Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0426, written 2 Aug 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Aug 2024 |
|---|---|
| Reference | 2024-0426 |
| Deceased | Thomas McAuley |
| Coroner | Brendan Joseph Allen |
| Coroner area | Dorset |
| 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 (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. , Chief Executive Health and Safety Executive 1 CORONER I am Brendan Joseph Allen, Area Coroner, for the Coroner Area of Dorset 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 the 13th July 2022, an investigation was commenced into the death of Thomas Joseph McAuley, born on the 1st April 1968. The investigation concluded at the end of the Inquest on the 19th July 2024. The Medical Cause of Death was: 1a Multiple Injuries 1b 1c 2 The conclusion of the Inquest recorded that Thomas Joseph McAuley died as a consequence of an accident. 4 CIRCUMSTANCES OF THE DEATH Thomas Joseph McAuley was employed by Kiely Brothers Limited (“KBL”) as part of a crew of men undertaking road resurfacing works. On 5th July 2022, Mr McAuley, together with a crew of 6 others, was undertaking resurfacing work 1 in Redwood Drive, Ferndown. At approximately 11 am Mr McAuley placed himself within the area between the third and fourth axles of a four axle, 32 tonne grab lorry that was on site. This was likely so that he could urinate. The driver of the grab lorry was unaware of Mr McAuley’s presence within this area and moved the grab lorry forward a short distance and at low speed, causing Mr McAuley catastrophic injuries that caused his death. 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. It is common practice for members of roadwork crews to use the space between the rear axles of LGVs to urinate, even when a welfare van has been provided on site. A witness who had worked for at least one company as part of a roadwork crew prior to joining KBL gave evidence that it was a practice that he was aware of “since starting on the roads”. Although it would seem that KBL employees no longer engage in this practice, likely because of the tragic death of Mr McAuley, there was no evidence available at the Inquest to suggest his death had had an impact on the industry more widely. 2. I have concerns with regard to the following: i. If the practice of using the space between the rear axles of an LGV is ongoing, there remains a risk of future deaths, as any small movement of the vehicle can cause fatal injuries. I am not aware of any safety notice(s) being issued since Mr McAuley’s death or any wider publicity that may have highlighted the risk. Ensuring that companies undertaking road resurfacing work or similar are made aware of the risk that this practice is ongoing will enable them to take measures to address this potential ongoing risk. 2 6 ACTION SHOULD BE TAKEN In my opinion urgent 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, by 27th September 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 I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: , Thomas McAuley’s sister; , Thomas McAuley’s mother; (1) (2) (3) (4) (5) DWF Law, representing KBL; (6) Dolmans Solicitors, representing Dorset Council. , Thomas McAuley’s brother; , Thomas McAuley’s partner; I am also under a duty to send the Chief Coroner a copy of your response. 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 2nd August 2024 Signed Brendan J Allen 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.
Health and Safety Executive Head of Construction Sector HSE Engagement and Policy Division Floor 11 William Morgan House 6 Central Square Cardiff CF10 1 EP Tel: http://www.hse.gov.uk/ Deputy Director Mr Brendan Joseph Allen HM Area Coroner – Dorset Civic Centre Bourne Way Bournemouth BH2 6DY Sent by email to Date Dear Sir, MR THOMAS JOSEPH MCAULEY – DECEASED REPORT TO PREVENT FURTHER DEATHS CORONERS (INVESTIGATIONS) REGULATIONS 2013 Thank you for your Regulation 28 letter dated 2nd August 2024 addressed to letter has been passed to me as Head of HSE Construction Sector to provide a response. May I take this opportunity to express my sadness and condolences at the tragic circumstances that gave rise to the inquest. . Your I understand from your report that your concerns centre on two main areas, welfare provision and workplace transport safety on construction sites. Industry Awareness of the Law and Guidance Pertaining to Welfare Requirements and Construction Site Traffic Management. The construction industry is aware that welfare must be provided on all sites and during all phases of construction work, from commencement to completion, even for short duration or mobile work such as road works. HSE will take enforcement action where welfare is not provided. Similarly, workplace transport is present on all construction sites and industry is aware that the risks posed by vehicles must be planned and managed to prevent people coming into contact with vehicles and plant. As the health and safety regulator for construction sites, HSE enforces legal requirements and works with industry stakeholders to raise awareness of the required standards to those who create the risk so that they understand the measures they need in place to control those risks. Availability of Construction Welfare Guidance HSE provides detailed guidance on construction site welfare requirements which is freely available. Examples of this guidance are: Provision of welfare facilities during construction work (hse.gov.uk) This guide gives good advice on the minimum standards to be achieved at all construction sites. Construction: Welfare - Managing occupational health risks in construction (hse.gov.uk) This HSE webpage offers clear information on the welfare standards to be provided and maintained during construction works. It also contains a number of additional links to relevant guidance and legislation. It applies to all sites including roadworks. Health and safety in construction HSG150 (hse.gov.uk) – page 11 onwards (para 41 to 68) This guidance document contains an extensive section relating to the provision and management of welfare on construction sites. The key message is that everyone who works on any site must have access to adequate toilet and washing facilities, a place for preparing and consuming refreshments and somewhere for storing and drying clothing and personal protective equipment. Welfare facilities What you need to know as a busy builder CIS62 (hse.gov.uk) This simple guide gives an overview of the basic welfare requirements needed for all construction sites, even small ones or those which are of short duration. HSE also produces internal guidance to assist Inspectors and Visiting Officers in achieving a uniform benchmark when considering these risks. In November 2022, a detailed operational guidance document was published concerning welfare provision for construction sites - Construction welfare standards (hse.gov.uk). This document is published on the HSE website and can be seen and used by industry and the public to better understand the benchmarks to be achieved and how HSE regulates welfare in construction work. Construction Traffic Management The risks from moving vehicles on construction sites are well known across industry and each year, on average seven to ten people die as a result of being struck by moving vehicles. In addition, there are hundreds of other preventable accidents and injuries involving workplace transport. Accidents involving vehicles occur across all work activities from groundworks to finishing works. Managers, workers, visitors to sites and members of the public can all be at risk. Availability of Traffic Management Guidance HSE publishes guidance relating to workplace transport safety which is freely available on our website www.hse.gov.uk. The core message of this guidance being that duty holders must ensure that vehicle movements and traffic routes are organised such that pedestrians and vehicles are segregated so far as reasonably practicable. It is important to note that controls for transport safety cover segregation of pedestrians from vehicles whether moving or stationary, as unauthorised access to vehicles should be prevented and there are risks that stationary vehicles can move unexpectedly. Examples of this guidance, which is freely available to all industries are as follows: Construction - Traffic management on construction sites (hse.gov.uk) This HSE webpage deals with traffic management in relation to construction works and contains links to additional guidance, the key message given is that construction site vehicle incidents can and should be prevented by the effective management of transport operations throughout the construction process. The safe use of vehicles on construction sites: A guide for clients, designers, contractors, managers, and workers involved with construction transport - HSG144 (hse.gov.uk) This guidance document covers the safe use of vehicles on construction works in some detail. The key message throughout the document is that every effort should be made to keep people and vehicles segregated from one another. Workplace transport safety: A brief guide INDG199 (hse.gov.uk) This short guide covers the basic principles of workplace transport safety and makes segregation a core part of the management of risk. 2 Workplace transport - HSE This HSE webpage gives wide ranging guidance for all industries on workplace transport safety and risk management Health and safety in construction HSG150 (hse.gov.uk) – page 54 onwards (para 264 to 307) This guidance document contains practical advice on all aspects of construction site traffic management and has a focus on segregation. All these links and documents are freely available on the HSE website. Having reviewed the circumstances of this fatal accident, it is HSE’s view that the need to provide adequate welfare facilities and control risks associated with transport safety are well known to industry and legislation and suitable and sufficient guidance already exists to assist duty holders in complying with their duties and adequately control the risks involved in this accident. Through our stakeholder engagement networks, we will continue to raise awareness of maters arising in this case with industry to ensure they manage them appropriately. These topics will also be raised at inspections where appropriate. The responsibility to achieve legal compliance, source suitable advice or information for their individual circumstance’s rests with the duty holder. Where HSE finds non-compliance, we use the standards in the above guidance to decide whether to take enforcement action. Our approach to enforcement decisions, including the role of guidance can be found on the HSE website - How we regulate health and safety law (hse.gov.uk). Conclusion In conclusion, the current legislative requirements and expected industry standards for welfare provision and transport safety are well known and there is a significant amount of supporting guidance to enable duty holder compliance. Where suitable welfare facilities are provided, and their use is appropriately managed by duty holders, and adequate controls are in place to ensure the safe movement of vehicles, tragic incidents like this should be prevented. I hope the above shows that the guidance provided by HSE provides a range of resources that are readily available to support the successful management of the risk from vehicle movements and inadequate welfare on construction sites. It is also to be noted that this incident has been widely reported in the construction industry press. I trust my response has been of use and am happy to help explain any of the contents of this letter should you require me to. I would like to reassure the family of Mr McAuley that HSE will seek to share the lessons learned from this tragedy to inform duty holders of these risks and prevent a reoccurrence. Yours faithfully Head of Construction Sector 3
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