Jason Holland: Prevention of Future Deaths Report
Skip to related content
Date of report: 12/07/2024
Ref: 2024-0490
Deceased name: Jason Holland
Coroners name: Fiona Butler
Coroners Area: Rutland and North Leicestershire
Category: Accident at Work and Health and Safety related deaths
This report is being sent to: The International Powered Access Federation | The Road Transport Industry Training Board | LANTRA | Independent Training Standards Scheme and Register | National Plant Operators Scheme | National Open College Network as part of the Construction Plant Competence Construction Scheme
| REGULATION 28 REPORT TO PREVENT DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: The International Powered Access Federation (IPAF) The Road Transport Industry Training Board (RTITB) LANTRA (LANd and TRAining) Independent Training Standards Scheme and Register (ITSSAR) National Plant Operators Scheme (NPOS) National Open College Network (NOCN) as part of the Construction Plant Competence Construction Scheme (CPCS) | |
| 1 | CORONER I am Miss F BUTLER, His Majesty’s Assistant Coroner for the coroner area of Rutland and North Leicestershire. |
| 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 16 February 2023 I commenced an investigation into the death of Jason Vaughan HOLLAND aged 51. The investigation concluded at the end of the inquest held before a Jury on 12th July 2024. The conclusion of the jury was that: Jason Vaughan Holland was an experienced self-employed electrician. On the 10th February 2023 he was working at the Mercia Park site when he was found entrapped between a scissor lift and ladder racking at a height of approximately 20 metres. As a result of this he suffered a cardiac arrest which resulted in an unsurvivable brain injury. Jason passed away at the Queens Medical Centre, Nottingham. Jason unintentionally activated the platform raising function instead of the drive function. The Jury returned a conclusion of accidental death. The cause of death was established as: I a Hypoxic Brain Injury. I b Traumatic Cardiac Arrest I c II |
| 4 | CIRCUMSTANCES OF THE DEATH Jason Holland had been sub contracted to work on a construction site at Mercia Park at the fit out stage for the purposes of installing cabling within containment. 90% of the work to be carried out was working at height. The height of the Unit was 20 metres high. The Unit was 100,00 m2. Mr Holland was an experienced electrician of over 20 years. He held his IPAF card. On 10th February 2023, whilst working on a scissor lift at a height of 20 meters, undertaking tie wrapping of armoured cable in containment tray which had been laid in the roof space, he became trapped between the scissor lift railing and the containment tray. The scissor lift could not be lowered from ground level, as Mr Holland was positioned over the rail and any movement could have caused him to fall 20 meters to the floor. Operatives from the principal contractor on site, and sub contractors had to carry out a basket to basket rescue of Mr Holland. Not one of those had been practically trained on how to conduct this rescue before. It took approximately 20 minutes from Mr Holland being discovered to him being lowered to the ground safely on the scissor lift platform whilst being supported by an operative who, harnessed, had climbed from a cherry picker at a height of 20m on to the scissor lift platform. Paramedics were on the scene at the point Mr Holland was lowered on the scissor lift. He was in cardiac arrest but paramedics were able to establish a return of spontaneous circulation. Mr Holland went into cardiac arrest for a second time, and again paramedics were able to establish a return of spontaneous circulation. A secondary part of his rescue necessitated Mr Holland’s retrieval from the scissor lift platform which was 8ft high, before he could be conveyed on to the back of an ambulance and was taken to the Queens Medical Centre in Nottingham. |
| 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) I heard from a number of organisations within the construction and electrical industry and self employed trades persons. I heard that the industry recognised standard within construction for individuals being assessed as competent to operate a mobile elevated working platforms (MEWPs) is IPAF (International Powered Access Federation) whereby individuals undergo a one day course to be assessed as competent to operate a cherry picker/boom lift (3a) or scissor lifts (3b). I understand that there are a number of training providers nationally who run the course but that the syllabus is set by IPAF. Operatives who pass the course are issued with an IPAF card which is renewed every 5 years. As part of the course, I understand that operatives are classroom trained and then practically assessed operating the necessary MEWPs. Whilst the theory touches upon rescue at height scenarios (albeit having seen the syllabus it deals with potential falls from heights not entrapment). It does not include practical training on rescue at height scenarios or basket to basket rescues drills as standard. I heard evidence of the challenges that the organisations had found in sourcing a practical drill based course for at an height rescue. All operatives I heard from working for a range of trades had their IPAF cards and not one had ever received practical training of at height rescue. They all told me that they had received theory based training only. I heard evidence that time is of the essence. For example in a suspension from a harness type scenario (not Jason’s case) between 5 and 15 minutes could be the difference between life or death. The same however can be said for someone who is suffering from positional asphyxia because they are trapped. I am therefore concerned to note that practical based rescue drills are not part of the standard competence based training offered for those operating these machines who are likely to be first on site facilitating rescues. Whilst Mr Holland’s case concerned the construction industry and the assessment of competency of operating MEWPs through IPAF, I understand that all of those organisations identified operate within their relevant sectors as IPAF does for the construction industry and MEWP operating competency based courses follow a similar syllabus, without any practical rescue from height drills being offered as standard. |
| 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 6th September 2024. 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 The Family of Mr Holland WinVic Construction Ltd Walter Miles Electrical Engineers Ltd Direct Electrical (Leics) Ltd 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: 12/07/2024 Miss F BUTLER His Majesty’s Assistant Coroner for Rutland and North Leicestershire |