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 results
Levi Alleyne
Partially Responded
2022-0346 4 Nov 2022 Berkshire
Accident at Work and Health and Safety related deaths Other related deaths
Concerns summary (AI summary) Ambulance operators lacked clear procedures and accessible contact information for electricity distributors during electrical hazards, leading to significant delays in cutting power. This confusion risked both bystander and emergency service safety and delayed life-saving treatment.
Noted (AI summary) ENA has asked each DNO and TNO member company to check that emergency services have contact details and know how to respond to incidents; ENA will open dialogue with the HSE to see whether it can support them to further enhance awareness and will review and update its safety leaflet - Safety advice for the Emergency Services. NHS Digital explains the function and governance of NHS Pathways, noting that standard operating procedures and contact numbers are the remit of local service providers and do not fall under NHS Pathways' responsibility. AACE shared South Central Ambulance Service NHS Trust's updated SOPs, including a map and contact details for electricity Distribution Network Operators, across all NHS ambulance services. They are also discussing the matter with all Heads of Emergency Operations Centres. HSE shared concerns with the Care Quality Commission (CQC) and Healthcare Inspectorate Wales (HIW), the Association of Police Health and Safety Advisors (APHSA), the National Police Chiefs Council (NPCC) and the National Fire Chiefs Council Health and Safety Committee, and the Energy Networks Association (ENA), who have requested that DNOs and TNOs check their arrangements with the emergency services on an annual basis; the ENA is currently reviewing their information leaflet on Safety Advice for the Emergency Services.
Charles Evans
Partially Responded
2022-0345 25 Aug 2022 Black Country
Care Home Health related deaths Other related deaths
Concerns summary (AI summary) The care home exhibited multiple critical safety failures including no CPR-trained staff, lack of emergency procedures or equipment, inadequate resident supervision during meals, and absence of post-hospital admission risk assessments.
Noted (AI summary) Wolverhampton City Council conducted an unannounced monitoring visit to Hibiscus House, suspended the service from new business, and implemented an improvement plan with the provider, including staff training reviews and relocation of one service user; they are also working with the CQC. Following a CQC inspection Hibiscus drew up an action plan for the three areas of improvement which were identified by the CQC. Plans to upgrade systems which held vital information are under way. The CQC details its role as regulator and its inspection processes. It acknowledges concerns around the safety of people’s care at Hibiscus DCA following a September 2022 inspection and that it is following internal enforcement processes.
Ashley Holden
All Responded
2020-0096 17 Apr 2020 Lincolnshire
Accident at Work and Health and Safety related deaths Other related deaths
Concerns summary (AI summary) Inconsistent and absent definitive guidance for stacking, unstacking, loading, and securing bales in agriculture creates a risk of unsafe practices and fatalities from falling bales.
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.
Eugeniusz Malek
Historic (No Identified Response)
2019-0439 17 Dec 2019 London Inner (West)
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) The absence of regulations for capping scaffolding poles in areas where workers may fall created a hazard, contributing to fatal injuries from uncapped poles.
Kristiyan Danailov
Historic (No Identified Response)
2019-0315 23 Sep 2019 Dorset
Other related deaths
Concerns summary (AI summary) Insufficient identity checks and obstacles exist to prevent vulnerable individuals from purchasing hazardous items online, indicating a lack of industry awareness about associated risks.
Hannah Bharaj
Historic (No Identified Response)
2019-0254 24 Jul 2019 Manchester (South)
Mental Health related deaths Suicide
Concerns summary (AI summary) Ineffective discharge planning, poor information sharing between health agencies and families, a lack of suitable young adult mental health beds, and inadequate oversight of private providers contributed to significant care failures. Additionally, universities need better training for staff to recognize mental health issues.
JJ Wilson
All Responded
2019-0243 17 Jul 2019 Surrey
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) The absence of mandatory regulations requiring fire retardant overalls for test track drivers creates a serious risk of injury or death from fire in the event of a crash, despite their availability.
Disputed (AI summary) The Health and Safety Executive believes existing UK law requiring assessment of foreseeable risk is sufficient regarding the need for fire-retardant overalls and that no further action is required. They state that FIA regulations are outside of HSE's comment.
Rosa King
Partially Responded
2019-0239 12 Jul 2019 Cambridgeshire and Peterborough
Accident at Work and Health and Safety related deaths Other related deaths
Concerns summary (AI summary) Hamerton Zoo lacks onsite conventional firearms and sufficient trained staff to manage an escaped tiger, compounded by unclear national guidance on firearm requirements for zoos, increasing risk to human life.
Action Planned (AI summary) Defra is revising the Secretary of State’s Standards of Modern Zoo Practice (SSSMZP) with expected consultation over the summer and publication by the end of 2020, to address concerns and place clear, legally enforceable obligations on zoos. Defra has undertaken a targeted consultation on draft new Standards of Modern Zoo Practice for Great Britain, addressing the need for clearer guidance and robust inspection processes. The new standards will come into effect on 23 May 2027 and will require zoos to have documented safe systems of work and regular staff training for those working with Category 1A, Category 1 or Category 2 listed animals.
Faye Allen
Partially Responded
2019-0147 29 Apr 2019 Manchester (South)
Alcohol, drug and medication related deaths Emergency services related deaths
Concerns summary (AI summary) Ambiguous interpretation of national ambulance service guidance led to inflated medical staffing numbers at events by including non-frontline first aiders, significantly reducing actual direct medical provision.
Noted (AI summary) The HSE raised the concerns regarding medical provision at events with representatives from the entertainment industry and will send the concerns and their letter to relevant Local Authority bodies.
Mark Parry
All Responded
2019-0094 19 Mar 2019 Cheshire
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) A critical lack of published Health and Safety Executive guidelines for mechanics working with Heavy Goods Vehicle air suspensions exists. This absence means workers lack essential guidance on risks and safety strategies.
Action Planned (AI summary) HSE plans to issue a safety alert identifying control measures for air suspension systems on all vehicle types, aiming to finalise it by August 2019. Longer term, HSE will amend PM85 and review HSG261 to address control measures in relation to ejection.
Kevin Miles
Partially Responded
2019-0058 20 Feb 2019 Leicester City and South Leicestershire
Other related deaths
Concerns summary (AI summary) The diver medical certification process is flawed as it doesn't require GP records, enabling misreporting of health issues and risking divers' and potential rescuers' lives.
Noted (AI summary) The UK Diving Medical Committee (UKDMC) discussed the coroner's points but sees no reason to change the current system of self-certification for divers, where the onus is on the diver to provide corroborative medical information if asked.
Dwayne Thompson
Partially Responded
2019-0055 15 Feb 2019 Manchester (South)
Other related deaths
Concerns summary (AI summary) Reservoir safety was compromised by a regularly damaged fence and warning signs that failed to consider the needs and understanding of individuals with learning disabilities.
Action Planned (AI summary) RoSPA intends to invite all Greater Manchester Local Authorities to a workshop to discuss findings from a City Centre review of drowning incidents and develop plans to prevent future incidents.
Kenneth Bardsley
Historic (No Identified Response)
2018-0407 27 Dec 2018 Manchester (South)
Product related deaths
Concerns summary (AI summary) The coroner raises concerns regarding the lack of minimum qualification standards for lift engineers, the absence of an escalation process for regulatory lift examination results, a lack of clarity on engineers following up on requirements, CQC's failure to identify unaddressed faults, and a lack of systems to ensure lift examination details are read and acted upon.
James McLaren
All Responded
2018-0330 4 Oct 2018 Sunderland
Other related deaths
Concerns summary (AI summary) Inadequate securing of commercial and communal bins, including unsecured lids and easily opened locks, increases the risk of people sheltering inside and potentially becoming trapped.
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.
Donald Berry
All Responded
2018-0324 28 Sep 2018 Manchester (South)
Care Home Health related deaths
Concerns summary (AI summary) The report outlined the medical cause of death resulting from injuries sustained years earlier, but did not detail specific coroner's concerns for future death prevention.
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.
Peter Lett
All Responded
2018-0356 28 Aug 2018 Lincolnshire
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded and dangerous, creating a high probability of further deaths.
Action Planned (AI summary) The HSE acknowledges the need to engage with voluntary organizations and volunteers and improve signposting to relevant guidance so they have a better understanding of their duties. They are actively working to improve web pages and develop further guidance and support networks for voluntary organizations including assisting them in finding bespoke guarding and risk control solutions to include heritage machinery.
Paul Daniels
All Responded
2018-0003 2 Jan 2018 Manchester (South)
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) An inadequate staffing ratio meant tree surgeons lacked qualified aerial support, and poor communication methods via shouting and hand signals hindered safety during work at height.
Action Planned (AI summary) The Arboricultural Association will publish a summary of the events in a safety bulletin to its members and partner organisations by the end of February 2018 and in their quarterly magazine in June 2018, reminding arborists to use correct methods and techniques. The Forestry Commission will circulate the Arboricultural Association safety bulletin, review emergency procedures with in-house arborists, re-brief employees supervising arboricultural contracts, and update the training module for supervisors. The Arboriculture and Forestry Advisory Group (AFAG) will promulgate learning points from the incident via its committee members, and will ensure that these points are considered when specific guidance leaflets are next reviewed.
Marko Petrovic
Historic (No Identified Response)
2017-0354 15 Sep 2017 West Yorkshire (West)
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) There are no written guidelines for dismantling cantilevered scaffolds, nor are specific Risk Assessment Method Statements (RAMS) required for this process, risking worker safety.
Shaun Carter
Partially Responded
2017-0245 29 Aug 2017 Gloucestershire
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Dumper truck safety procedures were not followed, understood by all personnel, or audited. There was also a lack of industry standards for managing spoil heaps, increasing the risk of accidents.
Action Planned (AI summary) The HSE is participating in a construction industry working group to improve safety related to dumper trucks and spoil heaps, and a manufacturers' sub-group is considering potential dumper truck design improvements. Other improvements being considered include features to prevent driving without a seatbelt and audible warnings.
Gustavo Da Cruz, Mohit Dupar, Inthushan Sriskantharasa, Gurushanth Srithavarajah, Kenugen Saththiyanathan, Kobikanthan Saththiyanathan and Nitharsan Ravi
All Responded
2023-0105Deceased 24 Jul 2017 East Sussex
Other related deaths
Concerns summary (AI summary) There is a lack of formal governance and risk management for beach safety. A national review of safety regimes and potential government powers to restrict beach access is needed.
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.
Peter Richardson
Partially Responded
2017-0162 10 May 2017 Surrey
Other related deaths
Concerns summary (AI summary) A lack of formal guidance on safe tolerances for critical elements of two-post vehicle lifts and insufficient torque specifications from suppliers creates an ongoing safety risk.
Action Planned (AI summary) HSB issued a technical document instructing surveyors to record pad wear on reports for vehicle lifting tables. They are also working with SAFed to establish a common approach to torque settings assessment, who are liaising with the HSE. The HSE intends to issue additional guidance concerning the inspection of two post ramps by thorough examiners, highlighting the risks and checks needed for the locking mechanism and lateral movement.
Alan Walsh
Historic (No Identified Response)
2017-0037 3 Mar 2017 London Inner (South)
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) A lack of awareness regarding the safety-critical role and vulnerability of ladder spigots poses significant health and safety risks due to potential inadvertent shearing.
David Alexander
All Responded
2017-0044 14 Feb 2017 Exeter and Greater Devon
Accident at Work and Health and Safety related deaths
Concerns summary (AI summary) Overturns in the industry are underreported and poorly understood, lacking investigation into causes like hydraulic ram bracket failures. There's inadequate industry guidance and a failure to routinely use inclinometers, despite known risks from slight gradients.
Action Taken (AI summary) HSE conducted a survey of Devon feed mills in 2017, finding awareness of vehicle overturn risks and industry guidance. Some businesses have moved to non-tipping vehicles or fitted tipping sensors; others have implemented driver systems or cameras. Advice was given on work at height, noise, and workplace transport issues.
Benjamin Wylie
Partially Responded
2016-0407 14 Nov 2016 Berkshire
Product related deaths
Concerns summary (AI summary) Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety risks.
Action Planned (AI summary) The HSE will issue a Safety Alert regarding the risks associated with grease being expelled from grease nipples at high pressure, the risks associated with the re-use of damaged hydraulic components, and the need for proper training of persons required to undertake track tensioning.
Zane Gbangbola
Historic (No Identified Response)
2016-0328 13 Sep 2016 Surrey
Child Death Product related deaths
Concerns summary (AI summary) Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading use of the HSE logo, increases the risk of harm.