Paul Daniels

Dear Mrs Mutch Re: Your letter dated O2nd January 2018 refence Paul Anthony Daniels; vour reference 5886/CLB With reference to the above please find listed below the actions being taken by the Arboricultural Association to advise its membership, the wider arboricultural audience and relevant partner organisations of the tragic events relating to Mr Daniels death: Publish a summary of the events (as described in your regulation 28 notice) to our membership via a safety bulletin notice (copy attached) This will be done electronically to our 2500 plus members: We will circulate this safety bulletin to relevant partner organisations namely the ICF and ISA This will be completed by the end of February 2018 We will also publish the safety bulletin in our quarterly magazine (Spring Issue published 6th June 2018). As can be seen from the safety bulletin we are reminding arborists to use the correct methods ad techniques whilst ensuring the correct training, preparation and planning is in place: Whilst having these measures in place will help to reduce risks that aerial tree workers are exposed to, the measures relating to adequate aerial rescue provision would not have prevented this type of accident in these circumstances; The deceased is described as an experienced tree surgeon; however, no explanation has been provided regarding the circumstances as to how both his life line and flip line were not correctly attached, which we believe to be the main cause of him falling: (Aerial rescue provision will not prevent falls from height) Aerial tree climbing requires individuals to apply personal control measures, 25 opposed to collective controls potential offered by other systems: e g Mobile Elevating Work Platforms This inevitably brings in a factor of human error; be that a lack of concentration, time pressure, stress, fatigue, feeling unwell; etc: Reducing the risk of future deaths from human error in this respect revolves around supervision, auditing and the measurement of operator proficiency: The Industry Code of Practice for Arboricuiture Tree Work at Height makes specific references to these requirements, but a5 we haven't seen any evidence presented as to how these have, or have not; been followed we are at present unable to comment further in this respect: The Malthouse Stroud Green; Standish Stonehouse; Gloucestershire GLIO 3DL T:01242 522152 Eadmin@treesorguk Arborkultural Atsoclalln Company Limited by Guarantee Ia 4070377 Regstered a5 Charity No 1083845 Arbarkultural Associalion and Ihe treg deve & Ihe Registered Callective Mark of the Arborcullural Assoclion Use of the Calleclive Mlark I$ striclly contralled in accardarce wlh repulalions

To ensure completeness we have copied AFAG and (HM Principal Inspector of Health and Safety; Forestry, Arboriculture and Agricultural Machinery Team} with this response,

Dear Ms Mutch RE Paul Anthony Daniels Thank you for your letter of 2 January 2018 to Mr Ian Gambles, Forestry Commission Director England , enclosing a copy of the Regulation 28 Report following your investigation in to the death of Paul Anthony Daniels: I have been asked to reply. The Forestry Commission has only a very minor role in the arboriculture industry and we do not have any great in involvement in the setting of standards within the industry or communication with practitioners in the industry which means that your opinion that we could take action to prevent further deaths may have been misplaced_ Nevertheless, our Head of Health and Safety and Technical Training has been in contact about the case with both the Arboricultural Association (the industry representative body) and the Health and Safety Executive to see if we can contribute anything to the follow up. Matters such as this are considered at the Health and Safety Executive's Arboriculture and Forestry Advisory Group (AFAG), but would not generaly fall within the scope of the Forestry Industry Safety Accord, where the Forestry Commission plays a leading role as a major player the forestry industry. In respect to our own staff, a small number of which are involved in arboriculture, either directly or through the engagement of contractors to carry out work o the land we manage we will be taking the following action: Circulating the Arboricultural Association safety bulletin regarding this matter; Reviewing the emergency procedures against AFAG guidance 401 & 402 with our in-house arborists; Re-briefing employees, who supervise arboricultural contracts, on the requirements of this guidance; Completing the process of updating the training module we offer for our supervisors regarding arboricutural contracts and we will ensure that the incident is covered within the scheme of work for this module. Protecting and expanding Englands forests and woodlands, and increasing their value lo society and the environment, WW. forestry-gov.uk/england receiVED 2018 key

Forestry Commission England would also like to confirm that the AFAG guidance and current best practice requires risk assessment to be carried out to establish the emergency procedures, methods of communications and sufficient competent resources to effect a rescue without delay. We recognise that reducing the risk of similar incidents occurring in future requires rigorous implementation of these requirements and we will continue to do this in areas where we have control: If you require any further clarification of the role of the Forestry Commission in regard to the Arboriculture Industry then please let me know. We have no objection to the contents of this letter published by the Chief Coroner.

C6 HSE Health and Safety Executive Ms A Mutch OBE Engagement & Policy Division HM Senior Coroner RECEIVED Mr Rlck Brunt Manchester South Coroner's Office Coroner's Court 26 FEB 2018 Head of Agriculture Waste & Mount Tabor Street Recycllng Unit Kingsley Dunham Centre Stockport Nicker Hill SK1 3AG Keyworth Notlingham NG12 5GG Tel: 0203 028 2794 Reference: Your reference: 5886/CLB rick brunt@hse.gov uk hpIhaahse govukl Deputy Director: Philip White Date: 23 February 2008 Prevention of future deaths report Paul Anthony Daniels Date of death 23 November 2016 Inquest at Manchester South Coroner's Court on 24 - 30 November 2017 am responding to your Regulation 28, Prevention of Future Deaths report addressed t0 Dr Richard Judge, Chief Executive of the HSE that arises from the inquest into the death of Paul Anthony Daniels. Your report was passed to me in my capacity as the Chair of HSE's Arboriculture and Forestry Advisory Group (AFAG): Mr Daniels's death is a tragic incident and express my sincere condolences to his family: AFAG is a sub-committee of the Health and Safety Executive's (HSE) Agriculture Industry Advisory Committee (AIAC) and provides a forum at which the Health and Safety Executive (HSE) and others, including the Forestry Commission; trade bodies, training organisations, employers and employees' representatives work together to respond t0 health and safety issues in arboriculture and forestry: AFAG produces guidance for the tree work industry which complements that produced by the Forestry Industry Safety Accord (FISA); the Arboricultural Association (AA) and HSE_ This guidance takes into account practical knowledge and experience of those working in the industry and by following the guidance, those working in trees will normally be complying with the standards required by the Health and Safety at Work Etc Act 1974 and associated health and safety legislation. Your report raises matters of concern in relation to:
1) the ratio of tree climbers t0 groundsmen;
2) the training of groundsmen for aerial rescue; and
3) the means of communication between groundsman and tree surgeons These three matters are addressed in long standing guidance produced by AFAG and effectively set out the standards expected to ensure legal compliance in this type of work the the

Specifically AFAG leaflets AFAG401: Tree climbing operations' and AFAG402: Aerial tree rescue? apply to the work being carried out at the time of Mr Daniels's death: Together these two pieces of guidance describe the responsibilities of ground staff and the need to consider the ratio of ground staff to tree climbers. state that a minimum of people should be present during all tree-climbing operations and one of the team must be available on the ground, competent and equipped to perform an aerial rescue immediately: also state that work should be planned before work starts. On busy sites consideration should be given to dedicating specific member of the ground staff to each climber. Therefore, contractors following current guidance, will ensure that at least one groundsman; trained in aerial rescue will be present at all times ad Will consider the ratio of groundsman to aerial workers as part of their planning for the work. AFAG 401 also states that ground staff should maintain effective communication with climbers at all times. The precise means of communication should be determined by risk assessment by those planning the work and will depend on the particular circumstances of the task to be undertaken. There will be sites where communication by voice and hand signals is appropriate. However, where this is not the case there are readily available alternatives, such as helmet mounted two-way radios_ have considered the AFAG guidance and believe that it adequately addresses the relevant requirements t0 ensure legal compliance. Clearly it is therefore opportune t0 remind the industry of the importance of applying the correct standards for the work being carried out. AFAG next meets as a committee on 8 May 2018 and will take this opportunity to promulgate the learning points from this incident via the committee members The range of organisations represented on the committee should enable the message, through their respective memberships, to have a wide reach throughout the industry: will ask that members underline the importance of all people involved in this type of work adhering to the standards set out in the guidance and highlight the concerns raised in your letter_ In addition as a matter of routine AFAG and its members guidance under review to ensure that lessons learned through incidents are reflected in the guidance and we will ensure that these points are again considered when these specific leaflets are next reviewed.