I refer to previous correspondence between my office and your who helpfully provided some information and a copy of your Investigation Report/ file.

By way of background, I initially opened an Investigation on 18 November 2014 into the death of Steven Curtis who was 56 years of age when he sadly died following a workplace accident in Shrivenham, Oxfordshire on 24 October 2014.Mr Curtis had been a patient at Southmead Hospital in Bristol since 1 October which is when he fell from a ladder (the ladder in fact snapped in two) whilst he was using the ladder to inspect a flat felt roof at first floor level. Mr Curtis was a Company Director of his own family roofing business. The ladder was a 3.75m telescopic ladder and it is thought that he fell a distance of about 8 feet. Despite treatment, he subsequently succumbed to the injuries sustained in the fall. The medical cause of death was Ischaemic Heart Disease, Pneumonia and Fracture Ribs (joint causes of death).

The Inquest was a jury Inquest due to the fact that the injury was sustained in the workplace. Having said that, it is not a case which the Health and Safety Executive deemed it necessary to investigate despite the fact that my office notified the HSE about the case. I believe that the reason for not investigating was because the HSE were of the opinion that this was a natural cause of death. I do not think that this is correct.

The Inquest was concluded on 8 June 2015 at Oxford Coroner’s Court. A copy of the Record of Inquest completed by the Jury is attached. It will be seen that the Jury gave a conclusion of “Accident” and made the following findings:

Snapped ladder led to a fall onto a hard surface at Lilac Cottage, 19 Manor Lane, Shrivenham. This caused fractured ribs resulting in lung damage which led to pneumonia and death as a result of Ischaemic Heart Disease. Death occurred on 24 October 2014 at Southmead Hospital, Westbury-On-Trym, Bristol.

In addition to the family, the other “Interested Person” for the purposes of the Inquest was Maplin Electronics Limited. The reason for this is the fact that the family of Mr Curtis believe that the ladder which snapped was one of two telescopic ladders purchased from the Maplin Store at Swindon on 23 April 2014 by the deceased accompanied by his son, Paul Curtis. There was a receipt and sales voucher (copies attached) which confirm that Mr Curtis purchased two N19KJ 3.75 metre Telescopic Ladders from the Swindon store on 23 April 2014. The ladders cost £79.99 each. The evidence from Mr Curtis’ family, particularly his sons who worked in the business with him, is that it is one of these ladders which snapped while Mr Curtis was ascending it. The family say that these were the only two telescopic ladders used in the business. The ladder which snapped was retained and was inspected as part of the evidence during the Inquest. The second ladder that was purchased at the same time was disposed of after the incident on 1 October - before the seriousness of the injury to Mr Curtis became apparent – so as to avoid anyone else using the ladder and suffering a similar accident.

Maplin are of the view however that the ladder involved in the accident is not one of the two ladders that they supplied in April 2014. It is similar but there are material differences. There was evidence produced on behalf of Maplin to substantiate this.

On the face of it, there was conflicting evidence which it was not possible to get to the bottom of at Inquest. In any event, I was mindful that establishing the origin of the ladder was probably something that went beyond the scope of the Inquest which is limited to finding the answers to what are called the four statutory questions (how, when and where the death occurred and the identity of the deceased). The family genuinely believe and assert that the ladder came from Maplin. On the other hand, Maplin have produced fairly persuasive evidence that it is not one of their ladders (not one of their ladders with the code N19KJ).

Maplin have produced evidence about other persons who purchased the N19KJ ladder from the Swindon store at about the same time as Mr Curtis but these people have not been contacted as part of the Inquest process. It would perhaps be possible to contact them and arrange examinations of the ladders which they purchased to see if the ladders conform to the N19KJ specification/ photographs supplied by Maplin or whether there are differences and they are in fact similar to the accident ladder.

It remains to be seen whether it will be possible to carry out any further enquiries to determine whether the accident ladder originated from Maplin or not. I respectfully suggest this is a matter for you to decide.

The circumstances are briefly set out in the Record of Inquest. It will be seen that Mr Curtis fell from the ladder and was then admitted to Southmead Hospital in Bristol by ambulance. He underwent treatment but there were complications leading to his deterioration and subsequent death.