Anthony Rockall: Prevention of future deaths report
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Date of report: 26/06/2023
Ref: 2023-0287
Deceased name: Anthony Rockall
Coroner name: Crispin Butler
Coroner Area: Buckinghamshire
Category: Other related deaths
This report is being sent to: REDACTED
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1 [REDACTED] | |
| 1 | CORONER I am Crispin Giles BUTLER, Senior Coroner for the coroner area of Buckinghamshire |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST On 28th April 2022 I commenced an investigation into the death of Anthony William Rockall, aged 68 years. The investigation concluded at the end of the inquest on 15th June 2023. The conclusion of the inquest was misadventure. |
| 4 | CIRCUMSTANCES OF THE DEATH Tony Rockall died during the early evening of 26th April 2022 at John Radcliffe Hospital, Oxford from the head injury he sustained when he fell from the tailgate of his truck the previous afternoon. The injury was sustained whilst another person was trying to offload a pallet of bricks from the truck at a reclamation yard in Aston Clinton, Buckinghamshire. It is likely that the pallet truck, which appears to have been longer than the depth of tailgate, had become stuck and Tony, who had been standing in a small area at the back corner of the tailgate, fell backwards to the ground whilst the pallet truck was stuck. It is not possible to ascertain whether Tony had a medical event leading to the fall, however his presence on the tailgate was in connection with the unloading of the truck. |
| 5 | CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) It was clear from the evidence that the pallet truck being utilised and the manner of unloading were incompatible with the truck being unloaded in that the pallet truck was longer than the tailgate of the truck and the method adopted required the pallet truck wheels to drop off the tailgate, grounding the load. There were also concerns expressed about the weight of the load, pallet truck and two individuals on the tailgate. Buckinghamshire Council evidence indicated a letter had been written to you on 27th September 2022 but your evidence was that this had never been received. The letter was described as informing you that you must review health and safety procedures at your premises, including the use of the pallet truck and the loading and unloading of client and casual workers’ vehicles. It was indicated you were also to assess the suitability of equipment for the task to be undertaken and to review who was permitted to use the equipment and when. Evidence at the Inquest was that there had been no review and no change of working practices since the incident involving Tony Rockall and that a pallet of bricks delivered on a truck such as was being used by Mr Rockall would be unloaded in exactly the same way now as then. It is clear that such practices could give rise to the toppling of a load, the pallet truck or an individual falling from a truck tailgate with the risk of fatal injuries arising. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by August 17, 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons [REDACTED] [REDACTED] who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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. |
| 9 | Dated: 26/06/2023 Crispin Giles BUTLER Senior Coroner for Buckinghamshire |