Wessam al Jundi: Prevention of Future Deaths Report
Accident at Work and Health and Safety related deathsProduct related deaths
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Date of report: 25/10/2024
Ref: 2025-0377
Deceased name: Wessam al Jundi
Coroners name: Lydia Brown
Coroners Area: West London
Category: Product related deaths | Accident at Work and Health and Safety related deaths
This report is being sent to: Department of Health & Social Care | Department of Housing, Community and Local Government | HSE
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: 1. Department of Health & Social Care 2. Department of Housing, Community and Local Government 3. HSE | |
| 1 | CORONER I am Lydia Brown, senior coroner, for the coroner area of West London |
| 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 On 23 May 2024 I commenced an investigation into the death of Wessam al Jundi, age 28. The investigation has not yet concluded and the inquest has not yet been heard. |
| 4 | CIRCUMSTANCES OF THE DEATH Diagnosis of severe silicosis lung disease. Awaiting lung transplant. Admitted on Friday 17th May 2024 for potential lung transplant to Harefield Hospital. Had deteriorated since last review with pulmonary hypertension. Bedside echo showed severe pulmonary hypertension with pericardial effusion and left ventricular compromise. Not suitable for transplant as too unwell. Deteriorated and died in hospital on 22 May 2024. Cause of death 1a Respiratory Failure 1b Silicosis (Occupational lung disease) Wessam had been working with artificial stone products which contain a very high percentage of Crystalline silica content. The dust created when these products are cut, sanded and carved creates respirable crystalline silica (RCS) and is too fine to see with normal lighting. It is recognised to cause silicosis if inhaled which causes a hardening or scarring of the lung tissue with initially no symptoms. Once silicosis develops it is untreatable apart from offering lung transplantation. The health risks are almost entirely preventable if exposure to dust is adequately controlled. |
| 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. – This young man presented with an untreatable lung condition probably caused by exposure to RCS in his workplace. This company, “Yes, Marble Ltd” is no longer trading. Any current surveillance health and safety monitoring is unlikely to achieve a satisfactory outcome as the onset of untreatable disease predates the 15 year surveillance programmes. In this case exposure appears to have commenced in May 2016 and he was diagnosed with silicosis in 2021, a mere 5 years after initial exposure. Evidence from photographs and an in-life statement suggest Wessam was working in completely unsafe conditions to avoid dust exposure. Australia has already taken the decision in 2024 to ban these artificial stone products. There are a number of patients in the UK currently awaiting lung transplants due to RCS exposure from their workplaces. The last 2 decades have seen rapid growth in the use of artificial stone and this death demonstrates the emergence of a severe progressive accelerated form of silicosis. Many of the companies specialising in the finishing process of working with this product have a small number of employees and there appears to be an absence of safe working conditions, with no adequate water suppression systems for the dust created, in adequate respiratory personal protection equipment and absent or inadequate ventilatory systems. This is therefore continuing to put the workforce at risk of death due to untreatable lung compromise. |
| 6 | ACTION SHOULD BE TAKEN In my opinion urgent 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 23rd December 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 Insurers of Yes, Marble Ltd [REDACTED] Family I have also sent it to 1. British Thoracic Society 2 Royal College of Physicians 3. Royal College of GPs 4. British Occupational Hygiene Society 5. Workplace Health Expert Committee 6. APPG, Respiratory Health. 7. APPG. Occupational Safety and Health The Trades Union Congress (TUC) 8. Worktop Fabricators Federation 9. UK Cast Stone Association 10. Engineered Stone Manufacturers Association 11. International Surface Fabricators Association 12. Hazards magazine 13. Joe Duggan – INews who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. 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 | 25 October 2024 Mrs L C Brown Senior Coroner West London |