Arthur Mason

PFD Report All Responded Ref: 2016-0128
Date of Report 1 April 2016
Coroner Jacqueline Lake
Coroner Area Norfolk
Response Deadline est. 27 May 2016
All 1 response received · Deadline: 27 May 2016
Response Status
Responses 1 of 1
56-Day Deadline 27 May 2016
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

Coroners Concerns
During (he course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future dealhs will occur unless action is taken: _ (1) As at July 2014 no member of staff had undergone fraining in respect of assessing risks and carrying out Risk Assessments. Following Mr Mason's death,, one member of staff involved in risk assessments has undergone training: This member of staff is involved in the administration side of documenls. Other; senior, members of staff involved in carrying out risk assessments have not undergone any such training and from the evidence did not appear to accept risks as set out in Health & Safety Executive documentation, preferring to rely on their own "experience and common sense The fully

(2) It was unclear from the evidence that staff involved in carrying out Risk Assessments recognised the risks of carrying out various tasks on the farm. The current document "Procedure for Cleaning out Grain Bins" does not recognise any risks or hazards in carrying out the tasks and it was not clear the evidence a Risk Assessment is in place for this new procedure, introduced following and as a result of Mr Mason's death_ (3) The "what to do in an emergency" Sheet in place as at July 2014 contained a list of persons to contact and telephone numbers and coordinates to pass to emergency services There was no Emergency Plan in place This has not changed following Mr Mason's death. Although the grain bins are not to be entered by ay personnel on cleaning, it was clear from the evidence, there are other hazardous areas on the farm: These "Emergency Sheets" are currently in use and there is no plan or procedure in place for employees to follow should another emergency occur:
Responses
Maurice Mason Ltd
Response received
View full response
MAURICE MASON LTD. Nm HALL FARM, FINCHAM, KING'S LYNN, NORFOLK, PE33 9Q TELEPHONE: FACSIMILE: 15" June '16 Attn - Jacqueline Lake Herewith is the response to the Coroner's Report and letter; dated 1 AprIl 16 and In partlcular to Section 5 relatlng to the Coroner' $ concerns and Section 6 relating to action to be taken: Section 5
1) For clarification, as of July 2014 there was a member of staff that had undergone training In respect of assesslng risk and carrying out rlsk assessments; Thls is who held a valid iOSH certifilcate (copy enclosed) and was part ofthe management team over seelng Health and Safety withln the Company: He has 15 vears of experlence, 10 of those years before joining Maurice Mason Ltd (MML): MML have now undertaken to provlde extensive tralning of more staff In the management of health and safety using the accredited IOSH scheme: Please see the below response under Sectlon 6 for full detalls ' It is also of note that who provided evldence at the Inquest In relation to the productlon of risk assessments and risk management Is no longer a emplovee of MML:
2) The Company is saddened that they were not able to get across to the Coroner that their staff endeavoured to understand the risks Involved and wlshes to relterate that all staff were worklng to the best of thelr abllities at all tlmes. MMLWlshes to express that have In the pastand will continue to strive to achieve good health and safety practices Section 6 MML has taken the actions set out below in order to comply with the Coroner's Reportand In order to further review health and safety across Its business, not Just In respect of the areas highlighted by the Coroner's Report; In relation to practlces on the farm concernlng the cleaning of graln blns It Is now the case that no personnel whatsoever are to enter the bins at any time for cleaning; or Indeed anv other purposes. This practice no longer forms part of any work at MML Therefore the potentlal rlsks in relation to working inside the grain bins have been eradicated As a result there is no remaining risk on slte of working in a confined space such that was the subject of evldence at the inquest; DIRECTOR; H. MASON REG_OFFICE A5 ABOVE. IEG. NO. 443412 ENGLAND they grain

With regards to the speclfic grain store buildlng a new rlsk assessment has been done along Witfj a method statement; It Is now more detalled and addresses the risks of the new method ofwork A copv is attached; This now addresses the rlsks that are present In the new cleaning method and the appropriate method of work for cleaning the bins Thls document was updated as result of a vislt from the HSE, after the Inquest; verslon of this updated document wlll also be sent Independently to the HSE and It will also be subject to further revlew by Cope Safety Management Ltd (see below) In order to address the Coroner's concerns and to address safety Issues across MML the Company has instructed Cope Safety Management Ltd (CSML) (quellflcatlons attached} to revlew and amend: a) Health and Safety Pollcy b) Bespoke rlsk assessments including a5 appendlxed to this document; a new rlsk assessment for the cleaning of the blns; c) Bespoke safe svstems of work; to include emergency plans as approprlate (also environmental) d) Employee H+S handbook
0) Slte safety Inspectlons (4 per vear)
1) 'Tool Box" talks held on site wlth staff, complete wlth appropriate literature
8) Internet access to CSML updated H+S docimentation, to keep MML updated wlth current legislatlon with telephone contact/support:
6) Quarterly updates on H+S matters CSML becomes MML's nominated safety advisor: Thls is a two year contract, formal signing was 28" April '16 (copy of agreement enclosed, please note that It Is Option 1 that Is belng taken} To broaden MML's understandIng of Health and Safety tostrengthen our abllity to ensure that_ that staff who are responslble for health and safety understand the Issues and rlsks Involved, further formal tralning has been booked as set out below, In particular:- "IOSH Directing Safely" (1 day; to be corpleted 27" July 16) "IOSH Managlng Safely" (4 days, to be completed 27" Sapt 16) 1s Aid at Work (3 date to be confirmed) office manager) (factory manager) "IOSH Managlng Safely" (4 days, completed 10"h June 16) grain along ` and days,

(farm manger) "IOSH Mariaging Safely" (4 to be completed 22nd June 16) There will be further training for staffjembers In more focused areas to staff Involvement and understanding It Is not possible at this time to glve detalls but it will be Or the advlce and wlth Input from CSML As referred to above emergency plans wIIl be speclfically reviewed by CSML and prepared as and where appropriate on the advlce of CSML and to address the concerns of the Coroner In relation to Emergency plans: At the time of the accident there were two fully trained and current; first aiders on site: These were There has been a fully maintalned defibrillator on farm slnce Jan '15; with open access. All MML staff have been fully tralned In Its use along with first-ald tralning; Conclusion Maurlce Mason Ltd has strlien to comply with The Health and Safety at Work Act 1974. It recognises that this process Is a Ilvlng one and needs contlnue work and Improvement MML believes that It has responded to the Coroner's report actlvely and positlvely but It wlll continue to work both with CSML and the HSE, where necessary; to ensure hlgh standards of practlce are adopted across Its slte: It is difflcult to articulate the Importance that MML attaches to adhering to the hlghest standards of health and safety practice on slte, both In the past and golng forward. V, as the director of MML, lost my son:
Action Should Be Taken
In my opinion action should be taken t0 prevent fulure deaths and believe your organisation has the power to take such action.
Report Sections
Investigation and Inquest
On 10 JULY 2014 commenced an investigation into the death of ARTHUR CAXTON MASON, AGED 21 YEARS. The investigation concluded at the end of the inquest on 18 MARCH 2016_ The conclusion of the inquest was medical cause of death: Ia) Asphyxiation and short-form conclusion: ACCIDENTAL DEATH
Circumstances of the Death
On 9 July 2014 Mr Mason was cleaning the inside of a grain bin at Hall Farm, Fincham_ King's Lynn, Norfolk: He was standing on moving grain whilst his colleague went to close the hatch shutter When he returned Mr Mason was benealh the grain. Following atlempts t0 rescue Mr Mason by colleagues and emergency services, his body was recovered through an access hatch and he was pronounced dead at the scene
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.