Prevention of Future Deaths reports · 2025

Afolabi Ojerinde

Regulation 28 report to prevent future deaths, reference 2025-0060, written 3 Feb 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report3 Feb 2025
Reference2025-0060
DeceasedAfolabi Ojerinde
CoronerZak Golombeck
Coroner areaManchester City
CategorySuicide (from 2015)
Organisation namedPennine Care NHS Foundation Trust
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

2

3

4

1 Secretary of State for Work and Pensions
2 Energy Institute
3 Association for Petroleum and Explosives Administration
4 The Petroleum Enforcement Liaison Group
CORONER

I am Zak GOLOMBECK, HM Area Coroner for the coroner area of Manchester City
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.
INVESTIGATION and INQUEST

On 05 September 2023 I commenced an investigation into the death of Afolabi Oluwafemi
OJERINDE aged 48. The investigation concluded at the end of the inquest on 29 January
2025. The conclusion of the inquest was that:

petrol station

The deceased, who suffered from a psychotic illness, attended an
on 4th September 2023 where he was able to pay for and dispense petrol into a plastic
water bottle. He then ignited the petrol and placed himself in the fire. The deceased died on
5th September 2023 at Wythenshawe Hospital from the effect of injuries sustained during
the incident on 4th September 2023.
CIRCUMSTANCES OF THE DEATH
The Deceased attended an
credit/debit card, was able to dispense petrol into a plastic bottle (not a suitable portable
container)
. It was confirmed
in evidence that the petrol station is not continuously watched, and that for a person attending
without a vehicle, an alarm would only be raised after minutes. Such control measures did
not, therefore, have any bearing on the Deceased being able to dispense petrol in
contravention of Regulation 12 of the Petroleum (Consolidation) Regulations 2014.

petrol station. After paying at the pump with a

The Deceased proceeded to ignite the petrol and place himself in the fire. He subsequently
died of his injuries.
CORONER’S CONCERNS

5

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)

I am concerned about the safety of
compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014.

petrol stations and how they do not ensure

When comparing this to

petrol stations,

ensuring that the individual is:
seeking to dispense petrol into a motor vehicle or motor boat; seeking to dispense petrol
into a suitable portable container; over the age of 16.

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

 6

7

8

The evidence at the Inquest from the companies that operated the site and provided
security accepted that the guidance available for
cannot ensure compliance with the 2014 Regulations.
ACTION SHOULD BE TAKEN

petrol stations do not and

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.
YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by March 31, 2025. 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

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

Tesco Stores LTD
Chubb Fire & Security UK LTD
Pennine Care NHS Foundation Trust

I have also sent it to

Greater Manchester Fire and Rescue Service

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: 03/02/2025

Zak GOLOMBECK
HM Area Coroner for
Manchester City

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

Responses

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.

Response from Energy Institute Petroleum Enforcement Liaison Group Association for Petroleum and Exp (PDF)
Dear Mr Golombeck 

Further to the recent Regulation 28 of 3rd February 2025, this response is submitted on behalf of 
Energy Institute (EI), Association for Petroleum and Explosives Administration (APEA) and 
Petroleum Enforcement Liaison Group (PELG). 

Firstly, all three organisations wish to pass on their sincere condolences to the family of Mr 
Ojerinde following these sad events. 

EI 

The  Energy  Institute  (EI)  is  the  leading  chartered  professional  membership  body  supporting 
individuals and organisations across the energy industry. With a combined membership of over 14 
000 individuals and 300 companies in 100 countries, it provides an independent focal point for the 
energy community and a powerful voice to engage business and industry, government, academia 
and the public internationally. 

As a Royal Charter organisation, the EI offers professional recognition and sustains personal career 
development  through  the  accreditation  and  delivery  of  training  courses,  conferences  and 
publications and networking opportunities. It also runs a highly valued technical work programme, 
comprising  original independent research and investigations,  and the provision of EI technical 
publications to provide the international industry with information and guidance on key current and 
future issues. 

APEA 

The APEA is a UK based organisation with worldwide membership. It draws membership from those 
in the retail petroleum industry who are involved with the design, construction and operation of 
filling  stations.  The  membership  includes  regulators  from  national  and  local  government 
authorities,  oil  companies,  equipment  manufacturers,  suppliers,  service  and  installation 
organisations and contractors. The APEA was founded in 1958 and has the same objectives as 
today: 

•  The advancement of scientific and technical knowledge 
•  The supply and interchange of information 
•  Uniformity of standards interpretation and application 

The APEA is consulted by governments and standards authorities in this specialist field. It also 
runs training courses, provides technical advice and holds an annual conference. 

PELG 

PELG was set with the aim to facilitate appropriate and consistent enforcement by Petroleum 
Licensing Authorities (PLAs) through the dissemination of advice, guidance and good practice. 

Under the sponsorship of the Health and Safety Executive (HSE) in Great Britain, PELG was set 
up to devise guidance and provide advice to PLAs and licensees on the Petroleum 
(Consolidation) Act 1928 and to produce circulars (PETELs). Later, the role was broadened to 
provide a platform for revisions to legislation and played a key part in the devising and 
implementation of the Dangerous Substances and Explosive Atmospheres Regulations 
(DSEAR) in Great Britain in 2002, and subsequently the Petroleum (Consolidation) Regulations 
(PCR) that came into force in Great Britain on 1st October 2014. PCR repealed the Petroleum 
(Consolidation) Act 1928 and introduced a certification regime to replace petrol licencing and 

Page 1 of 10 

 
 
 
 separate notification of keeper arrangements. The authorities allocated to enforce PCR are 
referred to in the Regulations as Petroleum Enforcement Authorities (PEAs). 

Aims and objectives 

The aim of PELG is to facilitate appropriate and consistent enforcement by PEAs and 
compliance by petrol dispensing premises operators through the dissemination of advice, 
guidance and good practice. 

PELG has six objectives; namely to: 

• Discuss the need for advice and guidance (including on technical issues where there is a need 
for a consensus view among PEAs and HSE); to commission and agree such advice and 
disseminate it to PEAs and make it available to operators of petrol dispensing premises. 

• Assess the implications for enforcement of new developments in technology, industry 
practice and procedures. 

• Liaise effectively with HSE, PEA’s, National Fire Chiefs Council, Environmental Agencies and 
the associations representing the retail petroleum industry on matters within its remit. 

• Assist in finding solutions to general problems that might otherwise incur costly and time-
consuming appeals.  

• Ensure the principles of the Regulators' Code, as issued by BEIS is being followed. 

• Advise PEAs on compliance with the National Local Authority Enforcement Code. 

Comment 

All incidents within the sector are taken extremely seriously and reviewed to ensure guidance 
and regulations remain fit for purpose. 

Following the incident and subsequent Section 28, the group have reviewed both the 
EI(IP)/APEA’s Guide the “Design, Construction, Modification, Maintenance and 
Decommissioning of Filling Stations” (The “Blue Book”) and EI/PELG Guide “Petrol Filling 
Stations Guidance on managing the risks of fire and explosion” (The Red Guide), paying 
particular attention to the following sections of each publication; 

Blue Book including hyperlink 

Section 7.6 – Control Systems  

Annex X – Safety Signs and Safety Information Notices.  

Red Guide including hyperlink 

Section 5 – Managing The Risk  

Section 6.4 – Operating and Emergency Procedures 

Section 7.3 – Dispensing Control Measures highlighting Section 7.3.8 – Sites operating in 
Unmanned Mode and Section 7.3.12 – Assessing The Risks 

Page 2 of 10 

 
 
 
 
 
 Annex A – CCTV Surveillance 

Annex C – Training 

It should be noted the guidance in place is goal setting, illustrating the fundamental principles 
for site operators to achieve across a spectrum of fuelling formats, with guidance to support 
this, however it remains for site operators to risk assess and implement appropriate control 
measures at premises deemed suitable to operate in such a way. 

Please note additional work in relation to the operation of petrol filling stations on an unmanned 
basis is being undertaken by industry with the support of PELG to develop a best practice guide 
to further support operators beyond the standard guidance in place.    

Conclusions 

Having completed the review, whilst the incident has caused obvious concern, it is felt that both 
publications remain comprehensive and fit for purpose. 

All three responding organisations and the various Trade Associations and manufacturers who 
they represent, remain keen to work closely with operators to ensure that risks are assessed 
and mitigated against to ensure incidents such as these are kept to a minimum. 

Please rest assured that APEA, EI and PELG will continue to ensure that publications are 
reviewed on a periodic basis and updated where applicable. 

Best regards 

Secretariat  

For and on behalf of Energy Institute, Petroleum Enforcement Liaison Group and 
Association for Petroleum and Explosives Administration 

9th April 2025 

Page 3 of 10
Response from Hse on Behalf of Dwp (PDF)
Health and Safety
Executive

Engagement & Policy Division

EPD TSEG UNIT 2
Basingstoke - Priestley House

Priestley Road
Basingstoke
HAM
RG24 9NW

Tel: 020 3028 1612
Fax:

http://www.hse.gov.uk/

Operations Manager:

H.M. CORONER’S OFFICE
Manchester City Area
Exchange Floor
The Royal Exchange Building
Cross Street
Manchester M2 7EF

Your reference -

Date 15th July 2025

Reply sent by email to:

Dear Mr Golombeck

Inquest into the death of Afolabi Oluwafemi OJERINDE (Deceased) – Regulation 28 report

Health and Safety at Work etc. Act 1974

Your letter of 25th April 2025 to the Secretary of State for Work and Pensions enclosing your Regulation 28 report
(dated 3rd February 2025) has been passed to me for reply.

I work in the Health and Safety Executive’s (HSE) Engagement and Policy Division which has the policy lead in
relation to these regulations and the interface with Petroleum Enforcement Authorities (PEAs) via the Petroleum
Enforcement Liaison Group (PELG).

I note your report was sent to a number of bodies with an interest in this issue. This response will address matters
that are within HSE’s areas of responsibility as the policy lead for the Regulations, and highlight where matters are
more appropriately addressed by other organisations. My comments are based on my discussions with
stakeholders and sight of relevant documents, together with my experience as a health and safety professional.

I would make the following observations –

Legal framework



The specific legislation governing the operation of petrol stations in Great Britain is the Petroleum Consolidation
Regulations 2014. The key point to note here is that whilst HSE has the policy ownership for PCR, HSE is not the
enforcing authority and PCR identifies PEAs in the Regulations which is consolidate in our enforcing authority
guidance: Appendix 1: Health and Safety (Enforcing Authority) Regulations 1998: A-Z guide to allocation.

  Other relevant legislation includes the Dangerous Substances and Explosive Atmospheres
Regulations 2002 (DSEAR) which the PEAs enforce, the Health and Safety at Work etc. Act
1974 and the Management of Health and Safety at Work Regulations 1999 which local
authorities enforce.
Suicides in the workplace are not reportable under RIDDOR (the Reporting of Injuries, Diseases
and Dangerous Occurrences Regulations 2013). The regulations only require the duty holder /
person in control of a workplace to report a death from a workplace accident (See Suicide
prevention - HSE.)



 Health and safety law is goal setting rather than prescriptive i.e. it sets out the standards that
are to be achieved, not how this is to be done. Regulations may be supported by Approved
Codes of Practice (ACOP) and / or sector or industry specific guidance. A common
requirement is for duty holders to assess the risks created by their undertaking. In the case of
PCR, the detailed industry guidance is contained in -

o ‘Petrol filling stations - guidance on managing the risks of fire and explosion’ (the Red

Guide), published by the Energy Institute. Sections 5, 6.4 and 7.3 address risk
assessment and section 8 includes guidance on unattended self-service and
unmanned sites; and

o ‘Design, Construction, Modification, Maintenance and Decommissioning of Filling

Stations’ (the Blue Book produced by the Association for Petroleum and Explosives
Administration - APEA)

Matters of concern

You raise concerns about the safety of unmanned petrol stations and whether they ensure
compliance with Regulation 12 of the Petroleum (Consolidation) Regulations 2014. i.e. those
dispensing petrol are over the age of 16, and that petrol is dispensed only into a motor
vehicle, motor boat or a suitable portable container.

Whilst this is undoubtedly a tragic incident, a person taking their life in this way is a rare event.
It is also very difficult to control against – provided a person is over 16 and dispenses petrol
into an approved container, there is nothing to stop them buying the petrol and then
subsequently using it to set themselves on fire in the same way as Mr Ojerinde.

The policy intent of the Petroleum Consolidations Regulations is to ensure that both manned
and unmanned petrol stations are equally safe for use by members of the public. Operators
must assess the risks and put in place suitable and sufficient measures to ensure risks are
adequately controlled and there is significant guidance, as detailed above, to assist the
operators in this respect. As stated above, there is no obligation to consider suicide risks in
their assessment or control measures.

However, as with all risk assessments, these must be reviewed periodically, particularly after
an incident to make sure they reflect the physical workplace and current systems and working
practices. Where deficiencies are identified they should be rectified or mitigated as
appropriate. I understand that Tesco and the Energy Institute on behalf of PELG have carried
out detailed reviews of the their systems and guidance which they believe now address the

2

 issues raised by this incident.

Greater Manchester Fire & Rescue Service can advise further on the specific changes made.

Yours sincerely

HM Principal Inspector of Health and Safety

3

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