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Other Work-Related Manslaughter Cases - acquittals



Name of Deceased Date of Death Acquittal Date Prosecuted Defendant Position
Claire Furmedge, Elizabeth Collings Jul 2006 6 Mar 2009

Maurice Agis

Artist
Isaac Rowlinson 23 Jul 2007 Jul 2008 Linda Wise Nanny
Peter Giles Oct 2004 May 2008 Kathleen Vitturini Care home manager
James Berry Dec 2005 Feb 2008 Philip Firth Drainage firm employees
David Jones
Jason Downer, Rupert Saunders and James Meaby Aug 2006 13 Dec 2007 Michael Hubble Officer of the watch
John Morton July 2004 Nov 2007 Mark Winter Site foreman
Frank Hutchison 28 Feb 2006 29 May 2007 Marion Dixon Care assistant
Christina Hooper Home owner
Doris Smith 11 Jul 2005 1 Feb 2007 Howard and Martin Baker Farmers
Alan Dunn 10 Dec 2005 Oct 2006 Charge dropped

John Gordon Stephen

Senior surgeon

William Kadama, Gameli Akuklu

July 2002 June 2006 PC Daniel Phillips Lifeguard
Kostadin Yankov Nov 2003 May 2004 Richard Wicks
Owner of equipment
David Aitkenhead
Operator
Kevin Sharman Jul 2002 Mar 2004 Matthew Doubtfire Training instructor
Mark Falivena Aug 2001 Nov 2003 Beverly Swane Railway Foreman
Tony Mayk Jan 2001 Dec 2003 John Chambers Lorry driver

Deaths of Claire Furmedge and Elizabeth Collings

Claire Furmedge and Elizabeth Collings died in an incident at Riverside Park in Chester-le-Street in July 2006 when a Dreamscape inflatable sculpture became airborne while a further 27 were injured.

In February 2008 charges of manslaughter were brought against Maurice Agis, 76, a renowned London-based artist. Mr Agis answered police bail at Charing Cross police station and was charged with gross negligence manslaughter.

Mr Agis also faced a charge under the Health and Safety at Work Act.
Chester-le-Street District Council, the council's director of development services, Tony Galloway, and Liverpool-based promotions company Brouhaha International have also been charged with breaches of the Health and Safety at Work Act.

All were summoned to appear before Peterlee Magistrates' Court on February 26 2008. On 26 February Mr Agis was granted unconditional bail by magistrates.

Mr Agis appeared at Newcastle Crown Court on 5 March 2008 when a trial date of 26 January 2009 was set.

On 19th December 2008 at Newcastle Crown Court Mr Agis denied manslaughter charges. Mr Agis also denied a charge under Section 32 of the Health and Safety at Work Act, 1974.

Brouhaha International Limited admitted a breach of Section 21 of the Act and was fined £4,000.

Chester-le-Street District Council pleaded guilty to breaching Section 31 of the act and was fined £20,000, while Tony Galloway pleaded not guilty to breaching Section 31.

The judge, Mrs Justice Cox, ordered that the charge lie on file and Mr Galloway will not face trial.

Maurice Agis was found guilty in February 2009 of breaching safety rules and was fined £10,000 but the jury was discharged after failing to reach a verdict on the manslaughter charge.

On 6 March 2009 the Crown Prosecution Service said it would not ask for a retrial.

6 Mar 2009 BBC News No retrial for Dreamspace creator
26 Feb 2009 Journal Live Dreamspace jury unable to convict Maurice Agis of manslaughter
20 Dec 2008 The Herald Inflatable artwork’s creator denies manslaughter
19 Dec 2008 Northern Echo Dreamspace: Council admits safety breaches
6 May 2008 BBC News Trial set in artwork deaths case
26 Feb 2008 BBC News Sculpture deaths accused in court
21 Feb 2008 Hartlepool Mail Dreamscape artist in court over deaths

Death of Isaac Rowlinson

Linda Wise, a nanny, was accused of murdering 13-month-old Isaac Rowlinson at his home in Penwortham on 23 July 2007 but had the charge she faced reduced to manslaughter.

The incidents were alleged to have taken place between August 13 and 21 August 2006, and on or between 21 August and 4 September 2006.

A hearing at Liverpool Crown Court was told the Crown had decided to reduce the charge from murder to manslaughter.

No plea was entered by Miss Wise.

The manslaughter trial started at Liverpool Crown Court on 23 June 2008 when Miss Wise, of Gaerwen, Anglesey, pleaded not guilty.

After a five-week trial Mr Justice David Clarke had informed the defence and prosecution, in the absence of the jury, that he considered there was insufficient evidence against the defendant.

The following day the judge told the jury he had been 'greatly troubled' by the prosecution evidence since around halfway through the case. Among other reasons, he said, in his view the jury could not reasonably conclude that the bleeding on Isaac's brain took place in the timeframe alleged by prosecutors.

He added, 'Yesterday, when I indicated the ruling I am giving today, I said there were no winners in this case. The loss to the parents of Isaac is incalculable and the defendant herself has been under a cloud of suspicion for a long time. And that cloud may not lift at once now the case has come to an end.'

Det Supt Mick Gradwell, of Lancashire Constabulary's Major Investigation Team, who led the inquiry, said, 'While we are naturally disappointed with this outcome, from the outset this has been an incredibly complex investigation. We respect the judge's ruling and accept his comments. Our thoughts remain with Paul and Lisa who, regardless of the outcome of this case, have lost their son.'

25 Jul 2008 BBC News Nanny cleared in baby death case
24 Jun 2008 Lancs Evening Post Nanny denies baby manslaughter
2 Apr 2008 Chorley Guardian Nanny charged with manslaughter
1 Apr 2008 Preston Citizen Manslaughter charge for nanny

Death of Peter Giles

The death of Peter Giles led to care home manager Kathleen Vitturini being charged with manslaughter.

That charge was dropped in April 2008 after Vitturini pleaded guilty to the lesser charge of wilful negligence.

Peter died of pneumonia in 2004 after being placed by social workers into the care of Abbeycroft Care Home in 2003 suffering from Parkinson's Disease and Alzheimer's.

His brother Ken told how Peter alarmingly lost two stone in 10 days while at the home. He also claims a report into Peter's death revealed he had at times been left in soiled clothing for up to 12 hours.

'We went away for 10 days and came back and I thought he was dead. He had lost about two stone, his tongue was black and I did a 'pinch test' on his hand which showed he was dehydrated. Something obviously went drastically wrong.'

By September 2004, Peter's condition was worsening quickly and detectives said it was the speed and extent of that deterioration which was at the centre of the police investigation into his death.

Officers felt Vitturini had failed to meet her responsibility in providing appropriate care and staff who could notice his worsening condition.

Vitturini, it was revealed during the preliminary court hearing, spent only one and a half days a week at the home.

She was to be sentenced on Tuesday May 20 at Preston Crown Court.

May 2008 Blackpool Gazette

Brother blasts care home death shame

May 2008 BBC News

Carer admits man's neglect death

Death of James Berry

13-year-old James, a promising racing cyclist, died in December 2005 after an incident when he was out training as on the Douglas to Peel road at Greeba, Isle of Man. James died from head injuries the following day.

Philip Firth and David Jones, two mechanics at Island Drainage and Groundwork, were charged in connection with the death. The two worked on the lorry, a 1992 Leyland DAF Constructor tipper truck, a few days before the incident and replaced a brake drum which required them to remove and replace the wheel which came loose on the road.

In February 2008 the two mechanics were cleared of James's manslaughter.

In a trial lasting 10 days the 12-member jury was told that the charge of manslaughter was made on the basis that the work the mechanics carried out was grossly negligent and the major factor in the cyclist's death.

But in their defence the two said that they carried out the work to a good standard and were sure that the vehicle was safe when it went out on the road.

David Hornby, a senior vehicle examiner from the Vehicle and Operator Services Agency, appeared as the prosecution's expert witness in the case. Mr Hornby examined the lorry after the fatal incident.

Walter Wannenburgh, prosecuting, asked him to explain the complex technical study he had compiled. To assist him in explaining his findings to the jury the wheel which came off the lorry was brought into court.

The jury were also shown a collection of photographs of the lorry, its hub and wheel mounting mechanism and pictures of the wheel which came loose.

Mr Hornby said that the wheel was held in position not just by 10 wheel nuts tightened onto 10 wheel studs but it was also balanced by six spigots, arranged radially, which were there to make sure the wheel was correctly aligned.

He said examination showed these spigots were 'excessively worn' which would have meant the vehicle would have failed an MoT.

He said that if the spigots were worn it would have meant the wheels on the axle would have been misaligned and would lead to vibration which would cause the wheel to come off no matter how firmly the wheel nuts were tightened.

'It's rather like an automatic washing machine on a spin cycle which vibrates when it is not loaded correctly,' said Mr Hornby.He added such severe wear on the hub spigots should have been clear to mechanics working on the vehicle hub assembly as they had to remove two wheels on the rear axle to get to the brake drum.

This would have allowed them to inspect the hub and the worn spigots, said Mr Hornby.

The lorry had 10 wheels, two at the front and eight at the back, arranged in pairs on two axles.Mr Hornby told the court he was in no doubt the defects on the hub were the major cause of the wheel coming loose.

But when cross-examined by defence advocate Jason Stanley, representing Mr Jones, he accepted at least one of his calculations was incorrect. Mr Hornby said it did not affect his conclusion about the accident's cause.

In a lengthy cross-examination Mr Stanley suggested to Mr Hornby he was 'ducking and diving' to fit the facts to his theory. Mr Hornby, who gave evidence for three days in the trial, rejected the allegation.

Mr Firth and Mr Jones were backed in their defence by expert witness Chris Sawyer a motor mechanics expert, who said his analysis showed that damage to the vehicle's wheel hub was caused during the accident and was not the cause of the accident.

22 Feb 2008 Isle of Man Today Cleared mechanic speaks out after manslaughter case
20 Feb 2008 Isle of Man Today Mechanics cleared of manslaughter charges
12 Sep 2006 Isle of Man Today Two in court on manslaughter charge

Deaths of Jason Downer, Rupert Saunders and James Meaby

Michael Hubble, an agency worker was officer of the watch on the P&O's Pride of Bilbao appeared in court in February 2007 charged with the manslaughter due to gross negligence of three sailors. The three men were on board the yacht, Ouzo, which vanished after leaving the Isle of Wight for Devon on 20 August 2006.

The bodies of Jason, Rupert and James were found in the sea a few days later.

Ouzo had left Bembridge, on the Isle of Wight, bound for the Dartmouth Regatta. The bodies of the three-man crew were found on 22 and 23 August in the sea off the Isle of Wight.

The cause of death for James was a combination of drowning and hypothermia, while the other two died of drowning. The 27ft (8.2m) Sailfish sloop has never been found.

The car ferry and its black box data recorder were later examined by investigators.

Mr Hubble was initially arrested on 2 September and released on police bail until he appeared before Portsmouth Magistrates' Court.

At a brief hearing at Winchester Crown Court in February defence counsel Oliver Saxby indicated Hubble, who was granted unconditional bail, would plead not guilty to the three counts at the next hearing.

The trial at Winchester Crown Court concluded in early December 2007 and on 5 December the jury retired to consider its verdict.

On 13 December 2007 Mr Hubble was cleared of manslaughter, but jurors could not reach verdicts on charges of endangering the men's lives under the Merchant Shipping Act.

The judge instructed that 'not guilty' verdicts be recorded on the charges the jury could not reach verdicts on.

Nautilus, the union that represents maritime professionals, commented, 'The official investigation into the loss of the Ouzo highlighted serious shortcomings in the adequacy of navigation equipment. There is now extensive evidence to show that the standards of lights and radar reflectors fitted to many yachts are simply not good enough, and the adequacy of the regulations in this area must also be questioned.

'The official investigation also raises questions about procedures on ships' bridges — not least in handover periods at night — and consequent implications for crewing levels need to be addressed by the industry.'

An investigation into Ouzo's disappearance was published by the Marine Accidents Investigation Branch (MAIB), which investigates all maritime accidents but does not apportion blame, in April 2007.

It concluded Ouzo was almost certainly affected by a collision or near-collision with a large vessel.

There is no doubt that the Pride of Bilbao was involved in a close encounter with a yacht at about 0107 BST on 21 August 2006. The ferry's 'black box' recorder revealed a conversation between Mr Hubble, and his lookout, David Smith, as the encounter took place.

The MAIB said it was of the 'firm opinion' that Ouzo was the yacht involved in the close encounter with Pride of Bilbao.

The MAIB investigation looked into the possibility that Ouzo had hull failure or suffered an explosion but dismissed the theories.

The MAIB report was not presented to jurors during Mr Hubble's trial because the Merchant Shipping Act does not allow them to be used as part of any prosecution.

The Crown Prosecution Service said there would be no retrial and that, from their point of view, the matter was now closed.

The initial coastguard response to the incident was 'seriously inadequate', according to an internal Maritime and Coastguard Agency (MCA) report .

A catalogue of serious mistakes were made, which included failing to begin even a routine helicopter search for the men for six hours. It later transpired that, despite the shortcomings, the sailor's lives could not have been saved. But in the report, the MCA acknowledged that in other circumstances those failures could have contributed to 'loss of life'.

Further doubt was cast on the trial verdict in an article in the Financial Times in August 2008 which included the transcript from the Pride of Bilbao's Voyage Data Recorder, of the conversation between the lookout and the officer of the watch Michael Hubble.

23 Aug 2008 Financial Times Lost at sea
13 Dec 2007 Nautilus UK Union raises concerns over Pride of Bilbao case
13 Dec 2007 BBC News Ouzo coastguard response 'flawed'
13 Dec 2007 BBC News Yacht deaths trial clears seaman
13 Dec 2007 BBC News Q&A: Ouzo mystery
13 Dec 2007 BBC News Will Ouzo mystery ever be solved?
5 Dec 2007 BBC News Yacht manslaughter jury retires
7 Nov 2007 BBC News Witness saw ferry yacht encounter
30 Oct 2007 BBC News Ferry 'near miss' was with yacht
30 Mar 2007 BBC News Ferry worker denies death charges
9 Mar 2007 ThisisLocalLondon Ferry man charged with deaths of three sailors
16 Feb 2007 BBC News P&O man in court over Ouzo deaths

Death of John Morton

On 13 July 2004 T G Beighton Ltd of Holmewood, Chesterfield, were working as the principal contractor building 11 industrial units on a brownfield site in Sheffield. During the course of this work a tank was being installed and the excavation collapsed.

Two employees of the company were crushed in the collapse. John sustained fatal injuries whilst his colleague, Daniel Thompson, sustained serious crush injuries from which he recovered. The area of the excavation in which the men were working was approximately three metres deep and had no precautions in place to prevent the sides from collapsing.

Following a joint investigation by the Police and the HSE a manslaughter charge was brought against one of the site foremen, Mark Winter of Chesterfield, whilst health and safety charges were brought against the company, its health and safety director, Richard Palmer of Sheffield, and Mark Winter.

Following a six day trial at Sheffield Crown Court in November 2007, Mark Winter was found not guilty of manslaughter, whilst fines of £35,000, £2,500 and £750, plus costs of £10,000, £1,000 and £150, were imposed respectively against T G Beighton Ltd, Richard Palmer and Mark Winter for the health and safety charges to which they pleaded guilty.

The HSE inspector who investigated the accident, Dave Bradley, said, 'This tragic incident was entirely preventable. The precautions to be taken at excavations are well known in the construction industry.

'Each job needs to be properly planned to ensure that the appropriate controls are identified and provided on site, and thereafter, they are communicated to the persons undertaking the work.

'Equally, where circumstances change on site as the work progresses, risk assessments and method statements need to be revised accordingly. It is also important that both directors and individuals on site realise that they too can be prosecuted if they fail to discharge their responsibilities relating to health and safety.'

John's mother, Joy Morton, left the court in tears after the sentencing.
John's father, Clive, said the fines were disgusting, 'We feel badly let down by the justice system. It appears that in the eyes of the law life is cheap. We have lost the most precious person in our lives and they haven't really been punished.'

30 Nov 2007

The Star

Parents disgusted at trench death fines
4 Dec 2007 Contract Journal Contractor Beighton fined after Sheffield earthmoving death
29 Nov 2007 HSE Safety alert to construction industry as firm is prosecuted after Sheffield excavation fatality

Death of Frank Hutchison

In May 2007 at Teeside Crown Court, Marion Dixon, a care assistant, and Christina Hooper, a residential home owner, were both found not guilty of manslaughter by gross negligence of 67-year-old Frank Hutchison.

Care assistant Dixon gave him another resident’s medication, including a dangerous drug, at The Hollies care home for people with mental difficulties in Norton on the morning of February 28 2006.

The court heard he died on April 7 after developing a deep vein thrombosis while immobilised in hospital.

Home owner and manager Hooper was accused of failing to assess the risks of making recently widowed Dixon solely responsible for giving some 15 residents their medication at the end of a ten-and-a-half-hour night shift.

In the middle of the trial, after two weeks of hearing evidence, the Crown decided to abandon their case. Prosecutor James Goss QC said he could not now ask the jury to decide whether Dixon or Hooper had been criminally or grossly negligent.

He told the jury, 'You could be satisfied that in the case of Mrs Dixon, she unquestionably gave the wrong medication to Mr Hutchison.' He said that was a mistake and a cause of the death, and she breached her duty of care.

He had suggested Hooper breached her duty by exposing Frank to the risk of being given the wrong medication with the home’s policies and procedures.

He said there were 'significant areas of concern' about the running of the home and Dixon’s situation at the time. But he said, 'There still is a fundamental question of whether it amounted to gross or criminal negligence.

'We have taken the decision that it would not be right to seek to secure convictions against either of these two ladies.'

Judge Peter Fox QC, the Recorder of Middlesbrough, said he was not surprised by this decision, which he said was 'fair-minded and right'.

On his direction, the jury formally acquitted both Dixon and Hooper of the manslaughter charges.

Martin Goldman, Chief Crown Prosecutor for Cleveland, decided the difficult case could no longer proceed after consulting with counsel, the police and the family.

The court heard that after the incident, Dixon was dismissed and procedures for giving medication were changed so that two staff members always administered the drugs.

30 May 2007 GazetteLive Cleared - Pair not guilty in home death case

 

Death of Doris Smith

Howard Baker and Martin Baker were acquitted at Chelmsford Crown Court in February 2007 of a charge of manslaughter of Doris Smith.

They were cleared of responsibility for the death of the 84-year-old woman who died after she was struck by a wheel which broke free from a trailer being towed by the defendants' tractor.

The jury took just under three hours to reach its unanimous verdict at the end of a two week trial.

In July 2005, as Doris was walking a neighbour's dog along a pavement in Rochford she was hit by a wheel which became detached from the trailer and died in hospital later the same day from her injuries.

John Dodd, QC, prosecuting, said the trailer was in a poor state of repair and alleged that the tractor driver and owners of the trailer 'bore criminal responsibility for the woman's death'.

At the time of the incident two tractors and trailers, owned by the Baker brothers, were travelling in convoy to carry out a grass cutting contract at Southend Airport.

Martin Baker told the jury he dealt with the basic maintenance of vehicles although he had no qualifications. If there was a more serious problem an engineer would be called in.

He said when he hooked up a trailer to a tractor he would make sure the lights and indicators were working and would check the tyre pressures by using a club hammer.

He said he 'completely rejected' a suggestion by prosecution counsel John Dodd that he took 'a cavalier attitude' towards vehicle maintenance.

Earlier the driver of the tractor, 66-year-old New Zealander Lewis Windust, was cleared of causing Doris's death by dangerous driving after Judge Christopher Ball QC directed the jury to return a 'not guilty' verdict.

1 Feb 2007 EssexChronicle FARMERS ARE CLEARED OF MANSLAUGHTER

 

Death of Alan Dunn

John Gordon Stephen, 62, a senior surgeon at Darlington and Bishop Auckland Hospitals, was charged with Alan's manslaughter, a patient at Darlington Memorial Hospital.

A Durham Police spokesman said Alan was taken to hospital on the morning of 10 December 2005 after plunging a knife into his chest in an apparent suicide attempt at his home. He died in hospital a couple of hours later.

In October 2006 the charge against Mr Stephen was dropped.

A Durham Police spokesman said a meeting had been held after Mr Stephen's court appearance on 8 September when he was granted unconditional bail.

He said, 'Since that court appearance a conference involving a senior barrister, in this case a Queen's Counsel, along with leading lawyers from the Crown Prosecution Service, police officers and a Home Office pathologist has been held. The outcome of the conference was a decision that the charge of manslaughter against Mr Stephen should be withdrawn. Both the surgeon and Mr Dunn's family were informed of the decision.'

1 Sep 2006 BBC News Surgeon charged over man's death
3 Oct 2006 BBC News Surgeon's killing charge dropped

Death of William Kadama and Gameli Akuklu

William and Gameli
drowned in the swimming pool of Hendon Police Training School. The two boys were from Barnet play schemes and had arrived at the pool with social workers, but Mr Phillips was the only lifeguard on duty at the time.

Mr Phillips had been helping another boy with a cut knee. As he waited with the hurt boy for an ambulance other youths saw the two boys at the bottom of the pool. He jumped in to the water to try to rescue them but was unable to save them.

Gameli was pronounced dead at Northwick Park Hospital. William was put on a ventilator but died six days later at Great Ormond Street Hospital.

On 25 April 2006 Mr Phillips went on trial at the Old Bailey facing two charges of manslaughter and one of failing to ensure the safety of children.

On 9 June 2006 Mr Phillips was found not guilty on the two counts by unanimous verdicts, but still faced a judgement on a charge of failing to ensure the safety of children under the Health and Safety at Work Act.

Mr Phillips was informed on 16 June that he had also been cleared of the health and safety charges. It was said in court that PC Phillips should not have been the only lifeguard on duty.

The Health and Safety Executive (HSE) announced on 1 August that the Metropolitan Police, the Metropolitan Police Authority and Barnet Council were to be prosecuted under Section 3 of the Health and Safety at Work Act 1974. They were due to appear at the City of London Magistrates' Court on August 8.

The 1974 Act states that non-employees must not have their health and safety adversely affected by an employer's actions. The trio face unlimited fines if found guilty.

On 5 October 2006 at the City of London Magistrates' Court Barnet Council pleaded guilty to a breach of health and safety laws in relation to the drowning.

The Metropolitan Police Authority (MPA) and the Metropolitan Police also appeared charged with the same offence under the Health and Safety at Work Act 1974. The Metropolitan Police pleaded not guilty while the MPA did not enter a plea.

The council pleaded guilty because it did not make a formal risk assessment or a formal register of the swimming ability of those on the placement, though both were done informally on the day.

Barnet Council leader Mike Freer said, 'Since July 2002, there is a tighter control of visits to facilities such as the Peel Centre. The youth service policy has been revised and now requires such trips to be expressly sanctioned by a member of the Youth Service management team who checks that risk assessments address all significant risks.'

The case against the MPA and MPS was heard at the Old Bailey in July 2007 when the Metropolitan Police pleaded guilty to failing to ensure the safety of the two boys.

On 13 July 2007 the Metropolitan Police force was fined £75,000 with £50,000 costs at the Old Bailey.

Barnet Council was fined £16,500 with £10,000 costs after it earlier admitted failing to carry out a proper risk assessment of the use of the Peel Centre pool.

1 Aug 2002 BBC News Tributes for police pool drowning boy
6 Aug 2002 BBC News Second boy dies in pool tragedy
16 Aug 2002 This is Local London Witnesses interviewed over police pool deaths
5 Sep 2002 This is Local London No answers on pool deaths for 18 months
2 March 2005 This is Local London Officer charged over pool deaths
30 Mar 2005 BBC News PC on boys' manslaughter charges
26 Apr 2006 BBC News Boys died 'while PC distracted'
26 Apr 2006 BBC News PC faces boys' manslaughter trial
9 June 2006 BBC News Drowning case policeman cleared
13 Jun 2006 BBC News PC may face pool deaths retrial
23 Jun 2006 This is Local London Pool death cop, 'It will live with me for the rest of my life'
28 July 2006 This is Local London Trio of agencies to be tried over pool deaths
7 Oct 2006 This is Local London Council guilty plea over boys’ pool deaths
3 Jul 2007 BBC News Met admits guilt over pool deaths
13 July 2007 HSE HSE issues pool safety advice following double drowning case
13 July 2007 BBC News Met Police fined over pool deaths
19 July 2007 Hendon Times An end of sorts to pool tragedies

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Death of Kostadin Yankov

Kostadin - a first year Bulgarian biochemistry student at Oxford University - died after taking part in a human catapult event at Middlemoor Water Park in Fiddinigton near Bridgewater. The medical cause of death was abdominal and chest injuries.

David Aitkenhead, of Fiddington, the owner and designer of the machine, and Richard Wicks, of Burnham, the operator, were found not guilty of manslaughter at Bristol Crown Court in May 2004.

An inquest jury at West Somerset Coroner's Court reached a narrative verdict on Kostadin's death in November 2005. Before the jury reached its verdict the coroner Michael Rose posed a number of questions so they could reach a conclusion.

The narrative verdict was read out by My Rose. It said: "The deceased died of injuries received when he failed to land in the safety net after being catapulted from the trebuchet. The accident would probably have been prevented if:

'a further set of test shots had been performed after the change of strop and before any human shots were performed;

'an effective means of accurate reporting of the results of each landing had been in place between the landing and launch sites;

'reports of short landings had been acted upon immediately, and human launches stopped until further test shots had been carried out.'

Mr Rose summed up by saying that Mr Aitkenhead and Mr Wicks had failed to see the warning signs and spot the different characteristics of the two strops.

He said, 'I fully understand the reasons and in the circumstances I think they have probably been punished enough. I must also give credit to all those who gave evidence. I never wish to see a trebuchet in this county unless it has been tested by the Health and Safety Executive. It is a dangerous machine and there are many factors and unknown elements that befell this tragedy.'

15 July 2003 BBC Manslaughter charges over catapult death
26 Sept 2003 BBC Pair deny charge over catapult death
5 Nov 2005 This is Somerset Catapult death could have been avoided says jury

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Death of Kevin Sharman
Kevin, a teenage army trainees, died during an exercise at the Porth-yr-Ogof cave complex in South Wales.

On 8 March 2004, a jury at Swansea Crown Court cleared Matthew Doubtfire, a caving instructor, of a charge of manslaughter through gross neglect.

The jury was then discharged after failing to reach a majority verdict on a different manslaughter charge.

The charge had been split into variations: One of manslaughter through gross negligence - that he deliberately and knowingly lead the recruits into the pool; the other of manslaughter - that he did so mistakenly.

The Crown Prosecution Service (CPS) then announced that it would not pursue that charge and a formal not guilty verdict was entered in court.

The court heard that after consideration over the weekend, CPS lawyers had concluded it would 'not be appropriate' to press for a retrial.

Mr Doubtfire's defence team said after the hearing, 'Ever since this tragedy his (Mr Doubtfire's) thoughts have been with Kevin Sharman and his family.

'He hopes that the evidence heard during the trial has allowed Kevin's family and the wider public to understand how this accident happened.

'He hopes that the outcome of this trial will encourage the Ministry of Defence to review its training procedure, especially in relation to recruits sent on external leadership courses despite having failed the military swimming test.'

8 March 2004 BBC Instructor cleared over cave death
24 Jul 2002 Western Mail Cave Death Soldier is Named
25 Feb 2003 BBC Man in Court over Caving Death

Death of Mark Falivena in August 2001
36 year old Mr Falivena died after he was hit by a train travelling at 85mph. Mr Swane was a safety supervisor for a team of men carrying out repairs on a section of the London to Derby track in Leicestershire. The prosecution had claimed that Mr Swane, of Desborough, Northamptonshire, did not close the track properly or check for oncoming trains. The judge, Mr Justice Harrison, at Leicester Crown Court said that the overwhelming evidence was that many workers would have done the job in the same way and it seemed Mr Swane was following standard practice and told the jury to return a not guilty verdict. The RMT General Secretary said, that "This whole case was about attempting to scapegoat a worker who had been expected to work in unacceptable conditions with insufficient staff."

6 Nov 2003 BBC Rail death supervisor cleared
6 Nov 2003 RMT Press Release No more scapegoats, says RMT as manslaughter case collapses

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Death of Tony Mayk in January 2001
John Chambers a lorry driver was cleared of the the manslaughter of Tony Mayk who died when an unstable 41 ton hydraulic steel print press fell off the back of the lorry he was driving. A jury at Bristol Crown Court had been told that John Chambers reversed his lorry carrying the print press some 60 yards to make way for another vehicle. Mr Mayk was on top of the printer at the time. Two weeks into the trial, the jury was directed to find Mr Chambers not-guilty since although there was lack of care, there was not evidence to say that this in itself caused the death. Mr Chambers and his employer, Cradley Electrical and Mechanical Services Ltd pleaded guilty to health and safety offences.

11 Dec 2002   HGV Driver cleared of Crushing Workman

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