidance therefore sets out the principles that should be adopted rather than be prescriptive for specific situations. In relation to the safe stacking of bales, the principles are set out on pages 2, 3 and 4 of the guidance supported by Figures 1, 2 and 3. In considering the concerns raised in your report we have concluded that there is sufficient information, by way of both images and supporting material, to allow duty holders to plan their stacking operations safely and that the current guidance is satisfactory. In relation to the safe loading and unloading of bales, the principles are set out throughout the guidance document but specifically on pages 6 and 7. We acknowledge the absence of images in this section however, having considered the concerns raised in your report we have concluded that there is sufficient information that will allow duty holders to plan and carry out the loading and unloading of bales safely and that the current guidance is satisfactory. Guidance on the safe loading and unloading of vehicles is also provided in HSE publication HSG136, A Guide to Workplace Transport. Although it does not specifically reference bales, the publication sets out employers’ responsibilities under health & safety legislation and provides guidance on key safety issues which also includes managing vehicle movements on sites, work at height, and coupling and uncoupling articulated vehicles. It too takes a broad and flexible approach due to the complexity and variety of the many different transport operations in GB and is available free from the HSE website at https://www.hse.gov.uk/pubns/books/hsg136.htm. Other enforcing authorities and industry associations HSE also works closely with other enforcing authorities and industry associations to support them in producing their own industry-specific detailed guidance. This includes work undertaken with the DVSA and trade associations on the production of on-road guidance for drivers and operators. In recognising that loads come in a variety of shapes and sizes, as do the vehicles transporting them, the DVSA guidance is also generally not prescriptive but sets out the general principles of load securing and advice to help vehicle operators and drivers comply with the law. The current version of this guidance can be found at https://www.gov.uk/government/publications/load- securing-vehicle-operator-guidance/load-securing-vehicle-operator-guidance. An updated version is due to be published in autumn 2024 which will contain advice that bales should be properly supported by the vehicle or trailer load bed. Further queries or comments on the DVSA guidance are best directed to the DVSA. In conclusion Having carefully considered the content of your report and your concern around a lack of information HSE provides we have concluded that the guidance currently available in relation to the safe stacking, loading and unloading of bales is sufficient and does not currently require further images or supporting material. HSE legislation is goal setting and not prescriptive. As such HSE guidance documents adopt a broad and flexible approach that will allow duty holders to plan and safely undertake work activities for a wide range of situations. 2 However we keep HSE guidance, including INDG125, under periodic review and we will keep your report on record for consideration when it is next reviewed. Yours sincerely, Head of Operations 3
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