Paul Whitehead
Action Taken
The company has reviewed and compiled new emergency procedures into a controlled document for staff and new inductions. They confirmed the ambulance was called before the H&S manager, provided refresher training to the first aider involved, and revised emergency procedures to ensure lookouts with flashlights are at all access points for emergency services. They also plan to introduce and train 'Appointed Persons' in basic first aid by March 2016. (AI summary)
View full response
Dear Mr McLoughlin,
Inquest into the death of Paul Whitehead (deceased)
Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters of concern in the Regulation 28 Report to prevent future deaths, I have the following information;
1) The provision of First Aiders within the Production Environment.
It is proposed to introduce a number of 'Appointed Persons' within the factory departments. Production Charge Hands across the manufacturing facility will be trained in basic first aid skills and will be able to provide initial and first response aid to a person in the event of an accident or injury in the immediate vicinity. The existing first aiders (First Aid at Work qualification) would then take over once arriving at the scene of an incident. We would expect this to enable a more immediate response in the event of a future incident. We are targeting this to be implemented and training provided as suggested above by 31 March 2016.
2) Mixed evidence about whether the designated first aider prioritised actions correctly and called the Ambulance or the company Health & Safety manager first.
Unfortunately mixed evidence on this issue was given at the inquest. We have checked the records of the security mobile phone and can confirm that the 999 call was made at 18.39 and the call to the H&S Manager was at
18.52.
We are therefore content that the first aider correctly prioritised the necessary calls following the incident.
02 FEB 2016
To ensure that calls would again be prioritised correctly after any future incident we are highlighting the importance of calling emergency services in our new Emergency Procedures. This makes it clear that in circumstances where calling 999 is appropriate, making that call as soon as is practicable in the circumstances is crucial because whilst a 999 call can always be cancelled, lost time can never be made up.
3) The First Aider was unable to perform mouth to mouth resuscitation.
The first aider was trained in resuscitation but found herself unable to perform mouth to mouth on account of shock at the severity of the situation and the nature of the injuries which she found. She did seek the assistance of a colleague who was previously a first aider in the coal mines and then performed CPR while her colleague carried out the mouth to mouth resuscitation.
Our first aiders are not medical professionals and it is very difficult to prepare them for incidents as severe as the one in question to avoid freezing from shock.
We will prepare all of our first aiders so far as possible by refreshing their first aid training on a regular basis in line with HSE guidance. The First Aider in question has already been provided with refresher training following the incident.
We hope that the presence of the Appointed Persons (to be introduced as set out at point one above) will act as support for the first aiders (and each other) when arriving at the scene of an incident, thereby reducing the effects of shock and enabling them to act in accordance with their training.
4) The attendance of the first Paramedic on scene.
Access was initially gained by the Paramedic into the first site entrance they happened to encounter. A second, main goods services entrance, some 70 metres further down Portobello Road was where an employee was waiting. When realising that it was just for car parking the paramedic left the car park and then saw a person waving for his attention. We appreciate that should this happen again any time lost could be critical.
The revised Emergency procedures document now clearly states that the "lookouts" must be stationed at all of the access points to the site. Additionally we are ensuring that flash lights are kept in the security cabin which the lookouts are required to use as an aid for attracting the attention of the emergency services.
As mentioned earlier the Emergency Procedures document is to be issued to all personnel as a refresher and we expect this to have been carried out by 31 March 2016.
Inquest into the death of Paul Whitehead (deceased)
Thank you for your letter dated 15 December 2015. We have undertaken a full review of our Emergency Procedures and have compiled a new controlled document to be issued to all staff as a refresher. This document is also included in the induction process for all new employees and contractors. We have enclosed this document and we feel that it covers all of the points you have raised. Additionally in response to the matters of concern in the Regulation 28 Report to prevent future deaths, I have the following information;
1) The provision of First Aiders within the Production Environment.
It is proposed to introduce a number of 'Appointed Persons' within the factory departments. Production Charge Hands across the manufacturing facility will be trained in basic first aid skills and will be able to provide initial and first response aid to a person in the event of an accident or injury in the immediate vicinity. The existing first aiders (First Aid at Work qualification) would then take over once arriving at the scene of an incident. We would expect this to enable a more immediate response in the event of a future incident. We are targeting this to be implemented and training provided as suggested above by 31 March 2016.
2) Mixed evidence about whether the designated first aider prioritised actions correctly and called the Ambulance or the company Health & Safety manager first.
Unfortunately mixed evidence on this issue was given at the inquest. We have checked the records of the security mobile phone and can confirm that the 999 call was made at 18.39 and the call to the H&S Manager was at
18.52.
We are therefore content that the first aider correctly prioritised the necessary calls following the incident.
02 FEB 2016
To ensure that calls would again be prioritised correctly after any future incident we are highlighting the importance of calling emergency services in our new Emergency Procedures. This makes it clear that in circumstances where calling 999 is appropriate, making that call as soon as is practicable in the circumstances is crucial because whilst a 999 call can always be cancelled, lost time can never be made up.
3) The First Aider was unable to perform mouth to mouth resuscitation.
The first aider was trained in resuscitation but found herself unable to perform mouth to mouth on account of shock at the severity of the situation and the nature of the injuries which she found. She did seek the assistance of a colleague who was previously a first aider in the coal mines and then performed CPR while her colleague carried out the mouth to mouth resuscitation.
Our first aiders are not medical professionals and it is very difficult to prepare them for incidents as severe as the one in question to avoid freezing from shock.
We will prepare all of our first aiders so far as possible by refreshing their first aid training on a regular basis in line with HSE guidance. The First Aider in question has already been provided with refresher training following the incident.
We hope that the presence of the Appointed Persons (to be introduced as set out at point one above) will act as support for the first aiders (and each other) when arriving at the scene of an incident, thereby reducing the effects of shock and enabling them to act in accordance with their training.
4) The attendance of the first Paramedic on scene.
Access was initially gained by the Paramedic into the first site entrance they happened to encounter. A second, main goods services entrance, some 70 metres further down Portobello Road was where an employee was waiting. When realising that it was just for car parking the paramedic left the car park and then saw a person waving for his attention. We appreciate that should this happen again any time lost could be critical.
The revised Emergency procedures document now clearly states that the "lookouts" must be stationed at all of the access points to the site. Additionally we are ensuring that flash lights are kept in the security cabin which the lookouts are required to use as an aid for attracting the attention of the emergency services.
As mentioned earlier the Emergency Procedures document is to be issued to all personnel as a refresher and we expect this to have been carried out by 31 March 2016.