David Mobsby

_ : (1) Brighton and Hove City Council were "advising" Blatchington Mill School (BMS) on health and safety: They were apparently template which made no mention of work at height when considering the health and safety of the facilities (caretakinglcleaning) department at BMS. This is dangerous and may have led to the fact that neither of their audits of 2014 or 2018 made any mention of the risks associated with and training requirements regarding working at height: (2) Although Mr MOBSBY was employed either by Brighton and Hove Council or BMS or a combination of the two, he was not monitored or instructed in his work. He was allowed to choose how; when and where he worked, Even though anyone who knew his job description or knew Mr MOBSBY was aware that he was using ladders and step ladders he was untrained with regard to working at height: On the 3rd August 2018 he was unchallenged when he announced his work programme for the His line manager's did not instruct him with regard to the jobs he did, even though those jobs were considered to be unnecessary by the managers_ No methodology was explored when he announced his job for the there was no discussion about the equipment that he was going to use There was no risk assessment undertaken in respect of any of the jobs that he did. He was allowed to work alone and unsupervised. He lay alone and unconscious for 9-10 minutes before he was spotted. It was over 20 minutes before CPR was started. There was no first aider or designated person on the school site that day: His working environment on the 3rd August 2018 meant that he was working with ambient temperatures of around 26 degrees centigrade_ He was not wearing a hat and he worked in the heat initially and then in direct sunlight latterly, from 0848 hrs until his fall at 1255 having taken one forty minute break at 1100 hrs_ using City day: day, hrs

VERONICA HAMILTON-DEELEY DL, THE CORONER 'S OFFICE LLB WOODVALE, LEWES ROAD Her Majesty's Senior Coroner BRIGHTON for the City of Brighton & Hove Assistant Coroners Telephone: Brighton (01273) 292046 CATHARINE PALMER LLB (HONS) Fax: Brighton (01273) 292047 GILVA DJJ.TISSHA W, BA(LA WJHONS It seems clear that working at BMS formed a huge part of Mr MOBSBY's life_ He had been there for many years and was probably in his ways and not amenable to being managed. Those managing him were all relatively new to their managerial posts and yet none of them had received any management training: It was clear had no idea how to deal with him; were not assisted by the fact that it was supposed to be the case that employee was appraised annually. There was no evidence at all to suggest that Mr MOBSBY had ever been appralsed. am concerned that this situation which was demonstrated to be in existence at BMS could well be replicated, not only throughout Brighton and Hove, but throughout England and Wales and this is the reason why this Report has been sent to the Department of Education and think the matters raised in it should have wider discussion throughout the Country. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you AND 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 31st May 2019. the coroner may extend the period. response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain no action is proposed. COPIES and PUBLICATION have sent a copy of my report to the Chief Coroner and to the following Interested Persons Brother Regulatory Inspector; Health and Safety Executive 3_ Health and Safety Inspectorate Secretary of State for Education, Department of Education 5_ Secretary of State for Health, Department of Health Simon Stevens, Chief Executive, NHS England set they They every Your why

VERONICA HAMILTON-DEELEY DL, THE CORONER 'S OFFICE LLB_ WOODVALE, LEWES ROAD Her Majesty' s Senior Coroner BRIGHTON for the City of Brighton & Hove Assistant Coroners Telephone: Brighton (01273) 292046 CATHARINE PALMER LLB (HONS) Fax: Brighton (01273) 292047 GILVA DJJ.TISSHA W, BA(LA WJHONS am also under a duty to send the Chief Coroner a copy of your response_ The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest: You may make representations to me; the coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner; Date: 11t March 2019 SIGNED BY: Irxhunlaw Senior Coroner Brighton and Hove xeley