Source · Prevention of Future Deaths
Christopher Bevan
Ref: 2019-0104
Date: 20 Mar 2019
Coroner: Tim Holloway
Area: Blackpool & Fylde
Responses identified: 0 / 2
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Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe work practices leading to falls and injury.
Date
20 Mar 2019
56-day deadline
6 Aug 2019 est.
Responses identified
0 of 2
Coroner's concerns
Ladders were used unsafely on a slippery surface, unfooted, and improperly secured. This highlights a risk of unsafe work practices leading to falls and injury.
View full coroner's concerns
(1) That ladders may be used in the course of your work (a) in circumstances in which their use may present & risk to life andlor (b) in a manner in which their use may present risk to life. The Court received evidence to the effect that the ladders in use at the time of the fatal accident on 14h August 2018 were used on a surface which may have been slippery, that they were not footed during use, that were not secured at the top save to the extent that were supported by the blockwork andlor by recently laid coping stones of wall above the door opening of the garage and that may have been used by the Deceased, with whom you had been working; in a manner which involved him assuming an awkward position in order to carry out work: The concern therefore arises that you may use or those with whom you may work may use ladders in circumstances Or in a manner which present a risk to YoU; to them and/or to others_
Report sections
Investigation and inquest
On 06/09/2018 I commenced an investigation into the death of Christopher BEVAN_ The investigation concluded at the end of the inquest held on 12th-14h March 2019. The conclusion of the inquest was that the Deceased died as consequence of an accident and that the medical cause of death was: 1(a) Diffuse brain swelling (operated) 1(6) Blunt head trauma with skull fractures
Circumstances of the death
The circumstances of the death, a8 determined by the jurywere that on 14th August 2018 between 1S00hrs and 1540hrs atl Ithe Deceased was last seen undertaking work to the garage roof whilst on a ladder and that he fell and sustained head injuries. The date of death was 15th August 2018 at 1900hrs at Royal Preston Hospital. The jury' $ conclusion as to death was Accident"_
Action should be taken
my they they facing they
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:
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Report details
- Reference
- 2019-0104
- Date of report
- 20 March 2019
- Coroner
- Tim Holloway
- Coroner area
- Blackpool & Fylde
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 6 Aug 2019 (estimated).
Sent to
- Holloway Assistant Coroner for Blackpool & Fylde
- Iam Tim