Sean O’Connor

PFD Report All Responded Ref: 2024-0257
Date of Report 8 May 2024
Coroner Mary Hassell
Response Deadline est. 3 July 2024
All 1 response received · Deadline: 3 Jul 2024
Coroner's Concerns (AI summary)
The lack of mandatory checks for lone workers and failure to integrate safety discussions about required checks into routine worker briefings increased the risk of harm.
View full coroner's concerns
I heard evidence at inquest that, as he was regarded as a lone worker, Sean O’Connor could and, according to the risk assessment method statement (RAMS), should have asked a CWML colleague to come to check on him during the day. He did not ask for such a check and, although a CWML employee thought of doing so, that person was busy and so did not.

Whilst such a check is likely to have taken place too late in the day to have changed the outcome for Mr O’Connor, that might be different for another lone worker.

Several witnesses gave evidence that discussions take place with every worker coming on site as a matter of routine, covering such matters as where the worker is meant to be located, the exact nature of the job and so forth. The CWML director who gave evidence at inquest agreed with me that it would be a straight forward matter to include within that as a point always for brief discussion, whether any checks are required during the day. In this way, if the operative forgets to ask, the discussion can act as a reminder.
Responses
Canary Wharf Management Other
11 Jul 2024
Action Planned
Canary Wharf Management will trial a new feature for work authorisations involving lone working, including a mandatory prompt for welfare checks, to be conducted and recorded by CWML staff if requested. They will also update the Contractor Handbook and Lone Working Policy to apply to contractors. (AI summary)
View full response
Dear Madam, Inquest into the death of Sean O’Connor We refer to the report made following the Inquest into Mr O'Connor's death in which you raised some concerns about the arrangements for lone workers employed by independent contractors whilst on the Canary Wharf Estate. We have reviewed the company's procedures for lone workers. Currently, contractors are required to obtain a Work Authorisation (WA)1 or permit to work (PtW) depending on the nature of the work to be undertaken. Where works are undertaken under a PtW, these are subject to spot checks. Spot checks may also occur when works are performed under a WA. CWML’s approach to facilitating access to its premises by independent contractors reflects what it understands to be recognised practice. CWML is not aware of any concerns raised by contractors (including Mitsubishi) before the incident involving Mr O'Connor. The existing CWML system prioritises checks based on risk (higher risk works requiring a PtW involve mandatory checks and are rarely performed by lone workers). CWML is mindful of the need to avoid potentially undermining the strengths of the system by diverting resource away from higher risk works. Notwithstanding the above, and as part of a process of continuous improvement, CWML has decided to trial a new feature to apply to WA, beginning July 2024. The arrangements will include:
• When applying for work authorisation involving lone working, a mandatory prompt now appears on the system which asks the contractor if a welfare check is required.
• If a check is requested, it will be conducted either by the person requesting the work on behalf of CWML or another competent CWML employee.
• The check / visit must be recorded in the system. 1 A Work Authorisation is now called an Access Permit but for ease we will refer to it as a WA in this letter. CANARY WHARF MANAGEMENT LIMITED, ONE CANADA SQUARE, CANARY WHARF, LONDON E14 5AB ISO 14001 ISO 9001 OHSAS 1B001 db. V iSOQAR tew Canary Wharf Management Limited is a member of the Canary Wharf Group of companies. Registered in England and Wales No. 2067510 Cert No. 11016

For the avoidance of doubt, these steps are in addition to the existing procedure which allows for ad hoc checks on lone workers, as has always been the case. These arrangements will apply in addition to the independent contractors' procedures for lone working. The trial is intended to run for 6 months at the end of which CWML will review the results, consider their effectiveness and decide whether to implement some or all of the trial or make any further changes. In addition to the above, CWML will be updating the Contractor Handbook and the Lone Working Policy to apply to contractors.
Sent To
  • Canary Wharf Management Limited
Response Status
Linked responses 1 of 1
56-Day Deadline 3 Jul 2024
All responses received
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Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On 2 December 2021, one of my assistant coroners, Sarah Bourke, commenced an investigation into the death of Sean O’Connor aged 34 years. The investigation concluded at the end of the inquest on 1 May 2024. The jury made a determination at inquest of death by accident.
Circumstances of the Death
On 24 November 2021, shortly after 10am, Mr O’Connor was electrocuted as a result of contact with a heat pump flow switch terminal, during the course of work at Columbus House 7 Westferry Circus, London. He was a Mitsubishi employee changing the flow switch.

His medical cause of death was: 1a electrocution.
Copies Sent To
Mitsubishi Electric London Borough of Tower Hamlets
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.