Source: http://frederickchambers.co.uk/2019/04/
Timestamp: 2019-11-20 07:42:16
Document Index: 523828585

Matched Legal Cases: ['art 3', 'art 2', 'art 1', 'art 18', 'art 17', 'art 16', 'art 15', 'art 14', 'art 13']

﻿ Frederick Place Chambers - Legal Advice Services Tel:0117 946 7059 April – 2019 – Frederick Place Chambers
April 26th, 2019 by Robert Spicer
LAW Part 3: the criticism continues
In the interests of fairness and balance, what is good, in summary, about the English legal system?
The independence of the judiciary.
The incorruptibility of the judiciary in the sense of financial bribery. The English judiciary, unlike the legislature, has never been the subject of financial scandal.
The jury system, as the only democratic element in the system, which is constantly under attack.
A general adherence to the rule of law.
A highly developed and sophisticated system of legal education.
The permitted scope for individualism in the legal profession, which results in a small number of highly committed progressive lawyers.
Law Centres.
The Legal Action Group and its publications.
The remnants of legal aid.
Health and safety law and some aspects of employment law.
The common law dealing with workplace stress.
Some other areas of substantive law, for example road traffic, food hygiene, environmental law and common law negligence. These areas are not generally concerned with commerce, property or money.
Progressive organisations, for example Liberty, the Haldane Society, Reprieve, Amnesty International and the Legal Action Group.
Resistance by the judiciary to the increasing power of the executive.
The intellectual achievements of the senior judiciary.
Before 2003 it seemed to be clear that the most important issue facing English law was the denial of justice to the poor. But the Iraq War has emerged as more significant than the buying and selling of justice, for the following reasons:
The application of English law has been seen to be partly responsible for a wholly avoidable humanitarian disaster.
Senior members of the former British government are regularly accused, in the press, of war crimes.
Any claims which the British government might have had to moral ascendancy have been swept aside. The moral high ground has been lost, and English law is implicated in this debacle.
English lawyers have not, in general, spoken out or acted against the first major illegal international act of the twenty-first century. Individual lawyers and judges have protested but professional associations have, to their shame, been largely silent.
The Iraq War is fully examined in Chapter 5.
April 25th, 2019 by Robert Spicer
LAW: a critical analysis of the English legal system Part 2
Some lawyers who have made a reasonable living from the practice of English law have not embraced the legal system as a saviour or a benefactor. They have always been critical. They aim to continue to be critical. They will not forget the circumstances in which their families struggled to survive and the role of English law in the preservation of a social and economic system which condemned their parents and grandparents to lives of unceasing toil and hardship.
Some lawyers do not love the law. They do not find it particularly fascinating. They do not like putting on fancy dress or enjoying the sound of their own voices.They do feel passionate about the denial of justice to the poor.
These lawyers do not find themselves under any obligation to put forward positive suggestions for the reform of the system other than to call for a national network of properly-funded Law Centres. Those who did not create the English legal system have no responsibility for its rescue.
Law reformers are thick on the ground in England, beavering away for years in committees which produce vast reports which are then often forgotten, or sweating over their chances of academic promotion by producing books and articles advocating the reform of specific areas of law.
When law reform is carried through, more often than not it creates more complexities and obscurities than it resolves. The conditional fee system, for example, imported from America despite decades of principled opposition from those who reacted with revulsion against ambulance chasing, sounds deceptively simple. Some claimants have an almost childlike faith in “no win no fee”, which on the face of it is a clear concept. The reality is different.
The conditional fee system is overlaid with a mass of detail related to insurance. Insurance companies have profited massively since the evisceration of legal aid.
The system of conditional and/or contingency fees is so complex that it has become a new area of specialism. It may soon be a specialist subject in its own right, on law degree syllabuses. Non-experts have very little chance of understanding, let alone explaining, its bewildering complexities. There is plenty of money to be made from specialising in conditional fee law without ever taking on a no win no fee client.The reality is that lawyers will not generally take on no win no fee cases unless they are virtually unloseable.
Another example of a failed reform was the introduction of the employment dispute regulations. This reform was money-based with the overall intention of cutting down the number of employment tribunal claims. The new regulations were generally accepted to be disastrous and have now been repealed. This is fully discussed in Chapter 6 (Mystery).
The key point to be made in summarising the current state of the English legal system is that poor people can’t afford justice.
April 24th, 2019 by Robert Spicer
LAW: a critical analysis of the English legal system Part 1: Introduction
of Cain and his brother, Abel
(Coleridge, The Devil’s Thoughts)
This book is written for non-lawyers and lawyers. It has the following aims:
In general, to communicate a highly critical analysis of the current state of English law and lawyers.
To analyse English law and lawyers from the perspective of class justice.
To discuss the concept of human rights.
To challenge existing preconceptions and accepted wisdom about the role of English law and lawyers.
To raise public awareness and stimulate discussion of the key current issues in English law.
Chapter 1 looks at Money. It puts forward the argument that money is the key which unlocks the meaning of English law. It discusses the relationship between poverty and the enforcement of legal rights. No win no fee arrangements and legal aid are critically analysed. The Chapter also considers lawyers’ earnings, law as business and the scandal of miners’ compensation. It also examines the cost of becoming a lawyer and discusses the dubious history of Claims Direct.
Chapter 2 concerns Class. It defines and discusses the concept of class justice. The Chapter discusses the Crimewatch television programme as an exemplar of the spectacle of class justice and goes on to provide examples of class justice in practice. These examples include alcohol prohibition in the United States and the English system of Crown immunity. The current role of the English judiciary is considered. The Chapter also looks at examples of revolutionary legal systems including the Paris Commune and Cuba.
Chapter 3 deals with Dissent. It sets out rarely-published views of law. These include statements on the legal system from voices including the Levellers, William Godwin, American radical lawyers, Jessica Mitford, Nelson Mandela, Albie Sachs, E.P. Thompson, Tolstoy, Kropotkin, Emma Goldman and the French Illegalists. The importance of the McLibel case is also considered. Material from the Haldane Society and the Up Against the Law collective is included.
Chapter 4 looks at Rights. It deals with the relationship between individual and collective human rights, examines the torture “debate” and sets out material dealing with human rights in Cuba and in the post-apartheid Constitution of South Africa.
Chapter 5 deals with war, specifically the Iraq War. It argues that the legality of the Iraq War is the most important issue which currently faces English lawyers. It examines the legal issues arising from the War and considers English case law connected with the War. The Chapter analyses the effect of the Iraq War on the relationship between law and morality. It discusses the Nuremburg principles and examines the death penalty as illustrated by the “squalid lynching” of Saddam Hussein. It concludes with a critical comparative analysis of health and safety in a war context.
Chapter 6 – Mystery – attempts to unravel the mysteries of English law. It sets out a list of words and phrases in common use by lawyers which form a sort of secret code. The Chapter considers the reasons for obscure legal language, discusses legal Latin and sets out examples of clarity in the law. Examples of extreme mystery are also considered. Aspects of employment law are analysed in detail as illustrations of unnecessary mystification. Recent examples of judicial comments on demystification are set out.
Chapter 7 discusses current legal practice. It considers the advocacy monopoly and suggests methods of alternative practice. The Chapter examines the apparent contradictions between the public perception of lawyers and the image which the profession aims to project. The Queen’s Counsel system is analysed. Barristers’ public access rules are examined. The Chapter continues with a consideration of the nature of advocacy, the position of unrepresented litigants and the process by which lawyers qualify.
The book concludes with a list of further reading, a glossary of technical words and phrases, a list of cases and a detailed index.
Footnotes are deliberately excluded from the material. The main reason for this is that the author has struggled through too many books with more footnotes than text to be able to follow the thread of the material, and aims to avoid these diversionary fragmentations. Full case references, further reading and a detailed index are provided for those readers who may wish to follow up references in the text.
The material is subdivided throughout into a number of levels of headings and frequent use is made of bullet points. The aim of these devices is to make the text more accessible to the reader than conventional legal textbooks.
April 16th, 2019 by Robert Spicer
Health and Safety Horrors Part 18: Final Part: Universities, Warehouses, Wells, Wind turbines
Bomblet explosion
In February 2011 three employees at the Explosives Research Section at Cranfield University were deactivating cluster bomblets. One of the bomblets exploded and caused serious injuries to a worker. The injuries included severe abdominal injuries and lacerations. No suitable risk assessment had been carried out for this type of activity and therefore the system of working was unsafe. The university’s management team were unware of the process being carried out by workers to deal with this type of ammunition.
Racking collapse death
In March 2009 Desanka Todovoric, an employee of Merley Paper Converters Ltd, was working at the company’s warehouse in Corby. She was waiting to collect flat pack boxes when racking collapsed and fell on her, causing fatal injuries. The racking which collapsed had been in a poor condition. Important locking pins were missing.
An HSE inspector commented after the case that if the company had properly erecetd and maintained its racking, the incident would never have happened. Virtually all industries use racking in one form or another. It was hoped that the case would serve as a reminder that attention to detail was crucial when erecting, maintaining and inspecting racking to ensure its integrity.
Fall down well: serious injuries
During an open house viewing of a property, a prospective buyer stepped onto a wooden board which was covering a well. The board gave way and she fell 30 feet down the well. She suffered head injuries and suffers from post-traumatic stress disorder. The estate agents had been warned about the well and that the board which was covering it did not look safe. The estate agents did not properly investigate if there was a risk of people falling down the well.
Fall into sewage well
In August 2011 an employee of Tardis Environmental UK Ltd, who wishes to remain anonymous, was clearing a sewage well blockage at a housing development in Halesowen, West Midlands. A pump at the bottom of the well had stopped working because it had become blocked with bulky waste material. The employee used a road tanker with pump and hose attachments. He opened a grid at the top of the well and stood over it to manoeuvre the hose. The hose moved and caused him to fall into the well. He ingested raw sewage and suffered friction burns and bruising. He had been trained in the use of the pumping equipment but had not received any instruction or training in how to empty deep sewage wells.
Wind turbine death in gearbox shaft
Colin Sinclair, an employee of Siemens plc, was inspecting a wind turbine at Causeymire windfarm in December 2015. He escorted RWE Innogy UK Ltd staff to the top of a wind turbine. His harness became entangled in a high-speed unguarded rotating shaft of a gearbox. He suffered fatal injuries. The gearbox had been inadequately guarded since January 2009 and the rotating shafts were exposed.
April 14th, 2019 by Robert Spicer
The Little Book of Health and Safety Horrors Part 17: Schools, Sporting Estates and Transport
Repton School staircase injuries
In November 2013 Christine Bywater went to Repton School to watch her grandson play football. She left the school pavilion and stepped on a stone staircase. She fell from the staircase to the ground five metres below. She suffered multiple injuries. The stone staircase had a parapet running along its edge but no handrail. An HSE inspector made the following comments after the case:
This was a foreseeable incident which could easily have been avoided if reasonable measures, for example the fitting of guard rails, had been taken.
Published guidance exists regarding appropriate edge protection and dimensions for handrails which the school could have used to identify the appropriate standard.
In July 2011a group of girls from a school in East Ham went on a camping trip in West Sussex. One of the girls poured methylated spirits from a five-litre container onto a cooking stove when she thought that it was going out. This caused a flashover. The girl suffered severe burns to her hands, arms, face, neck and legs. The incident could have been avoided if basic precautions had been taken. Fuel should have been kept in the correct containers, safely stored and simple procedures followed for lighting the stove.
An HSE inspector commented after the case that councils, schools and voluntary groups which organise camping trips involving the use of highly flammable stove fuel must ensure that they implement effective precautions to prevent the ignition of fuel or vapour.
In January 2012 Bret Thomas, a school pupil then aged 16, was on an extended work experience placement at Motorhouse 2000 Ltd’s site in Cannock. He was told to help an employee who was refilling a wheel stripping tank. The employee poured paint stripper from plastic containers into the tank and then passed the containers to Thomas who removed their labels and cut them in half. As he was cutting the last container with a Stanley knife, the container flicked up and the remains of the paint stripper splashed into his eyes and face. He was not wearing face or eye protection. He suffered burns to his face and eyes. His vision was seriously affected for a month and his face is scarred.
Four-year old pupil injured
In September 2016 a four-year old pupil at St Joseph’s RC Primary School in Mossley was allowed to go to the girls’ toilet alone. She was heard screaming and was found with her fingers trapped in the hinges of the toilet door. Her right middle finger suffered a partial amputation. The finger guard on the door was missing. It had not been fitted when the toilets were converted five years before. There was no system in place for checking and monitoring door guards. Staff had also notified the former head teacher that the door was too heavy for young children to open.
A worker was acting as a flanker to funnel grouse towards a line of guns and to stop birds flying out of the side of the drive at the Danby Moor Settlement in North Yorkshire. He was shot when he was directly in front of the line of guns. He was struck by shotgun pellets. The optic nerve in his left eye was severed and he was permanently blinded.
Death from crushing between two buses
In October 2011 Lee Baker, an employee of West Midlands Travel, a subsidiary of the National Express Group, was working a night shift at the company’s depot in Walsall. He was attempting to move a double-decker bus to gain access to a pit by pushing it manually. Baker inadvertently left the gearbox of the vehicle in drive. When he left the vehicle, the bus crushed him against another vehicle. He suffered fatal crush injuries. No supervisor had been on duty at the time of the incident and the company had failed to carry out a suitable risk assessment in relation to moving buses manually. Employees had not been trained in a safe system of work for moving buses not under their own power and had allowed the practice of workers pushing buses during night shifts. The company had a recovery agency to tow broken-down vehicles to the depot and inside it, but before the incident only supervisors knew how to call out the agency. The lack of a clear, safe system of work and a supervisor had led the deceased attempting to devise his own way of dealing with a problem which was preventing him from getting on with his work.
Ahmet Yakar, a Turkish national who did not speak English, made a delivery with his lorry at Morganite Electrical Carbon Ltd’s site in Swansea. He was supplied with a hand-operated pallet truck to move boxes of graphite parts to the back of his lorry. The boxes, which were stacked four high, became unstable. They toppled and crushed him. He suffered fatal injuries. The company did not have safe working procedures for receiving and unloading delivery vehicles. It did not carry out a suitable and sufficient risk assessment for unloading at the site. The company did not have a set policy for dealing with drivers who did not speak English.
In June 2012 Mark Wintersgill, a mechanic employed by PPR Transport Services, was attempting to jack up the axle of a double decker HGV trailer at the company’s site in Lutterworth, Leicestershire. He was using an air jack powered by a compressor. He was thought to have placed wooden blocks on top of the jack to increase its lifting height. The jack separated from the axle and struck him, causing fatal head injuries. He was attempting to jack the trailer on a set of concrete ramps. This meant that the trailer’s landing legs were below the level of the rear axles. This could have encouraged the unit to rock forward when the jacking began. Wintersgill should not have been under a vehicle being lifted until it was fully supported by appropriate chassis or axle stands.
Driver killed by runaway lorry
In December 2010 Russell Horner, an employee of Nightfreight (GB) Ltd, was working a nightshift at the company’s premises in Earls Barton, Northampton shire. He was coupling a tractor unit to a trailer when his vehicle moved off and crushed him against a stationary vehicle. He suffered fatal chest injuries. The HSE investigation discovered that drivers were coupling up vehicles without applying handbrakes or turning off vehicle engines. This dangerous practice was in breach of the company’s rules and was known to the company which had failed to effectively monitor employees and ensure that they followed the correct safe working procedure. There were no appropriate measures in place to prevent vehicles rolling away.
Driver impaled on steel tube
In August 2008 a horizontal swing barrier on Henry Williams Group Ltd’s Darlington site had been left open to allow Jason Ripley, a delivery driver, access to an unloading point. Ripley was delivering timber to the site. The barrier comprised a six meter long, 60mm diameter steel tube. As he drove towards the open barrier on his way through, the end of the bar was not visible. It broke through the windscreen of Ripley’s vehicle and impaled him through the chest. The tube fractured three ribs and caused damage to a lung. The company had failed to assess the risks involved with vehicles driving on and off the site and there was no means of securing the swing barrier in the open position.
Death from fume inhalation
In August 2011 Steven Conway, an employee of Diamond Wheels (Dundee) Ltd, was responsible for general duties at its premises. These duties included collections and deliveries, removing and replacing tyres and moving allow wheels in and out of a chemical paint stripping tank. He was overcome by dichloromethane vapour while attempting to remove stripping debris from the tank. He died as a result of the inhalation.The company had provided Conway with no formal training in respect of the use of the tank and the stripping agent used by the company
Shovel loader death
In September 2006 Wayne Meylan was working at Need a Skip Ltd’s site in West Bromwich. He was crouching over a manhole, cleaning out a drain pump, when he was run over by a 13- tonne shovel loader. He suffered fatal injuries. The company had no transport plan in place to segregate people from vehicles. Its on-site health and safety training plan had not been followed. The company had previously been warned of the risks associated with workplace transport during a routine HSE inspection.
An HSE inspector is reported to have commented that the ad hoc approach by the company to its on-site activities, combined with heavy machinery moving around, meant that there was a high potential for an incident.
Apprentice trapped under bus
In September 2009 Ben Burgin, an apprentice then aged 17, was working with an experienced colleague at Yorkshire Traction Company’s Barnsley depot to repair a braking fault on a bus fitted with an air suspension system. They attempted to deal with the fault while the bus was on the garage floor rather than moving the vehicle over an inspection pit. Burgin was working underneath the bus near the front passenger wheel when the air suspension failed and the bus dropped onto him. He suffered severe facial injuries and had to be freed by another worker. The injuries required restorative plastic surgery to his nose and eye socket.
The investigating HSE inspector is reported to have commented that when employing young people, it was crucial that companies took account of their obvious lack of experience and lack of awareness of risk. The risks involved when working on buses with air suspension systems were well known in the motor industry. The latest guidance had warnings about never working beneath them unless they were properly supported The purpose of assessing risks which young people might encounter was not to produce paperwork but to protect them.
Crushing incident: severe brain damage
An employee of Signature Support London Luton Ltd was working at Luton Airport in April 2015. She was opening the doors of a hangar to move aircraft inside. She was trapped by the doors and suffered serious crushing injuries which resulted in severe brain damage. The employing company had failed to conduct adequate planning and had also failed to provide adequate training and written instructions,
In May 2013 John Wallace, an employee of Ontime Automotive Ltd, was jet washing a twin deck recovery vehicle at the company’s premises in Hayes, Middlesex. The upper deck collapsed and crushed him. He suffered fatal injuries. The vehicle had been poorly designed by J&J Conversions Ltd. The upper deck was only stable when it was secured by two powered locking pins. It was possible to lower the locking pins was incorrectly operated by hand. A correct design would have used a device which could not be operated by hand. Ontime had failed to control this unsafe practice. J&J Conversions had failed to remedy the issue after the upper deck had collapsed on a previous occasion.
April 12th, 2019 by Robert Spicer
The Little Book of Health and Safety Horrors Part 16: Recycling, refuse collection, road traffic
Gas cylinder explosion death
In June 2009 Tony Johnson was working at Walter Heselwood Ltd’s site in Sheffield. A pressurised gas cylinder was put through a shearing machine. It exploded and a large section struck Mr Johnson on the head. He suffered fatal injuries. The company had no effective health and safety management system in place. It had failed to adequately assess the risks involved with processing different types of scrap material. It had also failed to put in place a range of measures to reduce risks. A spokesperson for the HSE is reported to have commented after the case that companies processing different materials should have good documented systems to ensure that materials such as pressurised cylinders are sorted and dealt with correctly.
Serious ash burns
In December 2009 an agency worker was cleaning ash from a filtration hopper at a Veolia Environmental Services site in Deptford. He prodded the ash with a rod in an attempt to clear a blockage. The ash fell onto him and he suffered 17 per cent burns to his body. He was hospitalised for a month. The worker, who wishes to remain anonymous, was from Eastern Europe. He spoke little English and had not been properly instructed on working practices at the site. Veolia had not followed its own policies and procedures for the management of dangerous tasks. This put a vulnerable worker at risk by failing to provide him with adequate information or supervision.
Collapse of waste material: worker asphyxiated
In August 2014 Neville Watson, an employee of New Earth Solutions Group Ltd, was driving a loading shovel near a pile of waste material which was eight metres high. He had connected a shredder to the vehicle. The pile collapsed on him and he died from asphyxiation. The company had failed to undertake and prepare risk assessments or safe systems of work for the creation and management of stockpiles of waste. It had also failed to provide adequate training. An HSE inspector commented after the case that the company had failed to ensure that the deceased was supervised by a worker trained in the task he was carrying out. He had never previously carried out that task.
Excavator fall death
In July 2012 Lindsay Campbell was working in the bucket of an excavator at South Coast Skips Ltd’s site in Arundel. He was running an electric cable to power a waste screening machine. The bucket was lifted nine metres from the ground when the hydraulic pressure dropped, the bucket tipped forward and Campbell fell nine metres to the concrete floor. He suffered fatal injuries. An HSE inspector is reported to have made the following comments after the case: nobody should ever be lifted in the bucket of an excavator. Neither the bucket nor the excavator have the necessary safety devices nor fail safe devices which would prevent a person falling. The company did not have in place the training and supervision and especially the health and safety culture that ensures that nobody would consider undertaking such an obviously unsafe act such as this.
Dumper truck death
Ben Sewell, an employee of Dittisham Recycling Centre Ltd, was working at its site in Dittisham, South Devon. He was driving a dumper truck to move oversized material. He drove the truck along a dirt track down a steeply sided valley. He was not wearing a seat belt. He was found lying at the side of the track a few metres from the truck. He had suffered fatal injuries.The HSE discovered a series of safety failings with vehicles at the site. Tipping operations were unsafe and some of the roadways were inadequately protected.The deceased had not been adequately trained.
An HSE inspector commented that dumper trucks are inherently unstable and dangerous machines to operate. The company had not enforced the necessary rules to make sure that they were driven safely, including the full and proper use of seat lap belts.
Reversing vehicle death
In April 2016 a 76-year old female employee of Savanna Rags International Ltd, a clothing and textile recycling company, was walking from a weighbridge to a smoking shelter in the company’s yard during her afternoon break. She was struck by the rear of a reversing delivery vehicle and suffered fatal injuries. The company had failed to make a suitable and sufficient assessment of risks arising from vehicle movement. It was custom and practice for vehicles to reverse from the weighbridge. This was used by workers to access the company’s factory. There were no measures in place to adequately segregate pedestrians from moving vehicles and no safe system of work in place to ensure that vehicles could manoeuvre safely
In May 2014 a refuse collection vehicle was being refurbished at John Fowler and Son (Blacksmiths and Welders) Ltd’s site in Chorley. An operative using the controls within the cab of the vehicle closed the tailgate on a worker. He suffered fatal crushing injuries. The vehicle was supplied with controls for raising and lowering the tailgate which were designed so that a one-metre gap should be left when it was closed. The safety limit switch was jammed, so that the tailgate could be completely closed. There had been a poor system of work and an inadequate risk assessment. Veolia ES Sheffield Ltd had failed in its inspection regime, which would have identified and corrected the fault with the safety limit switch.
Collision with traffic signs: multiple injuries
Carillon AM Government Ltd was responsible for placing a series of road signs warning of the closure of a junction on the A12 near Saxmundham. The roadworks ahead signs should have been placed at intervals of 800, 400 and 200 metres ahead of the closure. In fact, the first indication was less than 200 metres before the road closure on the 50 mph stretch of the road. Glyn Turner was driving his motorcycle south along the road when he collided with the traffic signs. He suffered multiple injuries and is now paralysed. A spokesperson for the HSE is reported to have commented after the case that roadworks provide increased risk in what is already a very hazardous environment. Anyone doing work on our roads must take great care to warn road users in good time what to expect on the road ahead.
Death on pedestrian crossing
In May 2009 Mary Whiting, a passenger at Luton Airport, was crushed by a 26 tonne milk lorry as she used a pedestrian crossing between a terminal building and a passenger drop-off zone. The crossing, designed by C-T Aviation Solutions Ltd and situated on private land leased by the airport operators, was badly positioned and did not conform to regulations which apply to public roads. London Luton Airport Operations Limited was responsible for maintaining the roads, parking enforcement and signage at the airport. The company was served with an improvement notice after the death of Mrs Whiting, which required chamges to be made related to the safety of pedestrians and vehicles.
April 11th, 2019 by Robert Spicer
The Little Book of Health and Safety Horrors Part 15: mines, poisoning, police, prisons
Death of coal miner in roof fall
In September 2011 Gerry Gibson was working at Kellingley colliery. He was killed when 15 tonnes of rock, which formed a section of roof, collapsed as a powered roof support was being operated. Six days previously, a similar roof fall had occurred. UK Coal Managers (now Juniper (No3 Ltd) had been aware of the earlier fall. No investigation had been carried out and insufficient precautions had been taken to prevent a recurrence. The company had not improved its system of monitoring roof supports to ensure that warning signs of ground movement would be quickly picked up.
Costs were not awarded so as not to jeopardise potential payments to the Miners’ Pensioners’ coal allowance scheme, a major creditor of UK Coal. An HSE inspector commented after the case that the HSE had prosecuted despite the company being in administration. There was significant public interest in a very serious offence and the company’s standard of managing health and safety was far below what was required.
Deaths of mineworkers
In June 2006 Trevor Steeples was killed at Daw Mill colliery near Coventry, operated by UK Coal Mining, when he was exposed to high levels of methane. In August 2008 Paul Hunt was killed at the same colliery when he fell from an inadequately maintained underground transporter into the path of a moving train. In January 2007 Anthony Garrigan was killed at the same colliery as he worked with colleagues to install rockbolts to keep a tunnel support wall in position. he was crushed to death when more than 100 tonnes of inadequately supported coal and stone fell on him. The tunnel had previously collapsed and UK Coal should have supplied a safer system of support. In November 2007 Paul Milner died at Welback colliery in Nottinghamshire. He was installing extra roof supports in order to salvage equipment from a coal face which had ceased production. Milner was crushed to death under 90 tonnes of rock when the roof collapsed. A suitable code of practice had been agreed to provide a safe system of work. This code was not properly implemented by UK Coal.
In 2008 B was employed as a storeman by a Scottish local authority. He was responsible for supplying gardeners with weedkiller containing paraquat. The weedkiller was stored in a locked container. B was a keyholder. He put some weedkiller into mineral water bottles to take home for use in his own garden. On the way home he stopped at a club. The bag containing the bottles became mixed up with bags belonging to F. F drank the paraquat and died.
Firearms death
In June 2008 PC Ian Terry was engaged in a firearms training session at a disused warehouse in Manchester. He was role playing an armed criminal. The training session involved practising to apprehend armed criminals from a car. Terry was killed by a colleague using a shotgun. He suffered fatal chest injuries. The officer responsible for the course, referred to as F to protect his identity, ran a course with a lethal combination of factors including the use of live ammunition in an aggressive scenario.
Prison suicide: Crown Censure
The National Offender Management Service (NOMS) has been subjected to a formal Crown Censure by the Health and Safety Executive, following the death of a prisoner. In September 2006 Daniel Rooney was a prisoner at HMP Bullingdon. He was observed in the act of attempting to hang himself. He was identifed as being at risk of self-harm and was moved to a safer cell. Later that day, Rooney hanged himself with a ligature made from his bedding and suspended from a shower rail support bracket. The bracket should not have been strong enough to support the ligature. Examination of the safer cell found a number of points where ligatures could be attached.
The provisions of the Health and Safety at Work etc Act 1974 apply to Crown bodies, but Crown immunity means that such bodies are excluded from statutory enforcement, including prosecution and penalties.
April 10th, 2019 by Robert Spicer
The Little Book of Health and Safety Horrors Part 14: Lawnmowers, Lifts and Local authorities
In March 2014 an employee of New Charter Housing Trust was using a ride-on mower with a grass box attached. The chute to the grass box became blocked because the grass was long and wet. The worker reached into the chute to clear a blockage, His hand came into contact with a rotating metal fan. He suffered serious injuries. He had not received training on how to use the mower and did not know that the fan continued to rotate for 30 seconds after the machine’s engine was switched off.
Strimmer chain death
In February 2010 Tony Robinson, a self-employed contractor, was using a chainsaw to cut back overgrown vegetation at Ramsden Dock in Barrow. He had been hired to help clear undergrowth at the site during the construction of the new Waterfront business park. A chain attachment had been fitted to a strimmer so that it could be used for more heavy duty work. The chain, spinning at 300 mph, became detached and struck him on the back of the neck. He suffered fatal injuries. The HSE investigation of the incident found that the work had not been planned or carried out safely. ThreeShires Ltd had not properly considered the risks of using the attachment and had allowed the deceased to work close to where the strimmer was being operated.
The HSE issued a Safety Alert following the incident, which warned that there was a risk of death or serious injury from the use of the chain attachment. It served a prohibition notice on the sole importer of the attachments into the UK. The attachment is now banned throughout Europe.
Hand caught in blades
In August 2011 a maintenance worker, who wishes to remain anonymous, employed by Clear Channel UK Ltd, an outdoor advertising company, was working at a billboard site in Bath Road, Bristol. He tried to clear a blockage from a petrol-powered mower which he was operating. He thought that the mower had been turned off. As he tried to remove the blockage, the mower’s blade started to rotate. His thumb was almost severed and his fingers were severely injured. A 14 hour surgical procedure was needed to reattach his thumb and repair the damaged fingers. A safety feature which cuts out the engine of the mower and stops the blades rotating was not working properly. Clear Channel did not have an effective reporting and maintenance system for reporting faults in equipment. It had allowed a lawnmower which was not in good repair or efficient working order to be used by its employees.
Lift crushing death: stately home operator fined
Arthur Mellar, a butler, was killed in July 2014 when a luggage lift descended on him. The luggage lift was being used to lift guests’ bags from the ground to the second floor of the house of the Burghley House stately home in Stamford, operated by Burghley House Preservation Trust Ltd. A bag became jammed and the lift stopped. Mellar tried to free the bag when the lift descended and crushed him, causing fatal injuries.The lift had not been fitted with a slack rope detector. An assessment of the lift would have shown that the lift should have been thoroughly examined and tested. A competent lift engineer would have identified defects with the lift.
Lift shaft fall death
In January 2011 work was being carried out on the decommissioning of a lift shaft in a building being converted into flats in the Victoria area of London. The chain supporting the lift car broke while two men were working on it. The car fell six storeys to the bottom of the shaft. One worker was wearing a safety harness and was seriously injured. The other was not wearing a safety harness and was killed. Planning and management of the project was inadequate in relation to work at height and the lift decommissioning work.
Craig Jones, a resident of Marsden House in Bolton, was trapped in a lift at the premises and was unable to raise the alarm. He attempted to self-rescue by forcing the lift doors open and sliding out onto the floor below. He slipped and fell five storeys down the lift shaft, suffering fatal injuries.Warwick Estates Property Management Ltd, as management company of the building, had failed to take suitable and sufficient steps to prevent the deceased from self-rescuing. An HSE inspector commented after the case that the problems with the lift were well-known. Those who manage lifts have a responsibility to ensure that if people are trapped they have a way to raise the alarm and are not in a position to try to rescue themselves.
Lift shaft fall: serious injuries
In March 2012 Terry Moore, an experienced lift engineer, was working on a lift shaft at Rosie Maternity Hospital in Cambridge. He was working on the top floor of a three-storey annex which was under construction. He fell into the shaft and fell nine metres to the foot of the shaft and suffered multiple fractures. The guard rails placed across the entrance to the shaft were 908 mm high. This did not meet the regulatory requirement that barriers must be at least 950mm above the edge from which a person is liable to fall. It could not be proved that the height discrepancy was a causative factor in the fall, but it was a serious safety failing.
Council road sweeper collision: death of motorcyclist
In September 2010 a council road sweeper lorry was cleaning a dual-lane slip road. Derek McCulloch, a motorcyclist, drove into the back of the sweeper. He suffered fatal injuries. The sweeper was travelling at 4 mph and there was a bend in the road which probably prevented the deceased from seeing the vehicle. The sweeper had flashing beacons and a large arrow on its back indicating that vehicles should pass. There should have been significantly more controls in place for sweeping a road of this type. There was no road-specific risk assessment in place but a generic one covering all road sweeping carried out by the council.
Dishwasher fluid
In May 2011 East Sussex County Council was fined following an incident in which a man died and five others were seriously injured when they drank dishwasher fluid.
A group of persons from the St Nicholas Centre in Lewes, a day care facility for adults with learning difficulties run by the council, were taken to Plumpton Agricultural College to use the sports facilities.
They were given a drink which had been prepared at the day centre and brought to the sports hall. This should have been orange squash but actually contained sodium hydroxide, a cleaning chemical.
The six who drank the fluid started vomiting blood and fitting. Colin Woods, who had Down’s Syndrome, died 17 months after drinking the chemical. Five others suffered burns to their mouths, throats and stomachs. Most had to undergo repeated surgery.
Three will never be able to swallow normally again.
East Sussex County Council had failed to ensure that the fluid was safely stored away. It was left on the side in an unlocked kitchen. The chemical was marked as corrosive but it was similar in appearance to that of orange squash.
Surviving service users at the day centre were too traumatised by the incident to be interviewed about who had mixed the drink.
A spokesperson for the HSE is reported to have made the following comments:
This was one of the worst incidents which he had investigated in all his time as a health and safety inspector.
It was impossible to adequately imagine the suffering and terror that the victims must have felt as the tragedy unfolded.
The terrible thing was that the incident and its horrific consequences could so easily have been prevented by simply locking away the container of sodium hydroxide.
Mr Woods had died a slow, painful and unnecessary death and others had suffered terrible and preventable injuries, some painful and permanent, because the council had failed in its responsibility to take proper care of them. It was imperative that authorities properly protected vulnerable people in their care.
Mobility scooter death from reversing lorry
In July 2008 Derrick Baines, aged 76, was returning to his home in Langold, Nottinghamshire, on his mobility scooter when he was struck by a reversing bin lorry. He suffered fatal multiple injuries. The lorry was on a missed bin collection. It had a one-man crew. The fatal incident could have been prevented if there had been a reversing assistant at the back of the vehicle. The driver became aware that something was wrong when he noticed shopping spilled in the road behind his vehicle.
An HSE inspector commented after the case that if the local authority had staffed the vehicle appropriately, Baines would probably still be alive today. Very large vehicles such as the one involved in the incident have a number of blind spots. It was impractical to expect a lone driver to reverse safely without the aid of a colleague walking behind to check that the route was clear. These vehicles are fitted with flashing lights and a reversing warning system, but the council needed to take into consideration that the system was not adequate. Another worker should have been present and could have prevented this needless loss of life.
April 9th, 2019 by Robert Spicer
The Little Book of Health and Safety Horrors Part 13: Industry
Foundry death from grinder
Stuart Stead, an employee of H.I. Quality Steel Castings Ltd, was using a hand-held grinder to work on a casting at the company’s foundry in Doncaster. The disc fitted to the machine exploded and sent fragments across his workbay. A shard struck him in the mouth. He suffered fatal injuries. The disc was nine inches in diameter despite the fact that the grinder had a maximum tool diameter of two inches unless guarded. It was attached to the grinder by using a non-proprietary tool. The disk was rated for 6650 rpm but was running at 12,000 rpm. The grinder had no guard. The excessive speed of the grinder, coupled with the added load caused by the non-standard attachment, had put stresses on the disc beyond its capacity.
The HSE’s investigation had discovered a number of previous incidents when discs had flown off grinders. None of these had been mentioned in monthly minutes of the company’s health and safety meetings. Despite some initial training in abrasive wheels, employees did not understand rotation speeds of machines versus discs and had free access to a number of grinders and discs. This contributed to the prevalence of unsafe combinations.
In March 2016 a worker at Pipework Engineering Services Ltd was operating a foot pedal saw. His hand came into contact with the saw’s rotating blade. He suffered a severed hand and wrist which required surgical intervention to reattach. The company had failed to install the machine correctly and in accordance with the manufacturer’s instructions. This meant that it could be operated from a position which took the operator very close to the blade.
Death of steelworker in blast furnace
In April 2006 Kevin Downey was working a night shift at Tata Steel’s Port Talbot plant. He went to the cast house at the site to inspect the slag pool of a blast furnace which was due to close for maintenance. He fell into the open section of a channel containing slag at 1500 degrees Celsius. The company had a reporting system which showed a significant number of near misses where steam had led to dangerous situations.It was common practice to operate the furnace with channels left uncovered without taking additional precautions to prevent workers from falling in.
Severe head injuries in pneumatic metal press
In August 2011 Wayne Hill, a maintenance engineer, was working at H & E Knowles (Lye) Limited’s site. He was repairing a pneumatic metal press when it unexpectedly started working and crushed his head. He suffered severe head injuries including a fractured nose and jaw and lacerations. He needed extensive reconstructive surgery. The press takes a sheet of metal and forms it into a wheelbarrow body. It should not have been able to operate if the door was open. The machine had a faulty interlocking guard which meant that it did not detect that the door was open. The machine had been designed and built by the company 25 years ago. There were no technical drawings or other documentation and an adequate risk assessment had never been carried out. The machine broke down regularly and maintenance staff repaired it with no instructions.
Factory death: overturned vehicle
In April 2008 Martin McMenemy, an employee of O. Turner Insulation Ltd and Clegg Food Projects Ltd, was working on the construction of a food processing plant in Leicester. He was driving a scissor lift to install wall and ceiling panels. The vehicle overturned when it went into an uncovered pit. McMenemy suffered fatal head injuries. O.Turner and Clegg Food Projects Ltd, the principal contractor for the project, had failed to take precautions to cover the hole. The incident could have been prevented if the pit had been covered with a metal plate or cordoned off.
Flammable solvent fire: worker severely burned
In November 2014 an employee of HMG Paints Ltd was using a highly flammable solvent to clean the floor of a spray booth at the company’s premises in Manchester. He complained about the difficulty of removing dried paint and was allowed to buy an industrial floor scrubber to carry out the work. The electric motor of the scrubber ignited a cloud of vapour which had built up in the booth. The worker suffered 26 per cent burns.The planning for cleaning floors with solvent had failed to recognise the hazard and level of risk associated with the use of highly flammable solvents to clean floors. The worker who was injured had not been trained to clean floors and was not adequately supervised.
Distillery fire: employee severely burned
In November 2012 ethyl acetate, a highly flammable liquid, was being moved from a bulk storage tank to an intermediate container at Alcohol Ltd’s warehouse.The liquid ignited. An employee was engulfed in flames and suffered twenty per cent burns to his head, neck and hands. The fire destroyed the warehouse and damaged nearby cars and houses.The HSE investigation found that the most likely cause of the fire was a discharge of static electricity generated by the transfer of the liquid.There was poor management of pipework and associated valves and a failure to completely inspect the equipment or monitor the systems of work.
Severed arm in conveyor belt
An employee of the company was making adjustments to a misaligned conveyor belt at Concrete Fabrications Ltd’s site in Henbury, Bristol. He had to adjust tensioning rods which were inside the machine’s guards. He tried, with a hammer, to remove material which had built up on a rod. The hammer was dragged into the rotating machinery with his arm. The arm was torn off between the shoulder and the elbow.The company should have had adequate guards on dangerous parts of the machinery. Clear procedures should exist regarding maintenance and adjustments of machinery and arrangements should be in place to ensure that machinery is not run without the necessary guarding in place, and that clear isolation and lock off procedures exist. A sufficient risk assessment would have identified the risks associated with tracking conveyor belts and identified appropriate control measures.
Death of worker in crude oil fire
In June 2010 a fire broke out at Total UK Ltd’s Lindsey Oil Refinery in Immingham. The fire was caused by an uncontrolled release of crude oil. Robert Greenacre, a contracted fitter, was working below a distillation column which contained hot crude oil. They opened equipment, which released crude oil. It ignited and Greenacre was killed.
Operators of major accident hazard establishments must have in place a functioning system of risk assessment for all work where hazardous substances could be released. Operators should always try to eliminate risk through hazard avoidance. In many circumstances this can be achieved by carrying out the work during shut-down conditions. Where this is not practicable, the highest achievable levels of isolation to industry standards are required.If Total had followed well established principles of risk assessment the major fire and the death could have been avoided.
Harvey Hopwood, employed by PAS (Grantham) Ltd as health and safety manager, was overseeing the jet washing of an oil storage tank at the company’s site in Easton, Lincolnshire.He climbed between the guard rails of a gantry at the top of the tank to check progress. He knocked a pipe which came away and released oil with a temperature of more than 160 degrees Celsius. The oil spread over his upper body, causing 10 per cent burns.The company had failed to carry out a risk assessment for the cleaning operation. It had done the work first and written the risk assessment retrospectively.
Multiple burn injuries from casting machine
In May 2009 Stephen Bond-Lewis, a foundryman employed by Special Metals Wiggin Ltd, was removing waste material from a metal casting machine at the company’s premises in Hereford.Part of the machine which weighed 964 kg and had a temperature of between 100 and 250 degrees centigrade, became detached, fell forward and pinned Bond-Lewis against a storage bin. He suffered severe burns to 25 per cent of his body and crush injuries.The method used to remove ingot moulds from the casting machine was unsafe. It involved the use of overhead cranes to pull the moulds free. This damaged the bolts and their fixing points. The fixing bolts on a large number of casting machines were in poor repair. This had not been noticed or put right. This, together with the company’s failure to have a proper maintenance programme in place, resulted in the mechanical failure of the machine.
Explosion injuries: both legs amputated
In December 2011 Clive Dainty, an employee of Filtration Service Engineering Ltd, was pressure testing a vessel. The vessel exploded and struck Dainty. He had to have both legs amputated, suffered head injuries and now has restricted movement in his arms.The vessel was being tested because of concerns about the quality of the welding. The company decided to use compressed air instead of water. The pressure built up to such an extent that the vessel exploded. An assessment of the risks involved in pneumatic pressure testing should have identified that air was not a suitable testing medium. The test could have been carried out by simply filling the vessel with water.
Two employees of PSL Worldwide Projects Ltd were cleaning a pipe system at its site in Cramlington. They were using sodium hydroxide granules through a hose as a cleaning agent. The sodium hydroxide reacted with water in the system. This caused the liquid to heat up and build pressure in the hose. It detached and sprayed the workers with the solution. One worker suffered life-threatening burns. The other sustained severe burns. The work had not been adequately assessed by the company. The equipment provided was not suitable and the company failed to provide adequate personal protective equipment for the work.
Mark Mclean, an employee of Princes Ltd, was working at the company’s site in Bradford in July 2013. A hose carrying a caustic substance spilt. He was sprayed with caustic solution and suffered chemical burns to the left side of his face and arms and temporary blindness. There was no evidence that the company had taken preventative measures.
Incidents at lead smelting works
In August 2009 a worker at a lead smelting works was transporting molten lead slag with a temperature of more than 800 degrees Celsius on a forklift truck. The container holding the molten metal fell off the truck. The liquid was spilt on the ground and ran into a drain.
When it came into contact with water, the liquid lead exploded and blew heavy drain covers several metres into the air. The employee fell onto the molten metal. He suffered severe burns to his face, arms, chest, back and left foot.
In May 2010 an employee of Key Engineering was investigating a fault on an overhead travelling crane. He was positioned on the crane gantry. As the crane ran along the tracks, he rested his right arm on top of the crane’s control panel. When it neared the end of the bay, the clearance between the control panel and a roof beam narrowed to a few millimetres. His arm was trapped and he suffered severe crush injuries.
Molten steel burns
In April 2013 Kevin Watts, a trainee crane driver employed by Tata Steel Ltd, and two workmates, escaped from the top of a crane when a ladle containing 300 tonnes of molten metal dislodged and spilled. They had been operating an electric overhead crane which carried the ladle. One of the hooks on the ladle was not working properly. The metal caught fire and reached the cab of the crane. Watts suffered severe burns on his head and forearms. His colleagues suffered less serious burns. The crane’s camera system had not been operating properly for some time. This had been reported on near-miss and pre-use checks but had not been remedied. Lighting, which employees stated was poor, cut out completely during the incident. Training documents were ambiguous and instructions had not been communicated
.An HSE inspector made the following comments after the case:
Given the potential consequences of a ladle of holding 300 tonnes of molten metal spilling its load onto the floor, control measures should be watertight. The incident could have been avoided if safety measures, which were introduced after the incident, had been in place at the time.
In October 2011 two employees of Meadow Foods Ltd were cleaning a tank at the company’s site in Chester. The cleaning process involved a complex series of valve changes. There were no written instructions or diagrams on how this should be done. One of the employees opened a valve. Compressed air which had built up was released, forcing out hot water with a temperature of 70 degrees Celsius. Both workers were severely scalded. The company had carried out a risk assessment for the cleaning process but had failed to identify basic risks, for example burns from hot water.
Drum explosion: life-threatening injuries
In August 2012 Andrew Foster, an employee of Highway Care Ltd, was using a plasma cutter to cut up a drum which had previously contained a flammable substance. The drum exploded in his face, causing severe and complex head and brain injuries. He has permanently lost vision in his right eye and has very limited vision in his left eye. The company had failed to ensure the health and safety of its employees. An HSE inspector commented after the case that if a welding torch or plasma cutter is used on a tank or drum which has contained a flammable substance, it can explode. It only takes a small amount of residue to create a potentially flammable atmosphere.
Fall of worker into pulping machine
In July 2014 a worker was carrying out maintenance work at a paper mill in Manchester. He was tightening coupling bolts with a torque wrench. The wrench slipped and the worker fell backwards from an unprotected edge into a paper pulping machine. He managed to swim in darkness to a ledge at the side of the pulper. He suffered fractures to his left foot. Valmet Ltd, the company which provided all the mill’s machinery, had carried out a risk assessment but did not identify the fall from height risk. An HSE inspector commented after the case that it was pure luck that the pulper blades were not working when the worker fell.
In January 2014 Jodie Cormack, a short-term contract worker, climbed onto a production line conveyor belt to clear potatoes into an auger in-feed for soup production. Operators used a ladder to access the conveyor belt and used a squeegee to push vegetables into the auger. Cormack slipped into the auger and suffered an amputated left leg. Baxters Food Group had failed to make a suitable and sufficient assessment of the risks to which workers were exposed when they were clearing vegetables from the conveyor belt. It had also failed to provide and maintain a safe system of work. The company had failed to provide necessary information, instruction, training and supervision to ensure the health and safety of employees.
Industrial blender death
In January 2011 George Major, an employee of Rettenmaier UK Manufacturing Ltd, was working at its site in Mansfield. He was helping to clear a blockage from an industrial blender in which shredded paper was mixed with bitumen and oil before being pressed into pellets for reinforcing asphalt mixes for use in road surfaces. Major was dragged into the blender and suffered fatal injuries. The guard had been removed from the blender and it had not been isolated and locked off from the electricity supply. The production line at the site was computer controlled with control screens on two floors. There was no control screen on the same floor as the blender. There was no written system of work or instructions for isolation, no manuals or written instructions, no proper training and no risk assessments.
Worker sprayed with molten metal
In March 2012 a furnace operative, who wishes to remain anonymous, was working at Tata Steel UK Ltd’s plant in Rotherham. A control system fault caused 25 tons of molten metal to spill from a furnace. The worker began to hose the spill with water to cool it, following standard practice. When the water made contact, there was a large explosion and the worker was showered with molten metal. He suffered life-threatening injuries and needed numerous skin grafts and reconstructive surgery. The HSE investigation identified serious safety failings by Tata in recognising and dealing with risks which resulted in workers being exposed to unnecessary danger. The company had no procedures for dealing with spillages of molten metal, no assessment of the dangers and risks and no safe system of work in place. It had become normal practice for workers to hose water onto spills. The water is trapped under the surface of the molten metal and rapidly turns to steam vapour causing a sudden rise in pressure and a massive explosion. This risk is well known within the industry.The company had no procedures for dealing with spillages. Employees used hoses to cool the metal. This was very dangerous but the scale of the risk was not recognised by workers who had received no information or instruction on what to do.
Death from crushing injuries
Christopher Williams, a maintenance supervisor employed by Morgan Technical Ceramics Ltd at its Wrexham premises, was moving a power press which was stored in a shipping container. As he was moving the press, which weighed half a tonne, on a pallet truck, it toppled over and struck him, causing fatal injuries. The lifting operation had been unsafe. The
An HSE inspector is reported to have commented after the case that thirty per cent of fatal accidents in manufacturing in Britain involve the fall of a heavy item. It was important that everyone involved in maintenance understood the risks, and that lifts were properly planned by a competent person.
Severed hand in lathe
In February 2012 Gavin Nobes was working at Marshall Brass’s site in Heckingham, Norfolk. He was polishing a brass clock face bezel on a lathe. The bezel snagged on a polishing wheel and drew his hand and arm into the machine. His left hand was severed and had to be reattached. The polishing lathe was not suitable for polishing the bezel because there was a high risk of snagging. The firm was prosecuted for failing to arrange an alternative method of polishing the bezel or adapting the machine or work system so that the work could be safely done.
In December 2011 three employees of Polimeri Europa UK Ltd were working on a roadway at the company’s site in Southampton. Pipework situated close to them split and sprayed them with sulphuric acid. A jet of sulphuric acid was sent 20 metres high. The workers suffered acid burns to their faces. The company had a plan to inspect its pipework systems in 2008 but initial target dates had been missed. Priority had been given to pipework carrying other hazardous substances. The company had failed to make sure that its pipework, much of it over 50 years old, was in a safe condition. Corrosion had been allowed to take hold of the section of the pipe which carried the acid. The company would have been well aware of the legal requirement to ensure integrity of the sulphuric acid pipework, But it had failed to do so for many years.
Unguarded power hammer: crushed hand
In March 2011 the employee, who wishes to remain anonymous, was using a 10-tonne power hammer at Johnson Mathey plc’s site in Royston, Hertfordshire. He was using the machine to crush waste pieces of metal when he caught his left hand under the automatic hammer. Two of his fingers were severed. The hammer was unguarded. It had regularly been used without a guard.
Crane death
In May 2011 Wilfred Williams was carrying out maintenance on an overhead travelling crane at C Brown & Sons (Steel) Ltd’s site in Dudley. He was working six and a half metres from the ground. he stepped from the gantry where he was working, to the rail of an adjacent crane and sat down. The crane was moved by an operator who had not seen him. He was crushed against an upright stanchion and suffered fatal injuries. Williams and a colleague had accessed the cranes via a cherry picker. Williams was not wearing a harness, there was no fall protection, nor a safe system of work at height. No measures had been taken by the company to isolate the other cranes in the bay where work was taking place, nor in the adjacent bay.
Severed arm in circular saw
In February 2012 Brian Morris, an employee of Stagecraft Display Ltd, was working at the company’s factory in Powys. He had finished sawing for the day and was cleaning sawdust from below a circular saw. He stopped the machine and reached into the machine as it was still running. The moving blade caught the arm of his jacket, severing his right arm. Although the saw was fitted with an interlock which stopped it when it was accessed, it took more than 30 seconds for it to stop completely. Three months before the incident, a machine maintenance engineer inspected the saw and told a manager that it should be taken out of service or fitted with a brake which would stop it more quickly. An HSE inspector is reported to have commented after the case that saws cause the most injuries in the woodworking industry. Power-operated circular saws are dangerous machines which have caused many serious incidents.
Severed finger in blending machine
In March 2010 an employee of Bee Health Ltd was working at the company’s factory in Bridlington, East Yorkshire. He was using a ribbon blender to mix product ingredients. He did not know that a fixed guard below the machine had been removed with a valve which required a new part. Another employee had taken the valve from the blender to clean it. He found that the valve needed a new part, so he did not reattach it. The blender continued to be used with a plastic bag below it to collect the product. The first employee attempted to make a hole in the plastic bag. His fingers were caught in the rotating blades. He suffered an amputation of the index finger of his right hand and severe cuts and nerve damage to the middle finger.
Manufacturing employment resulted in 21 % of fatalities at work in 2010/11. There were a total of 27 fatal injuries in the manufacturing sector. In the same year, there were 17,599 reported non-fatal injuries and an estimated 27,000 self-reported injuries.
Fall into molten metal pit
In May 2010 an employee of Copper Alloys Ltd, who wishes to remain anonymous, was working in the company’s foundry. He was using a long-handled tool to scrape impurities from the top of a freshly poured casting when he tripped and fell into an unfenced gap between the metal mould and the five-feet deep pit in which the mould was sited. The molten metal in the mould had a temperature of more than 900 degrees Celsius. The worker used the tool to try to stop himself falling into the pit. He landed on the edge of the mould. His arm was immersed in the molten metal. His upper legs were burned on the impurities which he had scraped from the mould. The worker suffered severe burns to his arm and upper legs. He needed skin grafts and continues to undergo physiotherapy for restricted movement in his arm and legs. He has been unable to return to work. The HSE investigation concluded that there was no guard railing around the edge of the mould pit and that Copper Alloys had failed to recognise the risk of workers falling into the pit.
In February 2015 Keith Brown, an employee of Poligrat (UK) Ltd, an electropolishing company, was told to dispose of waste cleaning materials at the company’s site in Aldershot. The disposal method involved pouring caustic granules into an intermediate bulk container (IBC) to neutralise acids in the container.An exothermic reaction caused the container to become unstable. It erupted over Brown. He suffered alkaline burns to his eyes.The activity, and the substances used in it, had not been suitably or sufficiently risk assessed.
An HSE inspector commented after the case that the use of an IBC as a reaction vessel had been wholly inappropriate. IBCs were designed for storage and not as chemical reactors. Other safer and reasonably practicable options were available, for example using a waste management company to remove and safely dispose of the chemicals.
Death in carding machine
In February 2012 Nasir Hussain gained access to a blocked carding machine which formed part of a production line at Felt Supplies Ltd’s site in Dewsbury. He overrode the safety system using a key to unlock one of the production line’s gates. He stood on top of the carding machine to use a metal bar to clear the blockage. The line was still running. His clothing became entangled and he was pulled into the machine. He suffered fatal injuries. The use of a spare key to access running machinery was custom and practice. Despite the HSE issuing a prohibition notice, this unsafe practice was allowed to continue following the fatal accident.
Amputated hand in carding machine
In March 2016 an employee of The Stuffing Plant Ltd, a soft toy filling company, was attempting to clear a blockage in a carding machine. The machine had a flange attachment for connecting pipework to supply loose fibre to a toy filling machine. The flange and pipework were left off to allow the machine to discharge into a wooden enclosure. A spiked roller inside the discharge chute was unguarded and accessible during the machine’s operation. The employee had entered the wooden enclosure and was clearing a blockage from the discharge chute. The spiked roller dragged him into the machine. He suffered severing of most of his fingers and his hand was amputated from the wrist because of the seriousness of his injuries.
Compressed air hose: eye injury
In July 2012 an employee of Faltec Europe Ltd, who does not wish to be identified, was working at the company’s premises on Tyneside. He was carrying out maintenance work on a paint fume filter. He isolated a compressed air hose at its connection point and disconnected it. He did not know that the hose had to be vented before it was disconnected. The hose whipped and struck him in the face, striking his eye and fracturing his cheekbone. He has permanently lost the sight in his right eye. Faltec had failed to provide the worker with adequate information, instruction or training on the equipment which he was using.
Saw blade: serious hand injuries
In February 2012 an employee of Envirowales Ltd, who wishes to remain anonymous, was working at Jamestown Industries’ lead recycling plant in Ebbw Vale. He was operating a saw to cut lengths of lead into smaller, more manageable pieces. The employee tried to dislodge a piece of lead which had become jammed, in the belief that the saw blade was fully retracted and out of reach. His right hand made contact with the blade of the saw, severing his third finger. He also suffered severe injuries to the tendons of his hand. The employee had not been supervised at the time of the incident and there was no experienced operator working with him. Training had been provided but it was not adequate to ensure that all workers understood the risks when the saw was retracted, or the procedure for removing jammed material. Neither company had provided the necessary measures to prevent access to the dangerous parts of the saw. They had also failed to supervise inexperienced employees or to ensure that the injured employee had understood every aspect of the operation.
Furnace valve death
In November 2009 Graham Britten, an employee of AETC Ltd, was carrying out maintenance work in a vacuum casting furnace at the company’s site in Leeds. The main isolation valve closed suddenly and trapped his head, causing fatal injuries. The deceased had gone to a furnace to deal with a fault after the main isolation valve had become jammed. He was inspecting the valve when it closed. AETC did not have an effective isolation procedure for maintenance work on the furnace, had failed to act on repeated recommendations from their health and safety manager and had failed to adequately train and supervise maintenance staff. The lack of a consistent, monitored isolation policy resulted in there being no effective procedures in place to prevent Britten from entering the furnace without first isolating the equipment and releasing stored energy.The furnace control systems, intended to protect operators when carrying out routine cleaning work, were inadequate and exposed workers to unnecessary risk.
Life-threatening crush injuries
A maintenance electrician employed by Jaguar Land Rover Ltd was working at its site in Solihull. He was investigating a production line stoppage and he approached a gap in the perimeter guarding of a conveyor. He was struck by an empty vehicle body carrier and was dragged through the gap into a restricted processing area. He suffered multiple fractures and lung punctures.The gap was unguarded until HSE enforcement required the provision of
.An HSE inspector is reported to have commented after the hearing that the incident had been entirely preventable. Although the gap in the perimeter guarding was minimally sized to allow empty carriers into the restricted area, it also allowed access to dangerous moving parts within the production process while in itself creating a crush hazard with the moving conveyor
Steelworks death
In April 2008 Kristian Lee Norris was working for Vesuvius UK Ltd at a steelworks in Redcar. He was re-lining a furnace. He was struck on the head by a metal bar which fell from a lift ten metres above him. He suffered fatal injuries. Adequate precautions were not in place to control the risks from falling tools or other materials. These failings were known to Vesuvius and to Tata Steel (the owner of the steelworks) but they allowed work to continue.
Unguarded machinery death
In December 2008 John Smith, an employee of Railcare Ltd, was killed when he suffered head injuries while working at an axle lathe with an unguarded chuck.The lathe was 25 years old at the date of the incident. Smith was using it to clean and polish sets of wheels from railway vehicles. He came into contact with the unguarded chuck and suffered fatal head injuries.
The subsequent HSE investigation found that the company had failed to carry out a suitable and sufficient risk assessment of the risks to employees when using the lathe to clean wheels. It had failed to implement a safe system of work and had also failed to provide adequate information, instruction, training and supervision on the use of the lathe.
Crane fatality
In December 2008 Michael Tilley, an employee of Parker Plant Ltd, a quarrying plant and equipment manufacturer, was working at the company’s site in Leicester. He and a colleague were using an overhead crane to load sections of structural steelwork into a shipping container. The steel structures were 9 metres long and weighed 1.5 tonnes. They would not fit into the container and the two workers were told to place one section on top of each other on the ground. As they released the lifting chains from the load, the top section fell onto Tilley’s head. He suffered fatal injuries. The two men had been working from an incorrect diagram. This showed that the structures would fit on top of each other, but in fact this was impossible. Also, the structures were not strapped together. This meant that the load was unstable and likely to fall unexpectedly. The work had not been properly planned or supervised and the lifting equipment was defective. Tilley and his colleague had not been provided with information on the size, weight or centre of gravity of the load. This would have enabled them to sling the load correctly. Further, they had not been given adequate training on how to manage such a complex lifting operation.
Cement explosion
In January 2008 Peter Reynolds, an employee of Cemex, was treating waste cement dust in a bypass dust plant at the company’s works in Rugby. He was clearing a blockage in the plant’s mixer when a violent explosion of dust and steam occurred. The force of the explosion blew Reynolds through the side of a building onto a road 10 metres below. He suffered fatal injuries. Cemex had recognised the potential for blockages to cause explosions as steam pressure built up within the mixer but it had failed to take action to prevent blockages.The company had also failed to review its risk assessment after an incident in May 2006 when an explosion in the same machine bent a metal-cladded external wall.
Cemex was fined £200,000 plus £172,000 costs for a breach of section 2, HSW Act, for failing to ensure the health and safety of employees.
The company’s protection against the buildup of pressure was for the plant to be continuously vented when processing waste cement dust. The vents frequently blocked, and the blockages caused steam to build up to a high pressure. Cemex could have made a number of changes to the mixer to reduce the flow of dust and improve the venting and cooling systems, or it could have devised a new system of work. No action was taken. Workers were expected to operate this dangerous piece of machinery.
Foundry death
Stuart Stead, an employee of H.I. Quality Steel Castings Ltd, was using a hand-held grinder to work on a casting at the company’s foundry in Doncaster. The disc fitted to the machine exploded and sent fragments across his workbay. A shard struck him in the mouth. He suffered fatal injuries. The disc was nine inches in diameter despite the fact that the grinder had a maximum tool diameter of two inches unless guarded. It was attached to the grinder by using a non-proprietary tool. The disk was rated for 6650 rpm but was running at 12,000 rpm. The grinder had no guard. The excessive speed of the grinder, coupled with the added load caused by the non-standard attachment, had put stresses on the disc beyond its capacity. The HSE’s investigation had discovered a number of previous incidents when discs had flown off grinders. None of these had been mentioned in monthly minutes of the company’s health and safety meetings. Despite some initial training in abrasive wheels, employees did not understand rotation speeds of machines versus discs and had free access to a number of grinders and discs. This contributed to the prevalence of unsafe combinations.
Death from electrocution
In March 2009 Jake Herring, a trainee design engineer, was carrying out electrical testing work at Grundfos Pumps Ltd’s factory in Windsor. He was working unsupervised while he tested a live electrical control panel. There was no formal training plan for Herring to undertake electrical testing. He came into contact with a live 3 phase electrical system and was killed. At the time of the incident he was working unsupervised outside the designated electrical test area. The company had not adequately risk assessed the testing of live electrical panels to identify a safe system of work. It had failed to provide suitable training and supervision.
Death by crushing: £20,000 fine
Martin Rice, an employee of The Stone Company UK Ltd, was working at the company’s site near Chelmsford. he was unloading a delivery of manufactured stone and placing it on storage A-frames in a warehouse.As he lowered a bundle of slabs which weighed three tonnes, the bundle fell on him and crushed him against the side of building. He suffered fatal injuries. The A-frames were poorly sited and were not appropriate within the confines of the warehouse.
Printing machine crushing death
In April 2012 a 23-year old agency worker from Lithuania was working in Gordon Leach t/a RGE Engineering Company’s print room. She entered the machine to apply thinners to the ink. The machine started. Her head was crushed between the printing pads and the printing table of the machine. She suffered fatal injuries. The machine had no effective guarding system.
Unguarded tyre shredding machine: amputated arm
In November 2013 Nathan Johnson was working at Cartwright Projects Ltd’s premises in Ashford, Kent. He was feeding tyres by hand into a tyre shredding machine. The machine failed to grip a tyre properly on its metal teeth. Johnson’s sleeve was entangled in the metal teeth and his arm was dragged into the machine. He lost his right forearm up to the elbow. Mark Anton Arabaje, the sole director of the company, had removed the metal bucket guard from the machine. This allowed easy access to the metal teeth.
Steel company: serious burn injuries
In August 2013 an in-house contractor was fitting a valve to an oxygen pipe carrying pure oxygen at Sheffield Forgemasters Engineering Ltd. He was carrying out checks when the pipe exploded. He suffered severe third-degree burns and was kept in a coma for several weeks.The oxygen pipe had been fitted with unsuitable parts. No action had been taken to take control of pipelines or to implement training or levels of responsibility for the management of the work.
Worker dragged through a CD-sized gap in machine
Compass Engineering Ltd and Kaltenbach Ltd, a machine supply company, were fined at Sheffield Crown Court in July 2011 after a worker was seriously injured when he was dragged through a gap in a machine. The gap was no wider than a CD case.
In December 2008 Matthew Lowe, an employee of Compass, was working at the company’s site in Barnsley. He looked into the machine’s outlet point to check a line of work. Lowe was caught on a conveyor used to move heavy steel beams. He was dragged through a 125mm opening between a moving measuring head and a wall. Lowe suffered serious injuries including a ruptured stomach and bowel, a fractured spine, both hips, his right arm, several ribs and a fractured pelvis. He has lasting physical and psychological damage. There was no guarding in place to protect Lowe from dangerous moving parts. This was a serious safety failing for both Compass and for Kaltenbach, which had supplied the machine. Both companies were responsible for ensuring that adequate guarding was in place. Although the machine belonged to Compass, Kaltenbach had installed the equipment and signed it off as being fit and ready for use. Lowe was inexperienced in operating the machinery after he had been moved from a different line at the premises because of a lull in his regular workload. The lack of guarding was the decisive factor.
An HSE inspector commented that it was remarkable that Lowe had survived. If appropriate guarding had been in place, the incident would never have happened. The prosecution would live long in the memory because of the shocking details. He hoped that it served as a reminder to those involved in the manufacturing, processing and supply of machinery of the need to prevent access to dangerous parts.
Lowe is reported to have made the following comments after the case:
What mattered most was that the industry learned from his experience. His life had changed forever and no matter how well he recovered from his physical injuries, he would still have the psychological impact of the accident hanging over him.
He hoped that his case highlighted the dangers posed by not following health and safety regulations. It would not put his life back to how it was before the incident, but at least it might prevent others suffering in the future.
Too many people are needlessly killed and injured in accidents at work. If hearing his story made them think twice about safety, and about the daily risks which they faced in the workplace, then he would be happy.
Meal blending machine
Norman Porter, who had only been working at J Murray & Son Ltd for eight weeks, died after he became entangled in moving parts of a meal blending machine. The investigation revealed that the company had removed safety panels from the top of the mixer to allow raw ingredients to be added more easily. This had the undesired effect of exposing the dangerous moving parts of the machine, which the company failed to identify and correct. The investigation also revealed that the blender was operated without the safety guards for approximately three years.
Steelworks fatalities: Corus (UK) Ltd
Corus (UK) Ltd, the steelmaking company, was fined £170,000 in April 2007 after a worker was killed by a falling crane.
In July 2003 Shane Eastwood, an employee of Corus, was working at the company’s site in Rotherham. He was working on machinery in an engineering workshop under an overhead crane. The crane’s hoist block, which weighed 260 kg, fell seven metres onto Eastwood, causing fatal injuries.
A limit switch, which was designed to cut power to the crane if its block was hoisted too far, and which was safety-critical, had failed. As a result, the hoist rope snapped and the block fell.
The accident had been entirely avoidable. Corus had failed to properly maintain the limit switch. The switch was defective and had progressively failed.
This was reported to have been the ninth time in five years that Corus has been fined for health and safety offences.
Corus was also fined £1.3million at Swansea Crown Court on December 15, 2006, for health and safety offences relating to fatalities at its Port Talbot plant.
In November 2001 a blast furnace exploded at the plant. The explosion lifted the top half of the furnace two feet into the air and resulted in molten metal falling on workers. Three were killed, twelve suffered serious burn injuries and five others were injured. The explosion was caused by water leaking into the white hot centre of the furnace, which had been in operation for 47 years. Some of the injured, and those who witnessed the incident, were still receiving psychological treatment five years after the explosion.
The Crown Court Judge criticised the company’s casual attitude to safety. During a two-day hearing, evidence was given of a catalogue of errors which resulted in the explosion. These included years of recommendations by senior employees at the plant, relating to the furnace, which were ignored.
In 1993 a decision was taken to prolong the life of the blast furnace. A committee was set up to discuss and report on the furnace four times a year. The committee made a series of recommendations, none of which were acted upon.
One example was a recommendation to carry out a comparative study into the benefits of electrical and diesel pumps. The failure of a succession of electrical pumps, which circulated cooling water to the furnace, resulted in the explosion. The furnace had suffered many pump failures before the explosion.
The power plant log for the period before the incident showed that an electrical transformer had been damaged by rain and needed repair. A plan to repair it was the start of events which eventually caused the incident. The transformer had to be partially isolated before repairs were carried out. This meant that the current to a furnace pump was transferred to another transformer. This operation needed monitoring to ensure that voltage remained constant.
The team of employees working on the furnace on the day before the explosion was not told about the repair work. When the current was transferred, the voltage in the transformer dropped. This caused a pump to trip and an auxiliary pump, which then came into operation, also tripped. The result of this was that water to cool the system ceased to circulate and approximately 50 tons leaked into the furnace. Employees who were sent to deal with the leak thought that it had been repaired. In fact, the water remained in the furnace. It reacted with the molten metal in the furnace and caused the explosion when the metal core was reheated on the next day.
Corus pleaded guilty to breaches of health and safety law. Defending counsel stated that this did not mean that the company acknowledged that it had foreseen that lives would be at risk. Modern blast furnaces went back to the Victorian era. There were no records of similar explosions having happened. The inquest into the deaths had recorded verdicts of accidental death. An internal report issued by Corus at the time of the inquest had concluded that the explosion was neither foreseen nor foreseeable.
Senior management responsible for the furnace had met to discuss problems with it one hour before the explosion. The risk of a discharge, but not an explosion, had been discussed at the meeting.
The families of the victims of the explosion were reported to have made the following comments:
They were disgusted and shocked at the outcome.
It was quite unbelievable that the company should have been fined such a meagre sum.
Corus should have been fined up to the maximum allowable. A large fine would have ensured that other companies sat up and listened and understood the consequences of not doing enough for health and safety.
The judge had stated that Corus had made £143 million this year after tax, so what they had been ordered to pay was a pinprick.
Molten metal spray
In September 2014 an employee of Gemini Corrosion Services Ltd was killed when he was sprayed with molten aluminium. He came into contact with a rotating pipe being spray coated with molten aluminium by a thermal spray application machine used to spray a coating into steel drill pipes used in the oil industry. The company had failed to ensure that the machine was adequately guarded or that adequate measures were in place to prevent access by any worker to dangerous parts of machinery.
In February 2014 Richard Blake, a welder and fabricator employed by Point Engineering (Hull) Ltd, was preparing a marine hutch and frame for inspection, using a sling and overhead crane to move it to a vertical position so that it could be stamped with an approval mark by a surveyor. The frame, which weighed more than 500kg, fell onto him, trapping his pelvis and legs. He suffered a shattered pelvis and fractured hip. The surveyor narrowly escaped injury. The work had not been correctly planned and assessed.
Death from mooring rope
Paul Houghton, a worker at Diverse Ventures, a Portsmouth shipbuilding and repair company, was killed in 2012 when he was struck by a mooring rope. The rope was being used to pull the jib of a small crane back into position. The rope broke under tension. He was standing in the danger area of the operation. There was no management of safety and no suitable and sufficient risk assessment.
Death in waste shredder
In July 2013 Karlis Pavasars, an agency worker working for Mid-UK Recycling Ltd at its site near Ancaster, was cleaning a conveyor. The recycling line started and Pavasars was drawn onto the conveyor, through a trammel and into an industrial waste shredder. He suffered fatal injuries. The fixed gate which fenced off the area and prevented access to the conveyor had been removed several weeks before the incident. This meant that workers could freely gain access to the area. Management knew that the gate was not in place.
Death of worker: £3.8 million fines
In July 2014 Richard Reddish, an employee of Explore Manufacturing Company Ltd, was working in the finishing area of the company’s site in Worksop, Nottinghamshire. He was working from a mobile elevating work platform to remove lifting attachments from a concrete panel which weighed 11 tonnes and which was stored on a transport pallet. The panel toppled and struck the platform. He was thrown from the platform and struck by a concrete panel. He suffered fatal injuries. The pallets had been supplied by Select Plant Hire Company Ltd. The frame used to secure the panel to the pallet was not properly connected. A locking pin had not been inserted and there was no pre-checking system. The pallets were in a poor and defective condition. Large freestanding concrete panels were stored in the finishing area instead of being secured in storage racks. There was a lack of adequate planning
Fatal forklift incident
In July 2014 a worker employed by Vacu-Lug Traction Tyres Ltd was transporting tyres with a forklift at the company’s site in Grantham, Lincolnshire. The truck ran over a loose tyre. The worker, who was not wearing a seat belt, was crushed between the truck and the ground. He suffered fatal injuries. There was no company policy in place instructing workers to wear seat belts when operating forklift trucks. If the tyres had been securely stored, this would have prevented them from rolling onto the roadway and would have reduced the risk of the vehicle overturning.
April 8th, 2019 by Robert Spicer
The Little Book of Health and Safety Horrors: hazardous substances and hospitals
In November 2011 methyl iodide, a highly toxic substance which can affect the central nervous system, was released into the atmosphere at Archimica Chemicals Ltd and Euticals Ltd’s site in Flintshire, because of poorly written procedures. In February 2012 an agency worker was exposed to the same substance because he was provided with inadequate respiratory protection. In June and July 2012 a worker was exposed to the same substance after having been given inadequate decontamination training. In July 2012 a worker suffered severe and permanent injuries following exposure to the same substance, having been issued with poorly fitting respiratory protection. In November 2012 three workers were exposed to dichloromethane, a hazardous substance with potentially fatal effects, when a process vessel overflowed. Both companies are now in liquidation and it is reported that the site is being decommissioned.
Drugs exposure at veterinary practice
Employees of Davies Veterinary Services Ltd in Bedfordshire, which included a total of 125 vets, nurses and support staff, were exposed to harmful drugs over a four-year period. The fume cabinet used for animal chemotherapy drug preparation was not used in the way for which it was designed. The employees were potentially exposed to substances which are harmful to human health and can cause cancer. A dangerous occurrence was reported to the HSE in 2011 by one of the vets who believed that the fume cabinet was unsuitable. There was no system of work in place to prevent or reduce the risk of exposure to employees. There had been no maintenance of the fume cupboard for many years. Cleaning procedures were inadequate.Employees had not been given any safety training in the use of the fume cupboard. There was inadequate personal protective equipment and no monitoring systems. From July 2007 until September 2011 workers at the practice could have been exposed to the drugs.
Death of patient from drowning
Mansoor Elahi was an inpatient at Birch Hill Hospital, operated by Pennine Care NHS Foundation Trust . On September 5 2013 he was taking part in a prearranged rafted canoeing activity provided by an outdoor activities centre in partnership with the Trust. He removed his buoyancy aid and jumped into the water to commit suicide. The Trust had failed to carry out a risk assessment for the property or to adequately assess the deceased’s suitability to attend. His actions had been entirely foreseeable because he had tried to enter the water on a previous occasion. If the Trust had carried out a suitable assessment it would not have allowed a vulnerable person the opportunity to end his life.
Death of patient in fall
Adam Withers was detained as a patient at Epsom Hospital, run by Surrey and Borders NHS Foundation Trust/ In May 2014 he was in the hospital courtyard with his mother. He climbed over a conservatory roof and up a 130-foot industrial chimney. He fell and suffered fatal injuries. There had been a series of failures to ensure the proper management of risk associated with absconding patients. There was insufficient communication between employees and inadequate systems to ensure that the risks identified were addressed and remedied. An HSE inspector commented after the case that if the Trust had carried out a suitable assessment and made the appropriate changes they would not have allowed a vulnerable person the opportunity to end his life.
Hospital window death fall
In June 2010 Robin Blowes was admitted to a hospital operated by Southend University Hospital NHS Foundation Trust for surgery. He developed signs of confusion and was moved to a side room. He fell nine metres through a window which was fitted only with a single restrictor and suffered fatal injuries.The hospital’s arrangements for managing the risk of patients falling from windows were inadequate. The window of the deceased’s room was fitted only with a single angle bracket restrictor which was bent to one side, allowing the window to be fully opened. Since 1989, guidance has been in place which states that windows in hospitals where there are vulnerable patients should be restricted to a maximum opening of ten centimetres to prevent falls.
In–patient fall death
Mark Scott-Green was an in-patient at Royal United Hospital Bath. He became confused and vulnerable. The NHS Foundation Trust authorised a Deprivation of Liberty Safeguard. This authorised the forcible return of patients to their rooms for treatment in their best interests. In November 2012 hospital security returned Scott-Green to his second-floor room. He fell from his window and was found dead in the hospital courtyard. The window was fitted with one restrictor. It was large enough to flex . the gap was larger than the recommended 100mm standard. Other windows at the hospital were not adequately restricted. The HSE issued an improvement notice to ensure that all restrictors were suitable and prevented the windows opening more than 100mm. A safety alert had been issued by the Department of Health to all NHS Trusts informing them of the risk of relying on one window restrictor.
In September 2014 Joan Darnell, aged 78, was admitted to a specialist dementia ward in a hospital operated by the Norfolk and Suffolk NHS Foundation Trust. In October she was reported missing and was found face-down in a bath full of water. She had dies from drowning. The Trust did not have adequate policies or procedures in place for managing patient safety. It had failed to complete an appropriate risk assessment for the deceased and to take steps to prevent vulnerable patients having unsupervised access to bathrooms. Nor did it have adequate systems and arrangements in place to ensure that patients under its care on the ward were effectively monitored.
Death of psychiatric patient
In August 2010 Gary Niven, a patient with a history of depression, hanged himself in the A&E department of Crosshouse Hospital in Kilmarnock. He died a few days later. The risk of psychiatric patients being left alone was identified by NHS Ayrshire and Arran. It had procedures for staff to follow but these were not followed for Mr Niven. Mr Niven had been taken by ambulance to the hospital after saying he was feeling suicidal and had already attempted to hang himself. He was taken to a room where the doors were always left open so that he could be observed. A charge nurse noticed that the doors were closed and Mr Niven was found inside, having made a ligature from the arm of his jumper.
W Hughes and Son Ltd was engaged to replace a roof in the Royal Preston Hospital. It installed scaffolding to reach the roof but failed to fence off the steps leading to the scaffold. A 17 year old mental health patient climbed the scaffolding. She fell six metres and suffered a fractured spine and pelvis. An HSE inspector is reported to have commented after the case that construction firms have a legal duty to make sure that construction sites are secure and clearly signed.
Deaths of patients: Mid Staffordshire Hospital Trust
The HSE investigated the deaths of four patients between 2005 and 2014 at Cannock and Stafford hospitals. Three of the patients suffered fatal flaws and a fourth suffered a severe anaphylactic reaction after being given penicillin despite having informed the hospital on several occasions that she was allergic to it. The HSE investigated the Trust in accordance with its policy to investigate deaths in the health sector where there was evidence that standards had not been met because of a systematic failure in management systems. The Trust failed to follow a number of its own policies in relation to handing over information, completing records, carrying out falls risk assessments and the monitoring of care plans.
Bacteria exposure
In January 2011 a test vial containing a strain of multi-resistant TB bacteria smashed when it fell to the ground while being handled. Four employees risked exposure but none suffered adverse effects. The Royal Brompton and Harefield NHS Foundation Trust should have developed and implemented a safe system of work to prevent such an incident. It should also have better implemented appropriate and adequate control measures, and ensured that staff were suitably trained. In 2002 the HSE had issued an enforcement notice for the same laboratory facility for failing to ensure that it was sealable for disinfection. Critical control measures, including the laboratory sealability and filters, were not examined, monitored, tested or maintained.
Hospital window fall
In September 2011 a patient in a ward at West Suffolk Hospital climbed up to a bay window in an attempt to escape. She fell three metres to the ground below and suffered a broken vertebra and a punctured lung. The hospital’s arrangements for managing the risk of patients falling from windows were inadequate. There was no window restrictor fitted to the window. A survey conducted by the Trust after the incident identified a number of issues with window restrictions. Guidance has been available since 1989 which states that windows in hospitals where there are vulnerable patients should be restricted to a maximum opening of ten centimetres to prevent falls.
Adam Withers was detained as a patient at Epsom Hospital. In May 2014 he was in the hospital courtyard with his mother. He climbed over a conservatory roof and up a 130-foot industrial chimney. He fell and suffered fatal injuries. There had been a series of failures to ensure the proper management of risk associated with absconding patients. There was insufficient communication between employees and inadequate systems to ensure that the risks identified were addressed and remedied.
Death of patient in hoist
In April 2012 John Biggadike, a patient at The Pilgrim Hospital in Lincoln, died from internal injuries after falling onto an exposed metal post on a standing aid hoist which staff were using to support him. The kneepad on the hoist had been incorrectly removed. This left the metal post exposed. The United Lincolnshire Hospitals NHS Trust did not have systems for training and monitoring the way in which staff used the hoist. Unsafe practices had developed. A spokesperson for the HSE is reported to have commented after the case that if staff had received effective training and monitoring in the use of the hoist, the death could have been avoided.
Death of diabetic
Gillian Astbury, a 66 year old Type 1 diabetic, died from diabetic ketoacidosis at Stafford Hospital in April 2011 because of failures to implement basic handover procedures and to ensure essential record keeping. Staff at the hospital did not follow or even sometimes look at medical notes which stated that Ms Astbury needed insulin, regular blood tests and a special diet. The system for communicating patient needs at staff handovers was inconsistent. Record keeping and monitoring of patient care plans were far below acceptable standards. Mistakes were made at up to eight shift changes and 11 drugs rounds. The failure to administer insulin was the direct cause of Ms Astbury’s death.
Mid Staffordshire NHS Foundation Trust has been the subject of two major inquiries into events at Stafford Hospital between 2005 and 2009.
Death of nil-by-mouth patient
In December 2013 James South was admitted to Raigmore Hospital suffering from a number of complaints. He was treated with naso-gastric feeding. A label stating that he was to be Nil by Mouth was placed at the head of his bed. South died following the lunchtime meal which was served to him. He was found to have mashed potato on his face and inside the mask which he had been wearing. The Highland Health Board had failed in its duty to ensure the health, safety and welfare of those not in its employment and had not taken all reasonable steps to ensure that risks to patients with special dietary requirements were managed.
NHS Hospital Trust fined after series of deaths
Between June 2011 and November 2012 five elderly patients died while being cared for in hospitals run by the Shrewsbury and Telford Hospital NHS Trust. Mohan Singh, aged 74, was admitted to the Princess Royal Hospital in Telford. It was recommended that he had bed watch. He fell to the floor and suffered fatal injuries. Eileen Thomson, aged 81, suffered three falls in the hospital, She died in May 2012. Edna Evans, aged 92, suffered a fall in the hospital. She died in October 2012. The post mortem found that the injury which she suffered in the fall contributed to her death. Ada Clarke, aged 91, died in October 2012 after falling out of bed in the hospital. Gerald Morris, aged 72, fell in the Royal Shrewsbury Hospital, He suffered a fractured hip and died in November 2012. Fall prevention measures, including close supervision of those in a confused mental state, were not properly applied. This was made worse by poor consideration and communication surrounding measures to protect against falls.