Health board fined following the death of an elderly patient and failure to comply with an Improvement Notice
A Health Board has been fined following the death of a vulnerable patient who left a hospital ward unnoticed through an unsecured door.
The Health and Safety Executive (HSE) investigation concluded that Cwm Taf Morgannwg Health Board failed to act on previous absconding incidents, which would have better protected 74-year-old Lynwen Thomas, who went on to fall in icy conditions in the hospital grounds and suffer a fatal head injury.
On 13 November 2019 Mrs Thomas, a patient on Llynfi Ward at Maesteg hospital, who was a known wanderer, left the hospital after 8pm unnoticed by hospital staff. That evening was very cold with snow on the ground. Mrs Thomas fell on a path resulting in her fatal injury.
An investigation by the Health and Safety Executive found that despite previous absconding incidents, including one involving Mrs Thomas, no reasonably practicable measures were taken at Llynfi Ward until after the fatal incident to protect vulnerable patients from wandering and potentially coming to serious harm.
Following another patient absconding incident at Princess of Wales Hospital, HSE served an Improvement Notice on the Health Board on 30 September 2020. The Notice applied to the Bridgend locality and required the Health Board to assess the risk to patients from escaping, absconding or wandering. The Notice was not complied with by the due date.
Before Cardiff Magistrates’ Court, Cwm Taf Morgannwg Health Board pleaded guilty to charges of breaching Section 3(1) and Section 33(1)(a) of the Health and Safety at Work etc. Act 1974 and were fined £850,000 with full costs awarded of £10,627.30.
Carlsberg fined £3m following 2016 ammonia gas leak
Carlsberg has been fined £3 million after a contractor died and another was seriously injured following an ammonia gas leak at one of its breweries.
The incident happened at Carlsberg’s site in Northampton. An investigation by the Health and Safety Executive (HSE) found Carlsberg hadn’t put proper controls in place. Father-of-two David Chandler, 45, was killed and David Beak, now 57, was seriously injured.
David Chandler was a father of two, from Bridge North, Shropshire. His family today said they welcomed the end of the case against Carlsberg and hoped no other families would have to suffer as they have.
Birmingham Crown Court heard that at its Northampton brewery Carlsberg had failed to put in place appropriate isolation controls to prevent exposure to ammonia before work started to remove a compressor from a refrigeration system.The Principal Contractor for the project was Crowley Carbon UK Ltd, which had appointed numerous contractors to assist in the works. On 9 November 2016 while the compressor was being removed, there was a large, uncontrolled release of ammonia.
David Chandler and David Beak were both employees of sub-contractor Speedrite NE Ltd. Twenty people needed hospital checks after showing symptoms of ammonia exposure. It was several days before the leak was contained and gas levels dropped to a safe level. David Beak, of Failsworth in Oldham, was seriously injured.
Carlsberg Supply Company UK Ltd, who were summonsed under their new company name of Carlsberg Marston’s Brewing Company, pleaded guilty to charges under Section 2(1) and Section 3(1) of the Health and Safety at Work etc. Act 1974, and Regulation 3(1) of the Management of Health and Safety at Work Regulations 1999. The company was fined £3 million with costs of £90,000.
MoD issued with Crown Censure by HSE after Marine recruit died during an exercise
The Ministry of Defence (MoD) has been issued with a Crown Censure by the Health and Safety Executive (HSE) after a Royal Marine recruit died during a routine training exercise.
On 21 January 2020, Royal Marine recruit Ethan Jones drowned while taking part in a training exercise involving a night beach landing at Tregantle Beach, Cornwall.
As the final part of their training, the recruits took part in an exercise which included disembarking from a landing craft into the sea and wading to shore. The depth of the water was deeper than anticipated and a number of recruits were submerged and had to be rescued. Recruit Ethan Jones was found floating next to the landing craft. Although he was recovered from the water and transported by air to hospital, he tragically died three days later. The HSE found the MoD failed to undertake a suitable and sufficient risk assessment, failed to properly plan, failed to properly supervise, and therefore failed to ensure the safety of their employees during what should have been a routine training exercise.
By accepting the Crown Censure, the MoD admitted breaching its duty under Section 2(1) of the Health and Safety at Work etc. Act 1974.
- The Health and safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise. hse.gov.uk
- The breach of law the Censure is being issued over is: Section 2(1) and Section 3 (1) of the Health and Safety at Work etc. Act 1974, which states that: “It shall be the duty of every employer to ensure, so far as is reasonably practicable, the health, safety and welfare at work of all his employees”.
- The MoD cannot face prosecution in the same way as non-Government bodies and a Crown Censure is the maximum sanction for a government body that HSE can bring. There is no financial penalty associated with Crown Censure, but once accepted is an official record of a failing to meet the standards set out in law.
- More information on Crown Censures can be found here
- The Code for Crown Prosecutors sets out the principles for prosecutors to follow when they make enforcement decisions. HSE’s approach to Crown Censure is set out in its enforcement policy statement
Firefighters left seriously injured in quarry training exercise
A fire service has been prosecuted after two of its firefighters received serious head injuries – with one paralysed from the chest down – after a training exercise.
A team of four firefighters from Staffordshire Fire and Rescue Service were carrying out a rope rescue training exercise at a disused quarry near Buxton on 29th September 2019. Two of the firefighters received head injuries when rocks fell from the cliff face and hit them.
An investigation by the Health and Safety Executive (HSE) found there were failures in the arrangements and controls of the exercise. The risk assessment failed to consider or identify the risk of falling rocks and or the impact recent heavy rainfall may have had on the stability of the rock face. The fire service didn’t have the health and safety guidance for off-site training events. The investigation also found that the service failed to provide sufficient information, instruction, training, and supervision to its firefighters.
Staffordshire Commissioner Fire and Rescue Authority of Pirehill Lane pleaded guilty to failing to discharge the duties imposed upon it by Section 2(1) of the Health and Safety at Work Act 1974. They were fined £10,000 And ordered to pay costs of £6,808.40.
Manufacturing company fined after worker loses part of hand
Laxtons Limited, a West Yorkshire manufacturing company, has been fined for safety breaches after a worker lost part of their hand in a textile machine.
On 24 March 2021 an employee of Laxtons Limited was running a number of textile machines. When he opened a guard to check on a build-up of fibres, he reached in to remove material, losing part of his hand. An investigation by the Health and Safety Executive (HSE) found that one of the machines had a defective interlock device. This allowed the machine to continue running when the guard, which was located over a pair of in-running rollers and gears, was opened.
Laxtons Ltd of Baildon, Shipley, West Yorkshire pleaded guilty to breaching Regulation 11 (1) of the Provision and Use of Work Equipment Regulations 1998. The company was fined £15,750 and ordered to pay £759 in costs at Leeds Magistrates’ Court.
Company fined after gable wall collapses
A building company has been fined £40,000 after the unsupported gable wall of a house collapsed on to a neighbouring property leaving a resident with a fractured sternum and collarbone.
The wall fell during a home refurbishment project in which the existing property had been reduced to a shell with its roof, internal walls, and structural support members for both gable ends removed. Temporary supports to prevent the collapse of both gable ends were not in place and the correct sequencing of works and co-ordination with the scaffolding contractor failed to take place, resulting in the collapse.
An investigation by the Health & Safety Executive (HSE) found that the incident at a house in Grange Road, Bushey, Hertfordshire, on 5 April 2021, could have been prevented by effective planning of the dismantling sequence of works.
Barote Construction Ltd of Clydesdale Avenue, Stanmore pleaded guilty to breaching Regulation 19 (1) of the Construction (Design and Management) Regulations 2015. The company was fined £40,000, ordered to pay costs of £686 and a victim surcharge of £190 at St Albans Magistrates Court on 6 July 2022.
Building contractor sentenced over unsafe work practice
A Blackburn based building contractor has been sentenced after unsafe work methods constituted a public risk and resulted in asbestos being disturbed.
Preston Crown Court heard that in November 2020, Mr Mohammed Shafiq, owner of a roller shutter business, purchased a former warehouse in Manner Sutton Street, Blackburn to convert into smaller work units, including one for his own use. He was using his own employees for this. A report was received by the Health and Safety Executive (HSE) from a member of the public, concerned about the fact that bricks from the blocked-up windows were being knocked out from inside onto the street below, causing risk to passers-by.
The HSE investigation found that as well as the risk posed to pedestrians, no edge protection had been installed to prevent the employees from falling. They were also at risk of an internal fall down an open shaft. Additionally, an asbestos survey had not been carried out on the building prior to work commencing. As a result, piles of disturbed asbestos containing materials such as asbestos cement and insulation, were lying throughout the site. Workers were dry sweeping construction dust and debris possibly containing carcinogenic asbestos dusts without any respiratory protective equipment or suitable personal protective equipment. None of them had been provided with any training in asbestos awareness. Live electric cables were being trained through water without RCD protection, posing a risk of electric shock, and there was a general lack of training and suitable equipment for work to be carried out in a safe manner. An experienced principal contractor should have been hired to assess risks and undertake refurbishment work in a controlled manner.
Mohammed Shafiq of Whitehead Street, Blackburn pleaded guilty to breaching Regulation 5 of the Control of Asbestos Regulations 2012, Regulation 4 of the Construction (Design and Management) Regulations 2015 and Regulation 4 of the Work at Height Regulations 2005. He received a 12 month suspended sentence and was fined £5,000 and ordered to pay costs of £4636.08
Company fined after fatality involving a mobile elevating work platform
A Lincolnshire based manufacturing company that specialises in lifting and handling equipment has been fined after an employee died after falling with a work platform onto the M25 motorway.
Reading Crown Court heard that Rick Jeager-Fozard, an employee of Kimberly Access Limited, was carrying out a routine pre-delivery inspection on a mobile elevating work platform (MEWP) on 5 June 2013. The MEWP extended to an unsafe angle and resulted in the MEWP falling onto the M25 motorway. Mr Jeager-Fozard was working in the platform of the MEWP, falling with the device.
An investigation by the Health and Safety Executive (HSE) found that the device had become unsafe because a miscalibration of its secondary boom angle sensor, which started to extend even though the boom had not been raised to the necessary angle. It was found that the MEWPs secondary boom had raised to an angle around 6-degrees lower that required, the boom then extended beyond its safe working limit and tipped over.
The miscalibration occurred through incorrect data being manually manipulated and uploaded onto the machine via a laptop using password protected WebGPI software. The carrying out of warranty repairs on the machine during this period, including granting access to the WebGPI software, fell within the conduct of Genie UK Ltd’s undertaking.
Genie UK Limited of The Maltings, Wharf Road, Grantham, Lincolnshire pleaded guilty to breaching Section 3(1) of the Health and Safety at Work Act 1974. The company was fined £270,000 and ordered to pay costs of £165,175.
Fabrication company in court after worker injured shoulder in lathe
A metal fabrication company has been fined £22,000 after a worker’s overalls were drawn into a lathe, trapping him and resulting in serious injury.
The employee of Oxford Engineering (Hampshire) Ltd, was working on the Semco Lathe at its site on Moreland Road, Gosport, when he became entangled by his work coat in the feed screws. The overalls did not rip, and they were drawn very tightly on him causing his injuries. The lathe was slowed by the employee by pressing the foot brake, and then fully stopped when a colleague came to assist and pressed the emergency stop button. The accident resulted in multiple breaks to his right shoulder, requiring a plate and screws to be inserted.
The Health and Safety Executive (HSE) found that the company failed to provide adequate guarding to prevent entanglement on the lead and feed screws for the lathe involved in the accident. The company failed to recognise the dangers, and that adequate guarding was required when working with machinery to protect workers from the dangerous moving parts.
Oxford Engineering (Hampshire) Ltd, of Anchorage, Gosport, Hampshire pleaded guilty to breaching Regulation 11 (1) of The Provision and Use of Work Equipment Regulations 1998 in the incident in February 2021. The company was fined £22,000 and ordered to pay costs of £6,617.42 at Portsmouth Magistrates’ Court on June 24 2022.
Glass company fined £80,000 after worker injured in fall from height
A glass manufacturing company has been fined £80,000 after a worker sustained serious injuries when he fell through a roof. A worker at NSG Pilkington (UK) Ltd stepped from a load bearing roof to a fragile roof at Pilkington premises in St Helens and fell nearly three meters to the floor below. He sustained life changing injuries including a fractured lower back and right heel plus injuries to his shoulder and elbow. The court heard he was unable to return to his job, forcing him to retire early.
An investigation by the Health and Safety Executive (HSE) found that the NSG Pilkington (UK) Ltd, did not provide a safe system of work for working at height or ensure its control measures were implemented.
NSG Pilkington (UK) Limited of European Technical Centre, Hall Lane, Lathom, Lancashire, pleaded guilty to breaching Section 2 (1) of the Health and Safety at Work etc. Act 1974 and was fined £80,000 and ordered to pay costs of £767.
Warehouse owner fined after worker falls 30 feet through skylight
A Blackburn based warehouse owner has been fined after an employee of a roofing contractor Nizamuddin Gorji fell approximately 30 feet through a glass skylight on a warehouse roof resulting in severe life changing injuries.
Preston Crown Court heard that roofing contractor Nizmuddin Gorji was engaged by Floors ‘n’ Carpets Limited of Gate Street, Blackburn to over-clad the existing roof. Three operatives were employed to carry out the work which started on 13 May 2020. The following day, one of the employees, Taj Zahir fell through the roof sustaining serious injuries to his pelvis, arm, knee and face and has undergone extensive surgery since.
An investigation by the Health and Safety Executive (HSE) found that Floors ‘n’ Carpets Limited failed to undertake due diligence checks on the roofing contractor’s documents and ensure a construction phase plan was prepared prior to work commencing. Nizmuddin Gorji previously pleaded guilty to failing to adequately plan the work and provide coverings or underslung nets to prevent or mitigate a fall through the fragile roof. He had not completed any health and safety training and did not adequately train the operatives he employed.
Floors ’n’ Carpets Ltd of Gate Street, Blackburn pleaded guilty to a breach of Regulation 4(1) of the Work at Height Regulations 2005 and was fined £96,000 and ordered to pay costs of £36,919.75
Farm building fall left worker with serious injuries
A FARM business has been fined £13,400 after a labourer was left with brain and spinal injuries when he fell from height while putting up farm building.
Eden Veg Limited, of King Cup Farm, Willets Lane, Denham, Buckinghamshire, had commissioned a new grain store from a Portuguese supplier, but because of the COVID pandemic, the supplier had been unable to travel to the UK to put up the building. The farm business decided to use employees to build the barn themselves. One of the employees, 34-year-old Florin Morariu, fell from height while helping to install profiled metal cladding to the roof of the steel-framed farm building. Florin sustained severely life changing brain and spinal injuries in the incident on 12 April 2021.
Eden Veg Limited pleaded guilty to a breach of Section 2(1) of the Health & Safety at Work etc. Act 1974, and was fined £13,400, with full costs of £8,303.08 and a victim surcharge of £195 on 16 June 2022 at Reading Magistrates’ Court. District Judge Goozee said that the incident had been an accident waiting to happen. The starting point for determining the level of the fine had been £160,000 – this was reduced to £13,400 after the company’s turnover, mitigating circumstances and early guilty plea were taken into consideration.
