Jamie Wood
PFD Report
All Responded
Ref: 2023-0061Deceased
All 1 response received
· Deadline: 14 Apr 2023
Coroner's Concerns (AI summary)
Heavy concrete panels on a farm were secured using a weaker, non-standard method, unrecognised during inspections, indicating a widespread lack of understanding of safe fixing practices among farmers and inspectors.
View full coroner's concerns
1. During the inquest evidence was heard that: i. The sections of box tubing used to secure one end of the concrete panels to the vertical RSJ was a weaker method of securing the concrete panels in place, as compared to the method typically used (securing the panel directly to the RSJ using metal brackets bolted to the rear of the panel). They had been in place for a number of years and would have appeared to have been present when Hawkins Farm was subject to inspections by outside agencies, yet no remedial action was required.
2. I have concerns with regard to the following: i. Pre-cast concrete panels are likely extensively used across farms throughout England and Wales. The equipment required to move panels between buildings is likely to be available on the majority of farms, meaning that there is a significant risk that farm owners/workers will move panels if necessary without the need to refer to external trades/professionals. As a consequence, there is a risk of the panels subsequently being fastened to vertical RSJs in a less secure manner, as occurred on Hawkins Farm. A collapsing concrete panel poses a clear risk of death, given their weight.
ii. There appears to be a lack of understanding of the importance of securing the panels in the optimal manner. It does not appear to have been understood by those working on the farm that the fixings that were used on the panel that collapsed were weaker, neither does it appear to have been appreciated by those that undertook inspections of the farm subsequent to the use of this weaker method of fixing. Publicising the risks and educating the farmers of the risks of departing from the recognised method of fixing the pre-cast concrete panels may reduce the risk of future deaths.
2. I have concerns with regard to the following: i. Pre-cast concrete panels are likely extensively used across farms throughout England and Wales. The equipment required to move panels between buildings is likely to be available on the majority of farms, meaning that there is a significant risk that farm owners/workers will move panels if necessary without the need to refer to external trades/professionals. As a consequence, there is a risk of the panels subsequently being fastened to vertical RSJs in a less secure manner, as occurred on Hawkins Farm. A collapsing concrete panel poses a clear risk of death, given their weight.
ii. There appears to be a lack of understanding of the importance of securing the panels in the optimal manner. It does not appear to have been understood by those working on the farm that the fixings that were used on the panel that collapsed were weaker, neither does it appear to have been appreciated by those that undertook inspections of the farm subsequent to the use of this weaker method of fixing. Publicising the risks and educating the farmers of the risks of departing from the recognised method of fixing the pre-cast concrete panels may reduce the risk of future deaths.
Responses
Action Planned
HSE is exploring how to promote key aspects of risk assessment, building maintenance, and work at height with Farm Safety Partnerships (FSPs) and the Agriculture Industry Advisory Committee (AIAC) and updates guidance and briefings to reflect emerging issues; they also plan to offer free webinars on farm safety. (AI summary)
HSE is exploring how to promote key aspects of risk assessment, building maintenance, and work at height with Farm Safety Partnerships (FSPs) and the Agriculture Industry Advisory Committee (AIAC) and updates guidance and briefings to reflect emerging issues; they also plan to offer free webinars on farm safety. (AI summary)
View full response
Dear Sir, Thank you for your letter dated 17th February to Sarah Albon Chief Executive of the Health and Safety Executive (HSE) and your Regulation 28 report to prevent further deaths following the inquest touching on the death of Jamie Paul Woods. I have been asked to respond as I lead the operational teams which undertake interventions and investigations on farms in South-West England. As you have identified the panels in this instance were not installed in accordance with the recommended fixings and an alternate arrangement was used to attach the panels a one end. The panels had provided a walling solution (to segregate the collecting yard from the storage area of the barn) for a considerable period and it appears that any deterioration in the structural integrity of any fixings and/or any instability in the wall was not obvious or recognised by the farm partnership or any other party. The circumstances associated with this instance appear to be an isolated bespoke fabricated solution which in the experience of the HSE is not replicated widely within agricultural buildings. Traditionally concrete panels are a fixed solution and not moved or routinely repurposed. The HSE enquires looked at the wider use of the pre-cast panels on the farm which were found to be installed in accordance with the manufacturer’s instructions. Where installed correctly concrete panels have been shown to have a considerable longevity. There is no history indicating any concern as to the integrity and structural stability of concrete pre-cast components used as a walling solution where they have been installed with the manufacturer’s prescribed fixings and attached firmly to steel uprights. The panels however can
only be loaded on one side as their integrity and strength is provided by load on the panels being transferred to the steel structure rather than relying on the tensile strength of the fixings. The HSE recognises the risks associated with buildings and promote this through guidance and working with wider industry stakeholders. The current guidance on the HSE web pages and through “gov.uk” extends to building work and maintenance that farmers may undertake themselves and includes managing contractors who undertake building work (including contractor selection/planning the work). Although pre-cast panels are not specifically referenced it includes the need to keep buildings in good repair and offers guidance on assessing and managing the risks on farms and sourcing competent advice. The HSE engages with a wide range of industry stakeholder and intermediaries to promulgate key messages and increase the awareness of the risks to health and safety in Agriculture. One part of this work is the distribution of timely messages following incidents. In February 2021 the HSE’s national agriculture team promoted information relating to building integrity through the Farm Safety Partnership (FSP*) chairs and Agriculture Industry Advisory Committee (AIAC**) members. This included the need to keep farm buildings in a safe condition and properly maintained and the importance of periodic structural checks The FSPs have a rolling programme of activities and building maintenance and work at height is regularly promoted. HSE will continue to look for opportunities to help farmers manage and control the risks on their premises, including those arising from building integrity. HSE uses a blend of health and safety interventions in agriculture to tackle the high injury rates. For example, the published HSE workplan includes the targeted inspection of farms including those with beef and dairy cattle in conjunction with HSE funded training to help farms prepare for the inspection. This covers key topics including risk assessment, building maintenance, work at height and the risks from falling objects. HSE’s work in the agriculture sector is regularly reviewed to reflect emerging issues and concerns in response to learning and recommendations following incidents. We update guidance where necessary and use briefings update industry and HSE inspectors. Further to your report we are exploring how we can promote the key aspects with the FSPs and AIAC. I hope that this response provides you with the necessary assurance that the HSE recognises the risks associated with farming activities, strives to prevent further ill health and injury, and will take proportionate action following your recommendation.
only be loaded on one side as their integrity and strength is provided by load on the panels being transferred to the steel structure rather than relying on the tensile strength of the fixings. The HSE recognises the risks associated with buildings and promote this through guidance and working with wider industry stakeholders. The current guidance on the HSE web pages and through “gov.uk” extends to building work and maintenance that farmers may undertake themselves and includes managing contractors who undertake building work (including contractor selection/planning the work). Although pre-cast panels are not specifically referenced it includes the need to keep buildings in good repair and offers guidance on assessing and managing the risks on farms and sourcing competent advice. The HSE engages with a wide range of industry stakeholder and intermediaries to promulgate key messages and increase the awareness of the risks to health and safety in Agriculture. One part of this work is the distribution of timely messages following incidents. In February 2021 the HSE’s national agriculture team promoted information relating to building integrity through the Farm Safety Partnership (FSP*) chairs and Agriculture Industry Advisory Committee (AIAC**) members. This included the need to keep farm buildings in a safe condition and properly maintained and the importance of periodic structural checks The FSPs have a rolling programme of activities and building maintenance and work at height is regularly promoted. HSE will continue to look for opportunities to help farmers manage and control the risks on their premises, including those arising from building integrity. HSE uses a blend of health and safety interventions in agriculture to tackle the high injury rates. For example, the published HSE workplan includes the targeted inspection of farms including those with beef and dairy cattle in conjunction with HSE funded training to help farms prepare for the inspection. This covers key topics including risk assessment, building maintenance, work at height and the risks from falling objects. HSE’s work in the agriculture sector is regularly reviewed to reflect emerging issues and concerns in response to learning and recommendations following incidents. We update guidance where necessary and use briefings update industry and HSE inspectors. Further to your report we are exploring how we can promote the key aspects with the FSPs and AIAC. I hope that this response provides you with the necessary assurance that the HSE recognises the risks associated with farming activities, strives to prevent further ill health and injury, and will take proportionate action following your recommendation.
Sent To
- Health and Safety Executive
Response Status
Linked responses
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56-Day Deadline
14 Apr 2023
All responses received
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Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 5th February 2021, an investigation was commenced into the death of Jamie Paul Woods, born on the 12th August 1980. The investigation concluded at the end of the Inquest on the 7th December 2022. The Medical Cause of Death was: 1a Multiple Injuries The conclusion of the Inquest recorded that Jamie Paul Woods died as a consequence of an accident.
Circumstances of the Death
Jamie Paul Woods was a farm worker at Hawkins Farm in Dorset. Hawkins Farm is a family-owned dairy farm. As part of the fabric of some of the buildings on the farm, pre-cast concrete panels were used extensively, predominately as external walls for barns or similar. Typically, the concrete panels, which weigh approximately 800kg, are placed between vertical reinforced steel joists (RSJs), secured to the RSJ by means of a metal bracket bolted to the concrete panel. On Hawkins Farm two concrete panels had been repurposed from another building to form a divide between a “collecting yard” (an area where cattle are held prior to be being encouraged into the milking parlour) and an adjacent barn where straw was stored, with one panel placed on top of the other, to form a wall that was approximately 6 feet in height. The concrete panels did not stretch between the two RSJs present. As a consequence, one side was secured using the above-described method, with the other side being secured using sections of steel “box” (hollow steel tubing) welded to the RSJ and “clipped” against the rear of the concrete panel using a metal bracket. On 30th January 2021, Mr Woods was in the collecting yard when the upper concrete panel that divided the collecting yard from the straw storage came away from its fixing, causing multiple injuries to Mr Woods, who was sadly confirmed deceased at the scene.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.