Archive for March, 2019

The Little Book of Health and Safety Horrors Part 11: Garages and Gas


Garage pit fall: serious injuries

The injured customer’s car was parked in front of a vehicle inspection pit. Farhad Mashinchi, the garage owner, was showing the customer a part fitted under the bonnet when the customer fell into the pit. He suffered multiple injuries. Mashinchi had allowed a member of the public into the garage with an open pit without suitable and sufficient precautions to prevent a fall. Putting a barrier around the pit would have prevented the fall.

Burns from oil drum

A mechanic employed by Kankku Ltd, a garage company, was badly burned while trying to cut the top off an empty oil drum.The remaining oil inside the drum caught fire and caused an explosion. The mechanic suffered burns to his hands and arms. Tops were cut from empty oil drums once every three months for the storage of scrap metal. The company failed to consider the risk of the propane torch creating and igniting a vapour from the small amount of oil remaining in the drums.



Carbon monoxide poisoning

Mehboob and Suraiya Bobat, landlords of a house in Bolton, were fined after tenants suffered carbon monoxide poisoning.

A man, his wife and their four-month old child were taken to hospital, suffering symptoms which included headaches, palpitations and breathing difficulties. They were treated for high levels of carbon monoxide poisoning. The HSE investigation found that four gas appliances at the house were unsafe, and the landlords had failed to arrange an annual gas safety check. A gas-powered water heater in the kitchen of the house should only have been used for five minutes at a time because it did not have a flue. It had emitted high levels of carbon monoxide. The heater and a gas heater in a bedroom were classified as immediately dangerous by a gas engineer.

Dangerous gas work: risk of carbon monoxide poisoning

In November 2010 Newport City Council contracted a home improvement company to carry out loft conversion work at a property in Bettws, Newport, South Wales. The householder had agreed to modifications of her property, with a grant from the local authority, to accommodate foster children. The work included moving a boiler into the loft and replacing a gas fire flue. The householder complained that the boiler was leaking and was not working properly. She arranged for an inspection by an independent engineer. The engineer discovered that the boiler was leaking and that the pressure relief valve had not been connected. He advised the householder not to use the equipment. A Gas Safe officer found that the boiler had not been correctly fitted and that the gas fire flue had been capped below the level of the loft. This allowed carbon monoxide gas into the loft, and was classified as immediately dangerous. Newport City Council had not checked the competence of the contractor and had not monitored its work. It had not followed its own procedures for choosing contractors. A spokesperson for the HSE is reported to have commented after the case that the shoddy and careless work by the contractors could have cost a family with young children their lives. Anyone carrying out work on or near a flue should get advice from a Gas Safe registered engineer before starting work.

Illegal gas work: prison sentence

Neil Simon McKimm carried out gas work including the servicing of boilers. He used the alias of a legitimate gas engineer to deceive his customers. He repeatedly falsely pretended to be a legitimate Gas Safe engineer and falsely signed official records in the name of a legitimate gas engineer. He was sentenced to 18 months imprisonment in May 2016. An HSE inspector commented after the case that the HSE would robustly pursue those who broke the law.

The Little Book of Health and Safety Horrors Part 10: Fisheries


Death of diver

Graeme Mackie placed an advert online offering his services as a trainee shellfish diver. John MacNeil engaged him to collect shellfish from his boat in the River Forth Estuary. Mackie drowned in his first dive. He was not wearing any Buoyancy Control Device.MacNeil failed to have any standby diver on hand in case of emergencies and he was not able to give immediate assistance.

The HSE Principal Inspector (Diving) made the following comments:

  • The dive resulted in tragic consequences which could have been avoided if MacNeil had planned the activity properly and employed the correct size dive team made up of competent divers.
  • Diving is a high hazard activity, bit if it is conducted properly, in accordance with the regulations and guidance, the risks can be managed.
  • The minimum team size normally required when diving for shellfish is three qualified divers – a supervisor, a working diver and a standby diver. Additional people may be required to operate the boat and to assist in an emergency.


Deaths of cockle pickers

In August 2006 a gangmaster in charge of Chinese migrant cockle pickers was sentenced to 14 years’ imprisonment on 21 counts of manslaughter. The facts, in summary, were that 23 Chinese migrant workers died after a group of 35 cockle pickers were cut off by the tide after dark in February 2004. Twenty-one bodies were later recovered.

The gangmaster – Lin Liang Ren – was also convicted of perverting the course of justice and facilitating illegal immigrants to work in the United Kingdom. His girlfriend, Zhao Xiao Qing, was sentenced to two years and nine months imprisonment for perverting the course of justice and facilitating. His cousin, Lin Mu Yong, received a sentence of four years and nine months imprisonment for helping cocklers to break immigration laws.

Crushing death

In October 2013 Tomas Suchy, an employee of Interfish Ltd, was clearing a fallen stack of frozen fish boxes at the company’s site in Plymouth. He was killed when a stack of frozen fish boxes fell onto him. There was no safe system of work or instruction to works as to how the stacks should be stored. There was no written procedure for dealing with falls of stock.

The Little Book of Health and Safety Horrors Part 9: Farms


Leg amputation

In July 2014 an employee of Clynderwen and Cardiganshire Farmers Ltd entered a wheat silo to clear a blockage. The rotating auger in the silo pulled him into the silo. His clothing was caught and he was pulled further into the silo. He suffered serious lacerations to his leg, which was later amputated. There was inadequate instruction and training on the electrical and mechanical isolation of the auger. The auger was not adequately isolated. The company was fined £10,000 plus £1300 costs.

Eight-year old farm boy: leg amputation

In October 2015 an eight-year old boy was sitting on the back of an all-terrain vehicle on his parents’ farm in Kirkbean, Scotland. The vehicle was being used to cut grass. The boy fell from the vehicle and suffered serious leg injuries. The leg was amputated below the knee. The driver of the vehicle had not been trained in its use and the company which operated the farm had allowed the boy to ride on it on previous occasions. The company which operated the farm was fined £10,000. It had taken no action to ensure that the boy was kept separate from the farm’s business activities.

Three-year old farm boy seriously injured

Four members of a farming family were fined in May 2015following an incident in which a three-year old boy was injured. In September 2013 a three year old boy climbed onto the first floor of a barn at a farm in Derbyshire. His foot was drawn into an auger. He suffered deep lacerations which needed plastic surgery. The auger was being used by the family to move grain around. It was guarded but the guard was not designed for the dimensions of a child.

Death from barbed wire

In February 2015 Adrian Pickett was contracted to carry out hedge cutting for James Headland at a farm. Pickett was using a rotary flail hedge cutter. A piece of barbed wire shot from the machine. It struck Headland in the neck, causing fatal injuries. Pickett had failed to ensure his own safety and that of others by following a safe system of work. His maintenance of the equipment and correct use of guards for the work activity were also faulty. He was sentenced to 80 hours of community service and ordered to pay £6500 costs.

Tractor death

In July 2009 Thomas Phizacklea, an employee of Stuart Webster, was working at a farm in South Lakeland. He was found dead under the wheel of a tractor. The tractor was 27 years old. It was in poor condition. The handbrake did not function. The most likely explanation for the fatality was that Phizacklea had left the tractor running in neutral without the handbrake on as he got out of the cab to walk around the vehicle. His body was found trapped between the front offside wheel of the tractor and a mound of earth. Webster had a legal duty to ensure that work could be carried out safely on his farm. He should have kept up the maintenance of the tractor  or taken it of use altogether .He was fined £20,000 plus £29,000 costs.


Dumper truck death

William Friend and Robert Plume, directors of Wedgewood Buildings Ltd were given suspended prison sentences in December 2014 following the death of a worker when a dumper truck overturned. The company was contracted to expand a pond on a farm near Tiverton, Devon .Daniel Whiston was driving a dumper truck to move spoil around the site. The truck overturned and crushed Whiston, causing fatal injuries. The deceased had been given 30 minutes training by a colleague who had not been trained to teach other workers and was not competent to supervise him. The dumper truck had a number of serious defects. These included steering failure and defective brakes. No sufficient risk assessments had been undertaken for the work and there was no safe system of work.

Death of migrant worker by electrocution

In July 2006 Gerard Faltynowski, a Polish migrant worker, was helping to build a polytunnel in a field near Blairgowrie in Scotland. The polytunnel was placed below three overhead power lines carrying 11,000 volts. Faltynowski had slotted thirteen poles, each one half a metre in length, and was carrying them vertically. The pole touched the cables. He was killed instantly.

Severed fingers and thumb

In February 2014 an assistant farm manager was operating a firewood processing machine which comprised a circular saw, log splitter and conveyor.  In the course of splitting a log, his left hand became caught between the log and the splitting wedge. All the fingers and thumb of his left hand were severed. The machine had recently been supplied. It did not comply with the relevant British standard and was not safe to use.

Pheasant shoot: all-terrain vehicle death

In October 2013 James Gaffney was driving an all-terrain vehicle to collect dead game following a pheasant shoot on the Urra sporting and farming estate in North Yorkshire.He was not wearing a seatbelt. The vehicle overturned and he suffered fatal head injuries. No-one had used the seatbelt on the vehicle because they had not been instructed to do so.

Tractor death

In June 2009 Kim Webb, aged 26, was working on a farm near North Cadbury in Somerset. She was driving a tractor on a sloping field. The tractor had no seat belt, cab or roll over bar. Ms Webb was checking cattle in a number of fields. The tractor rolled over twice and crushed Ms Webb, causing fatal injuries. The tractor had no rollover protection. Brake pedals on the tractor could not be linked together. This made it unsuitable for road driving. There was a lack of suitable and sufficient risk assessments for the type of work being carried out. There was no safe system of work for the tasks which employees were required to carry out using the tractor. No effective training had been provided. There had been a failure of management control, oversight and supervision in relation to use of the tractor. Ms Webb’s supervisor had no formal training qualifications to instruct her in the use of the tractor. The company had allowed the tractor to be used without a roll bar and had failed to monitor the use of the tractor in a sloping field.

Drowning in grain bin

In July 2014 Arthur Mason, an employee of a farm company, was cleaning inside grain bins at a farm run by the company. He stood directly on the stored grain. He was wearing a harness with a fall-arrest lanyard which was secured to a fixed ladder inside the bin.He began to sink into the grain and the forces involved caused the lanyard to unravel and extend. He became engulfed in the grain and died from drowning.The employing company had failed to adequately identify and manage the risks associated with cleaning grain stores. There was no safe system of work and no-one had been trained in how to complete the work safely.

Machine death

In May 2009 George Stokes, a farmer, was preparing a McHale square bale wrapping machine for the grass cutting season. He was found dead, slumped over the machine.The machine’s safety trip bar had not been designed to stop the rotating baling arms in sufficient time. This meant that anyone who activated the safety trip bar was at risk of being struck.

The failure of the trip bar to stop the rotating bale wrapping arms to stop meant that Stokes had suffered fatal head injuries.


Fatal fall from height

David William McVey employed William Sproat, a casual worker, in August 2012 to repair a storm damaged shed roof on a farm.McVey and Sproat accessed the roof using ladders. Sproat fell 18 feet through the roof to the concrete floor below. He suffered fatal injuries.Neither man was wearing a safety harness. There was no edge protection and McVey had taken no measure to prevent or mitigate a fall from height.

Farm explosion death

In May 2010 Peter James, an employee of Cantelo Nurseries Ltd,, was working at a nursery on a farm near Taunton. He was told to unbolt a hatch cover from a pressurised tank used to heat greenhouses. There was still pressure in the system. A release of pressure sent the hatch cover flying. It struck James, causing fatal injuries. Three other workers suffered serious injuries. The work had not been properly planned, workers had not been properly trained or supervised, and one of them spoke very little English and found it difficult to understand instructions. The hatch should not have been removed until all the pressure had been safely released from the system.

Trampling incident

In June 2013 Emma Smith was walking on a public footpath at a farm near Helston in Cornwall. She was trampled by cows belonging to Jonathan Bryant. She suffered life-threatening injuries including punctured lungs and multiple fractures.The path was well-used by local people. Bryant had not assessed the risk to walkers by putting cows with calves in the field adjoining the path.

Death and injury from cows

In May 2013 Mike Porter and his brother John were walking with dogs  on a pubic footpath through a field near Bradford on Avon. Cows with calves were grazing in the field. The animals belonged to Brian Godwin.Mike Porter died from crush injuries caused by cattle trampling him. His brother suffered multiple rib fractures, a punctured lung and general contusions.Godwin had not taken reasonable precautions to protect members of the public walking on footpaths through his fields, from his cattle.The incident was the fourth in five years involving injuries to members of the public caused by Godwin’s cattle.

Straw bales crushing injuries

A 20-year old veterinary student was on a work placement at RL Matson& Sons’ stud farm in Shropshire. She was collecting hay for horses’ troughs when she was struck by four falling straw bales which weighed more than 1.2 tonnes. The student suffered multiple crushing injuries including a fractured pelvis and ankle. The bales had to be removed using a telehandler. The incident could have been prevented if the bales had been properly stacked without risk of collapse.  HSE records show that since 2000, 18 deaths have resulted from being struck by falling bales.

Death from drowning

In September 2011 Luke Yardy drowned when he fell from a boat while trying to retrieve the carcase of a bird from a lake in Cambridgeshire.Yardy had been engaged by a farming partnership to undertake pest and predator control. He was not supplied with a life jacket nor had he receive any training in the use of boats.His brother attempted to rescue Yardy but he also drowned.

All-terrain vehicle head injuries

The fiancée of a director of a farming company lost control of an all-terrain vehicle (ATV) at one of the company’s farms in mid-Devon. The ATV crashed and rolled and threw her to the road. She was not wearing a helmet and suffered life-changing head injuries. The company failed to report the incident. The ATV was described by a police vehicle examiner as being in a dangerous and unroadworthy condition with longstanding defects to its brakes and steering.The woman had been given no formal training in the use of an ATV and no helmet was available for her.

Potato crusher hand injuries

In June 2009 a casual worker, who wished to remain anonymous, was helping Timothy Dean, a farmer, with the potato harvest. A potato crusher, designed and built by Grimme (UK) Ltd, had been fitted to a potato harvester. The crusher was frequently blocked with stones. Workers signalled the harvester driver to isolate power on the machine while they reached into the crusher to clear the blockage.The casual worker reached into the machine, thinking that the power had been isolated. It had not. His hand was caught in the machinery. He suffered three severed tendons in his right hand. Grimme had supplied the crusher to Dean. Defects were found in the machine. There was no safety guard to stop people from accessing the dangerous moving parts and no instruction manual had been provided. Dean had not properly assessed the risks entailed in the work and did not have a safe system of work for the farm workers.


Arm amputation in potato grading machine

In November 2013 Marek Walisewski, a Polish worker, was cleaning the rollers of a potato grading machine at a farm in Staffordshire. The farm was operated by WB Daw & Son.His duties included operating, cleaning and clearing blockages on the machine. He sat down under the rollers to clean them while they were moving, using a long screwdriver. The rollers drew his left arm into the machine. The crush injuries resulted in his arm having to be amputated. Unsafe work systems were being used which involved cleaning and clearing blockages from the rollers while they were rotating under power.The company had failed to give clear instructions to workers and failed to monitor their activities.

Grain bin asphyxiation

In August 2014 Zach Dean Fox, aged 19, was working at Seamore Farming’s farm in Hawick. He was trying to clear a blockage in a large metal container used for grain storage. The blockage was in an exit space at the bottom of the bin which still contained a quantity of grain. He became immersed in free-flowing grain and died from asphyxiation. The system of work in place to clear blockages in the bin was inherently unsafe.

The Little Book of Health and Safety Horrors Part 8: Electrocution



Death from electrocution

In June 2010 Bradley Watts,  a 21-year old subcontractor, was lagging pipes in the loft space of  Natures Way Foods premises in Chichester. He came into contact with a 240 volt live electrical cable and was killed.The live cable was part of an old system which had been removed by the company in 2008. It was not identified in any way. Its existence and nature was not known to the company.The company had plenty of opportunity to deal with redundant cables. It had always assumed that they were not live.  If the old cabling had been removed in a systematic and controlled way, or if subsequent checks of the loft space had identified examples of poor practice, the death of Watts could have been avoided.


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.

Electrical explosion death

In May 2008 John Higgins, an employee of UK Power Networks (Operations) Ltd, was working at an electrical substation in Chelmsford. He was working on a transformer tap charger which was a device for manually adjusting voltage ratios. The tap charger exploded. Higgins suffered fatal injuries. The explosion caused a fire and blacked out a large part of Chelmsford. The company had failed to properly assess work with tap changers and to devise procedures for the work. It had also failed to adequately train employees. A spokesperson for the HSE is reported to have commented that Higgins’ death illustrated how dangerous work on or near electrical distribution networks could be, and how imperative it was that employers, large or small, ensured that all activities involving high voltage equipment were properly assessed and that safe systems of work were put in place.


Serious burn injuries

In May 2015 a worker was trying to replace a traffic light pole in central Gloucester. He came into contact with a live underground cable. He suffered an electric shock and severe burn injuries to his hands, arms, stomach, face, legs and chest. This was the first time that a group of workers including the victim had worked on an Amey LG Ltd project. Amey had not provided adequate information on the location of underground services. The company’s supervision of the work was inadequate and it had not properly managed the risks from the underground services.

Runner electrocuted

In July 2012 James Kew was running on land in Essex when he came into contact with a high voltage cable. He was electrocuted. The cable was 1.5 metres above the ground. It straddled a well-used footpath. Parts of a porcelain insulator had disintegrated on a wooden pole which supported the cable. The cable should have been 5.5 metres above the ground. Members of the public had reported the matter to UK Power Networks (Operations) Ltd. The company should have immediately de-energised that part of the network. It did not do so and dispatched a technician to the scene. Mr Kew was killed before the technician arrived. UKPN had failed to fully assess the risk posed to members of the public. A spokesperson for the HSE is reported to have made the following comments after the case:

  • Witnesses to the incident had suffered severe trauma and stress-related illness.
  • Distribution network operators have an absolute duty to ensure that they do everything reasonably practicable to ensure the health and safety of members of the public who may be put at risk by the operation of their undertakings.
  • The risks posed by high voltage conductors which descend below the safe statutory height is entirely foreseeable.
  • Network operators must have robust procedures in place that facilitate dynamic risk assessment and the immediate implementation of effective risk control measures to protect the public.

Worker electrocuted

In January 2015 BAM Construction Ltd was constructing a railway operating centre in Basingstoke. BAM appointed Shoreland Projects Ltd as groundworks contractor for the project. Work began to install lampposts on the site entrance road. One of the lampposts touched 11kv overhead power lines as it was being lifted into position by an excavator. Mark Bradley was electrocuted. He suffered multiple life-changing injuries including severe burns to his neck. There had been a failure to properly identify the presence of the overhead power lines and to appropriately plan the work. No suitable control measures were in place to prevent contact with the overhead power lines.

Death by electrocution

In October 2010 Martin Walton was working at a data centre in Hounslow, Middlesex. He was working on a power distribution unit when his forehead made contact with the 415 volt live terminals of a unit. Balfour Beatty Engineering Services Ltd  had been contracted to carry out infrastructure works at the site. Norland Managed Services Ltd was contracted to provide mechanical and electrical maintenance and had control of the site. The underlying cause of the fatality was a succession of failures which indicated the complete breakdown of Balfour Beatty’s management of health and safety in relation to the project. Norland was responsible for the management of the impact of the construction project on the operational infrastructure under their control. It issued a permit to work to Walton, allowing him to reroute the existing site power supply through a new distribution unit, in the knowledge that it had the potential to receive a power supply from a source not under their control and without confirming that the other supply was isolated.

The Little Book of Health and Safety Horrors Part 7: day care, diving, docks


Choking death

In April 2012 Alison Evans, a 34-year old severely disabled woman, was attending an adult day care centre in Leeds. Ms Evans had not developed a rotary chew, the circular motion which allows food to be ground down for swallowing. Tracey Ann Gilboy, a support worker, allowed a sweet to be given to Ms Evans. She choked and later died in hospital. Gilboy had failed to take reasonable care for the safety of Ms Evans in a way which set in motion a chain of events which resulted in her death.

Death from drowning

Nikki Deaney was a care worker at Springwood Day Centre. She was supposed to be providing one-to-one supervision for Majid Akhtar during a group trip to a reservoir. She lost sight of Majid who died from drowning when he suffered an epileptic seizure when he fell into the water. Deaney had spent a significant amount of time on her mobile phone instead of giving her full attention to Majid while walking him around the reservoir.



Death of diver: prison sentence for boat skipper

In March 2011 James Irvine was scuba diving from Guthrie Melville’s boat in Largo Bay on the River Forth estuary. He descended as normal but failed to surface. His body was found and recovered the next day. Melville had failed to assess the risks to Irvine and to provide appropriate supervision, equipment including a means of communication and essential safety gear. He had also failed to ensure that there were enough competent people to take part in the diving project and failed to have a standby diver in place to provide assistance to Irvine in the event of a reasonably foreseeable emergency. Since April 2005 Melville had shown the same lack of regard to essential health and safety regulations and had exposed a number of other divers to serious risk.

Melville was sentenced to nine months imprisonment.

The HSE’s Principal Inspector of Diving commented that diving was a high hazard activity. If it was conducted properly, in accordance with regulations and guidance, the risks could be managed. The minimum team size normally required when diving for shellfish was three: a supervisor, a working diver and a standby diver. Additional people might be required to operate the boat and to assist in an emergency.

Simple measures taken to ensure that a diver in trouble could communicate to the supervisor and that the diver was marked by a line and float, or by a line to an attendant on the dive boat, maximised the chance of a successful outcome to an emergency.



Dock worker seriously injured in capstan

In June 2014 a three-man team was securing an ocean-going vessel’s heavy mooring ropes at an Essex maritime terminal. The fingers of the left hand of one of the workers became caught between the rotating drum of a powered capstan and a heaving line. His left arm was dragged into the capstan and wrapped tightly around the rotating drum. He suffered multiple fractures, nerve and ligament damage. C.RO Ports Limited had failed to suitably identify and control risk associated with the use of powered capstans at the port. The system of work adopted was unsafe. Arrangements for the instruction, training and supervision of workers using the equipment were inadequate, as were those for the audit and monitoring of safety. The company had failed to heed warnings raised by workers before the incident. The HSE served an improvement notice on the company requiring it to suitable identify relevant hazards and to control risk in accordance with legislation.

An HSE inspector is reported to have commented after the case that all capstans feature dangerous rotating components. Capstans are difficult to guard, so it is vital that all workers must be made to stand well away from the danger zone while they are in use.

Worker decapitated

In 1998 Simon Jones was sent by an employment agency to work at Shoreham docks. He was employed by Euromin. Jones’ work involved the unloading of bags of cobblestones from the hold of a ship. The system for this involved workers standing near an open grab bucket attached to a crane. The lever in the driver’s cab for closing the bucket was very sensitive. When it was operated, the bucket closed in one second. Jones was decapitated when the grab bucket closed on him.

The Health and Safety Executive (HSE) and the police investigated the killing. The HSE issued improvement and prohibition notices and decided to prosecute Euromin for statutory offences. The Director of Public Prosecutions decided not to prosecute the company for negligent manslaughter. This decision was challenged in the High Court on behalf of Jones’ family.

The decision of the High Court was as follows:

  • The DPP’s decision not to prosecute would be quashed.
  • The DPP had been wrong in applying a test of subjective culpability rather than objective liability for the dangerous system of work.

The test for negligent manslaughter was objective. Negligence would be criminal if, on an objective basis, the defendant showed a failure to advert to a serious risk going beyond mere inadvertence in respect of an obvious and important matter which the defendant’s duty demanded he should address

The Little Book of Health and Safety Horrors Part 6: Crown Censures


Royal Mint death

The case of John Wynne, employed by the Royal Mint at Llantrisant, South Wales, has highlighted the legal rules and procedures surrounding Crown immunity as a clear example of class justice. The facts, in summary, were that in 2001 John Wynne (W), suffered fatal crushing injuries when a six-tonne furnace fell from a crane. W, aged 50, had worked in the metal rolling department of the Mint for 21 years.

The Health and Safety Executive (HSE) found itself unable to prosecute the Mint for breaches of health and safety legislation. Instead, it brought Crown Censure proceedings. At the hearing of these proceedings it was stated that the Mint had failed to follow safety procedures. The hearing was not open to the public. A report of the hearing was sent to the government, the Royal Mint and the HSE. W’s widow was not entitled to a copy of the report.

W’s widow is reported to have commented that she was shown pictures at the hearing which showed the furnace hanging from a crane, but not sitting on the hook properly. The furnace was balancing on the top and it fell. It had fallen once before, and no-one was hurt. The Mint’s management had not carried out safety checks. If they had done so, they would have realised that it was faulty and the accident could never have happened.

An HSE inspector is reported to have made the following points to the hearing:

  • W’s death was an accident waiting to happen.
  • There was sufficient evidence to bring a criminal prosecution against the Mint.
  • Although Crown property, including the Mint, has to comply with health and safety regulations, it cannot be prosecuted because the Crown cannot prosecute itself.


The Little Book of Health and Safety Horrors Part 5: construction


Trench collapse death

Cooper Services Ltd  had been employed by a domestic client to connect new bungalows to mains drainage, gas and water supplies. Callum Osborne, an employee of the company, was digging a drainage trench. The trench collapsed and buried him, causing fatal injuries.The trench was excavated in a narrow driveway, about three metres wide. Material excavated from the trench was piled up on each side of the trench, which had no means of support to prevent collapse and no barriers or edge protection to prevent falls into the trench.


Serious burn injuries from skip fireball

A young employee of David Gordon Stead, the director of a construction company, was told to stand on top of a skip and pour a drum of flammable thinners onto burning waste to help it burn. The thinners ignited and the resulting fireball threw the worker form the skip. He suffered serious burn injuries to his arms and legs. Stead had not ensured that the burning of the waste material was carried out in a safe or appropriate manner. He failed to administer first aid to the injured worker and did not send him to hospital. He also failed to report the incident to the HSE.


Oxford Street hoarding collapse: passers-by seriously injured

In March 2012 a hoarding which weighed one tonne and was 3.6 metres high was erected by Oracle Interiors Ltd, a shopfitting company, to fence off a shop which was being refurbished.The hoarding was held in place by a single timber brace. It was inherently weak and could not withstand gusts of wind or contact with passers-by.When the hoarding collapsed. 20 people were trapped. Four were injured, of whom three suffered serious injuries.


Pedestrian injured by 380 kg of falling equipment

In September 2008 a woman was waiting for a bus in York Road, London. She was struck by a piece of machinery which was being lifted to the fifth floor of an office block. She suffered serious multiple injuries which included fractures and cuts. These injuries have affected her studies and work. The office block was being refurbished by Concentra Ltd. Instead of using traditional scaffolding, the company was using a mast climber which raised and lowered workers on the outside of the building. A crane and lifting slings were used to lift an air handling unit which weighed 380 kg. The crane was not correctly fitted. During the lift, the unit struck a mast climber and was knocked out of its sling. It fell from height and struck the woman.


Concrete collapse: seven workers injured

In September 2007, during the construction of an atrium at Liverpool John Moores University, workers were pumping concrete onto the third floor of the building. The supporting scaffolding holding up the concrete suddenly collapsed. Seven workers suffered injuries including cement burns and fractures.Both Wates Construction Ltd   – principal contractor for the project – and MPB Structures Ltd, the concrete subcontractor, allowed the supporting scaffolding to be erected from a preliminary design which was clearly marked as for discussion and pricing purposes only.The preliminary design did not include all necessary information for the correct or safe erection of the scaffolding. Neither company had checked the scaffolding before allowing the concrete to be poured.


Trench collapse: worker suffers multiple fractures

In July 2010 Grzegorz Waluszkowski was helping to lay a drainage pipe at a holiday park in Dawlish. He was working in a two-metre deep trench, the walls of which were propped up with plywood and metal plate with a piece of softwood between the sides of the trench. The wall of the trench caved in and buried Waluszkowski. An excavator had to be used to rescue him. He suffered multiple fractures of his skull, jaw and cheekbones. The HSE investigation found that Main Gate Leisure Ltd had failed to adequately plan the work or put necessary safety measures in place. The HSE found that the trench was clearly inadequately supported and the plywood and metal plate were no more than a rudimentary attempt to support the trench walls. Normally trench boxes would be used as shields whenever workers need to briefly enter a trench. These boxes can be rented from hire companies.


Crane collapse: worker and member of the public killed

In September 2006 sections of a tower crane on a housing development in Battersea separated when 24 bolts failed from metal fatigue. The crane operator was killed when he fell from the crane. A member of the public was killed when the crane fell onto him. Falcon Crane Hire Ltd had not investigated a previous similar incident when the bolts failed and had to be replaced. The company had an inadequate system to manage the inspection and maintenance of its fleet of cranes. Its process to investigate the underlying cause of components’ failings was also inadequate. The bolts were a safety-critical part of the crane. Their previous failure had been an exceptional and significant occurrence which should have been recognised by the company.

Corporate manslaughter

Peter Mawson, the owner of Peter Mawson Ltd, a building and joining company, was sentenced in February 2015 for health and safety breaches. The company was fined for corporate manslaughter.

In October 2011 Jason Pennington, an employee of the company, was working on a roof at a farm. He fell 7 metres through a skylight onto a concrete floor and suffered fatal injuries. In December 2014 the company and Mawson pleaded guilty to corporate manslaughter and to health and safety offences. It was admitted by the company and Peter Mawson that they had failed to utilise a safe system of work and failed to use the proper safety equipment to ensure the safety of the workers.

Mawson was sentenced to 8 months imprisonment, suspended for two years, 22 hours unpaid work, a publicity order to be posted in the company’s website and a half-page statement in the local newspaper, plus £31,500 costs.

The company was fined £200,000 for corporate manslaughter plus £30,000 under section 2, HSWA, for failing to ensure the health and safety of employees.

Excavator crushing death

In November 2012 Christopher Hartley, an employee of William George Sinclair Reid t/a E&M Engineering Services, was working on a pier in Hoy, Orkney. He was unloading metal panels from a van, using an excavator. Hartley was struck by the moving excavator and crushed between the machine and a fixed cabinet at the end of the pier. He suffered fatal crush injuries. Although Reid had carried out a risk assessment, he had not identified mechanical lifting as a hazard and the risks associated with using an excavator. Reasonable precautions had not been taken to reduce the risk of a person being struck by a moving load or excavator. Reid should have planned and controlled the task to ensure that a strictly-enforced exclusion zone was set up during all excavator manoeuvring and lifting operations, and that all personnel involved were wearing appropriate hi-vis clothing, particularly since the work was being undertaken in the dark.

Death fall

In December 2011 Lance Davies fell seven metres to his death through a roof light at industrial premises in Crumlin, South Wales. Work at height on the roof of the premises had not been properly planned, managed or monitored. There were inadequate control measures in place to prevent a fall through the roof lights.

Bitumen burns

In June 2013 John Terrell was felting a flat roof. He was using bitumen which he melted at ground level before lifting it up a ladder. The ladder slipped and a bucket of hot bitumen fell on a woman and her grandchild. They suffered extensive burns which needed extensive hospital treatment. The ladder had not been secured to prevent slipping. It was in poor condition with missing or badly worn rubber feet. Insufficient measures had been taken to prevent the slip and it had been a wholly unnecessary incident. A spokesperson for the HSE is reported to have commented after the case that members of the public must be kept out of harm’s way when dangerous materials are being used. The ladder aside, the incident could have been avoided if the victims had been told to stay at a safe distance.

Dumper truck death

In February 2012 Geoffrey Crow was driving a dumper truck at a construction site in Bedfordshire. The truck fell into a deep and unguarded excavation. It overturned and fell on him, causing fatal injuries. There were no measures in place to prevent people or vehicles falling into the excavation, which was up to 6.5 metres deep. None of the workers on the site were used to operating large plant machinery. The seatbelt on Crow’s machine was not operational.

Death fall

In May 2012 Kevin Brookes, an employee of Midlands Solar Solutions Ltd, was installing solar panels on a roof. He attempted to retrieve a drill which had started to slide towards the edge of the roof. He slipped and fell seven metres to the ground, suffering fatal injuries. Alumet Renewable Technologies Ltd was the principal contractor for the project. It had failed to put an adequate health and safety plan in place. The measures outlined in its plan were not sufficient to protect the workers. The measures which were in place had not been followed. The roof’s edge protection did not meet nationally agreed standards and employees of Rugby Scaffolding Services Ltd had not been properly trained or supervised. There were unsuitable provisions in place to prevent people falling through skylights.


Amputated leg in dumper truck incident

In June 2005 Michael O’Donovan was working on Arsenal football club’s Ashburton Grove stadium. He was kneeling to clean steel shuttering used to form reinforced structures and pillars. He was run over by a dumper truck. He suffered severe leg injuries and a fractured pelvis. The HSE investigation showed that Sir Robert McAlpine Limited, Skanska Utilities Limited and Maylim Limited had failed to ensure the proper segregation of vehicles and pedestrians on the site.

A spokesperson for the HSE commented after the case that traffic needs to be managed effectively on all construction sites. If proper controls had been in place, this appalling incident would never have happened. O’Donovan suffered a serious injury and his life has been changed for ever.

Death from overturned crane

In March 2007 Richard Mark Thornton was helping to construct a new floor on a warehouse at Wavertree Business Park in Liverpool. A 50-tonne crane toppled over as it was moving a steel column. Thornton was struck by the column and suffered fatal injuries. The crane was used to lift the column, which weighed six tonnes, when it was almost 18 metres away. This was well outside its safe lifting capacity. The crane had not been properly maintained and its external alarm could not be heard by employees working nearby. Its override switches were faulty. This included the switch which prevented the crane lifting loads beyond its capacity.


In 2006/7 79 workers in the construction industry were killed at work. There were 4500 injuries.


Trench collapse: crushing death

In June 2012 William Ryan Evans was contracted to construct a drainage field, comprising infiltration pipes laid at the bottom of deep trenches, at a farm in Pembrokeshire. He employed two workers and a subcontractor to carry out the work. Hywel Glyndwr Richards, one of the employees, entered a deep trench. It collapsed and buried him, causing fatal injuries. The work had not been appropriately planned and the risk assessment was neither suitable nor sufficient. Workers had not been properly trained and suitable equipment to prevent a collapse had not been provided.

An HSE inspector commented after the case that work in excavations needs to be properly planned, managed and monitored to ensure that no-one enters an excavation more than 1.2 metres deep without adequate controls in place to prevent a collapse.

Skip lorry death

In July 2008 David Vickers, an employee of Adis Scaffolding Ltd, was tipping a skip at the company’s site in Derbyshire. He left the cab of the lorry which he was driving, to deploy the stabilising rear outriggers. The lorry overturned and crushed him, causing fatal injuries. The skip had been mis-hooked. This meant that it broke free and swung out, causing the vehicle to tip over. There was no safe system of work for the skip operation. No guidance had been given in relation to the handling of mis-hooks and other foreseeable problems. There had been inadequate training and instruction. Skip lorry controls were not marked and the risk assessment for loading and unloading skips was inadequate.

Leg amputation in slurry mixer

In September 2012 Colin Boon, a contractor, was in charge of a gang of workers who were sealing a pavement in Stoke-on-Trent. A worker slipped as he climbed down from a flatbed lorry which was next to the mixer. His left leg fell through the unguarded opening of the mixer. The moving paddles in the mixer severely injured his lower left leg and resulted in amputation below the knee. He suffers from continuing mobility problems. The guard over the rotating paddles in the mixer had been removed on the day before the incident. Boon was aware that the guard had been removed but took no action to prevent use of the machine.

Scaffolding death fall

In December 2010  Tony Causby, an employee of S&S Scaffolding Ltd, was dismantling scaffolding on the roof of a warehouse in Skelmersdale. He stepped onto a skylight and fell 13 metres, suffering fatal injuries. There were 80 fragile skylights on the roof. Each measured one by two metres. The company had failed to arrange for covers to be placed on the skylights to prevent workers falling through.


Gas cylinder death

In November 2008 Adam Johnston, a plumber, was working on a construction project in Welwyn Garden City. He was struck by one of 66 argonite gas cylinders which flew at high speeds after one toppled over and discharged high-pressure gas. Johnston suffered multiple fatal injuries. Several other workers were injured. One or more of the cylinders was destabilised. It appears to have fallen over and released an uncontrolled jet of liquefied argon gas under high pressure. A chain reaction developed rapidly and caused a barrage of cylinders which continued until all 66 cylinders had been discharged. The three companies involved in the project had failed to recognise the significant risks involved in the project or to carry out an adequate risk assessment. The principal contractor and the main contractors failed to co-ordinate scheduled work activities or to co-operate meaningfully in light of the risks. There had been inadequate training and supervision.

Fall from height death

Alan Young, an employee of Barnet Homes Ltd, was working alone at a communal boiler house in one of the company’s housing estates. He was using a mobile tower scaffold and a ladder to repair a leak. His body was found at the foot of the scaffold. There were no witnesses to the incident. The deceased had suffered severe head injuries. The scaffold had not been properly erected, had missing guard rails and no wheel brakes. The ladder had not been secured. The company had failed to prepare a proper risk assessment. The deceased had unrestricted access to a ladder and a mobile tower scaffold and had not been given proper training. The company did not have adequate arrangements for the control of maintenance work. This had been a cause of the fatality.

Death of roofer

In June 2009 Robert Jozwiak was working on the roof of a disused factory in Leicester. The roof gave way and Jozwiak fell six metres to the concrete floor below. He suffered fatal injuries. Jozwiak had been instructed by Musa Suleman to carry out the work.

The Crown Court judge is reported to have commented that Jozwiak’s death had been a terrible tragedy which could have been prevented. There were clear lessons to be learned. He urged anyone working on buildings to treat health and safety as their top priority in order to prevent injury or death. A sposkesperson for the HSE is reported to have commented that the roof was made of corrugated asbestos sheets. The work required careful planning and consideration of the risks involved. Safe routes and protective equipment should have been in place to allow Jozwiak to get to work areas without injury, and measures to prevent or mitigate falls should have been in position.

Death fall

In August 2008 Peter Halligan, an employee of Galt Civil Engineering Ltd, was working at a farm in Macclesfield. He and a colleague were constructing brick manhole chambers above an empty water storage tank. Halligan fell 15 metres into the tank and suffered fatal injuries. Peter Stuart, the director with day-to-day responsibility for running the company, had seen both men working over exposed openings in the tank. He took no action to put safety measures in place. Neither man had been given sufficient information or a risk assessment for the work. They had not been given any advice about working above the storage tank by their employer.

Fall death

In January 2012 Ivars Bahmanis, a Lithuanian national, was carrying out refurbishment work, involving the installation of metal brackets for new  roof joists at the former canal works in Blackburn. He fell eight metres from a wall and suffered fatal injuries. No safety measures were in place. The defendants, Tameem Shafi and Mohammed Shafi Karbhari, had failed to plan the work at height or to employ competent contractors.They had deliberately chosen to save money and were well aware that work was being carried out in an unsafe manner using unskilled workers.

An HSE inspector commented after the case that the defendants had tried to save money by asking unskilled works to carry out hazardous work activities around the building. As a result, the deceased had died needlessly in a horrifying  incident which could and should have been prevented. There had been a previous incident on the site where a worker fell from height and broke his leg. This was never reported to the HSE.


Demolition death

In November James Stacey was working on the demolition of the former Cadburys factory near Bristol. He drove a mini digger out of a fourth floor opening. The opening was being used as a drop zone to drop large fibreglass tanks to the ground. The opening was not properly protected to prevent the digger falling from the building. The digger fell to the


An HSE inspector is reported to have commented after the case that the failings demonstrated the need for effective communication and understanding in the health care environment and the need to appropriately manage the risks to patients with special requirements.

Roof fall death

Barry Tyson, a self-employed bricklayer, was refurbishing the roof of a school in Knaresborough, Yorkshire, in August 2011.He fell through a fragile roof-light to the ground two metres below and suffered fatal head injuries. Watershed Roofing Ltd had prepared a construction phase plan. This stated that the plastic domes over all roof-lights should be removed, and apertures boarded over, before work started. It was found that the domes could not easily be removed and it was decided that work could progress without covering the apertures..

Death of worker from crushing

In October 2009 Daniel Hurley was employed as a groundworker by a company subcontracted by Morris & Spottiswood Ltd to work on a construction site in Glasgow. He was using a machine to compact hardcore next to area where a steel frame was being erected. The frame fell onto Hurley, causing fatal injuries. The subsequent HSE investigation found serious safety failings in the way in which the company had managed the project. The anchor bolts of the steelwork were so poorly installed that they could be moved by hand. They had not been properly checked. The company had failed to review the risk assessments and method statements submitted by the subcontractor for the work, and had failed to establish and maintain an exclusion zone around the steelwork while erection was being carried out.

Life-threatening injuries

In August 2007 Shah Nawaz Pola was fined and imprisoned following an incident in which a worker suffered life-threatening injuries on a construction site.

Pola employed a number of migrant Slovakian workers to build an extension to a house in Bradford. He paid them each £30 a day in cash. In November 2005 Dusan Dudi, one of the workers, fell from inadequately constructed scaffolding when the wall which he was demolishing collapsed on him. A concrete lintel struck him on the head. He suffered injuries which it was thought would be fatal. Although Dudi’s life support machine was switched off in hospital, he survived. He was left with severe disabilities and needs constant care. It is thought that he will never work again. He is ineligible for benefits in the United Kingdom and in Slovakia. Pola had no experience of running a construction site. When he was told by an HSE inspector what needed to be done to protect the safety of workers, he replied that he did not care. Pola had made no concessions at all to health and safety. He had not written a risk assessment nor method statements. He had failed to provide welfare facilities, proper scaffolding, adequate fall guards or personal protective equipment for his workforce. A number of contractors had left the site because safety standards were so poor. Pola denied being in charge of the site and refused to accept responsibility for the incident.


Construction site drowning

In January 2015 an 83-year old man walked onto a construction site operated by Sandford Park Ltd. The site was closed for the holidays. The man fell into a flooded excavation site and died from drowning. The company had failed to install an appropriate level of fencing around the site to prevent members of the public, including vulnerable adults and children, from accessing the site.

Demolition: serious crush injuries

In October 2015 an employee of S Evans and Sons Ltd, a demolition company, was injured when the managing director was operating machinery to stack girders, each of which weighed 10 tonnes. A girder dropped onto the worker’s arms, causing amputation of his left arm and right hand. The company had failed to apply appropriate measures, including ensuring that the correct equipment was used. Samuel Evans, the company’s managing director, was directly involved in the incident and was personally responsible for the choice of equipment and the way in which the work was carried out.

Death fall 

An employee of A-Lift Crane Hire Ltd, which had been contracted by Premier Roofing Systems Ltd to supply a crane to lift roofing sheets onto a factory roof, was killed in a fall. In August 2013, as the sheets were being lifted, the worker fell through an unprotected skylight. Preventative measures to allow workers to work safely on the roof had not been put in place.

Crossrail: death of worker

In March 2014 Rene Tkacik, from Slovakia, was working on a team enlarging the Crossrail tunnel by removing tings of the pilot tunnel and spraying walls with wet concrete. A section of the roof collapsed and Tkacik was crushed to death by wet concrete, In January 2015 Ian Hughes was collecting equipment from inside a tunnel when he was struck by a reversing excavator. He suffered serious injuries. Also in January 2015 Alex Vizitiu, who was part of a team spraying liquid concrete, was cleaning pipes which supplied the concrete. One of the pipes was disconnected and he was struck with pressurized water and concrete debris. He suffered serious injuries.There had been a failure to provide a safe system of work, a failure to properly maintain the excavator which reversed into Hughes, and a failure to enforce exclusion zones.

Trench collapse death

In April 2010 James Sim, a subcontractor working on behalf of Balfour Beatty Utility Solutions Ltd,  was laying ducting for new cable for an offshore wind farm off the coast of Heysham, Lancashire. He was working in a trench which was 2.4 metres deep, with no shoring. He was killed when the trench collapsed on him.The company had failed to adequately risk assess the work or control the way in which it took place.

Death from electrocution

In June 2010 Bradley Watts,  21-year old subcontractor, was lagging pipes in the loft space of Natures Way Foods’ premises in Chichester. He came into contact with a 240 volt live electrical cable and was killed. The live cable was part of an old system which had been removed by the company in 2008. It was not identified in any way. Its existence and nature was not known to the company. The company had plenty of opportunity to deal with redundant cables. It had always assumed that they were not live.  If the old cabling had been removed in a systematic and controlled way, or if subsequent checks of the loft space had identified examples of poor practice, the death of Watts could have been avoided.



The Little Book of Health and Safety Horrors Part 4: chainsaws and children


Chainsaw injuries

Gilbert Bradfield, a tree surgeon, and three casual workers were engaged to fell a tree which had become unstable. He climbed four to five metres up the tree on a ladder to cut through the top third of the tree with a chainsaw. As the top of the tree was cut, it swung around and knocked Bradfield down. He fell, with the chainsaw still running, and landed on a colleague who was footing the ladder. The colleague suffered severe lacerations, a dislocated shoulder, a punctured lung and other internal injuries. No personal protective equipment was being worn by any of the men operating chainsaws and no equipment for working at height was being used. Bradfield and the other workers had no certificates of competence.

Tree worker struck by branch: serious head injuries

In November 2015 Perry Regan climbed six metres up a ladder and cut branches from a tree, using a chainsaw. A large branch fell from the tree and struck am employee on the head. The worker suffered serious head injuries. His injuries included a fractured skull and the loss of an eye. He was placed in an induced coma. Perry Regan was not competent or qualified to carry out, manage or supervise the work. He was using a chainsaw without being qualified. The work was not properly planned to identify risks. No adequate training or instruction was given to workers. No personal protective equipment was made available.



Electric gate death

In July 2010 Karolina Golabek was playing near electric sliding gates outside flats near her home in Bridgend, South Wales. The gates automatically closed after a car passed through. The child’s body was found in the gap between the gates and a post. She suffered fatal crushing injuries. The closing force of the gate was 220 kg and did not meet European and British safety standards. There were dangers with the gate structure which left space for people to get trapped. There were insufficient and incorrectly set safety features to detect a person in the area which would prevent the gate closing automatically. John Glen (Installation Services) Ltd had fitted a new electric motor to the gate, which was put back into use despite the fact that there were obvious trapping points. The company had  also failed to properly test that the gate would close when it met an obstruction. Tremorfa Ltd was contracted for the maintenance of the gate. It did not carry out vital safety checks including closing force measurements.


National Grid death from drowning

In April 2014 Robbie Williamson, aged 11, and two of his friends, were crossing the Leeds and Liverpool canal using a pipeline. Williamson fell from the pipeline into the canal below. He died from drowning and a head injury. National Grid Gas plc had failed to properly protect the exposed pipeline from the risk of injury from falls. The boys were able to climb onto the pipe from a ramp. The company had a procedure for inspecting this type of above ground pipe crossing and requirements for providing measures to prevent access onto these structures. The company’s records incorrectly showed that the pipe was buried rather than exposed. The crossing had not been subject to any inspections and had no access prevention measures fitted. Maintenance work had been carried out on the pipe but records had not been updated. It is typical for pipe crossings to have steel fans or similar measures fitted to prevent access. These measures were fitted after the incident following the issue of an improvement notice. National Grid Gas plc was fined £2 million.


Sodium hydroxide burns at leisure centre

In February 2012 a two year old boy’s father took him to the leisure centre for his weekly swimming lesson. The boy slipped and fell onto a recently cleaned drain cover. The drain had been cleaned with sodium hydroxide. This caused full skin thickness burns to his buttocks and the back of his right leg. He was hospitalised for 10 days and received a skin graft. Leisure Connection Ltd had failed to put a robust system of work in place for cleaning the drain. That system should not only have included clear instructions on how the drains should be cleaned, but also should have established whose responsibility it was to clean them. The company had also failed to properly assess its use of chemicals and to provide proper training on the use of those chemicals. The leisure centre management team had been unaware of the presence of sodium hydroxide.


Death of child from falling fireplace

Kristian Childs, a stonemason trading as KD Childs Stonework of Luton, was contracted to install stone fireplaces in new houses in Towcester. In October 2005 the mantel from the fireplace, which weighed 47kg, came away from a wall without warning and fell onto a four-year old boy, causing fatal injuries. Childs had secured the mantel with mortar instead of using mechanical fixings. He was aware of the need to ensure that fireplaces were properly secured after two others which he had fitted were found to be insecure. The Head of Operations for the HSE’s Midlands construction division commented that every stone used in a fireplace must have a mechanical fixing, for example a steel bracket and screws, to hold them together and against the wall. A few small patches of mortar are not acceptable because they cannot guarantee a secure bond.

Child seriously injured on construction site

In April 2009 an eight-year old  boy was playing with friends on a construction site near Paisley. The construction work was nearing completion. BDW Trading Ltd had sold some of the houses, and families were living in them while work continued on the remaining homes. The boy and his family were living in one of the homes. The boy and his friends entered an unsecured storage area. A number of roof trusses fell onto him, trapping him and causing serious injuries. The construction site was only partially fenced. As a result, there was a large gap at the side and rear. This meant that the site could easily be accessed by the public, including children. The roof  trusses had been stacked upright. This meant that they were unstable and more likely to fall over. When an HSE inspector visited the site, BDW was not aware that a child had been injured. The inspector served an improvement notice, requiring the company to improve site fencing to prevent further unauthorised access.


The Little Book of Health and Safety Horrors Part 3: care homes


Death of resident

Caring Homes Healthcare Group Ltd, the owner and manager of the Coppice Lea Nursing Home in Surrey, was fined £450,000 in 2017 after the death of a resident. In October 2013 an 87-year old woman was a resident at the home. She fell four metres through her window, suffering fatal injuries. The window restrictor in place was easily overridden and was not fit for purpose. All windows which are large enough for people to fall through should be restrained sufficiently to prevent falls. The benchmark of 100 mm should only be allowed to disengage using a special tool or key.

Bedrail failures

At the Beacon Edge Specialist Nursing Home in Penrith, Cumbria, BUPA Care Homes (CFC Homes) Ltd failed to ensure that it managed the risk of bedrails through appropriate assessment and review of bedrail arrangements, and failed to train staff in the assessment of and safe use of bedrails. The use of bedrails is common in care homes to help prevent vulnerable residents from falling from bed, but they should to be used appropriately, and staff must be trained in both their use and the process of assessment to identify suitable measures to protect individual patients from falls.

The court was told the company had a policy on bedrail management but it was not fully implemented as staff were not trained and assessments not conducted or reviewed when required.The case related to the management of bedrails in relation to a vulnerable resident who died at the home. The company failed to ensure the patient’s bedrail assessment was suitable and sufficient, reviewed following falls and deterioration in health and that staff were trained in bedrail risk assessment.The reviews of the bedrail assessment should have identified further measures to prevent the risk of falls, but staff that carried out the initial assessment and reviews were not adequately trained. Furthermore, measures identified to protect the resident where not implemented correctly and increased checks on the resident were not carried out as instructed by a medical professional.

Nursing home death

In November 2012 Patrick Foale, aged 75, was living at the Redmount Nursing Home in Devon. He fell down a flight of stairs in his wheelchair when he accessed a staircase after a fire door had been left open. He suffered fatal injuries. Foale spent much of his time in his own room on the first floor of the nursing home. He was capable of moving freely around the home in his wheelchair. The nursing home was aware that he had deteriorating eyesight and had been suffering periods of disorientation.The nursing home had failed to carry out a suitable risk assessment for him, had neglected to make provision for his deteriorating eyesight and di not act on his apparent disorientation.

Death from drowning

In July 2013 two boys who were residents at the Castle Lodge Care home near Ely were taken on a day trip to a country park near Kings Lynn, Norfolk.The park is a disused sand quarry with flooded pits. The boys went into the water despite no swimming signs. One, aged 16, became trapped in weed and drowned.No risk assessment had been carried out and the company’s procedures were ineffective in ensuring the safety of the children while on trips outside the home.

Care home death

In May 2012 Walter Powley, aged 85, was admitted to Western Park View, a care home, after his family was advised that he could not be safely left at home because of his risk of falling. Powley fell in his room at the home. He was trapped between a wardrobe and a radiator. He suffered serious burns to his legs from the radiator pipe and valves. The injuries were fatal. The pipes and valves were not covered and had temperatures of 73 degrees centigrade.The company which owned the care home was aware that the deceased was at risk of falls and injury and that staff should be vigilant. It had failed to assess the risks in his room and had not taken appropriate action to control and manage the risks.

Care home scalding

In December 2008 Paul Cundy was living in a care home in St Austell, Cornwall. Comhome provided housing for vulnerable people and Solor provided care staff for the home Cundy needed physical help with all aspects of his daily life. He was lowered into a bath by a care worker, using a hoist. He was so severely scalded that his skin was left hanging from his body. He was hospitalised for four weeks. There was no thermostatic mixing valve (TMV) fitted to the bath. This would have regulated the water temperature to below 44 degrees centigrade. Four internal maintenance reports had stated that the TMV was not functioning and identified it as high risk because the water from the hot tap was at 60 degrees.    Cundy’s care plan, drawn up by Solor, did not refer to the risk of scalding and there was no system to ensure that care workers had read the plan.


Care home window death

In November 2010 Olga Llewellyn, a 92-year old resident at the home, suffered fatal injuries when she fell from her bedroom window. All the windows at the home were fitted with the same type of window restrictors. These were unsuitable because they could be easily overridden and the windows opened wide.Between 2005 and 2010 there were 21 fatal accidents from falls from windows.


Death of dementia sufferer

Kenneth Terrey, a dementia sufferer aged 74, was a resident at the Paternoster House Care House in Essex.In March 2011 Terrey tried to leave the dementia unit. He climbed out of a window and fell to the ground. He suffered fatal injuries. At the time of the incident, a window restrictor, which would have prevented the window opening fully, was not working. Staff at the home had not been properly trained in how to carry out proper window safety checks and no window management safety system was in place.

Care home death

In August 2012 Beatrice Morgan, aged 88, a resident of the Greencroft Nursing Home in Queensferry,  Deeside who was unable to walk, was lowered into a bath using a hoist. She cried out when she touched the water and suffered nine per cent burns from the scalding water. She later died from her injuries. The temperature of the water was not properly controlled to prevent it exceeding 44 degrees Celsius. Mixing valves had been fitted to control the temperature but they had not been properly maintained. Staff at the home had been instructed to check the temperature of bath water with a thermometer but no checks were made by management to ensure that this was done. The company had failed to adequately assess the risks of using hot water and had failed to provide sufficient training, instruction and supervision.


Care home injury: fall from window

In December 2012 a 63-year old man, a resident of the Nada Residential and Nursing Home in Manchester, suffering from dementia, was found below his bedroom window suffering from multiple fractures. He told staff that he wanted to get some fresh air. The risk of residents falling from open windows was well known in the care home sector. The windows should have been fitted with restrictors to prevent them opening more than ten centimetres. The care home had failed to properly assess the risk of residents falling from windows and had not taken suitable action to prevent this happening.


Care home scalding in bath

In August 2013 Nicola Jones, a resident of a care home in Bathgate, was given a bath by Sharon Dunlop, a care support worker. Dunlop failed to check the temperature of the water. Ms Jones was scalded. She suffered 40 percent burns.  She required major surgery and now has to use a wheelchair. Employees were supposed to check the water temperature before a service user bathed, and to make a record of this check. The company did not provide written instructions confirming this.

An HSE inspector is reported to have commented after the case that the injuries had been easily preventable by the simple act of checking the water temperature. Employers should ensure that their staff are provided with a thermometer and training in the safety aspects of bathing or showering people for whom they provide personal care.


Care home death in fall from hoist

In August 2010 May Ward, aged 100, was being moved by two carers at the Meppershall Care Home in Bedfordshire. She fell from a hoist and suffered multiple fatal injuries. The two carers had been employed for less than a year. The hoist used to move Mrs Ward had a complex operating procedure and the carers had not been trained in how to use it safely. The hoist was not recommended by the local authority as being suitable for Mrs Ward’s condition. She was not securely positioned and when she moved forwards she fell out.

There was a history of serious safety breaches at the Home. The HSE had served five improvement notices between October and December 2010 related to resident handling, risk assessment and a lack of competent health and safety advice.Another resident had suffered leg fractures after falling when being moved from a wheelchair to an armchair in September 2009.

Mohammed Zarook, the director of the company which owns the Home, had no knowledge or experience of running care homes. He proceeded to take vulnerable residents into his three care homes. There was no evidence that he had taken steps to fulfil his health and safety obligations through the provision of training and the management of risks most commonly associated with the care industry, including resident handling.

The Care Quality Commission had inspected the Home and had given it poor ratings. The Home was closed in July 2013.


Care scalding death

In June 2013 Joseph Hobbin, who suffered from cerebral palsy and epilepsy, was assisted into a bath in his home by a care worker employed by Ark Housing Association Ltd. As his legs were lowered into the bath he suffered an epileptic fit. His legs remained in the water and he sustained extensive scalding to his feet and lower legs. He died in hospital.

Mr Hobbin needed support in all aspects of day to day living. The local authority contracted Ark to provide his care.Ark had not provided care workers with training or instruction in relation to bath and shower temperature. The company was not aware of guidance in relation to safe bathing. It did not provide thermometers to staff and did not carry out adequate risk assessments in relation to the bathing of service users, including the deceased.


Fatal legionella exposure

In September 2012 Lewis Payne, aged 95, went to a care facility operated by Reading Borough Council. He had been in hospital and went to the care facility for intermediate care before returning to his home. He complained of tightness of the chest, shortness of breath, difficulty in breathing and nausea. He was readmitted to hospital and treated for Legionella’s disease. He died from legionella-related pneumonia.

Control and management arrangements at the centre were not sufficiently robust. Legionella training for key personnel were below required standards. There were inadequate temperature checks. Some of the checks of thermostatic mixer valves were done incorrectly.Showers were not descaled and disinfected quarterly as required. Flushing of little used outlets was reliant on one member of staff and there was no procedure for this to be done in the absence of that staff member. The failings were systemic and continued over a period of time. There was a history of legionella problems at the centre.Monitoring, checking and flushing tasks were the responsibility of the centre’s handyman. He was inadequately trained and supervised. There was no system in place to cover for him when he was away so that the requisite checks were not done.


Death of dementia patient from hoist

In April 2008 an 87-year old dementia sufferer was being cared for by the Kent and Medway NHS Social Care Partnership Trust at a Unit in Sittingbourne. As he was being bathed he slipped from a hoist and fell, suffering fatal injuries. The HSE investigation found that there was poor communication between the nursing staff and the agency care workers. The care plan was unclear and was not shared with agency carers. There had been no consideration of the risk of using a bathroom in another ward which precluded active supervision of the agency workers.
Care centre death from choking

In September 2012 Michael Breeze attended Shropshire Council’s run day services care centre, Hartley’s Day Centre, in Shrewsbury.The Centre caters for adults with learning disabilities. Mr Breeze was taken there for the day with a packed lunch provided by the carers at the residential home where he lived. At midday Mr Breeze started to eat his lunch. He started to choke and collapsed. He went into respiratory arrest and did not recover. He had a history of choking incidents. Appropriate safeguards were not put in place at the Centre despite these warnings.


Care home death from fire door

In November 2010 Irene Sharples, a 92-year old resident at Alexian Brothers Care Centre, was killed when a heavy fire door fell on her during renovation work.Healthcare Management Trust, the company which ran the home, engaged Rothwell Robinson Ltd to  carry out renovation work. Mrs Sharples, who suffered from dementia, wandered into a room where building work was being carried out. A fire door fell on her and caused fatal injuries. Both companies had failed to make sure that the room was locked when it was unoccupied. The fire door had been removed during the building work and leant against wardrobes. Other hazards in the room included loose skirting boards, exposed wiring, broken glass and rusty nails.


Death from asphyxiation in care home

In April 2010 Mrs Elsie Beals, aged 93, a resident of the Aden Court Care Home in Huddersfield, run by New Century Care Ltd, died from asphyxiation after being trapped in the gap between her mattress and incorrectly fitted bed safety rails. Mrs Beal had been a resident for two years. She had been helped to bed on the evening before her death by two care assistants. She was checked before midnight and was due another check two hours later. When the care assistants entered her room, they found her dead, trapped in the gap between her mattress and the bed safety rail. The company had failed to train staff at the care home to fit bed safety rails properly. Staff had not been trained to carry out regular in use checks to make sure that bed rails remained properly adjusted, nor to carry out risk assessments for their use.

Bed safety rails are used extensively in the health and social care sectors to protect vulnerable people from falling out of bed. The risks of their use are well documented, actively published and widely recognised in the health care industry.


In May 2016 Angus John MacLennan, who had learning difficulties and received 24 hour support from Western Isles Council, suffered serious burn injuries while bathing. The Council had failed to adequately manage the risk of scalding despite having been made aware of the risk through their own risk assessment. Employees had received no training in managing the risks of scalding, including how to run the bath or check the temperature. They had not been provided with thermometers.

Death from scalding

In 2011 an 89 year old woman was a resident of the Old Wall Cottage Nursing Home, operated by European Healthcare Group plc. She was receiving personal care from two employees when she died from scalding injuries. Bathroom taps were not adjusted to limit the safe temperature of the water. The company had policies and procedures in place, but they were deficient. The company had not effectively communicated information and instruction to staff, so that control measures could be properly implemented. An HSE inspector commented that all healthcare premises have a legal duty to control the risks of scalding injuries.

Hoist death

In November 2013 an 89-year old resident at the company’s care home in Sudbury, Suffolk, was moved by two care workers, using a hoist, from her bed to a chair. She slipped through the hoist sling onto the floor. She suffered a fractured femur and ribs. She died two weeks later. The company did not have adequate health and safety arrangements in place to ensure that users could be safely hoisted. There was no manual handling policy. Individual risk assessments were inadequate because they failed to provide specific information about the equipment to be used. This resulted in some residents being hoisted with the wrong type or size of sling. Nurses and care workers had not been given suitable training and several slings were found to be unsafe to use. They had not been inspected or examined for six months. Disposable slings were being washed and reused.

The Little Book of Horrors Part 2: bakers and butchers


Industrial bakery explosion death

David Cole, a baker, repeatedly attempted to light an industrial bakery oven. He was not aware that gas was building up to a critical flashpoint in the baking chamber. The gas exploded and blew the oven door from its hinges. Cole was struck and suffered fatal injuries. Andrew Jones Pies’ procedures for operating the oven was inadequate and informal. Bakery workers were not given sufficient instruction in its use or the potential hazards arising and precautions necessary to operate it safely. The company had failed to appreciate that direct-fired ovens could potentially fill with a flammable mix of gas and air if repeated unsuccessful attempts were made to fire them up. An explosion relief panel on the back of the oven, which should have safely vented excess pressure, had been rigidly fixed in place.




In July 2011 an employee of Rare Butchers of Distinction Ltd at its premises in Lewisham suffered a deep cut to his forearm while deboning a lamb shoulder. He was off work for more than three months and underwent physiotherapy to restore strength in his hand and thumb. The employee, who wishes to remain anonymous, was wearing a wrist-length chainmail glove. He should have been wearing a chainmail glove as far as his elbow. The company failed to report the incident within the ten-day limit required by RIDDOR. It took 29 days for it to notify the HSE.