Talk given by Penny Allan

TUC/CCA Conference, 8 July 2002 on
 “Law Enforcement and Corporate Accountability”

My son, Ridgley Allan, died on 26 February 1999 - he was 24.  His death was investigated as a work related death by North Somerset Council Health & Safety Inspector and the Police.  Today I would like to talk to you about the adequacy of these investigations and the prosecution decisions made by the Crown Prosecution Service and the Council. 

First, a few words about my son.  He had Asperger Syndrome a form of autism at a higher functioning level.  Somerset Social Services managed his adult Care Plan and at the time of his death he was living in a private residential home in Weston-Super-Mare.  The home specialised in people with learning difficulties and challenging behaviour.  North Somerset Council is responsible for monitoring that the home complies with the Health and Safety at Work Act 1974

On the evening of 20 February 1999 Ridgley was returning to the home from a trip to the cinema.  He sat at the back of the home's minibus travelling along the M5 motorway.  There were 4 residents and 2 staff in the vehicle. Both staff sat in the front with no physical access to the residents if there were problems.  One resident, not Ridgley, began shouting, and the care workers turned up the radio to drown out the noise.  Next thing they knew Ridgley was falling or stepping out of the mini bus which was travelling at about 50 mph.  He died 6 days later.

My son's death raises important questions:

	What procedures were in place at the home regarding management of residents while travelling in the minibus?
	Was there an obvious risk?  How foreseeable was it that someone might try to exit the moving mini bus?

Remember, these were special needs young people, most with known problem behaviours, and they were being taken along the motorway in an unsecured vehicle.

The Investigation 

The joint  investigation showed that the care home had taken no precautions to prevent residents from either falling or stepping out of a moving vehicle and there were indications of negligence by the care home.

The evidence was submitted to the Crown Prosecution Service to consider if there was sufficient evidence of gross negligence to justify bringing a manslaughter charge.  The Crown Prosecution Service decided there was not.

An inquest was held, after which the Council  brought a health and safety prosecution.

There were 2 charges:

One was section 3 of the Health and Safety at Work Act concerned with failing to take reasonable and practicable measures to ensure the safety of those other than employees.

The other charge was under reg. 3 of the Management of Health and Safety at Work Regulations 1992 – that is for failing to carry out an adequate risk assessment. 

This was the position in Aug 1999, immediately after the Inquest.

At this time we were contacted by a concerned care worker who had known Ridgley at the home.   

She told us that 
	incidents in the mini bus had been common 
	she herself had been involved in three incidents involving residents in the mini bus and
	that these incidents were recorded in the record book for management to read, but were not serious enough to bring specifically to the attention of management

We passed this information onto the police asking them to investigate. Two-witness statements were taken by the police. 

A month later the care worker contacted us again this time to inform us that
	she had overheard a conversation between  a member of staff and the home's owner 
	the member of staff had been so concerned about the minibus arrangements that she suggested alternative plans to the owner, that is, they use two cars instead of one minibus to transport residents. However this had not been done

We felt that layers of carelessness were unraveling, but it was vital evidence coming to light.

A final duty statement was taken from the care worker and details of the 2nd care worker who had voiced concerns earlier, were provided.

So, how was this new evidence used?

1. the Police contacted  this 2nd care worker, but she refused to speak to them.

2.	The Crown Prosecution Service told us it was relevant but inadmissible in court- 
	because it was  hearsay evidence

3.  Following a meeting with the Council it materialised:

The Council had not received the new evidence  -  they later said this was a mistake and that they had in fact received it but had not taken this new evidence into account when considering what charges to  bring  or  taken any steps to interview these individuals.  

The care worker who had suggested alternative ways of transporting residents had  refused to speak to the police.  However the Council has powers to compel an individual to be interviewed and answer questions on Health and Safety matters.

Sadly, in our case they chose to turn a blind eye, look the other way, when evidence was clearly being offered.

We move now on to the Health and Safety prosecution.

By late 1999 this began going through the courts.

In June 2000 the first of the two charges was dropped, but we were re-assured there was sufficient evidence for a successful prosecution under reg. 3 the failure to have an adequate risk assessment.

The case proceeded to the Crown Court.

In June 2001 we telephoned the court to confirm dates for when the council would be presenting its case – we were told that no evidence would be presented.  In plain English the case had been dropped,

We had not been informed or consulted when these decisions were made.  

You can imagine that at this point we were extremely disappointed and angry.
We now wanted to know how these decisions had been arrived at.

It was at this point my husband and I contacted the Centre for Corporate Accountability for advise and assistance on how we could seek clarification from the Council of the reasons why they withdrew the health and safety charges and why no individual manager or indeed the owner of the care home were ever prosecuted.

A meeting was arranged by the Centre for Corporate Accountability.  At the meeting a year ago the Council told us the reasons for its decisions.  

The section 3 charge under the Health and Safety at Work Act was dropped in June 2000 because the Council's barrister had advised them  - that it would not be possible for the Council to establish that the owner could have foreseen what Ridgley might do and should have taken steps to prevent it.

However had the Council used its powers to take compulsory statements from the care workers who had raised concerns with management about the dangers to staff and residents in the mini bus and had suggested alternative transporting arrangements prior to February 1999  - there may have been a different outcome – vital, pertinent information was ignored by the council  

The second charge under regulation 3 – failure to have a risk assessment was withdrawn because weeks prior to the Crown Court hearing a new document had come to light - from the defence barristers.  It was claimed that the care home had employed a professional to carry out a risk assessment before Ridgley's death.  This they said showed that the care home had carried out a suitable a risk assessment – even though the supposed risk assessment failed to mention vehicles, the home's minibus, the highway or travel by residents and staff on the highway.  

We saw the alleged risk assessment - How on earth was this document relevant? The council said it was relevant in so far as the owner now had grounds to pass on his liability to another person. 

Finally, an area we find disturbing.  Inspections carried out by the Council several months prior to Ridgley's death had said of the care home that it had 'very good standards'.

I feel this was perhaps the biggest factor in the council dropping the case. The Council barrister advised:

"Whilst Local authority inspection reports which do not criticise risk assessment cannot provide a defence, at the very least it will lay North Somerset Counsel as the prosecuting council, open to a charge of hypocrisy when they failed to spot the inadequacy themselves. The point will both undermine the prosecution and possibility lead to bad publicity."

Were charges withdrawn merely to protect the council from bad publicity because they had failed to do their job properly? In these circumstances one can not help but wonder how independent was their decision?

The Council have failed to acknowledge the potential conflict of interest which this can create and refused to provide us details of their arrangements for dealing with potential conflict of interest when considering health and safety prosecutions.

In conclusion

It is obvious that our son's death occurred in a work-related situation and that some negligence occurred.

That the negligence was serious is plain from the fact that the case was referred to the Crown Prosecution Service.

At the end of lengthy investigations and two years through the courts, no case was actually brought to trial.

There were leads not followed up along the way, although they appear to have been highly relevant.

In our view, there was curious prosecution advice.

It is difficult to believe we have seen all their reasoning.

We don't feel that the reputation of the system for health & safety enforcement has been enhanced.

Our only recourse now is to seek explanations why the LA acted in the manner in which it did.  We are currently awaiting a reply from the LGO to our complaint.