Christopher Bevan
PFD Report
Historic (No Identified Response)
Ref: 2019-0104
No published response · Over 2 years old
Sent To
Response Status
Responses
0 of 1
56-Day Deadline
6 Aug 2019
Over 2 years old — no identified published response
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
(1) That ladders may be used in the course of your work (a) in circumstances in which their use may present & risk to life andlor (b) in a manner in which their use may present risk to life. The Court received evidence to the effect that the ladders in use at the time of the fatal accident on 14h August 2018 were used on a surface which may have been slippery, that they were not footed during use, that were not secured at the top save to the extent that were supported by the blockwork andlor by recently laid coping stones of wall above the door opening of the garage and that may have been used by the Deceased, with whom you had been working; in a manner which involved him assuming an awkward position in order to carry out work: The concern therefore arises that you may use or those with whom you may work may use ladders in circumstances Or in a manner which present a risk to YoU; to them and/or to others_
Action Should Be Taken
my they they facing they
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
Report Sections
Investigation and Inquest
On 06/09/2018 I commenced an investigation into the death of Christopher BEVAN_ The investigation concluded at the end of the inquest held on 12th-14h March 2019. The conclusion of the inquest was that the Deceased died as consequence of an accident and that the medical cause of death was: 1(a) Diffuse brain swelling (operated) 1(6) Blunt head trauma with skull fractures
Circumstances of the Death
The circumstances of the death, a8 determined by the jurywere that on 14th August 2018 between 1S00hrs and 1540hrs atl Ithe Deceased was last seen undertaking work to the garage roof whilst on a ladder and that he fell and sustained head injuries. The date of death was 15th August 2018 at 1900hrs at Royal Preston Hospital. The jury' $ conclusion as to death was Accident"_
Similar PFD Reports
Reports sharing organisations, categories, or themes with this PFD
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
BR to rigorously implement cutting, insulating, securing redundant wires before commissioning
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
BR to audit resources and authority for national signal testing instruction implementation
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Ensure independence of testing and commissioning engineers from new works staff
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Establish effective systems for personal distribution of departmental instructions to all employees
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Require staff to understand, re-read, and biennially confirm understanding of instructions
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Provide necessary technical training for all staff to ensure safe practices
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Provide mandatory refresher courses for installers at least every five years
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Urgently progress and monitor training, certification, and refresher courses for testers
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Regularly review the structure and content of all training courses
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Monitor staff overtime to prevent individuals working excessive levels
Hidden Inquiry
Public Infrastructure Physical Hazards
Staff training and development
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.