Health and Safety Executive
PFD Addressee
Reports: 60
Earliest: Oct 2013
Latest: 23 Mar 2026
80% 2-year response rate (below 83% average). 18% of classified responses show concrete action taken.
PFD Reports
60 resultsRichard Hopkins
Partially Responded
2026-0155
23 Mar 2026
Coventry and Warwickshire
Other related deaths
Concerns summary (AI summary)
An unrecognised proximity risk exists from sudden, unexpected failure of pressurised air suspension systems during undisturbed visual inspections, unsupported by current guidance or sector awareness.
Action Planned
(AI summary)
• The Health and Safety Executive (HSE) acknowledged that the proximity risk associated with visual inspection of air suspension systems was previously unrecognised.
• The HSE stated that employers are required to manage risks to their employees so far as is reasonably practicable. • DVSA engaged fully with the Health and Safety Executive (HSE) and attended hearings to determine whether there was anything we could or should do.
• DVSA engaged with the vehicle manufacturer in the same way we would where there is the suggestion of a potential vehicle safety defect.
• DVSA will continue to collaborate with HSE to find opportunities to discuss mitigations that employers can implement to address this kind of problem, for example, in any trade communications or guidance.
Brody O’Brien
All Responded
2026-0084
9 Feb 2026
Lancashire and Blackburn with Darwen
Child Death
Concerns summary (AI summary)
An unsecured ligature point was accessible, and emergency services faced difficult, treacherous access to the location, hindering timely intervention.
Action Taken
(AI summary)
• HSE inspected the site in November 2025 and took enforcement action regarding improvements to site security.
• A further visit was made on 17th March 2026 to re-assess site security and the necessary improvements to the site fencing have been made.
• Liaison with legal and planning representatives from Rossendale Borough Council took place to share concerns and ensure that both organisations are working together. • A copy of the report was sent to the owner of Sunnyside Works, together with a s29 Local Government (Miscellaneous Provisions) Act 1982, requiring the building to be secured.
• The Council has been in communication with the owner of the Albert Mill site and they have confirmed that they are agreeable to taking access over their land to his property in order to carry out the securing of the building.
• The Council has been working alongside of the Health and Safety Executive and officers have spoken with him both over the telephone and in person on site.
Leonardo Machado
Partially Responded
2025-0611
5 Dec 2025
Dorset
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Insufficient oversight of 'rental' food delivery licenses to underage individuals places children in vulnerable lone working situations, increasing their risk of road traffic collisions and harm.
Noted
(AI summary)
HSE acknowledges the concerns around the rental of food delivery licenses to under 18s, lone working, and road safety but states road traffic accidents are generally a police matter. HSE notes actions being taken by other government departments and the food delivery industry to tighten controls.
Brian Davies
All Responded
2025-0631
17 Sep 2025
Swansea Neath & Port Talbot
Other related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
The investigation into a domestic explosion was compromised by police disposing of critical debris. There was no understanding of evidence preservation or protocol between police and HSE for such events.
Action Planned
(AI summary)
The HSE will raise the coroner's concerns at an upcoming WRDP National Liaison Committee (NLC) meeting, recommending refresher communications to signatory organizations, providing an update on national training material for work-related elements of investigations, and providing an update on a proposed 'Suspected Gas Explosion checklist'. They will also provide the Senior Coroner with HSE guidance related to gas safety investigations. South Wales Police will raise the coroner's concerns with the National Liaison Committee regarding the Work Related Death Protocol and collaborate with the HSE and other signatories to ensure any appropriate amendments are made to the protocol. They also noted that they will work with the HSE to ensure the service is able to gather evidence and information needed to identify the cause of explosion.
Stuart Gilchrist
Partially Responded
2025-0460
10 Sep 2025
East Riding of Yorkshire and Hull
Care Home Health related deaths
Concerns summary (AI summary)
Restaurants and food establishments are largely unaware of useful anti-choking devices, and there is no clear responsibility for advising them to stock such potentially life-saving equipment.
Noted
(AI summary)
East Riding Council confirms it does not have powers to specify equipment in first aid kits or publish guidance, instead signposting businesses to HSE guidance, and recommends the Regulation 28 be served to the HSE. HSE outlines health and safety legislation regarding workplace first aid provision and clarifies that there is no requirement for employers to provide specific equipment such as anti-choking devices, advising that the MHRA is responsible for regulation of medical equipment.
Jean Dye
All Responded
2025-0412
21 Jul 2025
Greater Lincolnshire
Hospital Death (Clinical Procedures and medical management) related deaths
Concerns summary (AI summary)
An unexplained Emergency Power Off (EPO) circuit activation caused a critical power loss during an emergency procedure, with no in-lab indicators or reset, significantly delaying treatment and highlighting a guidance gap.
Noted
(AI summary)
NHS England will review and update guidance in HTM 06-01 regarding Emergency Power Off (EPO) controls, including the location of reset buttons, with completion due in the financial year 2026-27. Competency and training for engineers will be included in the HTM update. The CQC acknowledges the concerns regarding guidance on Emergency Power Off (EPO) controls, but states it does not have the power to set guidelines or training expectations. They note that the Trust has confirmed actions taken including durable labels on EPOs, quarterly Electrical Safety Group meetings, and completed installation reports.
Jacqueline Langworthy
All Responded
2025-0386
18 Jul 2025
Coventry and Warwickshire
Accident at Work and Health and Safety related deaths
Product related deaths
Concerns summary (AI summary)
The widespread use of platform lifts without hold-to-run controls in care settings, coupled with limited awareness of these risks and easy retrofitting options, poses safety hazards.
Noted
(AI summary)
The Lift and Escalator Industry Association (LEIA) published a safety notice on their website on behalf of Phoenix Lifting Systems regarding lifting platforms with one-touch platform controls and emailed it to all their members. HSE will raise the matter of platform lifts without hold-to-run controls at the national Local Authority Health and Safety Practitioner Forum and in a technical LA bulletin, and will share the circumstances with CQC and the wider healthcare industry. They are also aware that LEIA has raised the concerns with their relevant committees. LEIA published a further safety notice addressing similar hazards in other lifting platforms from other manufacturers and has made proposals for inclusion of recommendations for the revision of BS 5655-11 to cover legacy lifts with similar hazards. DHSC acknowledges the concerns regarding platform lifts in care settings, but states the responsibility lies with the Health and Safety Executive, who have already responded and are monitoring similar incidents. DHSC shares concerns about the incident but states the matters do not fall within their responsibilities; they have written to the HSE to monitor for similar incidents and review if further action is needed.
Joel Ineson
All Responded
2025-0183
10 Apr 2025
Sunderland
Accident at Work and Health and Safety related deaths
Other related deaths
Concerns summary (AI summary)
Organised open water swimming events lack clear safety responsibilities, specific briefings, participant oversight, and regulatory guidance, creating significant unmanaged risks.
Noted
(AI summary)
The Minister will write to Swim England to explore how awareness of the 'Beyond Swim' accreditation scheme and associated guidance can be increased. They will also continue to work with sports bodies to ensure safety is prioritised. HSE acknowledges the concerns, explains that existing regulations (HSWA and MHSWR) apply to open water swimming events, and that relevant guidance is available from other sources. HSE will not be publishing specific guidance at this time but will raise awareness with local authority enforcement officers.
Peter Konitzer
All Responded
2025-0159
25 Mar 2025
Wiltshire & Swindon
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
HSE website guidance for volunteers is insufficient, failing to emphasize written risk assessments for construction work or provide a comprehensive guide on safety obligations for charitable and voluntary organizations.
Action Planned
(AI summary)
The HSE will work with their communications team to send out a copy of the Wilts & Berks Canal Trust prosecution press release in the main HSE ebulletin series and will consider the coroner's recommendations when they next review the volunteering pages of the guidance on their webpages.
Neville McKenzie
All Responded
2025-0044
24 Jan 2025
Birmingham and Solihull Districts
Care Home Health related deaths
Concerns summary (AI summary)
Care homes lack widespread knowledge and regulatory requirement for anti-choking devices, even for high-risk residents, creating an avoidable risk of deaths from choking.
Noted
(AI summary)
HSE states it is not the appropriate regulator to address concerns about anti-choking devices in care settings, deferring to the CQC for registered providers and the MHRA for medical device regulation. The ICB commissioned training for nursing homes, including a guest speaker on choking prevention and provided free training on modified diets and choking risk. The ICB also shared resources from the RCUK, MHRA and DSI.
Jon-Paul Prigent
All Responded
2024-0648
26 Nov 2024
Derby and Derbyshire
Road (Highways Safety) related deaths
Concerns summary (AI summary)
Agricultural tractors and trailers lack independent roadworthiness testing and essential safety features like decoupling prevention, despite their increasing size and road usage. Current regulations are outdated, posing significant public road safety risks.
Noted
(AI summary)
The Department for Transport will examine what more could be done to ensure the roadworthiness of tractors, trailers and coupling devices and will investigate how best to raise awareness of the DVSA's published guidance on maintaining roadworthiness and vehicle loading, as well as of the existing voluntary trailer maintenance scheme. The NFU provides information and guidance to its members via its website, Business Guides, the British Farmer and Grower magazine, and electronic newsletters, and regularly highlights the importance of tractor and trailer maintenance when communicating with its members. HSE outlines its role as Britain’s national regulator for workplace health and safety and highlights that the health and safety legislative framework and associated guidance is sufficient and clear in its requirement to use equipment suitable for the task that is maintained in a safe condition. The AEA and BAGMA would support proposals for change from the Department for Transport including extending mandatory roadworthiness testing to vehicles travelling below 25mph and requiring failsafe breakaway systems on all trailers.
Wessam al Jundi
All Responded
2025-0377
25 Oct 2024
West London
Accident at Work and Health and Safety related deaths
Product related deaths
Concerns summary (AI summary)
Workers fabricating artificial stone are exposed to unsafe conditions with inadequate dust suppression and PPE, causing rapid onset of untreatable silicosis. Current surveillance is insufficient for this accelerated disease, risking future deaths.
Noted
(AI summary)
The HSE is publishing further guidance, aimed at installers, their managers and supervisors to remind them of the steps they must take to control the exposure risk. They are also working with the Worktop Fabricators Federation to support development of their own information leaflet which they can share amongst their networks. MHCLG is requesting an extension and states that the concerns fall within the remit of the HSE, offering to provide a formal response explaining the limitations of MHCLG's policy remit. DHSC states that they have no comments or suggestions and that responsibility for the Coroner's concerns sits with HSE. The Worktop Fabricators Federation provides a 'state of the art' positioning statement on silica dust risks associated with quartz worktops, highlighting the need for safe working environments and suggesting potential market controls. The Agglomerated Stone Manufacturers Association highlights existing efforts to promote safety and calls for governmental involvement, suggesting clear rules and/or a licensing program for fabricators.
Thomas McAuley
All Responded
2024-0426
2 Aug 2024
Dorset
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
The dangerous practice of roadwork crews urinating between LGV axles risks fatal injuries. Despite a previous death, no industry-wide safety notices or publicity have addressed this ongoing hazard.
Noted
(AI summary)
The HSE acknowledges the coroner's concerns regarding welfare provision and workplace transport safety on construction sites, but asserts that existing legislation and guidance are sufficient and well-known within the industry. They will continue to raise awareness through stakeholder engagement and inspections.
Tony Williams
All Responded
2024-0385
18 Jul 2024
Cheshire
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
There were no clear images in the guidance or support materials produced by HSE to assist drivers who load and unload bales, and the accident would not have occurred if Mr Williams had not unloaded with the overhang facing downhill.
Noted
(AI summary)
The HSE states that current guidance on safe stacking, loading, and unloading of bales is sufficient and does not require further images or supporting material, but they will keep the report on record for consideration when it is next reviewed.
Graham Faulkner
All Responded
2024-0317
13 Jun 2024
Cheshire
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
The HSE failed to promptly investigate a serious workplace injury, leading to the loss of critical evidence and hindering the ability to establish facts and implement preventative measures.
Noted
(AI summary)
HSE explains its decision-making process regarding the investigation and clarifies its Incident Selection Criteria. While the suggestion to specifically name 'paraplegia' in the ISC will be considered, HSE states they are unable to take further action to change procedures, as their focus is shifting to risk-based selection.
Benjamin Leonard
All Responded
2024-0106
22 Feb 2024
North Wales (East and Central)
Child Death
Other related deaths
Wales prevention of future deaths reports
Concerns summary (AI summary)
The Scouts Association lacks a culture of candour and independent regulatory oversight for safety and safeguarding. A critical internal Fatal Accident Inquiry Panel Report was not completed in a timely manner, hindering learning.
Noted
(AI summary)
The Charity Commission acknowledges the report and states they are closely examining the concerns as part of their ongoing engagement with The Scout Association. They will be meeting with TSA again to discuss improvements and will take further regulatory action if needed. The Minister for Education and Welsh Language has noted the recommendations and passed them on to Welsh Government officials, noting that the UK Government is best placed to respond to the recommendation for a Public Inquiry into the Scout Association. The Children's Commissioner for Wales will seek updates from the Scouts Association and will share the PFD report with Estyn, who are expanding their inspections framework to include youth work. The Children's Commissioner will request updates from the Scouts Association by April 30th regarding actions to prevent future deaths/injuries. They have also called for Ofsted to play a larger role in assuring safety in youth work organisations. The Department for Education acknowledges the concerns raised, expresses condolences, and references existing guidance related to safeguarding and activity licensing but commits to no specific new actions. HSE will begin an investigation into Ben’s death and will also look at how they intervene generally with volunteering organisations that provide activities to young people such as the Scout Association to identify lessons for the future regulation of this sector. HSE will undertake a review to identify how this error occurred, and to ensure that it is not repeated and will be writing directly to Ben’s family to offer them an apology. The Scouts Association details actions taken including updating POR (Policy, Organisation and Rules), developing new training modules ('Growing Roots'), creating a new safety committee, and updating risk assessment processes. They also describe planned reviews and consultations. Unity Insurance Services acknowledges receipt of the report and expresses sympathy, noting they are working with insurers and The Scout Association to support customers, and clarifying a factual inaccuracy regarding the chair in 2018.
Owen Garnett
Historic (No Identified Response)
2023-0434
8 Nov 2023
Warwickshire
Other related deaths
Concerns summary (AI summary)
A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful materials. Staff lacked clear guidance on identifying and escalating health and safety issues.
Kellie Poole
All Responded
2023-0364
4 Oct 2023
Derby and Derbyshire
Other related deaths
Concerns summary (AI summary)
There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, and insufficient safety measures for participants.
Noted
(AI summary)
The HSE acknowledges the concerns regarding cold water immersion activities, stating that existing regulations and guidance from other organisations (RNLI, National Water Safety Forum) provide a suitable basis for businesses to operate safely. They will not be publishing specific guidance at this time but will keep the activity under review and raise awareness among local authority enforcement officers.
Karl Mitchell
Partially Responded
2023-0168
22 May 2023
Avon
Accident at Work and Health and Safety related deaths
Other related deaths
Concerns summary (AI summary)
Many older lorry-mounted cranes with dangerous stabiliser designs remain in use, posing a crush injury risk as safety modifications are not universally applied. There is an urgent need to disseminate safety learning and modification awareness throughout the industry.
Action Planned
(AI summary)
The Office of the Traffic Commissioner will assist in providing the HSE's safety notice relating to swing-up stabilisers to lorry operators, once it is published.
John Ibboston
Historic (No Identified Response)
2023-0093Deceased
16 Mar 2023
North Yorkshire and York
Accident at Work and Health and Safety related deaths
Tomas Ceida
Partially Responded
2023-0086Deceased
9 Mar 2023
Inner South London
Other related deaths
Concerns summary (AI summary)
Regulatory bodies failed to follow up on known fire risks from an acoustic wall and communicate effectively regarding building safety. There is also a lack of clarity on fire safety responsibilities for contractors.
Action Planned
(AI summary)
The LFB has integrated peak activity inspectors into mainstream fire safety inspection teams and reminded all fire safety officers to review premises databases before visits. They are also preparing to tender for a single point of reference premises risk database. Planning Enforcement is committed to identify where compliance checks are necessary through their investigation processes, especially for high-risk buildings. Officers are now able to raise concerns relevant to the Fire Brigade through the Integrated Enforcement initiative.
Jamie Wood
All Responded
2023-0061Deceased
17 Feb 2023
Dorset
Other related deaths
Concerns summary (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.
Action Planned
(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.
Evelyn Burcham
All Responded
2023-0421
31 Jan 2023
Somerset
Care Home Health related deaths
Concerns summary (AI summary)
Care homes failed to foresee the risk of cognitively impaired residents misusing riser-recliner chair controls, and there are no regulatory or manufacturing standards for safer remote control features.
Noted
(AI summary)
Aria Care will direct all future requests for riser/recliner chairs to Shackleton's, ensuring lockable handsets, and inform newly admitted residents of this requirement from December 1st, 2023. They are also working to replace existing chairs without lockable handsets and will reduce the use of riser/recliner chairs across the organization. HSE outlines the regulatory regimes applicable to the circumstances. HSE has contacted CQC on the patient safety aspects and notified OPSS regarding consumer product safety. The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs. The Department of Health and Social Care acknowledges the concerns, notes the CQC's investigation and outcome, and mentions Aria Care's move to use lockable remotes on riser-recliner chairs.
Michael Holmes
Partially Responded
2023-0023Deceased
20 Jan 2023
West Yorkshire (Eastern)
Other related deaths
Concerns summary (AI summary)
The current layout of public footpaths through fields with cattle, particularly cows with calves, creates an unacceptable risk of trampling incidents, exacerbated by a lack of clear regulations for dogs on leads.
Noted
(AI summary)
Wakefield Council acknowledges the PFD report but states that many of the concerns are national issues. They state that no action is proposed by Wakefield Council in the absence of change to the statutory framework within which it operates and that a Diversion Order application process takes time. The HSE acknowledges the concerns, explains their role as a regulator, and refers to existing guidance for farmers and landowners. They state that posting notices about dogs is outside their remit but will consider including information on re-routing footpaths in a future review of guidance. DEFRA acknowledges the concerns around safety on public rights of way and refers to existing legislation and guidance, particularly the updated Countryside Code. They state they are responsible for setting out the legislative framework and producing guidance and will look at how to make diverting public rights of way more accessible as part of reforms.
Malcolm Basten
Partially Responded
2023-0004Deceased
30 Dec 2022
Surrey
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary)
There are no mandatory requirements for statutory agency notification, inspection, or accredited health and safety training for principal contractors undertaking significant work-at-height projects.
Noted
(AI summary)
HSE acknowledges the concerns raised, notes the ongoing investigation, and explains the existing notification requirements for construction projects. They clarify that enforcement action, including requiring training, is proportional to the risks and seriousness of the breach and that previous poor performance is taken into account.