Matthew Gunn

PFD Report Partially Responded Ref: 2016-0217
Date of Report 9 June 2016
Coroner Katy Skerrett
Coroner Area Gloucestershire
Response Deadline est. 4 August 2016
Coroner's Concerns (AI summary)
An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.
View full coroner's concerns
_ (1) observed or reported epileptic event occurring to a Morrison's employee whilst at work was not recorded
Responses
Morrisons
Action Planned
Morrisons will issue a bulletin to stores instructing employees to report observed epileptic events to a first aider. They will update first aid training and policy, and record epileptic events reported via return-to-work procedures with a reminder to review risk assessments. (AI summary)
View full response
Dear HM Senior Coroner Matt Gunn Prevention of Future Deaths write in response to the Prevention of Future Death report ("PFD report") under Regulation 28 received from you on June 2016 and which requires Wm Morrison Supermarkets PLC "Morrisons") to respond within 56 days detailing the action taken or to be taken whether in response to the report or otherwise: The PFD report indicates that the matter of concern was that: observed or reported epileptic event occurring to a Morrisons employee whilst at work was not recorded You are of the opinion that this gives rise to a risk of future deaths_ As Morrisons understands, the suggested purpose of recording any observed or reported epileptic event is so that it has information that may be of assistance to assess an employee' $ epilepsy with respect to their work as necessary: As the evidence clearly reflected at the inquest, it is important to recognise that in order for Morrisons to have full and accurate picture of an employee' $ epilepsy, it would be necessary for it to be informed by the employee of epileptic events that occurred outside of work, for example; at home: It is only possible for Morrisons to record and act on the epileptic events that it is informed of_ Therefore, it follows that the information recorded at the store about observed or reported epileptic events will inevitably only be a partial picture given that there will be other episodes that take place outside of work that Morrisons will be unaware of unless the employee chooses to volunteer that information, which the employee is unlikely to do unless it affects their attendance at work As you are aware, and indeed the evidence at the Inquest reflected, in dealing with an employee with epilepsy, or indeed any other disability, equality legislation would prohibit Morrisons from requiring the employee to disclose the information. Where an epileptic event occurs in store, then the process is as follows. The first stage after an epileptic episode occurring is for a first aider to attend. If the epileptic event resulted in an accident or was reportable under RIDDOR then it would be recorded in the accident book and/or reported to the local authority or HSE_ Where it does not, then the record of first aid attendance and treatment given should be given to the People Manager and kept in the personnel file for the Wm Morrlson Supermarkets Plc Telephone; +44 (01845 611,5000 Registered office: Www morrisons co,uk Hilmore House, Gain Lane; Bradford, West Yorkshire BD3 7DL Registered in England no. 358949 Katy "Any

member of the store team the People Manager reviews all first aid records and determines if there was a trigger for an occupational health assessment for the emplovee. In light of your concern; Morrisons has taken the opportunity to refresh this procedure in order to re-emphasise the expected approach: As a result; Morrisons is implementing: (a) A bulletin will be sent to all stores instructing them to brief all emplovees to remind them that any employee who has observed an epileptic event of an employee should contact a first aider regardless of the nature of that event whether it is an epileptic event or a temporary absence; (b) An update to the first aid training and the first aid policy to remind of The need to complete a first aid slip for every call attended even if there is no treatment given; (ii) Where first aider is not present; appointed persons will be instructed to complete a first aid slip; (iii) That all first aid slips must be reviewed by the People Manager and held on file this will be trained out to all People Manager' s. (c) Where the epileptic event is reported via the return to work procedures this will be recorded on the employee's file and a reminder included of the need to review the risk assessment for the individual and refer them to Occupational Health for Assessment; if necessary: For the avoidance of doubt; this procedure was in place at the time of Matt's death but Morrisons has reviewed and will re-emphasise as set out above aspects to its employees_ The bulletin is anticipated to be issued by the end of August 2016 and the amendments to the first aid training, and policy and the return to work procedures will be issued, and trained out completely by the end of December 2016.
Sent To
  • DWF LLP
  • W M Morrisons PLC
Response Status
Linked responses 1 of 2
56-Day Deadline 4 Aug 2016
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections
Investigation and Inquest
On the 15th October 2014 commenced an investigation into the death of Matthew Joseph Gunn: investigation concluded at the end of the jury inquest on the 23r 2016. The conclusion of the jury was accidental death and a narrative conclusion: The medical cause of death was 1A traumatic head
Circumstances of the Death
At approximately 14.30 hours o the 25th September 2014, Matthew Joseph Gunn fell from height whilst using the staff staircase at Morrison's supermarket;, Ashchurch road, Tewkesbury GL2O 8BN. The jury found that Matthew's fall was probably caused by an epileptic event; and he subsequently died in hospital on the 7lh October 2014 from the injuries he sustained in the fall
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
Copies Sent To
Gloucestershire GL5O 1PJ
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.