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Deaths
in 2001
Click on the names below for further case details
Click on the names below for further case details
No details of deaths available Click on the naes below for further case details
FURTHER DETAILS OF DEATHS Kenneth Lloyd
Kenneth, a self-employed builder, was killed when he fell from a farm building roof while working for his son. Because Kenneth was not in an employment relationship there was no Health and Safety Executive (HSE) investigation or jury.
Jonathan Ruell
Jonathan, a farm worker, was driving a tractor for a friend when it stuck in the mud and overturned, killing him. Because Jonathan was not in an employment relationship there was no Health and Safety Executive (HSE) investigation or jury.
William Gittins
William, a two year old, was run over by a tractor and killed on New Year's Day as he helped his father feed cattle on their farm. The tractor was being driven by a neighbour as William's father's tractor was not working. William's death came within weeks of the launch of an agricultural safety campaign by the Health and Safety Executive (HSE). The inquest was held at Powys Coroner’s Court on 11 March 2002. A verdict of 'Accidental Death' was returned.
Andrew Witherston
Andrew, a lorry loader at a Powys sawmill, was knocked down and killed when he was hit from behind by a lorry as he walked along a road at the BSW plant at Newbridge-on-Wye. The inquest was held at Powys Coroner’s Court on 26 March 2003. A verdict of 'Accidental Death' was returned. The Health and Safety Executive (HSE) brought a prosecution against the company, which was charged with a breach of the Health and Safety at Work Act relating to failing to ensure safety of employees. The company was fined £100,000 and £ 9,192 costs at Merthyr Tydfil Crown Court after pleading guilty at Llandrindod Wells Magistrates Court in November for breaching safety rules. Speaking after the hearing, HSE Inspector Tania Stewart said, 'This sentence should prompt other employers who have vehicles running through their premises, to re-examine their workplace, in order to ensure that pedestrians and vehicles are adequately segregated.' The prosecution over Andrew's death followed two other serious accidents in less than 12 months in one of which a worker suffered serious multiple fractures in an accident involving the drive mechanism of the mill. Sandra Witherston, Andrew's widow, said after the sentencing she would consult her lawyers about possible further action. 'It really doesn't matter how much the fine was because it can never undo what's happened,' she said. 'It's been a very difficult time for my family and until now I have concentrated on the Health and Safety Executive's prosecution,' she added. 'I suppose I will now have to talk to lawyers to consider whether I want to take legal action myself.'
Robert Mann
Robert was killed in an incident involving a forklift truck in GF Potter's recycling plant in Welshpool. The inquest was held at Powys Coroner’s Court on 27 February 2004 when a verdict of 'Accidental Death' was returned. In October 2004 at Mold Crown Court James Edward Potter admitted a charge under the Health and Safety at Work Act of failing to ensure the safety of an employee. Judge John Rogers QC fined him £20,000, with costs of £6,500. The court heard Robert had driven the forklift over a weigh-bridge because his usual route was blocked by an articulated trailer. But as he crossed the raised weighbridge, the forklift mysteriously accelerated, veered to the left, and toppled over. David Abberton, prosecuting for the Health and Safety Executive (HSE), said Robert tried to jump clear but was trapped by the overhead guard of the truck, which struck his head. Colleagues lifted the truck by six inches, enough for paramedics to get him out, but he died. An investigation by the HSE concluded the accident had been caused, or contributed to, by the company's failure to insist Robert wore a seat belt, and to erect safety barriers. The judge said, 'Whatever penalty I impose, it will not begin to reflect the fact an employee died and the distress that has been occasioned to his family.' A year before safety experts warned seat belts and barriers were needed, but the company had considered them unnecessary. Potter has now spent £13,000 installing them. 'I am quite satisfied the failures on behalf of the defendant resulted simply from an oversight which unfortunately had these terrible consequences,' the judge said. Simon Morgan, defending, said Mr Mann had been a close family friend of Potter and his most experienced and valued employee. His death had been felt particularly keenly. Mr Morgan said the company's safety consultants had not been aware of new regulations requiring forklift trucks to have seat belts.
Sylvan Money
Sylvan, a chronically depressed patient on suicide watch in the psychiatric unit at Bronllys Hospital, Brecon, used her night-gown cord to hang herself from her bedroom curtain rail. Sylvan's death came within a week of a failed attempt to take an overdose and days after she was admitted to the unit. The inquest was held at Powys Coroner’s Court sitting in Ystradgynlaisand concluded on 6 October 2006 when the Coroner recorded a narrative verdict contributed to by neglect. The Coroner Geraint Williams listed 36 separate errors which led to Sylvan's death. Mr Williams announced his verdict by saying, 'Sylvan's death was contributed to by a catastrophic failure of the system at the adult psychiatric unit at Bronllys Hospital.' That failure was the rota system for nursing staff operating the suicide watch duty. When Sylvan had been admitted to the unit she was put on 15-minute suicide watch for at risk patients. Within days that was downgraded to 30 minutes, despite evidence suggesting her mental state had not improved. But a catastrophic breakdown in operating the rota meant Sylvan had not been checked on for more than an hour when she was discovered dead. Mr Williams highlighted the fact that none of the nursing staff had had any training for suicide watch. He said he would be sending a letter to Powys Local Health Board calling for nursing staff to be habitually trained, and annually updated, in suicide awareness, current observation policy and practice and risk management. Among his concerns was the fact that one member of the care staff had reading difficulties which had apparently been unknown even to a colleague of 20-years standing. Other deficiencies highlighted by the coroner was a general attitude among many staff that there was no need to inform anyone if they could not carry out their hourly suicide-watch duties. No one was responsible for monitoring the situation which meant such failures were never detected. He said there was no structure to the way information was passed on to staff, records were not properly kept and many staff did not appear to read patient files. This compromised their ability to make informed decisions and meant nobody was aware of the 'desperation' Sylvan was feeling. The coroner said not enough time was spent with Sylvan and daily reviews of suicide watch frequency were not carried out. Senior staff at the unit also failed to carry out obligations to provide a safe environment. A report instructing the hospital to check for potential ligature points was passed on to a department which then ignored or forgot it for almost 18 months. Senior staff members believed curtain and other rails at the unit had been made safe or collapsible, to prevent them being used as ligature points, when that was not the case. The inquest heard all curtain rails had since been removed from the unit and major changes to the monitoring system were in place or under way. Among other problems was that the person responsible for passing on official danger and warning bulletins was untrained and inexperienced. Mr Williams had praise for some members of staff at the unit. He commended Dr Dineon Murugesan, the psychiatrist who admitted Sylvan to the unit, for the 'very skilled' way he had done his job. He had initially put Sylvan on 15-minute suicide watch and had written in his notes when they first met, 'Major depression, severe episode.' But a colleague, Dr Heshan Rushton, came in for criticism for later making decisions about Sylvan based on very limited information. He had defended this in evidence to the inquest, saying that at the time he was just carrying out a 'review and not an assessment' of her case. Mr Williams said, 'It is perhaps my deficiency that I do not understand the difference. I would have thought that constant assessment of patients was required.' The coroner also praised Dr Gillian Todd, the medical director of Powys Local Health Board. He described her evidence as 'honest and honourable' and said it was evident she was 'genuinely distressed' by what had happened. He said she had read out at the inquest part of the board's own official report into the tragedy. It had stated that Sylvan's care had been 'uncoordinated, poorly documented and in an environment which was not compliant with best practice'. It concluded that she had received 'sub-optimal care'. The coroner added, 'She was unable personally to link this with Sylvan's death. She accepted that Sylvan was not afforded the high quality clinical care that she should have been afforded in a safe environment.' Sylvan's parents spoke after the verdict of their treatment by the local health board. 'From the outset when Sylvan died, there was no contact between the hospital and ourselves,'said father Christopher Money. 'Nobody from the hospital informed us of Sylvan's death, we found out from one another or from the police. We were all left absolutely on our own without any support. That memory will stay with me forever.' Sylvan's mother, Carol Horne, said she had no faith that the health board was capable of making the changes needed to the way the unit operated. 'For me they are obviously not capable of doing that themselves. Some outside body, such as the Health and Safety Executive, should come in and oversee what they do.' With regard to the verdict, she added, 'We could have written that ourselves two-and-a-half years ago. It has taken until now for it to come out.' Marjorie Wallace, chief executive of Sane, said, 'Sylvan Money is one of the 167 patients who take their own lives each year while supposedly being cared for in the safety of a hospital unit. Although it was known that she was at high risk of suicide, and it is also known about the dangers of ligatures in in-patient suicides, Sylvan was failed by the very people and systems who should have protected her. This is a betrayal of the trust of her family who, like others, have had to give a duty of care to hospital authorities.' She continued, 'It is unusual for a coroner to openly criticise the health services, but there has been such a deterioration in conditions in many mental health units that people and families often have no other voice. We support the family in their quest for ways in which such 'catastrophic failings of systems and individuals' do not allow others to lose their lives.' The case was still under investigation by HSE Wales in January 2009.
Thomas Cliff
Thomas was working in a forestry plantation at Dolanog near Welshpool on Monday when he died after being crushed by a falling tree. The inquest
is to be held at Powys Coroner’s Court. No date has yet been set.
James Hornby
James, a self-employed roofer, suffered fatal injuries when he fell from a roof while working on M Burgins and Son garage building in Fronwen Lane, Dolau, near Llandrindod Wells. The inquest
is to be held at Powys Coroner’s Court. No date has yet been set.
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