I opened an investigation into this death on 16.10.14 after the deceased had fallen from a ladder and died the same from injuries Sustained in the fall The matter was investigated by the HSE. An inquest was opened on 26.02.16 and concluded before a jury on I8th January 2017. Accident was the conclusion of the jury as to the death: CIRCUMSTANCES OF THE DEATH The deceased fell from & 2.Sm Combination (Combi 100) Youngman's A ladder whilst inspecting a fault in a 12,5 foot or 3.8m ceiling void at Eltham Leisure Centre. The deceased fell with the ladder; which was found under the deceased; and was deformed with Inissing spigots. The jury reached no conclusion on the accident had occurred, The deceased was experienced in use of this ladder. HM Inspector of Health and Safety, was reluctant to give an opinion: But the court inspected the damaged and undamaged ladders and heard that: HSE, Energy Strategy: day - why

1. The inspector advised that the spigots O stops were safety critical maintain the position of middle and lower sections relative to each other in the A mode, to ensure that they cannot be separated, The lower spigot on C is to stop C section up too far; 2_ The role of the spigots was not appreciated by the salesperson from ladder hire company; (which has since drawn attention to these in their hire agreements) nor by the assistant to the deceased_ HSE had not issued any statements on these.
3. The inspector concluded that the ladder was erected in the A position with 4 rungs showing above apex, at the time of its usage in the Leisure Centre.
3. He said that the positions adopted by the deceased on the ladder were safe and its use was within the safe use intended by the design The ladder was not footed at the time.
4. He said that premature opening of the ladder without undue force to erection can cause the spigots to suddenly shear off. 5 . He agreed that the deformation of the ladder could not have been present before the accident a5 the ladder could not be put back together in the used position.
6. He said that if the ladder was not locked properly at the apex it would on the balance of probabilities collapse on usage. If it was locked it would not be in the position and state was after the accident: If it fell with the deceased, a8 the jury concluded, toncluded it was not locked, CORONER'S CONCERNS The MATTER OF CONCERN is as follows. There would appear not be awareness of the safety critical role of the spigots on this ladder; nor the fact that can easily and inadvertently be sheared off, on premature opening of the ladder. Whilst the absence of these spigots was not found to be the cause of this accident; they may have had a role in the injuries sustained and the implications of the lack of awareness may create risks to health and safety: ACTION SHOULD BE TAKEN I consider the evidence given at this inquest gives rise to a concern that circumstances creating a risk of other deaths will occur and in my opinion; action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances Lam therefore reporting this matter to those who manufacture and regulate and inspect usage of this ladder_ YOUR RESPONSE You are under a to respond to this report within 56 of the date of this report, namely by 27h April 2017. 1, the coroner, may extend the period. They sliding being prior ic they duty days

Your response must contain details of action taken O proposed to be taken; setting out the timetable for action. Otherwise you must explain why no action is proposed. If you require any further information about the case,please contact the case officer If you require further information about the process of responding to this report please contact my clerk to whom your response should be sent_ COPIES and PUBLICATION Ihave sent a COpY of my report to the following Interested Persons: of Slater Gordon UK LLP for (widow) , Senior Associate of DWF LAW for Argent FM,E of DAC Beachcroft for HSS of Weightmans LLP for Royal Borough of Greenwich and] HM Inspector of Health Safety: am also sending a copy tc Chartered Medical Engineer and Health & Safety Practitioner for Oliver & Rawden Consulting Forensic Engineers. am also under a to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me, the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner: [DATE] [SIGNED BY CQRONER] 3d M~l %'7 Hire, duty

The deceased fell from & 2.Sm Combination (Combi 100) Youngman's A ladder whilst inspecting a fault in a 12,5 foot or 3.8m ceiling void at Eltham Leisure Centre. The deceased fell with the ladder; which was found under the deceased; and was deformed with Inissing spigots. The jury reached no conclusion on the accident had occurred, The deceased was experienced in use of this ladder. HM Inspector of Health and Safety, was reluctant to give an opinion: But the court inspected the damaged and undamaged ladders and heard that: HSE, Energy Strategy: day - why

1. The inspector advised that the spigots O stops were safety critical maintain the position of middle and lower sections relative to each other in the A mode, to ensure that they cannot be separated, The lower spigot on C is to stop C section up too far; 2_ The role of the spigots was not appreciated by the salesperson from ladder hire company; (which has since drawn attention to these in their hire agreements) nor by the assistant to the deceased_ HSE had not issued any statements on these.
3. The inspector concluded that the ladder was erected in the A position with 4 rungs showing above apex, at the time of its usage in the Leisure Centre.
3. He said that the positions adopted by the deceased on the ladder were safe and its use was within the safe use intended by the design The ladder was not footed at the time.
4. He said that premature opening of the ladder without undue force to erection can cause the spigots to suddenly shear off. 5 . He agreed that the deformation of the ladder could not have been present before the accident a5 the ladder could not be put back together in the used position.
6. He said that if the ladder was not locked properly at the apex it would on the balance of probabilities collapse on usage. If it was locked it would not be in the position and state was after the accident: If it fell with the deceased, a8 the jury concluded, toncluded it was not locked,

I consider the evidence given at this inquest gives rise to a concern that circumstances creating a risk of other deaths will occur and in my opinion; action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances Lam therefore reporting this matter to those who manufacture and regulate and inspect usage of this ladder_