Source · Prevention of Future Deaths

Gary James

Ref: 2025-0083 Date: 12 Feb 2025 Coroner: Clare Bailey Area: Teeside and Hartlepool Responses identified: 1 / 1 View PDF

The workplace exhibited a severe lack of risk assessment, inadequate training, unsafe equipment, and inappropriate working conditions, compounded by a culture that disregarded employee safety concerns and supervision.

Date 12 Feb 2025

56-day deadline 9 Apr 2025 est.

Responses identified 1 of 1

Accident at Work and Health and Safety related deaths

Coroner's concerns

AI summary

View full coroner's concerns

No risk assessment and subsequent safer working practice document in respect of new work undertaken_ Work was undertaken on a trial-and-error basis, exposing employees to hazards. There was inadequate and inappropriate training for employees_ The use of unsafe and unsuitable equipment in new work undertaken_ Lack of suitable PPE worn by employees i.e. hard hats_ Employees working in inappropriate conditions (in the dark inside containers/alongside Forklift Truck inside containers) There was a failure to acknowledge or act upon employee's health & safety concerns A general approach of having to "get on with a task" in spite of health and safety concerns and dangers to employees: No first aid assistance was provided by a trained first aider before the arrival of the emergency services_ 10, Failure to adequately supervise employees_

Responses

1 respondent

Ward Bros Malton Ltd Other

9 Apr 2025 PDF

Action Taken

Ward Bros ceased the devanning operation immediately after the accident and conducted a full review of their health and safety procedures in conjunction with third-party experts, leading to improved risk assessments and systems of work which are reviewed annually, as well as a training program for employees. (AI summary)

View full response

WARD BRos doadorma { SoutA aiS MADDLESBROUGHL Tsgexh EL 01642 430150 TRANSPORT AND DISTRIBUTION FAK 01642 8014b Ms Clare Baily Senior Coroner The Coroner's Office Middlesbrough Town Hall Albert Road Middlesbrough TS1 20] 09 April 2025 Regulation 28 Report Action to Prevent Future Deaths James Ward Bros (Malton) Limited make this response to the Future Deaths Report issued by the Senior Coroner for Teesside and Hartlepool following the Inquest into the tragic death of Lee James which occurred as a result of an accident at work on 08 January 2019 Mr James was an employee of Ward Brothers (Malton) Limited. At the time he was engaged in the process of removing metal racking affixed to the ceiling of shipping containers, a process known as devanning: Ward Bros commenced the devanning programme on 19 December 2019_ Devanning containers was not a process that Ward Bros had been involved with prior to 19 December 2019, Ward Bros are primarily an operator of goods vehicles, alongside operating maintenance workshop and a warehousing facility. The devanning process was to be undertaken on a relatively small scale. Ward Bros had in place risk assessments and systems of work for other activities the business was engaged in. However, there was no written risk assessment or written safe system of work for the devanning process_ This was due to devanning not being something Ward Bros had experience of. system was developed through experience. Ward Bros accept that a risk assessment should have been carried out and a safe system of work developed in advance of employees undertaking the devanning exercise: No further devanning has been undertaken by Ward Bros since the accident involving Gary James and we have no plans to become engaged in the process again in the future: For this reason, there is no risk of future deaths occurring at Ward Bros as a result of employees, or anyone else, devanning shipping containers. On the wider subject of Ward Bros general health and safety procedures, risk assessments and safe systems of work were in place for all other activities These had been drafted with the assistance of third parties with the appropriate expertise: Following the accident involving Mr James, Ward Bros conducted a full review of the existing health and safety procedures, in conjunction with third party experts. This resulted in improved risk assessments and systems of work which are reviewed on an annual basis. training programme is in place which ensures employees receive regular training on the safe systems of work and updates are provided by way of toolbox talks and safety notices: Palletways RHA WARD BRos are a member of Palletways (UK) Ltd Registered Office: WARD BROS (Malton) Ltd Company Number: 4068959 Dormor Way, South Bank; Middlesbrough; TS6 6XH VAT No: 5O0 6885 58 Depots at:- Malton, Immingham Please visit WW wardbrosmalton couk Directors: S.J. Ward, CW: Sharpe, R.G.G. Bowes Gary Gary

A third party consultancy is retained by Ward Bros who understands the business and the activities it engages in. The consultancy provides us with updates where developments occur that are relevant to the activities we engage in. Ward Bros then provide its employees with the relevant information. Ward Bros believe that action was taken by the business following the accident on 08 January 2019 which addresses the matters raised in the future deaths report by (1) ceasing the devanning operation with immediate effect and (2) undertaking a full review of health and safety procedures and implementing improved risk assessments and systems of work for all activities undertaken: future activities that Ward Bros may become engaged in will be risk assessed and a safe method of work created, with the assistance of experts, before the task is commenced_

Report sections

Investigation and inquest

On 16 January 2019 [ commenced an investigation into the death of Gary Lee JAMES 30 , The investigation concluded at the end of the inquest on 31 January 2025_ The jury determined that, Gary Lee James was employed as a fork lift truck operator at Ward Bros (Malton) Ltd, He was working at South Bank Middlesbrough plant; On 19, 20 & 21 December 2018, Mr James was shown and engaged in the devanning of welded storage containers. On 19 & 20 December the first three frames were stood flat, stacked on top of each other. Later during 20 December , the first three frames were moved so that they were stood upright; On 20 & 21 December the remaining three frames were stored upright: The vertical frames were not secured. The storage container housing the six vertical frames was relocated on 21,12.2018, The container was moved again on 07.12.2019. The movement of the storage container caused the frames inside to fall: Gary checked upon the frames on 08.01.2019 and saw that the six frames were stood at a 45 degree angle: He entered the storage container with a colleague: They tried to move the six frames by hand, so the frames were stood up. Whilst moving the sixth frame the fifth frame started to fall towards them: This was followed by the other four frames. Gary was trapped by his neck by the frames: He was transported to James Cook University Hospital. He died at James Cook University Hospital on 11.01.2019 due to injuries sustained by being trapped in the frames.

Circumstances of the death

The jury came to narrative conlusion; died at James Cook University Hospital from injuries sustained in trapped by metal frames at Ward Bros on 08.01.2019. His death was contributed to by"
1) There was not appropriate risk assessment & safe working practices and procedures in place prior to the commencements of devanning the welded conta ners:
2) Ward Bros had not considered the potential hazards in removing; transporting and sorting the welded frames in advance of the first frames being dismantled on 19.12.2018
3) The logistics of storing 20 horizontally stacked frames had not been fully considered and assessed,
4) Gary_had not received adequate and appropriate training_in the devanning role: Regulat on 28 After Inquest Document Templale Updated 30,07/2021 aged falling being Gary

This document was cassified as: OFFICIAL
5) There was not sufficient and appropriate supervision of and his colleagues whilst the devanning of welded containers was undertaken
6) No consideration was given to the vertical frames secured in the container.
7) The 6 standing frames were not secured on 21.12.2018 and subsequently became loose before the container was checked on 08.01.2019.
8) Employees did express concerns to Ward Bros about of the devanning process and such concerns were not listen to and acted upon:
9) The general attitude in Ward Bros was one of getting a task completed in spite of health & safety concerns and risks
10) thought he was acting in line with earlier Ward Bros directions in trying to stand the frames on the morning of 08.01.2019.
11) On 08.01.2019 it was not safe for and a colleague to move the 6 frames by themselves and in relative darkness.
12) The methods employed by and a colleague to move and stand the frames on 08.01.2019 were not safe:
13) and a colleague were not appropriately and adequately supervised on 08.01.2019.

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you (and/or your organisation) have the power to take such action_ Your RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by April 09, 2025. 1, the coroner, may extend the period _ Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise_YOU must_explain_why no action is_proposed

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Gary being safety Gary Gary Gary Gary

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Report details

Reference: 2025-0083
Date of report: 12 February 2025
Coroner: Clare Bailey
Coroner area: Teeside and Hartlepool

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 9 Apr 2025 (estimated).

Sent to

Ward Bros (Malton) Ltd

Source links

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Data: judiciary.uk under OGL.