Health and Safety Executive

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.

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.

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.

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.

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.

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. 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. DHSC states that they have no comments or suggestions and that responsibility for the Coroner's concerns sits with HSE. 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.

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.

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.

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.

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. 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. 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.

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.

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.

Noted (AI summary) HSE acknowledges the concerns and highlights existing guidance and enforcement approaches related to vehicle loading and workplace safety, particularly regarding bales. They will consider improvements to guidance INDG125 during its next periodic review. The DVSA will update the 'Load Securing - Vehicle Operators Guidance' in collaboration with HSE, focusing on generic safe loading principles rather than specific bale/trailer combinations. The DfT Code of Practice, 'Safety Loads on Vehicles' (2002) will be amended to cross-reference the updated guidance.

Noted (AI summary) The HSE clarifies the meaning of 'secure' in the WISH WASTE 25 guidance, stating that it requires a risk assessment to determine appropriate measures to prevent bin access, but does not mandate a specific type of lock. They emphasize liaison between waste producers and collectors. The ESA has been raising awareness of the dangers of people in waste containers since 2009 through various means, including the press, a cross-sector steering group, a safety week, a safety alert to members, and contribution to the WISH Waste 25 guidance. CIWM has produced imagery promoting the use of WASTE25 guidance and encourages waste producers and waste collectors to check the bins while filling and unloading, which has been shared on social media. CIWM will aim to write an article for the CIWM journal / website to promote the ‘People in Bins’ Steering Group and call for volunteer waste collection companies to get involved by providing data to mirror the 2014 report by February 2019. The LGA will include an item on the risk of death and injury in large bins in relevant LGA bulletins and updates to councils to raise awareness at a national level.

Noted (AI summary) The Department acknowledges the concerns but states that the issue falls under the remit of the Health and Safety Executive (HSE). Kendal Calling appointed Ground Control, an event production company, as their Health and Safety advisor after the incident. The HSE will raise awareness of the incident with industry stakeholders, emphasizing adherence to event safety guidance regarding overhead power lines.

Noted (AI summary) The RNLI recommends that landowners are responsible of implementing a range of appropriate control measures at beaches, and states that it can only establish new lifeguard units with the express permission of the relevant local authority, landowner, beach owner or operator. The council acknowledges the concerns and refers to previous reports and statements regarding beach management at Camber Sands, and states that restricting public use of beaches would be disproportionate. The Forum intends to update and expand the use of the WAID database and is seeking to identify suitable sources of funding for this development work. RoSPA states that it seeks to influence, inform, coordinate activity and advise within the existing structures for water safety, and states that significant landowners successfully manage sites with significant hazards to the public without noticeable impacts or blanket restrictions. The MCA has recently started working closely with the RNLI on coastal risk management, including a programme of visits to landowners to discuss and advise on local risks and the potential for raising public awareness through targeted safety interventions, and will conduct an independent review of its accident prevention activity.