Dear Mrs Brown,

Prevention of future deaths report – your investigation into the death of Wessam Al-Jundi

Thank you for your letter and Regulation 28 report made under the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

Firstly, I would like to express my sympathy to the family of Wessam Al-Jundi at the loss of their loved one.

In your report, you outlined matters of concern for consideration by the Health and Safety Executive (HSE), as highlighted by the key issues quoted below:

“Any current surveillance health and safety monitoring is unlikely to achieve a satisfactory outcome as the onset of untreatable disease predates the 15 year surveillance programmes.”

“Evidence from photographs and an in-life statement suggest Wessam was working in completely unsafe conditions to avoid dust exposure”…..….”there appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created, in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems. This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise.”

The Health and Safety at Work etc Act 1974 and the Control of Substances Hazardous to Health Regulations 2002 (COSHH) (as amended) provide a robust regulatory framework requiring employers to put in place measures to prevent workers being exposed to hazardous substances, such as artificial stone dust containing respirable crystalline silica (RCS).

COSHH requires employers to make a suitable and sufficient assessment of the risks to health, and to ensure that exposure to substances hazardous to health is either prevented or, where this is not reasonably practicable, adequately controlled. Exposure to RCS is preventable where adequate control measures are in place to protect workers.

HSE provides a range of free resources and guidance online for employers setting out how workers can be protected from exposure to RCS. Suitable control measures include combinations of the enclosure and automation of processing equipment, the use of water suppression and control of any mist generated, as well as personal protective equipment such as respirators (masks).  The effectiveness of controls must be maintained, and workers must have been trained and competent to use such controls.

Engagement & Policy Division

Deputy Director

2 Victoria Pl Carlisle CA1 1 ER

M: E:

Suitable health surveillance must also be provided for workers liable to be exposed to RCS. Where there is a risk of developing conditions such as accelerated silicosis, or where there is evidence of significant overexposure to RCS, the timing and performance of health surveillance should be adapted. This means chest x-rays being performed well before the 15-year time period you refer to, and referral to an occupational lung disease specialist being made as appropriate. In May 2024, we clarified these requirements in the updated ‘Health surveillance for those exposed to respirable crystalline silica (RCS), Supplementary guidance for occupational health professionals’, which is available on HSE’s website at https://www.hse.gov.uk/pubns/guidance/g404.pdf.

HSE works with industry and suppliers to raise awareness of managing the risks of exposure to RCS, and works proactively with key stakeholders and trade associations, for example, in the construction industry. We have delivered several national inspection campaigns and continue to investigate reported ill-health and concerns about inadequate risk management in industries where there is potential for exposure to RCS.

On 7 October 2024, we met with manufacturers of stone products to discuss practical solutions businesses and dutyholders can take to protect workers from exposure to RCS when working with high silica content stone. We also met with key fabrication employers on 25 November 2024. Further workshops are proposed to ensure a broad understanding of how engineered stone is being supplied and used to enable us to devise further interventions targeting key issues.

As part of this engagement, we have confirmed the requirements for working high silica content stone worktops, and we will shortly be publishing further guidance, aimed at installers, their managers and supervisors to remind them of the steps they must take to control the exposure risk. We are also working with the Worktop Fabricators Federation to support development of their own information leaflet which they can share amongst their networks.

Collectively, this raises awareness of the need for controls when engineered stone is being worked. HSE continues to review the latest global evidence to consider what additional controls or action may be necessary and it is engaging with occupational lung disease clinicians to build understanding of affected workers. HSE has commissioned research to better understand the underlying causes of poor compliance with use of controls by employers closest to the problem (e.g. fabricators).

I understand that you are in contact with our lead investigator who is examining the circumstances leading to the death of Wessam Al-Jundi. They will keep you updated as this investigation progresses.

I hope this confirmation of HSE’s work in this area and our commitment to tackling this health risk is helpful to your investigations.

WFF Silica Dust – draft ‘state of the art’ positioning statement: November 2024

1 Quartz worktops have been headline news since the end of 2023, when first major Australian retailers and then the Australian government announced a country-wide silicosis-scare product ban. Australia's government H&S agency, Safe Work Australia, made these findings of occupationally-acquired silicosis in a report released in October 2023:
• Engineered stone workers develop silicosis at a "disproportionate" rate compared to other industries
• Most engineered stone workers who developed silicosis were under 35
• Engineered stone workers faced a faster disease progression (which means they become unwell more quickly) and a higher mortality rate (which means they are more likely to die) than silicosis victims in other industries
• Overall, the report concluded that "the use of all engineered stone should be prohibited".

2 ‘Quartz’ is a catch-all term for man-made engineered stone materials, created in factories by combining quartz sand, colourings and additives with thermosetting resins to create large- format slabs which exhibit all the appearance, weight and aesthetics of natural stone. Quartz dominates the UK stone worktops market (70%+ by volume of all stone worktops sold). The main reason is design consistency: engineered stone slabs deliver a genuine ‘stone’ aesthetic, but with all the advantages and consistencies of factory-engineered products. Colour, texture, porosity, patterning and dimensional stability are no longer products of random nature, but of precise engineering and considerable research and development. Quartz is a product with which retail showrooms are familiar and consumers are comfortable, and which fabricators’ machine minders are confident in processing.

3 The first point to emphasise is the very distinct and discrete nature of the occupational risk. It exists entirely and exclusively at the point at which the stone is processed by cutting and polishing instruments: preeminently when large-scale stone slabs are cut down and finished to meet the precise dimensions and design requirements of the finished worktops. Risk can also occur when processing smaller stone pieces and/or in renovation and remodelling if worktop removal involves cutting or grinding tools.

4 It needs to be understood that consumers, specifiers or installers are not at risk in using these products once this fabrication process has been completed. Respirable silica dust is released only when cutting or polishing tools are applied to the material. This issue is not analogous to asbestos exposure, or to more contemporary consumer concerns about formaldehyde, fire retardants or similar chemicals leaching from consumer products over time and compromising indoor air or water quality.

5 There need be no question of anyone being at risk from existing work surfaces or interior features. There are negligible risks associated with conventional demolition or removal either
-- provided the worktops are not cut with machine grinding tools.

6 Any risks from crystalline silica dust occur only when the surface is cut by fast moving abrasive tools in the factories or work-places where the worktops are cut, shaped and polished prior to installation. The cutting process flings invisibly-small fragments of crystalline silica into the air where it can be then breathed into the lungs.

7 It is this Respirable Crystalline Silica (RCS) dust that creates the specific Silicosis health risk which sparked the Australian ban, and lies behind proposals for similar regulatory interventions in parts of the USA.

8 It should be emphasised that both fabrication and enforcement practices in those countries have historically been significantly less ‘tight’ than in the UK, which has had the Health & Safety at Work Act since 1974. Australasian, American and Spanish fabricators featured in case studies have been characterised by widespread use of dry-cutting, poor factory controls and reliance upon natural ventilation. (see for example, Spain in 2018)

9 It is significant in this regard that the first identified UK cases of occupationally-acquired silicosis specifically related to worktop fabrication are all associated with poorly-controlled workplace environments which (from the victims’ descriptions) did not comply with more than the most basic UK regulatory requirements. (Feary et c, 2024:

10 There are two distinct, but complementary, issues which need to be addressed in a safe fabricating workplace. The first is the risk of exposure to workplace dust in general, and to respirable fractions (sub- 5 micron) in particular. The second is exposure to dust specifically containing respirable crystalline silica (RCS) dust, which has been identified as carcinogenic.

11 The above is important when considering the conventional risk-prevention hierarchy. The first consideration is always substitution with a lower-risk alternative. In the case of stone worktops, substitution is only an option where distinct alternative categories exist. The obvious substitutes for engineered quartz are either the traditional natural stone it largely replaced, or the new generation of extra-large-format ceramic tiles. But both natural stone and man-made large-format porcelain/‘sintered stone’ products also create dust when cut. And naturally-occurring granites and quartzites may contain as much silica as engineered quartz products.

12 The HSE provides a range of resources and guidance online setting out how workers can be protected from exposure to RCS including use of water suppression, equipment enclosure, extraction and personal protective equipment, such as respirator masks. Workers must also be trained and competent to use such controls. (See for example https://www.hse.gov.uk/pubns/guidance/st0.pdf;

13 The important principle here is the use of ‘proper controls’. Great Britain has long- established Workplace Exposure Limit metrics, and it is incumbent upon factory owners to manage staff training and production line processes to operate below those limits. And also incumbent upon workers to wear any PPE provided, and to ensure they do nothing to put themselves or fellow workers at risk of exceeding the WEL.

14 The use of water as both a dust suppressant and as a tool lubricant is long established among professional fabricators in the UK. Cutting slabs and upstands to size, creating cut-outs for taps, sinks and hobs and polishing cut edges are routinely carried out on large-scale CNC machinery, typically using enclosures to reduce workforce exposure and water suppression at the cutting or polishing head. Hand-finishing and polishing is usually carried out wet, with the need to control dust-laden mist being met typically by air extraction at point of use, often involving further water-wall booths. Risks to individuals undertaking hand-finishing are usually further mitigated by the use of face-fit or positive-pressure RPE.

15 Different factories will all use different machinery and different processes. But they are all required to operate below the same WEL.

16 There are no barriers to entry to the market. Light industrial units (Class B-2) are typically suitable for setting up worktop factories; second-hand machinery is easily available; major brands of engineered stone may require fabricators to make minimum stock investments and

adhere to specified processing requirements, but non-branded raw materials are widely available, either sourced direct from overseas suppliers or via UK distributors.

17 There is no SIC code specific to the manufacture of stone worktops. This makes it impossible to identify a specific universe of practitioners, or even estimate the total number of organisations carrying out business as fabricators. Artificial stone appears three times in the SIC code notes uksic2007webamend8531 (9).pdf:

• 22.23 Manufacture of builders’ ware of plastic - manufacture of artificial stone (e.g. cultured marble)
• 23.61 Manufacture of concrete products for construction purposes – manufacture of precast concrete, cement or artificial stone articles for use in construction
• 23.69 Manufacture of other articles of concrete, plaster and cement – manufacture of other articles of concrete, plaster, cement or artificial stone
• Plus there is also the option of registering under cutting and finishing of stone – 23.70.

18 Because of the growth in the market over the last 20 years (largely driven by the quartz worktop manufacturers’ marketing efforts and consistency of product, particularly into new homes and the top end of the kitchen market), engineered stone worktops are desirable, aspirational products. Naturally, kitchen showrooms wish to offer them. They can easily add several thousand pounds to the contract value in supplying a new kitchen.

19 Kitchen showrooms lack the skills, equipment or expertise to process and supply stone worktops. They inevitably sub-contract the template-supply-and-fit process to third-party specialist fabricators. This often extends to the fabricator inviting the end customer to come and view the stone slab from which their worktop will be created, and to discuss the detail of the fit or the flow of the grain or ‘value add’ options like draining groove details which can be incorporated in the factory worksheet. The end-user’s contract, though, is usually with the showroom, rather than direct with the fabricator.

20 Similarly with interior designers, house-builders or other specifiers: the role of the fabricator is often that of a specialist consultant and sub-contracted supplier.

21 The combination of a widely-desired, high-ticket aspirational product, the reliance upon fabricators for third-party specialist expertise, the comparative lack of experience among purchasers and the infrequent or one-off nature of the purchasing decision, together with the low cost of entry to the profession, means there is no shortage of ‘worktop fabricators’ in the UK. In many ways, the industry at its present stage of professionalism resembles the double- glazing industry of a generation ago. Or the current market for retro-fit solar panels.

22 In particular, the natural consumer desire to obtain a high-ticket item for the lowest possible price creates a natural ‘pull’ for low-cost operators.

23 The way for a fabricator to reduce the purchase price of the raw materials is governed either by quantity (volume-based discounts) or by quality (non-branded product of unproven provenance or formulation). So that leaves building occupancy costs, sunk costs of capital equipment and employment costs of workforce. Of which the costs of creating and maintaining a safe working environment, purchasing and maintaining correct protective equipment and undertaking appropriate training, safety monitoring and occupational health procedures are all (a) invisible to the customer and (b) additional to the costs of producing worktops.

24 If the retail showroom or the housebuilder is the Principal Contractor, they carry a statutory duty to ensure their subcontractors are following correct HSE regulations. Retailers and

specifiers should exercise their duty of care by ensuring they buy only from fabricators who can demonstrate a commitment to Health & Safety including proper demonstrably effective factory controls for dust, ensuring any on site cutting is minimised and the risks of RCS managed.

+ + + +

25 The industry has explored several ‘what-ifs’ about somehow controlling or regulating the market for stone worktops. As all engineering stone is imported, it would be possible to create controls at point of entry, such that the product could only be released either to the manufacturer’s licenced UK distribution arm, or to a registered fabrication business. Selling- on would need to be accompanied by a provenance certification route, similar to that for certificated timber or waste-transfer notes.

26 The double glazing industry’s code of practice and associated FENSA registration model may also be worth exploring. Especially as FENSA certification is universally required when homes come subsequently to be sold.

27 Because worktop fabricators are usually trade suppliers of business customers, many of the approaches being considered by the Federation of Master Builders’ current campaign to license the UK building industry might also be appropriate for consideration.

From: Sent: Thu Jan 16 2025 17:37:26 GMT To: Subject: RE: Death of Wassam al Jundi - HMC Regulation 28 Report (ref: 35218597) Good afternoon, Thank you for forwarding this on. DHSC has no comments or suggestions for this document. Our response to this PFD case suggested that responsibility for the Coroner’s concerns sits with HSE. It may be worth forwarding to them. Kind regards, DHSC PFD Oversight Team Quarry House, Quarry Hill, Leeds, LS2 7UE E: Department of Health and Social Care

Dear , Thank you for your email below to the Government Legal Department’s (GLD) central litigation team. With sincere apologies, the report contained within (attached) has unfortunately been subject to delays in reaching the relevant department for consideration within the Ministry of Housing Communities and Local Government (MHCLG) and confirming any preceding GLD litigation team involvement in this case. Please find attached a request for an extension to the 56 day period permitted in order to issue a formal response. Also attached is the Health and Safety Executive’s (HSE) response to the report. The concerns raised within the report relate to working practices and protections which would fall within the remit of HSE and the regulations its response set out. Policy owned by MHCLG would not be applicable in addressing these issues and there is consequently little substantive addition MHCLG could provide to HSE’s response. We are of course able to provide a formal response explaining the extent of MHCLG’s policy remit and why this would be a matter for HSE, but wish to highlight this limitation in case it would mean a formal response and additional delay would be unhelpful to the coroner’s investigation. Kind regards , on behalf of , Deputy Director, Construction Products Reform, MHCLG (she/her) Head of Strategy, Communications & Engagement, Construction Products Reform Ministry of Housing, Communities & Local Government Regulatory Stewardship & Reform

Dear Mrs. Young,

please see below a statement on behalf of the Agglomerated Stone Manufacturers Association (A.St.A), in response to your enquiry sent on January 10th 2025. The statement can be attributed to , director of A.St.A. Our association A.St.A. was formed in 2010 to promote Environmental Health and Safety standards among all members in the engineered stone industry, including the thousands of third-party fabricators that fabricate our products and other stone products in their workshops prior to their installation. A critical safety issue in the stone fabrication industry is the requirement to follow well-established regulations and rules to protect workers from overexposure to respirable crystalline silica which can be generated during fabrication (e.g., cutting, grinding, and polishing) of stone products that contain crystalline silica. Regulatory bodies have established regulations and requirements to control silica dust and prevent overexposures to employees, and all employers who work on products containing silica must follow these standards. While many fabricators care about this issue and follow the rules to protect their workers, there remains a need for increased compliance and enforcement activities to ensure that all stone fabrications workers are safe from respirable silica overexposure in their workplaces. Unfortunately, recent years have shown an increase in prevalence of silicosis and other occupational pulmonary diseases among employees of stone fabricators. Silicosis is prevented through compliance with well-established safety regulations and requirements and it is essential that all fabrication employers ensure the safety of their employees at all times. Many industry stakeholders have been working toward increasing awareness, compliance and enforcement of the safety regulations and requirements in the stone industry. Regulators, have made clear and simple rules (such as allowing only wet cutting) or have placed emergency standards with requirements aimed to improve compliance and increase enforcement. We and our members have been advocating for awareness, placing warning stickers, providing data sheets, creating educational materials all aimed to protect workers, and indeed many fabricators have invested behind the necessary equipment that allows them to completely protect their employees form this threat. Importantly, this is a workplace safety issue, not a product issue. It seems that positively influencing such behaviors requires focused governmental involvement, and we are calling to consider the adoption of either clear and easy to follow rules, implement a licensing program for the fabricator’s professions (similar to electricians, plumbers, and gas technicians) or of both. As example for clear rules, we would suggest considering requiring:

A.St.A. World-Wide Agglomerated Stone Manufacturers Association Via Brennero 108 - 37015 DOMEGLIARA (VR) - ITALY P.I. 03965830239 - C.F. 93080320232 - info@astaworldwide.com
a. That all cutting tasks be performed using wet equipment and that no dry-cutting, dry-grinding or dry-polishing be allowed (manual or CNC)
b. Wet cleaning methods
c. Occupational review of the site and periodic air sampling
d. Medical surveillance
e. Mandatory training for employees As for the proposed licensing program we believe following components should be considered: (a) Worker training required to obtain licenses, (b) Familiarity and implementation of environmental control measures (e.g., air testing) with on-site auditing by inspectors or outsourced authorized bodies, (c) Restrictions on fabrication of stone products without a license, (d) Prohibition against dry cutting, dry grinding, and dry polishing, (e) Prohibition to supply to or purchase from an unlicensed fabricator, (f) Appropriate enforcement and penalty provisions. We remain at your disposal for any support you might need in this field.

Sincerely,