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24 Pages·2010·0.33 MB·English

by  Rachel Lewellen

Health and Safety Executive Board Paper No: HSE/13/85
Meeting Date: 25 September 2013 FOI Status: Open
Type of paper: Above the line Exemptions: None
Trim reference: 2013/344480

Chief Executive’s Report to the Board

Mid Staffs NHS Foundation Trust Prosecution decision.

1. The Health and Safety Executive (HSE) announced its decision to prosecute Mid
Staffordshire NHS Foundation Trust over the death of Gillian Astbury on 29 August
2013. HSE concluded an investigation into the death of Gillian Astbury at Stafford
Hospital and has decided there is sufficient evidence and it is in the public interest to
bring criminal proceedings in this case. HSE will be charging Mid Staffordshire NHS
Foundation Trust under Section 3(1) of the Health and Safety at Work Act.

2. Gillian Astbury died on 11 April 2007, of diabetic ketoacidosis, when she was an
in-patient at the hospital. The immediate cause of death was the failure to administer
insulin to a known diabetic patient. HSE's case alleges that the Trust failed to devise,
implement or properly manage structured and effective systems of communication
for sharing patient information, including in relation to shift handovers and record-
keeping.

Update on Löfstedt recommendations

3. HSE continues to deliver the Löfstedt recommendations in line with the timetable
announced by the Government. Recent developments include:
The Biocidal Products and Chemicals (Appointment of Authorities and
Enforcement) Regulations 2013 came into effect on 1 September 2013,
consolidating seven regulations in to 1. In addition, the Biocidal Products
(Fees and Charges) Regulations 2013 came into effect on the same day.
Two consultations close on 24 September 2013 on: (i) HSE’s proposal to
consolidate and modernise the Acetylene legislative framework in GB and (ii)
HSE’s proposals to consolidate and modernise the explosives legislative
framework in GB, which includes a proposal to withdraw the Manufacture and
Storage of Explosives ACOP (L139).
The consultation on the revised Approved Code of Practice 'Work with
materials containing asbestos' (L127) closes on 30 September 2013.
Ministerial Visit to the Health and Safety Laboratory
4. Mark Hoban, Minister for Employment, visited the Health & Safety Laboratory
(HSL) on Thursday, 5 September 2013. After a brief introduction to HSL, the Minister
was taken on a tour, which included the rig constructed as part of a major hydrogen
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safety project for the Energy Technology Institute; this work has an international
profile and is aimed at developing low carbon technologies to exploit waste streams
and help meet the energy challenge of the future. He was also introduced to
scientists in the Geographical Information Systems team, Engineering, Microbiology
and Ergonomics, who focused on key examples of HSL’s work.
5. The Minister commented positively on the range of expertise HSL has to offer and
was very supportive of the work of both HSL and HSE.
Hillsborough Investigation

6. On the 12 September 2012 the Hillsborough Independent Panel published its
report into the events at the Hillsborough Stadium on 15th April 1989 which resulted
in the deaths of 96 people. On 19 December 2012, the Home Secretary appointed
the former Chief Constable of Durham, Jon Stoddart, to lead a new criminal
investigation into the events of 15 April 1989. This investigation is called Operation
Resolve. Amongst other things, the police are investigating possible criminal
offences under health and safety laws and have requested the assistance of HSE. A
Principal Inspector and Enforcement Lawyer from HSE and experts from HSL are
assisting Operation Resolve in their investigation.

Super Puma

7. The Air Accidents Investigation Branch (AAIB) is continuing enquiries into the fatal
AS332 L2 Super Puma helicopter crash on 23 August 2013. To date, no evidence of
a causal technical failure has been identified. This follows analysis of the black box
recording and recovery of the helicopter wreckage, which has shown both the rotors
and gear box to be intact. HSE has been participating in meetings of the Helicopter
Safety Steering Group (HSSG), which made the decision to resume Super Puma
flights on 30 August. Proactive inspection of offshore installations resumed in the
Southern North Sea and Irish Sea on 9 September and in all other areas on 16
September. There are however some operators who continue to experience
significant difficulties with regard to flight availability and we are in regular dialogue
with them to ensure that normal business resumes as soon as possible.

8. Arrangements have been made for senior industry leaders to deliver helicopter
briefing events for HSE offshore inspectors to address any concerns. The first of
these took place on 10 September and the second event is scheduled for Aberdeen
on 30 September. HSE has also invited DECC inspectors to attend. Helicopter
safety is outside of HSE's jurisdiction and is regulated by the Civil Aviation Authority
(CAA) under the sponsorship of the Dept of Transport.

Fire Brigade Strike

9. The Fire Brigade Union (FBU) have announced their intention to take strike action
and the first strike will commence in England and Wales only on 25 September 2013
from 12:00 to 16:00. The Government response to this industrial action has been
coordinated by the Department for Communities and Local Government (DCLG), in
close liaison with the Scottish and Welsh Governments. HSE has been working with
Government departments and agencies in preparing for any strike action.
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10. Earlier this summer, a letter was sent by HSE on behalf of the Competent
Authority for the enforcement of the Control of Major Accident Hazard (COMAH)
Regulations to operators of sites that come under the COMAH regulations to make
them aware of the possibility of a strike and advising them to consider the
implications of, and risks associated with reduced emergency response cover and
where appropriate provide supplementary measures and arrangements to prevent
potential major accidents and to minimise their consequences. In addition, a web
page signposting dutyholders to relevant information will be available on the HSE
website for the duration of the strike http://www.hse.gov.uk/services/fire/industrial-
action.htm

KEVIN MYERS
Acting Chief Executive
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Annex 1
Communications Overview August 2013

Introduction
This is the first monthly report to the Board summarising key communications activity
supporting organisation priorities for the month of August.

Small Medium Enterprise (SME) - The H&S ABC
Work continued to encourage use of HSE’s free tools and guidance by SMEs involved
in office based activities and those within the small manufacturing, retail, leisure and beauty
industries.

Health and Safety Made Simple; The Health and Safety Toolbox and HSE's online risk
assessment tools have been branded as the H&S ABC on HSE’s website. HSE is
continuing to identify commercial organisations and trade associations to work in partnership
to promote the H&S ABC to their customers and members. Support has been agreed in
principle with ten organisations and bodies in banking, insurance, product supply and
through trade associations and together have potential to reach more than 260,000 SMEs.

Asbestos Safety Campaign 2013-14
HSE is continuing to work closely with Cabinet Office to develop proposals for a further
communications campaign, aimed at making at-risk workers aware of the dangers posed by
asbestos and helping them understand how they can change their work behaviours to
protect themselves.

Research has been carried out to develop an in-depth understanding of current attitudes and
behaviours in relation to asbestos and working with it. A report summarising the results will
be available in October. The strategy and communications approach have been developed
based on the research findings and updated plans have been submitted to Cabinet Office for
consideration.

Successful Health and Safety Management (HSG65)
The recently launched updated Managing for health and safety microsite on HSE's website,
was promoted to business leaders, owners, trustees and line managers through targeted
emails, e-bulletins, Newsletter, media release, website and Twitter. During August, there
were around 38,500 visits to the updated microsite – an 89% increase based on July.
Around a third of visits were generated by eBulletins, 10% by the media release and 9%
from the website, pushing Managing for Health and Safety into the Top 20 of all HSE
websites.

Work is now underway to update the ‘Successful health and safety management (HSG65)'
publication and further communications are being developed to promote the free
downloadable version (available end of 2013) and the printed book (available January 2014).
Businesses and safety representatives will be able to browse through the document to find
the information they want, and if they wish, print it out.

Online Revisions
A total of 167 online content revisions were made during the period including:
• Personal Protective Equipment (PPE) at work: a brief guide (INDG174 rev2);
• CHIP for everyone: Chemicals (Hazard Information and Packaging for Supply)
Regulations 2009;
• Electricity at work: safe working practices;
• Safety at ‘bring-sites’ in waste management and recycling industry; and
• Updated information on ‘Contact HSE’ pages

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Annex 1
Online Consultations
Three ACoP-related consultations ended on 23 August:
• Control of Substances Hazardous to Health Regulations resulting in 4,780 consultation
downloads, 74 responses;
• The control of Legionella bacteria in water systems Regulations resulting in 7,178
consultation downloads, 100 responses;
• Dangerous Substances and Explosive Atmospheres Regulations resulting in 2,493
consultation downloads, 32 responses.

Legislative controls of acetylene; explosives legislation and managing and working with
asbestos consultations will end in September.

Digital Marketing
The summer edition of HSE’s Newsletter was published in August and Newsletter eBulletin
continues to be one of our fastest growing services, with more than 41,000 subscribers.
Total subscriptions for HSE’s eBulletins passed the two and quarter million mark during
August and highlights for the month include:
• More 'elf and safety excuses exposed by watchdog release was the most popular
eBulletin article in August, accounting for 58% of visits to the page (15,790 visits
overall, 9,203 from eBulletins);
• New guidance to help with health and safety press release for 'Managing for Health and
Safety' was the second most popular eBulletin article, accounting for 60% of visits to the
page in August (11,898 visits overall, 7,086 from eBulletins);
• Judith Hackitt's Half baked or overcooked? Blog post was the third most popular
eBulletin article, accounting for 57% of visits to the page in August (11,096 visits
overall, 6,363 from eBulletins).

News and PR
The latest round of Myth Busters Challenge Panel publicity took place in August. The Daily
Telegraph, Daily Express and The Sun, plus a number of regional titles, covered the story,
which included quotes from Minister Mark Hoban and HSE Chair Judith Hackitt.
Communications Directorate are working on a refresh of the PR approach to ensure Myth
Busters Challenge Panel continues to appeal to the media.

The release of work related injury and death statistics, guidance on the dangers on farms
during the school holidays and publicity ahead of the construction initiative also achieved
regional coverage. In addition, a number of significant media issues were handled including
the Super Puma helicopter North Sea crash and HSE’s decision to prosecute Mid-
Staffordshire NHS Foundation Trust over the death of patient Gillian Astbury.

Internal Communications
Communications to staff included updates from Cabinet Office on the Civil Service Learning
Self Assessment Tool; senior management changes at HSE; reminders about the new staff
directory and annual leave form; and notification of new consultations (explosives and
acetylene), plus promotion of HSE’s latest newsletter and the Chair’s blog. Planning for the
2013 series of SMT Visits continued with the development of briefing materials
(presentation, talking points and Q&A) in advance of the first presentations at the beginning
of September.

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Annex 2

Operations
Fatality details

Since the last update to the HSE Board on Wednesday 14th August 2013, 1 fatal
accident for 2012/2013 was reported to HSE and 24 fatal accidents for 2013/2014
under RIDDOR and subsequently published on HSE’s website. Please see Annex 2
for details.

In some cases, the publication of a fatality on the HSE website and notification to the
Board may be some months after the actual date of the initial incident. This is due to
the verification checks that are carried out to ensure that the fatality is within HSE’s
enforcement remit and if so, the correct information is subsequently published. The
complex nature of some fatality investigations may mean that it can take some time
to verify this information.

Of the 25 fatalities listed in the current report, 10 occurred prior to July 2013.

15 fatalities occurred in July 2013, compared with 23, which occurred in July 2012.

The full list of the names of the deceased plus additional details may be viewed at:
http://www.hse.gov.uk/foi/fatalities/in-year-names.htm.

Significant Prosecutions during August 2013
1. General Motors UK Ltd was fined £150,000 and ordered to pay £19,654 in
prosecution costs at Liverpool Crown Court over the death of a long-serving
worker who was crushed in machinery at its car factory in Ellesmere Port
2. Kenneth George Miller was sentenced to a 24-week prison sentence
suspended for two years and ordered to pay a contribution towards costs of
£600 after admitting safety failings after he reversed his vehicle into a lorry
trailer at a Cambridgeshire waste site, crushing and killing its driver. He will
also be tagged with a home curfew between 10pm and 6am for three months
3. Tyre Renewals Ltd was fined £9,000 and ordered to pay £16,302 in costs at
Yeovil Magistrates' Court after a labourer was injured when his trousers
became entangled in an unguarded lathe
4. Nature’s Power Ltd fined a total of £30,000 and ordered to pay a further
£5,840 in costs by Westminster Magistrates’ Court after a trainee employee
suffered multiple fractures in an eight-metre fall from a roof
5. Patrick Regan was sentenced to 12 months in prison and was ordered to pay
£2,500 in costs at Luton Crown Court for illegally carrying out sub-standard
gas work at a lone pensioner’s home in Bedfordshire
6. Gainsborough Silk Weaving Co Ltd was fined £20,000 and ordered to pay
£10,000 towards costs at Ipswich Crown Court failings after a worker suffered
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Annex 2
three years of ill-health and was left disabled following his exposure to
chemicals
7. Pfiefer Rope & Tackle Ltd was fined £20,000 and ordered to pay £6,348 in
costs at Southampton Magistrates' Court after an outdoors activity instructor
was left permanently disabled when he used a defective rope for a simulated
parachute landing
8. Eagle Freight Terminal Ltd was fined a total of £50,000 and ordered to pay
costs of £4,501.23 plus £120 victim surcharge at Ipswich Magistrates' Court
after a forklift truck toppled and spilled its load onto a worker, breaking his
back
9. Rolls Royce Plc was fined a total of £60,000 and ordered to pay £18,168 in
costs at Derby Crown Court after an employee was diagnosed with a
debilitating condition that has left him with permanent nerve damage
10. Woodall Nicholson Ltd was fined £10,000 and ordered to pay £13,485 by
Trafford Magistrates' Court after seven employees developed a debilitating
nerve condition over a six and a half year period
11. Murdoch Mackenzie Construction Limited was fined £13,400 by Kilmarnock
Sheriff Court after a worker was seriously injured when he fell more than four
metres from the flat roof of a single storey extension being built at Ardrossan
12. Ecobuild Homes Ltd was fined a total of £40,000 and ordered to pay costs of
£10,035 by Canterbury Magistrates’ Court for repeatedly failing to manage
risks on a construction site and exposing workers to needless risk of injury
13. Indo European Foods Ltd was fined £16,000 and ordered to pay costs of
£910.65 plus a victim surcharge of £1,600 by Ipswich Magistrates' Court after
a worker suffered serious injuries to his arm when it became trapped in
unguarded machinery
14. Pirelli Tyres Ltd was fined £20,000 and ordered to pay £4,330 in prosecution
costs by Carlisle Magistrates' Court after an employee sustained major
injuries to his left arm when it became trapped in a tyre-testing machine
15. Mother Redcaps Care Home Ltd was fined £6,525 and ordered to pay
£33,475 in costs at Liverpool Crown Court after it failed to manage the risk of
elderly residents catching a potentially fatal form of pneumonia
16. South Lanarkshire Council was fined £35,000 by at Hamilton Sheriff Court
after two workers suffered flash burns when they struck an electrical cable
while digging a ditch
17. Preston Plastics Ltd was fined £10,000 and ordered to pay £4,533 in
prosecution costs by Preston Magistrates' Court when a 400kg bale struck an
employee as it toppled from an overladen forklift truck
18. North West Mechanicals Ltd was fined £20,000 and ordered to pay £11,247
in prosecution costs at Blackpool Magistrates’ Court and Senior Contracts
Manager David Hanmer received two concurrent eight-week prison
sentences, suspended for 12 months. Mr Hanmer was also ordered to pay
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Annex 2
£8,976 in costs. The sentences relate to health and safety breaches when
NWML fitted two industrial boilers at a Lytham hotel despite having no
experience nor having the required Gas Safe registration.

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Annex 3

The following table is an extract of all 2012/13 and 2013/2014 work-related deaths notified to HSE since the last update to the Board on Wednesday 14th
August 2013, it contains fatalities notified to us in July 2013. It is taken from the latest "Names and details of fatalities" update published on HSE's website on
Monday 2nd September 2013.

HSE's internet publication is the collated picture of ‘as reported’ information on fatalities. It does not purport to be a formal statistical release. Subsequent
investigation may determine that some are not reportable under RIDDOR, for example deaths due to natural causes. Other deaths shown here may have
been caused by gas incidents in the home. In such cases these deaths will not be counted in our statistics for workplace fatal injuries. Provisional quarterly
figures for workplace fatal injuries are available from our latest quarterly injury figures and validated figures and information will only be available on
publication of the annual fatality statistics for Great Britain.

Date of Name Age Description of incident Location of Local Authority General Industry Detailed Standard Industry Employment
incident incident Sector Classification status
23/03/2013 Edith Selby 86 The deceased died Caerphilly Caerphilly UA Service Residential Nursing Care Member of
whilst in care home the Public
premises

17/04/2013 John Dodd 63 The deceased died Havering Havering Construction Other specialised Self
following a fall construction activities Employed
n.e.c.

18/04/2013 Dainius Stogis 45 The deceased fell from London City of Construction Construction of Buildings Employed
height Westminster By Other

17/05/2013 Maureen Upton 73 The deceased died Brighton Brighton & Hove Service Hospital activities Member of
following a fall UA the Public

25/05/2013 Lawrence 79 The deceased died Borders Borders UA Service Residential Nursing Care Member of
Ruthven whilst in care home the Public
premises

11/06/2013 Terry Lewis 65 The deceased fell from Cheshire East Cheshire East UA Service Landscape service Member of
height activities the Public

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Annex 3
Date of Name Age Description of incident Location of Local Authority General Industry Detailed Standard Industry Employment
incident incident Sector Classification status
11/06/2013 Gordon 50 The deceased was Highlands Highland UA Manufacturing Manufacture of agricultural Self
Crombie struck by a vehicle and forestry machinery Employed
other than tractors

13/06/2013 Marjory Clee 94 The deceased died Edinburgh Edinburgh UA Service Residential Nursing Care Member of
whilst in care home the Public
premises

24/06/2013 Thomas 51 The deceased died Orkney Orkney Agriculture Manufacture of agricultural Self
Shearer whilst riding a quad bike and forestry machinery Employed
other than tractors

28/06/2013 Stephen Gruffud 61 The deceased died Wrexham Wrexham UA Service Hospital activities Member of
Jones whilst under medical the Public
care

04/07/2013 William 74 The deceased was Shropshire Shropshire UA Agriculture Raising of other animals Self
Frederick Dunn trapped by an object Employed

05/07/2013 Ian Nicholls 51 The deceased was Bangor Gwynedd UA Service First-degree level higher Employee
struck by an object education

10/07/2013 Jordan Begley 23 The deceased died Bury Bury Service Public order and safety Member of
whilst in Police custody activities the Public

13/07/2013 Stephen Hunt 38 The deceased died Manchester Manchester Service Fire Service Activities Employee
after being exposed to
fire

16/07/2013 Umar Balogun 16 The deceased Kings Lynn W Norfolk & Kings Service Residential Care Activities Member of
asphyxiated Lynn the Public

17/07/2013 Edith Bourne 84 The deceased died Cannock Chase Cannock Chase Service Other human health Member of
following a fall activities the Public

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