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safety of workplaces will encourage similar
organisations to implement changes before
a similar death occurs,’ she says. ‘Using
coronial data to build a culture that embraces Two examples from
THE BUSINESS CORONER REPORTS
learning rather than blame will help the

findings from coroners’ inquests be used fishing and agriculture

to effectuate actions that would make UK
working environments – and employees –
CAPSIZED may be operating, which an inadequately secured
much safer.’
Three crew members have been modified since pre-cast concrete panel –

of a fishing boat died the issue of the original collapsed onto him due to

Responsibility shifting to employers after it capsized due to safety certificate, and structural weaknesses.

‘PFD reports often lead directly to changes a combination of vessel which require a full stability ‘Publicising the risks

being implemented to improve public modifications, the weight assessment before their and educating the farmers
health, welfare and safety,’ says Ali. ‘In a and distribution of the operational safety can be of the risks of departing
large organisation, or where the PFD report catch and equipment, and properly evaluated.’ from the recognised

effects on stability. method of fixing the

is sent to a governing body, for example, any
The coroner stated: ‘I COLLAPSED pre-cast concrete panels
remedial action could result in change on a
am concerned that other A farm worker died from may reduce the risk of
very large scale. However, it’s important to

vessels (whether of a injuries suffered when future deaths,’ the coroner
note that the coroner is not able to compel
similar size or otherwise) part of a farm building – concluded.
that action be taken. It is not uncommon for
a PFD response to set out that no remedial
action will be taken, for example where a
potential remedy is not economically viable.’
Sarah says: ‘There are examples of
employers who respond to cases of work- change, leading to amendments to company enables organisations to search and review

related suicide very effectively by carrying policy or practice that address suicide risks deaths through the conclusions available
out a full investigation and ensuring that and recognise the impact of work on mental to coroners. Industry bodies and groups
the circumstances that may have led one health. can use information from PFD reports
employee to suicide are fully investigated so Now that coronial data on preventable as topics/areas to increase awareness of
that they do not continue to pose a risk to deaths is available in an accessible database, common issues, promote discussion and
other employees. there is a huge opportunity for it to be improve industry-wide practices.’
‘The problem is that relying on employers leveraged by safety practitioners, employers OSH professionals are crucial in helping
alone is very haphazard – some employers and professional bodies, says Georgia. ‘To organisations to create reporting and

understand the importance of suicide reduce the duplication of efforts, a centralised learning cultures in which prevention
prevention and put measures in place – but professional body could commission an lessons are learned, says Ruth. ‘They are
others do not. We need basic regulatory annual review of coroners’ PFD reports best placed to work across the business
requirements across all workplaces.’ involving OSH to identify learnings and issue to support social sustainable practices
Any organisation with remote workers – alerts to prevent avoidable deaths in the and OSH performance evaluation and
including those working from home – must workplace,’ she says. reporting. This can include increasing
develop OSH systems that protect all of Responsible employers have an awareness and understanding about
their employees, wherever they work, says opportunity to actively monitor any trends or coroners’ PFD reports, and how these can
Ruth. ‘OSH practitioners can certainly play patterns of work-related employee suicides be used within organisations as relevant.’
a vital role within organisations to develop in the vertical sector or industry in which ‘Learning lessons from near misses and
strategies, initiatives or policies to prevent they operate. This action could serve as an adverse incidents is critical to safer ways of

and mitigate psychosocial risk factors and intentional best-practice first step that OSH working,’ Ali continues, ‘and disseminating
support worker mental health,’ she explains. practitioners are well placed to help deliver. the key learnings from PFD reports is a
Employer organisations can subscribe prime opportunity to do this.’
Lessons for OSH practitioners to the Courts and Tribunals Judiciary to
When a PFD report is issued to an employer receive email alerts and other updates, To view references for this article, visit IMAGE: SHUTTERSTOCK
it can act as a powerful mechanism for Sarah says. ‘The website search function ioshmagazine.com/PFD-reports

68 JANUARY/FEBRUARY 2024 | IOSHMAGAZINE.COM

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