Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, written 3 Dec 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Dec 2015 |
|---|---|
| Deceased | Codrut Iederan |
| Coroner | Me Hassell |
| Coroner area | London Inner (North) |
| Category | Accident at Work and Health and Safety related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Codrut IEDERAN (died 03.12.14)
THIS REPORT IS BEING SENT TO:
1. Mr Brendan Bacon
Director
Zelltec Limited
41 Brownfields
Welwyn Garden City
Hertfordshire
AL7 1AN
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 5 December 2015, one of my assistant coroners, Richard Brittain,
commenced an investigation into the death of Codrut Iederan, aged 30
years. The investigation concluded at the end of the inquest on 23
November 2014. The determination made at inquest by the jury was of
accidental death.
4
CIRCUMSTANCES OF THE DEATH
Just before 9am on 3 December 2014, whilst working at the Anchor and
Hope Public House construction site, Mr Iederan pushed an unstable wall
which then collapsed on him.
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 at inquest that the site manager for the Anchor and Hope Public
House construction was the site first aider, but he was off site at the time
of the fatal accident. The remaining four workers were all Romanian non
native English speakers, and none was first aid trained.
Mr Iederan had the best English of the four, but of course after the
accident he was not in a position to help himself. When one of his
colleagues tried to call an ambulance, he realised that he did not know
the number. He asked a passer by and so no time was lost in this case.
However, when I asked him in court if he now knew the number, some
eleven months after Mr Iederan’s death, he did not, despite still being
employed by Zelltec.
I am conscious that many construction sites in London are heavily
supported by foreign workers. It seems to me that it would be of great
assistance if employers and site managers were to ensure that all
members of their workforce were able to summon help in an emergency.
In addition to signs (perhaps in languages other than English) with the
999 number displayed clearly, this could be covered in toolbox talks – of
course how it is done is of course a matter for you.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and 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 1 February 2016. 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.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Health and Safety Executive
, partner of Codrut Iederan
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
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
03.12.15
3
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