Brian Davies
PFD Report
All Responded
Ref: 2025-0631
All 2 responses received
· Deadline: 12 Nov 2025
Sent To
Response Status
Responses
2 of 2
56-Day Deadline
12 Nov 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner’s Concerns
During the course of the inquest it was established that the cause of the explosion could not be ascertained since the clean up operation removed debris from the scene which was subsequently disposed of. It was confirmed that evidence ascertaining the cause of that explosion was not secured and as such was disposed of without an exercise to determine its significance to the investigation.
The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation.
It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding by the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events.
I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion;
2. There was no order given to secure such evidence;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation
The HSE’s Principal Gas Engineer commented that on viewing the television footage of the incident prior to attending the scene he feared that any investigation would be compromised due to evidence having been lost or disposed of. He also noted that the Police may not have come across a scene like this since gas explosions are rare. If the HSE are not involved then decisions made by Police in the interests of search and rescue that then hinder the investigation process and he would not expect them to understand the intricacies of what he would be looking for as part of his investigation.
It is acknowledged that in search and rescue operations the preservation of life has to take precedence, however there should be an understanding by the Police as to what evidence should be preserved due to them having the initial primacy of investigation, and the information to fuel that understanding as to what evidence should be preserved where possible should come from the HSE who have the experience of investigating such events.
I am concerned that without thorough investigations into the causes of domestic explosions then those causes cannot be determined and steps put in place to prevent future deaths by way of recurrence.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion;
2. There was no order given to secure such evidence;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation
Responses
The HSE will raise the coroner's concerns at the WRDP National Liaison Committee, recommend refresher communications to all signatory organisations, provide updates on national training material development, and work on a proposed 'Suspected Gas Explosion checklist' for the WRDP Practical Guide.
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Dear Mr Gruffydd, I’m writing to you in response to your letter received by HSE on 17th September 2025 as part of your inquest into the death of Mr Brian Lyn Davies on 13th March 2023 at his home of , Swansea. In your ‘Regulation 28: Prevention of Future Deaths Report’, we note that the cause of Mr Davies’ death was determined to be due to neck and chest injuries sustained following an explosion at his home address. Your report noted three areas deemed to be ‘Matters of Concern’ and you have requested that HSE respond to you regarding these. These matters were –
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion;
2. There was no order given to secure such evidence;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation.
The response to incidents where there may be a work-related death, is managed through joint implementation of the Work Related Death Protocol (WRDP). HSE and thirteen other organisations, including the Police, Fire Authorities, and Local Authorities, are signatories to the WRDP, and in response to your concerns, we would like to bring to your attention the two main documents, which have been in place in various revisions since 1998, the Work-related Deaths: A protocol for liaison (England and Wales) - WRDP1 and Work-related Deaths Protocol: Practical Guide (England and Wales). The purpose of the protocol and supporting (practical) guide is to ensure effective joint investigation of work-related deaths in England and Wales. The WRDP National Liaison Committee (NLC), ‘owns’ the protocol and HSE sits on the committee alongside the other signatories.
2 Since its introduction, the protocol has become a tried and tested approach to effective liaison between whichever signatory organisations are involved in investigating a work-related death. By signing the protocol, signatories confirm their commitment to the joint investigation approach, appreciating that the public want to be confident that those investigating work-related deaths are doing all that they can to co- ordinate activities, and to cooperate with each other in the best interests of public safety, justice and compassion for those affected. The protocol ‘has been prepared on the assumption that those tasked with investigating such serious and tragic matters, from whichever organisation, are qualified to do so.’ In order to ensure HSE carries out its functions within the WRDP, HSE trains its operational staff in the understanding and implementation of the protocol, from initial contact, through investigation and potential enforcement. HSE would expect that all signatory organisations to the WRDP are assured that their staff are aware of the nature and content of the WRDP. In relation to the specific ‘Matters of Concern’ raised in your letter, it is HSE’s opinion that the Work Related Death Protocol (WRDP) addresses your points. I have responded to each of those points individually with excerpts from the protocol below.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion; At an early stage of the investigation, the Police and other relevant authorities should agree to the following: (e) how relevant material is gathered or generated during the investigation is to be stored, revealed and shared between parties. Normally it would appropriate for the parties to the investigation to share evidential material with each other, or permit access to it, as the investigation progresses;
(f) what specialist and expert advice is required; for what lines of enquiry, i.e. gross negligence manslaughter, corporate manslaughter or health and safety breaches; and how they are to be commissioned and funded. The aim is to ensure, where possible, that an expert addresses the issues in relation to all potential offences at the same time;
2. There was no order given to secure such evidence;
(e) how relevant material is gathered or generated during the investigation is to be stored, revealed and shared between parties. Normally it would appropriate for the parties to the investigation to share evidential material with each other, or permit access to it, as the investigation progresses;
(f) how the forensic examination of relevant material is to be co-ordinated e.g. physical items, DNA evidence, digital material;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation; The WRDP provides an appropriate framework to enable the Police and HSE to successfully manage a Gas Explosion incident. No one explosion is the same. It is important that an incident is investigated on a case-by-case basis to ensure that the HSE is able to gather evidence and information needed to identify the cause of explosion, without impacting the primary objective of preserving life.
3 The process as identified by the WRDP will enable investigators to determine what evidence should be preserved on a case-by-case basis. In addition to this, Appendix 1 of the WRDP provides duties for first officers in Domestic Gas Incidents, however, these questions relate to Carbon Monoxide fatalities rather than gas explosions. HSE believes that the current WRDP is fit for purpose as a framework to ensure collaboration between organisations responding to major incidents and makes a note where any issues arise to bring them to the attention of the WRDP NLC. In relation to this incident, HSE was contacted by South Wales Police at approx. 1700 on 13th March 2023 and made aware of a ‘Gold Command’ meeting by South Wales Police that was arranged for 1730 – HSE was not invited to attend this meeting and was informed that the site was a ‘live’ search and rescue site as it was believed a person was still trapped. HSE were advised not to attend site as it was not yet deemed safe. The first direct contact with the South Wales Police Senior Investigating Officer occurred at 1845 on the 13th, at which point Mr Davies’ body had been recovered. The WRDP was discussed as well as some other matters. HSE attended site on the 14th by which time search and rescue efforts had meant material had been moved offsite to waste and recycling facilities. Although the gas meter, gas cooker and gas boiler had been retained off site, all other evidential material had been disposed of by the waste and recycling company. HSE investigators on site had requested that material be retained for future examination. The scene and lead for the investigation remained with South Wales Police. However, in response to the matters of concern you raised and to further improve the current WRDP and guidance, HSE will:
• Raise your concerns at an appropriate WRDP National Liaison Committee (NLC) and recommend that refresher communications be issued to all signatory organisations, highlighting the need to ensure that all new and existing staff, who could be involved in WRDP incidents, are fully aware of its requirements;
• Provide an update to the NLC regarding work HSE has been doing in preparing national training material focussing on the work related elements of such investigations for those responding to incidents including more specific advice for those first on scene. This will in due course be put to the NLC for consideration and endorsement;
• Provide an update to the NLC on other HSE on-going work to develop a proposed ‘Suspected Gas Explosion checklist’, to sit alongside the current ‘Carbon Monoxide checklist’ within Appendix 1 of the WRDP Practical Guide – ‘Additional duties of first officer – Domestic Gas Incidents’. This would be for the NLC to agree and update the guide.
Thank you for your letter and if I can be of any further assistance, please contact me via email
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion;
2. There was no order given to secure such evidence;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation.
The response to incidents where there may be a work-related death, is managed through joint implementation of the Work Related Death Protocol (WRDP). HSE and thirteen other organisations, including the Police, Fire Authorities, and Local Authorities, are signatories to the WRDP, and in response to your concerns, we would like to bring to your attention the two main documents, which have been in place in various revisions since 1998, the Work-related Deaths: A protocol for liaison (England and Wales) - WRDP1 and Work-related Deaths Protocol: Practical Guide (England and Wales). The purpose of the protocol and supporting (practical) guide is to ensure effective joint investigation of work-related deaths in England and Wales. The WRDP National Liaison Committee (NLC), ‘owns’ the protocol and HSE sits on the committee alongside the other signatories.
2 Since its introduction, the protocol has become a tried and tested approach to effective liaison between whichever signatory organisations are involved in investigating a work-related death. By signing the protocol, signatories confirm their commitment to the joint investigation approach, appreciating that the public want to be confident that those investigating work-related deaths are doing all that they can to co- ordinate activities, and to cooperate with each other in the best interests of public safety, justice and compassion for those affected. The protocol ‘has been prepared on the assumption that those tasked with investigating such serious and tragic matters, from whichever organisation, are qualified to do so.’ In order to ensure HSE carries out its functions within the WRDP, HSE trains its operational staff in the understanding and implementation of the protocol, from initial contact, through investigation and potential enforcement. HSE would expect that all signatory organisations to the WRDP are assured that their staff are aware of the nature and content of the WRDP. In relation to the specific ‘Matters of Concern’ raised in your letter, it is HSE’s opinion that the Work Related Death Protocol (WRDP) addresses your points. I have responded to each of those points individually with excerpts from the protocol below.
1. There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion; At an early stage of the investigation, the Police and other relevant authorities should agree to the following: (e) how relevant material is gathered or generated during the investigation is to be stored, revealed and shared between parties. Normally it would appropriate for the parties to the investigation to share evidential material with each other, or permit access to it, as the investigation progresses;
(f) what specialist and expert advice is required; for what lines of enquiry, i.e. gross negligence manslaughter, corporate manslaughter or health and safety breaches; and how they are to be commissioned and funded. The aim is to ensure, where possible, that an expert addresses the issues in relation to all potential offences at the same time;
2. There was no order given to secure such evidence;
(e) how relevant material is gathered or generated during the investigation is to be stored, revealed and shared between parties. Normally it would appropriate for the parties to the investigation to share evidential material with each other, or permit access to it, as the investigation progresses;
(f) how the forensic examination of relevant material is to be co-ordinated e.g. physical items, DNA evidence, digital material;
3. There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation; The WRDP provides an appropriate framework to enable the Police and HSE to successfully manage a Gas Explosion incident. No one explosion is the same. It is important that an incident is investigated on a case-by-case basis to ensure that the HSE is able to gather evidence and information needed to identify the cause of explosion, without impacting the primary objective of preserving life.
3 The process as identified by the WRDP will enable investigators to determine what evidence should be preserved on a case-by-case basis. In addition to this, Appendix 1 of the WRDP provides duties for first officers in Domestic Gas Incidents, however, these questions relate to Carbon Monoxide fatalities rather than gas explosions. HSE believes that the current WRDP is fit for purpose as a framework to ensure collaboration between organisations responding to major incidents and makes a note where any issues arise to bring them to the attention of the WRDP NLC. In relation to this incident, HSE was contacted by South Wales Police at approx. 1700 on 13th March 2023 and made aware of a ‘Gold Command’ meeting by South Wales Police that was arranged for 1730 – HSE was not invited to attend this meeting and was informed that the site was a ‘live’ search and rescue site as it was believed a person was still trapped. HSE were advised not to attend site as it was not yet deemed safe. The first direct contact with the South Wales Police Senior Investigating Officer occurred at 1845 on the 13th, at which point Mr Davies’ body had been recovered. The WRDP was discussed as well as some other matters. HSE attended site on the 14th by which time search and rescue efforts had meant material had been moved offsite to waste and recycling facilities. Although the gas meter, gas cooker and gas boiler had been retained off site, all other evidential material had been disposed of by the waste and recycling company. HSE investigators on site had requested that material be retained for future examination. The scene and lead for the investigation remained with South Wales Police. However, in response to the matters of concern you raised and to further improve the current WRDP and guidance, HSE will:
• Raise your concerns at an appropriate WRDP National Liaison Committee (NLC) and recommend that refresher communications be issued to all signatory organisations, highlighting the need to ensure that all new and existing staff, who could be involved in WRDP incidents, are fully aware of its requirements;
• Provide an update to the NLC regarding work HSE has been doing in preparing national training material focussing on the work related elements of such investigations for those responding to incidents including more specific advice for those first on scene. This will in due course be put to the NLC for consideration and endorsement;
• Provide an update to the NLC on other HSE on-going work to develop a proposed ‘Suspected Gas Explosion checklist’, to sit alongside the current ‘Carbon Monoxide checklist’ within Appendix 1 of the WRDP Practical Guide – ‘Additional duties of first officer – Domestic Gas Incidents’. This would be for the NLC to agree and update the guide.
Thank you for your letter and if I can be of any further assistance, please contact me via email
South Wales Police will raise the coroner's concerns with the National Liaison Committee and work with the HSE and other signatories to the Work-Related Death Protocol (WRDP) to ensure appropriate amendments are made to the protocol and to develop national training material and checklists for suspected gas explosions.
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Dear Mr Gruffydd, Re: South Wales Police Response to the Regulation 28 Report arising from the death of Brian Lyn Davies I write on behalf of the Chief Constable of South Wales Police in response to the Prevention of Future Deaths Report issued on the 17 September 2025. The report was issued following the conclusion of the inquest into the death of Brian Lyn Davies who tragically died on the 13 March 2023. Unfortunately, the Chief Constable of South Wales Police was not an Interested Person for the purposes of the Inquest and did not appear and was not represented at the Inquest. Accordingly, it has been necessary for me to familiarise myself with the background events and the matters you have set out in your report. I am grateful for the additional time you have granted to enable me to provide a response on behalf of the Chief Constable. I have carefully considered the entirety of the report and wish to reiterate that as an organisation, South Wales Police have taken the opportunity to seriously reflect on the evidence heard during Mr Davies' inquest. We are committed to ensuring the duty of care shown by our officers to the individual concerned is always paramount and welcome any findings and recommendations to ensure the highest standards of service are maintained. The cause of Mr Davies' death was determined to be due to neck and chest injuries sustained following at explosion at his home address. Thankfully, events such as this are extremely rare and it has long been long recognised that there is a need for practical guidance for investigators and others. Please reply to/Atebwch I: BRIDGEND OFFICE Croesyceiliog Office / Swyddfa Croesyceiliog Gwent Police Headquarters, Croesyceiliog, Cwbran, NP44 2XJ Pencadlys Heddlu Gwent, Croesyceiliog, Cwbran, NP44 2XJ Tel/Ffon: 01633 642310 Fax/Ffacs: 01633 642283 Special Legal Casework / Achosion Cyfreithiol Arbennig South Wales Police Headquarters, Cowbridge Road, Bridgend, CF31 3SU Pencadlys Heddlu De Cymru, Heol Y Bont - Faen, Penybont, CF31 3SU Tel/Ffon: 01656 306013 Fax/Ffacs: 01656 302118 We do not accept service by email or fax. Nid ydym yn derbyn cyflwyniad dogfennau cyfreithiol wrth ebost neu ffacs
This is one of the reasons for the creation of practical guidance which is contained in two documents. The first is the "Work-Related Death Protocol: Practical Guide" and the second is the "Work-Related Deaths: A Protocol for Liaison" I have attached a copy of each document to this letter and taken together, I will refer to them as "the Protocols". The Protocols apply in England and Wales and have been in place since 1998. They are described as "living documents" and are updated and revised by the Work Related Death Protocol, National Liaison Committee as necessary. The signatories to these documents are: National Police Chiefs' Council (NPCC); British Transport Police (BTP); Care Quality Commission (CQC); Care and Social Services Inspectorate Wales (CSSIW); Chief Fire Officers' Association (CFOA); Crown Prosecution Service (CPS); Health and Safety Executive (HSE); Healthcare Inspectorate Wales (HIW); Local Government Association (LGA); Maritime and Coastguard Agency (MCA); Medicines and Healthcare products Regulatory Authority: Medical Devices Division; Office for Nuclear Regulation (ONR); Office of Rail and Road (ORR); Welsh Local Government Association The foreword of the Work-Related Deaths: A Protocol for Liaison contains the following narrative: "The Protocol is a high level document which is supported by, and should be read in conjunction with the Work-related Deaths Protocol Practical Guide which sets out a straightforward step-by-step approach to the joint investigation of work-related deaths. The purpose of the protocol and supporting guide is to ensure effective joint investigation of work-related deaths in England and Wales. Since its introduction in 1998, the protocol has become a tried and tested approach to effective liaison between the signatory organisations when investigating a work-related death. By signing the protocol, signatories confirm their commitment to the joint investigation approach, appreciating that the public want to be confident that those investigating work-related deaths are doing all that they can to co- Please reply to/Atebwch I: BRIDGEND OFFICE Croesyceiliog Office / Swyddfa Croesyceiliog Special Legal Casework / Achosion Cyfreithiol Arbennig Gwent p° lice Headquarters, Croesyceiliog, Cwbran, NP44 2XJ South Wales Police Headquarters, Cowbridge Road, Bridgend, CF31 3SU Pencadlys Heddlu Gwent, Croesyceiliog, Cwbran. NP44 2XJ Pencadlys Heddlu De Cymru, Heol Y Bont - Faen, Penybont, CF31 3SU Ffon: 01633 642310 Fax/Ffacs: 01633 642283 Tel/ Ffon: 01656 306013 Fax/Ffacs: 01656 302118 We do not accept service by email or fax. Nid ydym yn derbyn cyflwyniad dogfennau cyfreithiol wrth ebost neu ffacs
ordinate activities, and to co-operate with each other in the best interests of public safety and of those affected by work-related deaths." As would be expected, the Protocols contains provisions and guidance which provide full or partial answers to the issues you have raised. However, it remains important that the Protocols are reviewed and refreshed as appropriate. In this regard, it is significant that Detective Superintendent from South Wales Police attended the National Work Related Death Liaison Committee on 17 November 2025 which is the national multi agency meeting that oversees the Protocol and linked matters. At that meeting the Protocols, were discussed as it was universally agreed that these documents need to be updated. The motion to give effect to the same was carried, and the National Liaison Committee has committed to undertaking a review and update as appropriate. This illustrates the national governance and oversight of the Protocol and the multi-agency cooperation between Policing, the HSE and the other signatory organisations. In addition, Detective Superintendent has also re-established which he chairs and chairs a Wales region Work-Related Deaths Group with partner agencies including the HSE. This response will be focused on the points raised in section 5 of the Preventing Future Deaths Report. Each issue you have identified is intrinsically related, and I will address each of your concern in turn below:
1) There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion; Guidance on the Management of the Investigation is contained in section 3 of the Work Related Death Protocol Practical Guide. The relevant extract from the Guidance states: At an early stage of the investigation, the Police and other relevant authorities should agree to the following: 3 (e) How relevant material is gathered or generated during the investigation is to be stored, revealed and shared between parties. Normally it would appropriate for the parties to the investigation to share evidential material with each other, or permit access to it, as the investigation progresses; 3 (f) What specialist and expert advice is required; for what lines of enquiry, i.e. gross negligence manslaughter, corporate manslaughter or health and safety breaches; and how they are to be commissioned and funded. The aim is to ensure, where possible, that an expert addresses the issues in relation to all potential offences at the same time; This was a dynamic and fast moving situation. South Wales Police had primacy of the investigation and there were a series of meetings, seven in total, of the Tactical Co-Ordinating Group ("TCG") during the initial hours and days following the explosion. The TCG discussions included direct consideration of the Protocols. Attendees at the TCG varied as events become clearer. It was identified that the investigation was a joint investigation between the police and the HSE, with the police having primacy. The primary concern for the police was the preservation of life and limb and the search and rescue operation for Mr Davies. At the early stages, it was initially believed that Mr Davies may be still trapped, and efforts were directed to locate him and to provide any assistance required. There was also the objective to contain the emergency as a whole and to secure the site and limit escalation.
It is acknowledged that it is possible that any actions taken to achieve the primary objectives may have had the unintended consequence of limiting the effectiveness of the subsequent investigation to ascertain the cause of the explosion. In this respect, South Wales Police will take steps to raise your concerns with the National Liaison Committee in order that due regard may be had to such a possibility in the future, so that any amendments which are considered appropriate, may be made to the Protocol.
2) There was no order given to secure such evidence; The Guidance in section 3 continues with following provisions: 3 (/J How relevant material is gathered or generated during the investigation is to be stored, revealed and shared between parties. Normally it would appropriate for the parties to the investigation to share evidential material with each other, or permit access to it, as the investigation progresses; 3 (f) How the forensic examination of relevant material is to be co-ordinated e.g. physical items, DNA evidence, digital material. The objective from the TCG was to facilitate investigations and inquires, working closely with the HSE and others identified key agencies. This occurred during the course of the TCG Meetings. There is no record of HSE attending the initial TCG meetings, although the HSE made a request to be kept informed of developments and representatives of the HSE attended the later TCG Meetings. Following the recovery of Mr Davies' body the TCG discussions included consideration of the practical guidance on appropriate next steps. The search and rescue requirements had led to material being removed offsite to waste and recycling facilities. It is unfortunate that although the gas meter, gas cooker and gas boiler had been retained off site, all other material had been disposed of by the waste and recycling company. The Protocols recognise that infrequent and tragic events, such as this one, are different and must be investigated on a case by case basis. If it is possible that any actions taken by a police force to achieve their primary objectives of preserving life and limb and search and rescue may have an unintended consequence of limiting the effectiveness of the subsequent investigation to ascertain the cause of the explosion, then this is a matter which South Wales Police will seek be included in the review of the Protocols.
3) There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation The Protocols, including their appendices, are the only documents that currently exist in this respect. The Protocols are framework documents to provide practical guidance to ensure collaboration between organisations responding to major incidents. Please reply to/Atebwch I: BRIDGEND OFFICE Croesyceiliog Office / Swyddfa Croesyceiliog Special Legal Casework / Achosion Cyfreithiol Arbennig Gwent Police Headquarters, Croesyceiliog, Cwbran, NP44 2XJ South Wales Police Headquarters, Cowbridge Road, Bridgend, CF31 3SU Pencadlys Heddlu Gwent, Croesyceiliog, Cwbran, NP44 2XJ Pencadlys Heddlu De Cymru, Heol Y Bont - Faen, Penybont, CF31 3SU Tel/ Tfon: 01633 642310 Fax/Ffacs: 01633 642283 Tel/Ffon: 01656 306013 Fax/Ffacs: 01656 302118 We do not accept service by email or fax. Nid ydym yn derbyn cyflwyniad dogfennau cyfreithiol wrth ebost neu ffacs
I have had the benefit of seeing the HSE response dated 12 November 2025, which I note was before the national multi agency meeting of the National Work Related Death Liaison Committee on 17 November 2025. The HSE's response in this regard is that: "The WRDP provides an appropriate framework to enable the Police and HSE to successfully manage a Gas Explosion incident. No one explosion is the same. It is important that an incident is investigated on a case-by-case basis to ensure that the HSE is able to gather evidence and information needed to identify the cause of explosion, without impacting the primary objective of preserving life." Whist this remains the case, for the reasons I have set out earlier, it is important that the Protocols are reviewed. In this regard, the HSE also helpfully state that, as a result of the concerns you have raised, they will:
• Raise your concerns at an appropriate WRDP National Liaison Committee (NLC) and recommend that refresher communications be issued to all signatory organisations, highlighting the need to ensure that all new and existing staff, who could be involved in WRDP incidents, are fully aware of its requirements;
• Provide an update to the NLC regarding work HSE has been doing in preparing national training material focussing on the work related elements of such investigations for those responding to incidents including more specific advice for those first on scene. This will in due course be put to the NLC for consideration and endorsement;
• Provide an update to the NLC on other HSE on-going work to develop a proposed 'Suspected Gas Explosion checklist', to sit alongside the current 'Carbon Monoxide checklist' within Appendix 1 of the WRDP Practical Guide - 'Additional duties of first officer - Domestic Gas Incidents'. This would be for the NLC to agree and update the guide. In common with our response to issues 1 and 2, South Wales Police will take steps to raise your concerns in relation to issue 3 with the National Liaison Committee. In doing so, we will work closely with the HSE and other signatories to the Protocols to ensure that due regard is given to these matter so that any appropriate amendments may be made to the Protocol. I hope that this response addresses the concerns that you set out in your report, and I am grateful to you for you bringing them to the attention of South Wales Police.
This is one of the reasons for the creation of practical guidance which is contained in two documents. The first is the "Work-Related Death Protocol: Practical Guide" and the second is the "Work-Related Deaths: A Protocol for Liaison" I have attached a copy of each document to this letter and taken together, I will refer to them as "the Protocols". The Protocols apply in England and Wales and have been in place since 1998. They are described as "living documents" and are updated and revised by the Work Related Death Protocol, National Liaison Committee as necessary. The signatories to these documents are: National Police Chiefs' Council (NPCC); British Transport Police (BTP); Care Quality Commission (CQC); Care and Social Services Inspectorate Wales (CSSIW); Chief Fire Officers' Association (CFOA); Crown Prosecution Service (CPS); Health and Safety Executive (HSE); Healthcare Inspectorate Wales (HIW); Local Government Association (LGA); Maritime and Coastguard Agency (MCA); Medicines and Healthcare products Regulatory Authority: Medical Devices Division; Office for Nuclear Regulation (ONR); Office of Rail and Road (ORR); Welsh Local Government Association The foreword of the Work-Related Deaths: A Protocol for Liaison contains the following narrative: "The Protocol is a high level document which is supported by, and should be read in conjunction with the Work-related Deaths Protocol Practical Guide which sets out a straightforward step-by-step approach to the joint investigation of work-related deaths. The purpose of the protocol and supporting guide is to ensure effective joint investigation of work-related deaths in England and Wales. Since its introduction in 1998, the protocol has become a tried and tested approach to effective liaison between the signatory organisations when investigating a work-related death. By signing the protocol, signatories confirm their commitment to the joint investigation approach, appreciating that the public want to be confident that those investigating work-related deaths are doing all that they can to co- Please reply to/Atebwch I: BRIDGEND OFFICE Croesyceiliog Office / Swyddfa Croesyceiliog Special Legal Casework / Achosion Cyfreithiol Arbennig Gwent p° lice Headquarters, Croesyceiliog, Cwbran, NP44 2XJ South Wales Police Headquarters, Cowbridge Road, Bridgend, CF31 3SU Pencadlys Heddlu Gwent, Croesyceiliog, Cwbran. NP44 2XJ Pencadlys Heddlu De Cymru, Heol Y Bont - Faen, Penybont, CF31 3SU Ffon: 01633 642310 Fax/Ffacs: 01633 642283 Tel/ Ffon: 01656 306013 Fax/Ffacs: 01656 302118 We do not accept service by email or fax. Nid ydym yn derbyn cyflwyniad dogfennau cyfreithiol wrth ebost neu ffacs
ordinate activities, and to co-operate with each other in the best interests of public safety and of those affected by work-related deaths." As would be expected, the Protocols contains provisions and guidance which provide full or partial answers to the issues you have raised. However, it remains important that the Protocols are reviewed and refreshed as appropriate. In this regard, it is significant that Detective Superintendent from South Wales Police attended the National Work Related Death Liaison Committee on 17 November 2025 which is the national multi agency meeting that oversees the Protocol and linked matters. At that meeting the Protocols, were discussed as it was universally agreed that these documents need to be updated. The motion to give effect to the same was carried, and the National Liaison Committee has committed to undertaking a review and update as appropriate. This illustrates the national governance and oversight of the Protocol and the multi-agency cooperation between Policing, the HSE and the other signatory organisations. In addition, Detective Superintendent has also re-established which he chairs and chairs a Wales region Work-Related Deaths Group with partner agencies including the HSE. This response will be focused on the points raised in section 5 of the Preventing Future Deaths Report. Each issue you have identified is intrinsically related, and I will address each of your concern in turn below:
1) There was no understanding of what evidence was required to be preserved for the purposes of an investigation as to the cause of the explosion; Guidance on the Management of the Investigation is contained in section 3 of the Work Related Death Protocol Practical Guide. The relevant extract from the Guidance states: At an early stage of the investigation, the Police and other relevant authorities should agree to the following: 3 (e) How relevant material is gathered or generated during the investigation is to be stored, revealed and shared between parties. Normally it would appropriate for the parties to the investigation to share evidential material with each other, or permit access to it, as the investigation progresses; 3 (f) What specialist and expert advice is required; for what lines of enquiry, i.e. gross negligence manslaughter, corporate manslaughter or health and safety breaches; and how they are to be commissioned and funded. The aim is to ensure, where possible, that an expert addresses the issues in relation to all potential offences at the same time; This was a dynamic and fast moving situation. South Wales Police had primacy of the investigation and there were a series of meetings, seven in total, of the Tactical Co-Ordinating Group ("TCG") during the initial hours and days following the explosion. The TCG discussions included direct consideration of the Protocols. Attendees at the TCG varied as events become clearer. It was identified that the investigation was a joint investigation between the police and the HSE, with the police having primacy. The primary concern for the police was the preservation of life and limb and the search and rescue operation for Mr Davies. At the early stages, it was initially believed that Mr Davies may be still trapped, and efforts were directed to locate him and to provide any assistance required. There was also the objective to contain the emergency as a whole and to secure the site and limit escalation.
It is acknowledged that it is possible that any actions taken to achieve the primary objectives may have had the unintended consequence of limiting the effectiveness of the subsequent investigation to ascertain the cause of the explosion. In this respect, South Wales Police will take steps to raise your concerns with the National Liaison Committee in order that due regard may be had to such a possibility in the future, so that any amendments which are considered appropriate, may be made to the Protocol.
2) There was no order given to secure such evidence; The Guidance in section 3 continues with following provisions: 3 (/J How relevant material is gathered or generated during the investigation is to be stored, revealed and shared between parties. Normally it would appropriate for the parties to the investigation to share evidential material with each other, or permit access to it, as the investigation progresses; 3 (f) How the forensic examination of relevant material is to be co-ordinated e.g. physical items, DNA evidence, digital material. The objective from the TCG was to facilitate investigations and inquires, working closely with the HSE and others identified key agencies. This occurred during the course of the TCG Meetings. There is no record of HSE attending the initial TCG meetings, although the HSE made a request to be kept informed of developments and representatives of the HSE attended the later TCG Meetings. Following the recovery of Mr Davies' body the TCG discussions included consideration of the practical guidance on appropriate next steps. The search and rescue requirements had led to material being removed offsite to waste and recycling facilities. It is unfortunate that although the gas meter, gas cooker and gas boiler had been retained off site, all other material had been disposed of by the waste and recycling company. The Protocols recognise that infrequent and tragic events, such as this one, are different and must be investigated on a case by case basis. If it is possible that any actions taken by a police force to achieve their primary objectives of preserving life and limb and search and rescue may have an unintended consequence of limiting the effectiveness of the subsequent investigation to ascertain the cause of the explosion, then this is a matter which South Wales Police will seek be included in the review of the Protocols.
3) There was no memorandum of understanding or protocol between the Police and the HSE to provide information on what the HSE would need to be able to identify the cause of the explosion as far as practicable without impacting upon the primary objective of preserving life undertaken by the search and rescue operation The Protocols, including their appendices, are the only documents that currently exist in this respect. The Protocols are framework documents to provide practical guidance to ensure collaboration between organisations responding to major incidents. Please reply to/Atebwch I: BRIDGEND OFFICE Croesyceiliog Office / Swyddfa Croesyceiliog Special Legal Casework / Achosion Cyfreithiol Arbennig Gwent Police Headquarters, Croesyceiliog, Cwbran, NP44 2XJ South Wales Police Headquarters, Cowbridge Road, Bridgend, CF31 3SU Pencadlys Heddlu Gwent, Croesyceiliog, Cwbran, NP44 2XJ Pencadlys Heddlu De Cymru, Heol Y Bont - Faen, Penybont, CF31 3SU Tel/ Tfon: 01633 642310 Fax/Ffacs: 01633 642283 Tel/Ffon: 01656 306013 Fax/Ffacs: 01656 302118 We do not accept service by email or fax. Nid ydym yn derbyn cyflwyniad dogfennau cyfreithiol wrth ebost neu ffacs
I have had the benefit of seeing the HSE response dated 12 November 2025, which I note was before the national multi agency meeting of the National Work Related Death Liaison Committee on 17 November 2025. The HSE's response in this regard is that: "The WRDP provides an appropriate framework to enable the Police and HSE to successfully manage a Gas Explosion incident. No one explosion is the same. It is important that an incident is investigated on a case-by-case basis to ensure that the HSE is able to gather evidence and information needed to identify the cause of explosion, without impacting the primary objective of preserving life." Whist this remains the case, for the reasons I have set out earlier, it is important that the Protocols are reviewed. In this regard, the HSE also helpfully state that, as a result of the concerns you have raised, they will:
• Raise your concerns at an appropriate WRDP National Liaison Committee (NLC) and recommend that refresher communications be issued to all signatory organisations, highlighting the need to ensure that all new and existing staff, who could be involved in WRDP incidents, are fully aware of its requirements;
• Provide an update to the NLC regarding work HSE has been doing in preparing national training material focussing on the work related elements of such investigations for those responding to incidents including more specific advice for those first on scene. This will in due course be put to the NLC for consideration and endorsement;
• Provide an update to the NLC on other HSE on-going work to develop a proposed 'Suspected Gas Explosion checklist', to sit alongside the current 'Carbon Monoxide checklist' within Appendix 1 of the WRDP Practical Guide - 'Additional duties of first officer - Domestic Gas Incidents'. This would be for the NLC to agree and update the guide. In common with our response to issues 1 and 2, South Wales Police will take steps to raise your concerns in relation to issue 3 with the National Liaison Committee. In doing so, we will work closely with the HSE and other signatories to the Protocols to ensure that due regard is given to these matter so that any appropriate amendments may be made to the Protocol. I hope that this response addresses the concerns that you set out in your report, and I am grateful to you for you bringing them to the attention of South Wales Police.
Report Sections
Investigation and Inquest
On the 21st March 2023 I commenced an investigation into the death of Brian Lyn Davies. The investigation concluded at the end of the inquest on the 15th September 2025.
The medical cause of death is 1a) chest and neck injuries
The conclusion of the inquest as to how Mr Davies came to his death was a narrative conclusion and is as follows:-
It is not possible to determine the cause of the explosion, due to a lack of preserved material evidence, it cannot be determined how the explosion came about or occurred.
The medical cause of death is 1a) chest and neck injuries
The conclusion of the inquest as to how Mr Davies came to his death was a narrative conclusion and is as follows:-
It is not possible to determine the cause of the explosion, due to a lack of preserved material evidence, it cannot be determined how the explosion came about or occurred.
Circumstances of the Death
The deceased was Brian Lyn Davies who was pronounced dead on the 13th of March 2023 at his home address , Swansea. The cause of death was chest and neck injuries sustained following an explosion at his home address.
The explosion occurred shortly after 11:00am on the above date, and the result of the explosion was that there was complete destruction of , and partial destruction of resulting in a significant amount of rubble and debris.
In order to undertake the search and rescue operation debris needed to be cleared to allow access to areas of the property, and to ensure that the search and rescue team operated in a safe environment. Brian was discovered beneath the rubble in the area that used to be the kitchen approximately 6 hours after the explosion occurred.
Enquiries revealed that the gas service pipe to the property had been severed during the explosion and there was a compete circumferential crack to the gas main that ran adjacent to the property resulting in leaking gas.
The investigation into the cause of the explosion undertaken by the HSE could not attribute the cause of the explosion to a gas leak since the clean up had removed vital evidence from the scene. They were unable to rule out other potential causes such as an internal gas leak or the explosion of other potential combustibles within the property. As such a gas leak was one of several possible theories, with none of them being able to be advanced as a probable cause of the explosion.
Although the main gas appliances consisting of the gas cooker, the gas boiler and the gas meter had been secured, inspected, and eliminated as the cause, other items such as internal pipework and the internal walls were not available for inspection and the Police had not given instructions for those items to be secured as evidence.
The explosion occurred shortly after 11:00am on the above date, and the result of the explosion was that there was complete destruction of , and partial destruction of resulting in a significant amount of rubble and debris.
In order to undertake the search and rescue operation debris needed to be cleared to allow access to areas of the property, and to ensure that the search and rescue team operated in a safe environment. Brian was discovered beneath the rubble in the area that used to be the kitchen approximately 6 hours after the explosion occurred.
Enquiries revealed that the gas service pipe to the property had been severed during the explosion and there was a compete circumferential crack to the gas main that ran adjacent to the property resulting in leaking gas.
The investigation into the cause of the explosion undertaken by the HSE could not attribute the cause of the explosion to a gas leak since the clean up had removed vital evidence from the scene. They were unable to rule out other potential causes such as an internal gas leak or the explosion of other potential combustibles within the property. As such a gas leak was one of several possible theories, with none of them being able to be advanced as a probable cause of the explosion.
Although the main gas appliances consisting of the gas cooker, the gas boiler and the gas meter had been secured, inspected, and eliminated as the cause, other items such as internal pipework and the internal walls were not available for inspection and the Police had not given instructions for those items to be secured as evidence.
Inquest Conclusion
-
It is not possible to determine the cause of the explosion, due to a lack of preserved material evidence, it cannot be determined how the explosion came about or occurred.
It is not possible to determine the cause of the explosion, due to a lack of preserved material evidence, it cannot be determined how the explosion came about or occurred.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.