David Lyth: Prevention of future deaths report

Accident at Work and Health and Safety related deaths

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Date of report: 07/07/2023

Ref: 2023-0233

Deceased name: David Lyth

Coroner name: Charlotte Keighley

Coroner Area: Cheshire

Category: Accident at Work and health and Safety related deaths

This report is being sent to: 3D Trans, Health and Safety Executive

3D Trans
Health and Safety Executive
I am Charlotte KEIGHLEY, Assistant Coroner for the coroner area of Cheshire
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.
On 10 December 2021 I commenced an investigation into the death of David Alan LYTH aged 45. The investigation concluded at the end of the inquest on 27 June 2023. The conclusion of the inquest was that:   On 30 November 2021 at 3D Trans Shell Green Industrial Estate, Widnes, David Alan Lyth became trapped between two trailers resulting in asphyxia.   From the evidence presented the rollaway could only have occurred from neither the unit and the trailer brake not being applied.
On the 30th November 2021 David Lyth had been working for 3D Trans Limited through a driving agency. That day he had complained of an issue with the air cables on his trailer and had been advised to collect a new trailer from the 3D Trans Limited yard. As he coupled up to a new trailer, the trailer started to roll back and he put his arms out to stop it and became trapped between two HGV trailers. When he was found, he was unresponsive and was taken to Whiston Hospital where his death was confirmed.
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)  
(1)  I received evidence that since 2020, there have been four rollaway incidents involving drivers working for 3D Trans Ltd:
a. An incident causing damage to a fence between the 17th September 2020 and the 9th October 2020;
b. An incident leading to the death of Mr Lyth on the 30th November 2021;
c. An incident on the 15th November 2022;
d. An incident on the 12th June 2023.

I acknowledge that these incidents involve different circumstances and that only one resulted in a fatality.
(2) I received evidence that following each of the incidents, refresher training was provided and various measures were put in place at the yard to physically prevent the vehicles or trailers rolling away. In addition to this, signage has been placed on the tractor and trailer units to serve as a reminder to drivers of the importance of securing the parking brakes on the tractor and trailer units. I have concerns regarding the provision of regular and periodic training for all drivers in respect of coupling and uncoupling procedures.
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.
You are under a duty to respond to this report within 56 days of the date of this report, namely by September 01, 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.
I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
3D Trans

I have also sent it to
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.
9Dated: 07/07/2023
Charlotte KEIGHLEY Assistant Coroner for Cheshire