Brian Davies

HMSC Aled Gruffydd 
Swansea Neath and Port Talbot 

Health and Safety 

   Executive 

Director of Regulation’s Office 

HSE 
William Morgan House 
6 Central Square 
Cardiff 
CF10 1EP 

Date – 12th November 2025 

Dear Mr Gruffydd, 

I’m writing to you in response to your letter received by HSE on 17th September 2025 as part of your 
inquest into the death of Mr Brian Lyn Davies on 13th March 2023 at his home of 
, 

 Swansea. 

In your ‘Regulation 28: Prevention of Future Deaths Report’, we note that the cause of Mr Davies’ death 
was determined to be due to neck and chest injuries sustained following an explosion at his home 
address. 

Your report noted three areas deemed to be ‘Matters of Concern’ and you have requested that HSE 
respond to you regarding these. 

These matters were –  

1.  There was no understanding of what evidence was required to be preserved for the purposes of 

an investigation as to the cause of the explosion; 

2.  There was no order given to secure such evidence; 

3.  There was no memorandum of understanding or protocol between the Police and the HSE to 
provide information on what the HSE would need to be able to identify the cause of the 
explosion as far as practicable without impacting upon the primary objective of preserving life 
undertaken by the search and rescue operation. 

The response to incidents where there may be a work-related death, is managed through joint 
implementation of the Work Related Death Protocol (WRDP). HSE and thirteen other organisations, 
including the Police, Fire Authorities, and Local Authorities, are signatories to the WRDP, and in 
response to your concerns,  we would like to bring to your attention the two main documents, which 
have been in place in various revisions since 1998, the Work-related Deaths: A protocol for liaison 
(England and Wales) - WRDP1 and Work-related Deaths Protocol: Practical Guide (England and 
Wales). 

The purpose of the protocol and supporting (practical) guide is to ensure effective joint investigation of 
work-related deaths in England and Wales. The WRDP National Liaison Committee (NLC), ‘owns’ the 
protocol and HSE sits on the committee alongside the other signatories. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Since its introduction, the protocol has become a tried and tested approach to effective liaison between 
whichever signatory organisations are involved in investigating a work-related death. By signing the 
protocol, signatories confirm their commitment to the joint investigation approach, appreciating that the 
public want to be confident that those investigating work-related deaths are doing all that they can to co-
ordinate activities, and to cooperate with each other in the best interests of public safety, justice and 
compassion for those affected. 

The protocol ‘has been prepared on the assumption that those tasked with investigating such serious 
and tragic matters, from whichever organisation, are qualified to do so.’  In order to ensure HSE carries 
out its functions within the WRDP, HSE trains its operational staff in the understanding and 
implementation of the protocol, from initial contact, through investigation and potential enforcement.  

HSE would expect that all signatory organisations to the WRDP are assured that their staff are aware of 
the nature and content of the WRDP.  

In relation to the specific ‘Matters of Concern’ raised in your letter, it is HSE’s opinion that the Work 
Related Death Protocol (WRDP) addresses your points.  I have responded to each of those points 
individually with excerpts from the protocol below. 

1.  There was no understanding of what evidence was required to be preserved for the purposes of 

an investigation as to the cause of the explosion;  

At an early stage of the investigation, the Police and other relevant authorities should agree to the 
following: 

(e)  how relevant material is gathered or generated during the investigation is to be stored, 

revealed and shared between parties. Normally it would appropriate for the parties to 
the investigation to share evidential material with each other, or permit access to it, as 
the investigation progresses; 

(f)  what specialist and expert advice is required; for what lines of enquiry, i.e. gross 

negligence manslaughter, corporate manslaughter or health and safety breaches; and 
how they are to be commissioned and funded. The aim is to ensure, where possible, 
that an expert addresses the issues in relation to all potential offences at the same 
time; 

2.  There was no order given to secure such evidence; 

(e)  how relevant material is gathered or generated during the investigation is to be stored, 

revealed and shared between parties. Normally it would appropriate for the parties to 
the investigation to share evidential material with each other, or permit access to it, as 
the investigation progresses; 

(f)  how the forensic examination of relevant material is to be co-ordinated e.g. physical 

items, DNA evidence, digital material; 

3.  There was no memorandum of understanding or protocol between the Police and the HSE to 
provide information on what the HSE would need to be able to identify the cause of the 
explosion as far practicable without impacting upon the primary objective of preserving life 
undertaken by the search and rescue operation;  

The WRDP provides an appropriate framework to enable the Police and HSE to successfully 
manage a Gas Explosion incident.  No one explosion is the same.  It is important that an incident is 
investigated on a case-by-case basis to ensure that the HSE is able to gather evidence and 
information needed to identify the cause of explosion, without impacting the primary objective of 
preserving life.   

2  

 
 
 
 
 
 The process as identified by the WRDP will enable investigators to determine what evidence should be 
preserved on a case-by-case basis.  In addition to this, Appendix 1 of the WRDP provides duties for first 
officers in Domestic Gas Incidents, however, these questions relate to Carbon Monoxide fatalities rather 
than gas explosions. 

HSE believes that the current WRDP is fit for purpose as a framework to ensure collaboration between 
organisations responding to major incidents and makes a note where any issues arise to bring them to 
the attention of the WRDP NLC.     

In relation to this incident, HSE was contacted by South Wales Police at approx. 1700 on 13th March 
2023 and made aware of a ‘Gold Command’ meeting by South Wales Police that was arranged for 
1730 – HSE was not invited to attend this meeting and was informed that the site was a ‘live’ search 
and rescue site as it was believed a person was still trapped.  HSE were advised not to attend site as it 
was not yet deemed safe. 

The first direct contact with the South Wales Police Senior Investigating Officer occurred at 1845 on the 
13th, at which point Mr Davies’ body had been recovered. The WRDP was discussed as well as some 
other matters.  HSE attended site on the 14th by which time search and rescue efforts had meant 
material had been moved offsite to waste and recycling facilities. Although the gas meter, gas cooker 
and gas boiler had been retained off site, all other evidential material had been disposed of by the 
waste and recycling company.  HSE investigators on site had requested that material be retained for 
future examination. The scene and lead for the investigation remained with South Wales Police. 

However, in response to the matters of concern you raised and to further improve the current WRDP 
and guidance, HSE will: 

•  Raise your concerns at an appropriate WRDP National Liaison Committee (NLC) and 

recommend that refresher communications be issued to all signatory organisations, highlighting 
the need to ensure that all new and existing staff, who could be involved in WRDP incidents, 
are fully aware of its requirements; 

•  Provide an update to the NLC regarding work HSE has been doing in preparing national 
training material focussing on the work related elements of such investigations for those 
responding to incidents including more specific advice for those first on scene. This will in due 
course be put to the NLC for consideration and endorsement; 

•  Provide an update to the NLC on other HSE on-going work to develop a proposed ‘Suspected 
Gas Explosion checklist’, to sit alongside the current ‘Carbon Monoxide checklist’ within 
Appendix 1 of the WRDP Practical Guide – ‘Additional duties of first officer – Domestic Gas 
Incidents’. This would be for the NLC to agree and update the guide. 

Thank you for your letter and if I can be of any further assistance, please contact me via email 

Yours sincerely, 

Head of Director of Regulation’s Office 

3

:>W

Keeping South Wales Safe

Cadw De Cymru'n Ddiogel

Protecting and Reassuring

Diogelu a Thawelu Meddwl

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Special Legal Casework
Achosion Cyfreithiol Arbennig

Mr Aled Gruffydd
Senior Coroner for Swansea, Neath & Port Talbot
The Coroner’s Office
Swansea Guildhall
Swansea SA1 4PE

15 December 2025

Dear Mr Gruffydd,

Re: South Wales Police Response to the Regulation 28 Report arising from the death
of Brian Lyn Davies

I write on  behalf of the Chief Constable of South Wales Police in response to  the  Prevention of Future

Deaths Report issued on the  17 September 2025.

The report was issued following the conclusion of the  inquest into the  death of  Brian Lyn Davies who

tragically died on the 13 March 2023. Unfortunately, the Chief Constable of South Wales Police was

not  an Interested Person for the  purposes of the Inquest and did not  appear and  was not

represented at the Inquest. Accordingly, it  has been necessary for  me to  familiarise myself with  the

background events and the  matters you have set out  in your  report. I am grateful for the  additional

time  you  have granted to  enable me to  provide a response on  behalf of the Chief Constable.

I have carefully considered the  entirety of the  report and wish to  reiterate that  as an organisation,

South Wales Police have taken the  opportunity to seriously reflect on the  evidence heard during Mr

Davies' inquest.

We are committed to  ensuring the  duty of care shown by our  officers to  the individual concerned is

always paramount and welcome any findings and recommendations to  ensure the highest standards

of  service are maintained.

The cause of Mr  Davies' death was determined to be due to  neck and chest injuries sustained

following at explosion at his home address. Thankfully, events such as this are extremely rare and it

has long been long recognised that there is a need for  practical guidance for  investigators and others.

Please reply to/Atebwch I: BRIDGEND OFFICE

Special Legal Casework  /  Achosion Cyfreithiol Arbennig
South Wales Police Headquarters, Cowbridge Road, Bridgend, CF31 3SU
Pencadlys Heddlu De Cymru, Heol Y  Bont - Faen, Penybont, CF31 3SU
Tel/Ffon: 01656 306013 Fax/Ffacs: 01656 302118

Croesyceiliog Office /  Swyddfa Croesyceiliog
Gwent Police Headquarters, Croesyceiliog, Cwbran, NP44 2XJ
Pencadlys Heddlu Gwent, Croesyceiliog, Cwbran, NP44 2XJ
Tel/Ffon: 01633 642310 Fax/Ffacs: 01633 642283

We  do  not  accept service by  email  or  fax.

Nid  ydym  yn  derbyn cyflwyniad dogfennau cyfreithiol wrth  ebost  neu  ffacs

Page 1 of 5

 This is one of the  reasons for  the  creation of practical guidance which is contained in two  documents.

The first is the "Work-Related Death Protocol: Practical Guide" and the second is the  "Work-Related

Deaths: A Protocol for Liaison"  I have attached a copy of each document to this letter and taken

together, I will refer to them  as "the  Protocols".

The Protocols apply in England and Wales and have been in place since 1998. They are described as

"living documents" and are updated and revised by the  Work Related Death Protocol, National

Liaison Committee as necessary.

The signatories to these documents are:

National Police Chiefs' Council (NPCC);

British Transport Police (BTP);

Care Quality Commission (CQC);

Care and Social Services Inspectorate Wales (CSSIW);

Chief Fire Officers' Association (CFOA);

Crown Prosecution Service (CPS);

Health and Safety Executive (HSE);

Healthcare Inspectorate Wales (HIW);

Local Government Association (LGA);

Maritime and Coastguard Agency (MCA);

Medicines and Healthcare products Regulatory Authority: Medical Devices Division;

Office for  Nuclear Regulation (ONR);

Office of Rail and Road (ORR);

Welsh Local Government Association

The foreword of the  Work-Related Deaths: A Protocol for  Liaison contains the  following narrative:

"The Protocol is a high level document which is supported by, and should be read in

conjunction with  the  Work-related Deaths Protocol Practical Guide which sets out  a

straightforward step-by-step approach to the  joint investigation of  work-related deaths.

The purpose of  the protocol and supporting guide is to ensure effective  joint investigation of

work-related deaths in England and Wales. Since its introduction in 1998, the protocol has

become a tried and tested approach to effective liaison between the signatory organisations

when investigating a work-related death. By signing the protocol, signatories confirm their

commitment to the  joint investigation approach, appreciating that  the  public want  to  be

confident that those investigating work-related deaths are doing all  that  they can to co-

Please reply to/Atebwch I: BRIDGEND OFFICE

Special Legal Casework  /  Achosion Cyfreithiol Arbennig 
South Wales Police Headquarters, Cowbridge Road,  Bridgend, CF31 3SU 
Pencadlys Heddlu De Cymru, Heol Y  Bont - Faen, Penybont, CF31 3SU 
Tel/  Ffon: 01656 306013 Fax/Ffacs: 01656 302118

Croesyceiliog Office /  Swyddfa Croesyceiliog
G w e n t   p ° lice Headquarters, Croesyceiliog, Cwbran, NP44 2XJ
Pencadlys Heddlu Gwent, Croesyceiliog, Cwbran. NP44 2XJ

Ffon: 01633 642310 Fax/Ffacs: 01633 642283

We  do  not  accept service by  email  or  fax.

Nid  ydym  yn  derbyn cyflwyniad dogfennau cyfreithiol wrth  ebost  neu  ffacs

Page 2 of 5

 ordinate activities, and to co-operate with each other in the best interests of  public safety and
of  those affected by work-related deaths."

As would be expected, the Protocols contains provisions and guidance which provide full or partial
answers to the issues you have raised. However, it remains important that the Protocols are reviewed
and refreshed as appropriate.  In this regard, it is significant that  Detective Superintendent 

 from South Wales Police attended the National Work Related Death Liaison Committee on 17

November 2025 which is the national multi agency meeting that oversees the Protocol and linked
matters. At that meeting the Protocols, were discussed as it was universally agreed that these
documents need to be updated. The motion to give effect to the same was carried, and the National
Liaison Committee has committed to undertaking a review and update as appropriate. This illustrates
the national governance and oversight of the Protocol and the multi-agency cooperation between
Policing, the HSE and the other signatory organisations.

In addition, Detective Superintendent 
Wales region Work-Related Deaths Group with partner agencies including the HSE.

 has also re-established which he chairs and chairs a

This response will be focused on the points raised in section 5 of the Preventing Future Deaths
Report. Each issue you have identified is intrinsically related, and I will address each of your concern
in turn below:

1)  There was no understanding of what evidence was required to be preserved for the purposes

of an investigation as to the cause of the explosion;

Guidance on the Management of the Investigation is contained in section 3 of the Work Related
Death Protocol Practical Guide. The relevant extract from the Guidance states:

At an early stage of  the investigation, the Police and other relevant authorities should agree to
the following:

3 (e) How relevant material is gathered or generated during the investigation is to be stored,
revealed and shared between parties. Normally it would appropriate for  the parties to the
investigation to share evidential material with each other, or permit access to it, as the
investigation progresses;

3 (f) What specialist and expert advice is required; for what lines of  enquiry, i.e. gross
negligence manslaughter, corporate manslaughter or health and safety breaches; and how
they are to be commissioned and funded. The aim is to ensure, where possible, that an expert
addresses the issues in relation to all potential offences at the same time;

This was a dynamic and fast moving situation. South Wales Police had primacy of the investigation
and there were a series of meetings, seven in total, of the Tactical Co-Ordinating Group ("TCG")
during the initial hours and days following the explosion. The TCG discussions included direct
consideration of the Protocols. Attendees at the TCG varied as events become clearer. It was
identified that the investigation was a joint investigation between the police and the HSE, with the
police having primacy.

The primary concern for the police was the preservation of life and limb and the search and rescue
operation for Mr Davies. At the early stages, it was initially believed that Mr Davies may be still
trapped, and efforts were directed to locate him and to provide any assistance required. There was
also the objective to contain the emergency as a whole and to secure the site and limit escalation.

 It is acknowledged that  it is possible that  any actions taken to  achieve the  primary objectives may

have had the  unintended consequence of limiting the  effectiveness of the  subsequent investigation

to  ascertain the cause of the  explosion.

In this respect, South Wales Police will take steps to  raise your concerns with  the  National Liaison

Committee in order that  due regard may be had to  such a possibility in the  future, so that  any

amendments which are considered appropriate, may be made to the Protocol.

2)  There was no order given to secure such evidence;

The Guidance in section 3 continues with  following provisions:

3 (/J How  relevant material is gathered or  generated during the investigation is to be stored,

revealed and shared between parties. Normally it  would appropriate for  the parties to the

investigation to share evidential material with  each other, or permit access to it, as the

investigation progresses;

3 (f) How  the forensic examination of  relevant material is to be co-ordinated e.g. physical

items, DNA evidence, digital material.

The objective from the TCG was to  facilitate investigations and inquires, working closely with the HSE

and others identified key agencies.  This occurred during the  course of the TCG Meetings.

There is no record of HSE attending the initial TCG meetings, although the HSE made a request to be

kept informed of developments and representatives of the  HSE attended the  later TCG Meetings.

Following the recovery of Mr  Davies' body the TCG discussions included consideration of the practical

guidance on appropriate next steps. The search and rescue requirements had led to  material being

removed offsite to  waste and recycling facilities. It is unfortunate that  although the gas meter, gas

cooker and gas boiler had been retained off  site, all other material had been disposed of by the  waste

and recycling company.

The Protocols recognise that  infrequent and tragic events, such as this one, are different and must be

investigated on  a case by case basis. If it is possible that  any actions taken by a police force to  achieve

their primary objectives of preserving life and limb  and search and rescue may have an unintended

consequence of limiting the  effectiveness of the  subsequent investigation to  ascertain the cause of

the  explosion, then  this is a matter which South Wales Police will seek be included in the review of

the  Protocols.

3)  There was no memorandum of understanding or protocol between the Police and the HSE to

provide information on what the HSE would need to be able to identify the cause of the

explosion as far as practicable without impacting upon the primary objective of preserving life

undertaken by the search and rescue operation

The Protocols, including their appendices, are the  only documents that currently exist in this respect.

The Protocols are framework documents to provide practical guidance to ensure collaboration

between organisations responding to  major incidents.

Please reply to/Atebwch I: BRIDGEND OFFICE

Special Legal  Casework  /  Achosion Cyfreithiol Arbennig 
South Wales Police Headquarters, Cowbridge Road, Bridgend, CF31 3SU 
Pencadlys Heddlu De Cymru, Heol Y  Bont - Faen, Penybont, CF31 3SU 
Tel/Ffon: 01656 306013 Fax/Ffacs: 01656 302118

Croesyceiliog Office /  Swyddfa Croesyceiliog
Gwent Police Headquarters, Croesyceiliog, Cwbran, NP44  2XJ
Pencadlys Heddlu Gwent, Croesyceiliog, Cwbran, NP44 2XJ
Tel/  Tfon: 01633 642310 Fax/Ffacs: 01633 642283

We  do  not  accept service by  email or  fax.

Nid  ydym  yn  derbyn cyflwyniad dogfennau cyfreithiol wrth  ebost  neu  ffacs

Page 4 of 5

 I have had the benefit of seeing the  HSE response dated 12 November 2025, which I note  was before

the  national multi agency meeting of the  National Work  Related Death Liaison Committee on 17

November 2025.

The HSE's response in this regard is that: "The WRDP provides an appropriate framework to enable

the Police and HSE to successfully manage a Gas Explosion incident. No one explosion is the same. It is

important that  an incident is investigated on a case-by-case basis to ensure that  the HSE is able to

gather evidence and information needed to identify the cause of  explosion, without impacting the

primary objective of  preserving life."

Whist this remains the  case, for  the reasons I have set out  earlier, it is important that  the  Protocols

are reviewed. In this regard, the  HSE also helpfully state that, as a result of the concerns you have

raised, they  will:

(cid:127)  Raise your  concerns at  an appropriate WRDP National Liaison Committee (NLC) and

recommend that  refresher communications be issued to all signatory organisations,

highlighting the need to ensure that  all new  and existing staff, who could be involved in WRDP

incidents, are fully  aware of  its requirements;

(cid:127)  Provide an update to the NLC regarding work  HSE has been doing in preparing national

training material focussing on the work  related elements of  such investigations for  those

responding to incidents including more specific advice for  those first on scene. This will  in due

course be put to  the NLC for  consideration and endorsement;

(cid:127)  Provide an update to  the NLC on other  HSE on-going work  to develop a proposed 'Suspected

Gas Explosion checklist', to sit alongside the current 'Carbon Monoxide checklist' within

Appendix 1  of  the WRDP Practical Guide -  'Additional duties of first officer -  Domestic Gas

Incidents'. This would be for  the NLC to agree and update the guide.

In common with  our response to issues 1 and 2, South Wales Police will take steps to  raise your

concerns in relation to  issue 3 with the National Liaison Committee. In doing so, we  will  work closely

with the HSE and other signatories to the Protocols to  ensure that  due regard is given to these matter

so that  any appropriate amendments may be made to  the  Protocol.

I hope that this response addresses the  concerns that  you set out  in your  report, and I am grateful to

you for  you bringing them  to the  attention of South Wales Police.

Yours sincerely,

Assistant Director
Head  of Special Legal Casework