Death in the WorkplaceGuidance for United Kingdom Fire and Rescue Services

May 2013

Death in the Workplace

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Contents

1. Introduction

2. Initial Notification (and Immediate Action)

3. Agency Reasoning for Accident Investigation 3.1 Fire and Rescue Service (FRS) 3.2 The Police 3.3 Health and Safety Executive (HSE) 3.4 Representative Bodies/Trade Unions 3.5 Inter-Agency Liaison 3.6 Crown Prosecution Service (CPS) 3.7 Chief Fire and Rescue Advisers Unit (CFRAU)

4. Fire and Rescue Service Accident Investigation (Organisation) 4.1 Appointment of Accident Investigation Team (AIT) 4.2 InvolvementofOtherAgencies(FRS)toUndertakeSpecificRoles, eg: Fire Investigation 4.3 Logistics and Equipment 4.4 Finance and Budget Issues 4.5 ConfidentialityClauseforAITMembers 4.6 Legal Advice/Assistance 4.7 Contemporaneous Notes 4.8 AccesstoEvidenceheldbyPolice 4.9 Interview of Service Personnel 4.10 EvidenceGatheringIncludingStatements,HardTimeline Occurrences 4.11 Filing System 4.12 Security 4.13 ExhibitsInventory 4.14 Organisational Improvement Steering Group (OISG) 4.15 Data Protection 4.16 Media Strategy 4.17 Fire and Rescue Service Welfare 4.18 Bereaved Family Liaison and Welfare 4.19 Other Financial Matters 4.20 Inter-Agency Meetings

5. Fire and Rescue Service Accident Investigation (Methodology) 5.1 AIT Guidance 5.2 Impound and Collect all Equipment Immediately 5.3 Evidence Sources 5.4 Rationale for Conducting Interviews of FRS staff 5.5 Interview Process - Police 5.6 Projected Timeline of Investigation 5.7 Produce a Timeline of Events

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6. Research Modules 6.1 Operational Policies and Procedures 6.2 Training and Competence 6.3 Equipment and Personal Protective Equipment (PPE) 6.4 Supervision and Management 6.5 StatutoryResponsibilitiesandLegislativeRequirements 6.6 National Guidance 6.7 Service Policies and Procedures 6.8 Health and Safety Executive Guidance Documents

7. Investigation Report 7.1 Synopsis 7.2 Report Body 7.3 Findings and Conclusions 7.4 Recommendations and Action Plan 7.5 Promulgation of Information Internal/External

8. Coroner Inquest Process 8.1 The Purpose of an Inquest 8.2 How the Coroner is Informed of a Death 8.3 Time Limits 8.4 Pre Inquest Review 8.5 SubmissionofReports 8.6 NotificationofanInquest 8.7 Opening of an Inquest 8.8 Witnesses 8.9 Juries 8.10 Summing Up and Decision 8.11 Verdicts 8.12 Rule 43 Recommendations 8.13 Article 2 Inquests 8.14 Coroners Rules

9. Service Funeral / Memorial Service

10. Acknowledgements

11. Appendices

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Thank you to Hampshire Constabulary and Hampshire, Hereford and Worcester and Hertfordshire Fire and Rescue Services for allowing us to use their photographs in this guidance document.

Death in the Workplace

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1.1 Thisguidancedocumenthasbeendevelopedfollowing the experiences of Hertfordshire and HampshireFireandRescueServiceswhobothlostfirefightersin2005and2010respectively.

1.2 Suchguidancecanneverbeviewedasfinishedorcompletebuttheauthorstrustitwillgosomewayinprovidingfireandrescueservicesfacedwiththeunexpecteddeathofamemberofstaff,withusefulassistanceastheybeginthechallengeofconductingan investigation.

1.3 Adeathintheworkplaceiscausedbyaseriesofevents,actionsorinactionsthat,occurringinsequence,resultinatragicoutcome.Assuch,itisrarely foreseen and almost never prepared for.

1.4 The unexpected death of a colleague in the workplace is a traumatic experience for the family and also for the colleagues that knew the deceased. Indeed it is likely that the emotional impact of the death will affect the whole Service. This sense of lossmaybeexacerbatedastheServiceconductsits investigation into the events leading up to the tragedy.

1.5 Mercifully,suchinstancesarefewandfarbetweenbutthisinfrequencybringsissuesofitsown,notleasttheinexperienceofFRStodealwithsuch investigations.

1. Introduction

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2.1 TheinitialnotificationofadeathorseriousinjurywillusuallybepassedtoFireControlwhowillinformtheDutyPrincipalOfficer(DPO).

2.2 Action: Prior to any further action the DPO must confirm the identification of the casualty(s). Accurate and speedy identification of the casualty should be undertaken ideally by someone that knows the casualty well. View with caution any names written on clothing (helmet/tunic, etc) as instances are widespread of personnel using a colleague’s kit.

2.3 Action: As soon as the identification is confirmed, the Duty Principal Officer must nominate an Officer to visit the family and break the news

•LiaisewiththePolicewhohavetheresponsibility for informing the next of kin in the case of a suddendeath.WiththeagreementofthePolice, itispreferableforajointinitialvisittobe arranged i.e. Police and Fire and Rescue Service Note: duplicated visits are as insensitive as no visit.

•WhentheFRSselectsaseniorofficertovisitthe families,itshouldconsiderthelongerterm likelihoodofappointingaFamilyLiaisonOfficer (FLO)andtheopportunityforcontinuitybyusing thesameindividualforbothtasks.

•TheServiceFLO’sroleistomaintaincontact withthefamily,eitherviaorwiththePoliceFLO, and ensure they are kept informed of progress with the investigation.

•Anumberofcoursesareavailablethatprovide guidanceonhowtoconductthisdifficulttask. FRS should consider ensuring that they have a cadreofsuitablytrainedindividualstoundertake family liaison duties if required.

•ThePolicewillappointtheirownFamilyLiaison Officers(FLOs)tokeepthebereaved,witnesses andotherinterestedparties,suchasthe Coroner,informedofdevelopments.

2.4 Action: Consider the emotional impact on personnel present at the incident and the need for relief crews and initial welfare arrangements.

2. Initial Notification (and Immediate Action)

q Duty Principal Officer/CFO/DCO/ACO/Service

Duty Manager

u Family (in liaison with Police)

Fire Control

Death in the Workplace

2.5 Action: Appoint a Senior Officer to initiate the Service investigation process.

Instruct all staff involved with the incident (including Control Staff) to produce contemporaneous notes of eventsastheyrecallthem.Theyshouldbeadvisedto write them independently and as soon after the incidentaspossible.Theyshouldensuretheyhaveseveral copies. The Service should request a copy. (Please refer to paragraph 4.7)

2.6 There is a comprehensive summary and aide memoire in Appendix G providing a helpful checklist ofconsiderationsfortheSeniorOfficersappointedto deal with the practical and organisational issues arising from the fatality at work.

q Health and Safety Executive + Police

(if not already involved)

OR,ifappropriate.otherenforcingauthorities

www.hse.gov.uk/contact/contact.htm

q Chief Fire and Rescue Advisers Unit (CFRAU) (A unit of the Department for Communities and

Local Government)

q Fire and Rescue Service:

Occupational Health Manager

Appoint Fire Investigator if appropriate and Accident Investigation Team

q Employee Trade Union

Health and Safety Representative (FBU/FOA/UNISON)

q Chair of Fire Authority u

Marketing,MediaandCommunicationsTeamService Insurance Company

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3.1 Fire and Rescue Service

3.1.1 The Management of Health and Safety at Work Regulations1999,Regulation5,ApprovedCodeofPractice,Monitoring,Paragraph36(b)requiresemployers to ensure they adequately investigate the immediate and underlying causes of incidents and accidentstoensurethatremedialactionistaken,lessonsarelearntandlongertermobjectivesareintroduced.

3.2 The Police

3.2.1 The Police will investigate a workplace death andtaketheleadtoestablishifoffencesundertheCorporate Manslaughter & Corporate Homicide Act 2007(i.e.deliberateintentorgrossnegligenceorrecklessness on the part of an individual or company) havebeencommitted,andtoascertainifcriminaloffenceshavebeencommittedrelatingtothecauseofafireorroadtrafficcollision.Ifthedeathwasduetoaroadtrafficcollision(RTC)theywillcarryouta detailed RTC investigation. Note: RTCs are not reportableundertheRIDDORregulations.

3. Agency Reasoning for Accident Investigation

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3.2.2Whererelevant,thePolicemayrequesttechnical support from any appropriate health and safety enforcing authority - not just the HSE. Section 25 of the Health and Safety at Work Act 1974 definesan‘enforcementauthority’asanauthorityresponsiblefortheenforcementofanyhealthandsafety legislation.

Thisincludes,forexample: •LocalAuthorities •TheMaritimeandCoastguardAgency •TheCivilAviationAuthority •TheOfficeofRailRegulation •TheVehicleandOperatorServicesAgency.

ThiscouldalsoincludeanindependentfireandrescueservicefortheirprofessionalsupportinfireInvestigation.

3.2.3 The Police will take primacy over any investigation into a death in the workplace. They will liaise with the Health and Safety Executive under a nationally agreed protocol and may carry out a joint investigation.

3.2.4ThePolicemayfinditusefultorequestexpertsfromthefireandrescueservicetoexplaintheworkingsofequipment,processesandproceduresand to explain organisational jargon. The Service willneedtoappointsomeonetoberesponsibleforthis. All FRS have their own policies and procedures whichwillnotalwaysbeinaccordwitheachother,thisshouldbefactoredintoanyadviceprovided.

Experience suggests that this might best be provided by an independent FRS.

3.3 Health and Safety Executive (HSE)

3.3.1IftheServicehasbeeninchargeof,orinvolved in an incident involving the serious injury orfatalityofamemberofstaff,theymustinformthe HSE immediately. The HSE will need to know thenameofthePoliceofficerinchargeoftheinvestigation.Ifitisoutof‘officehours’therewillbeadutyHSEInspectorwhowillbecalledoutormaydecidetopassitontothelocalInspectorwhowillbemore familiar with the Service.

3.3.2OncethePolicearesatisfiedthereisinsufficientevidencethataseriouscriminaloffence(other than a health and safety offence) caused the death,theinvestigationshould,byagreement,betakenoverbytheHSE.

3.3.3TheHSEisresponsibleforenforcinghealthandsafetylegislationandwilldecideifanybreacheshaveoccurredwhichwarrantaprosecutionbeingbrought.

3.3.4Todischargetheirfunctions,theHSE(oranyotherenforcingauthority)canobtainfurtherinformation under Section 27 of the Health & Safety at Work Act.

3.3.5 The HSE want organisations to learn from their mistakesandthisisachievedbybeingopen,honestandprobing.Theymaywanttosetupandagreemeetings at regular intervals to review the progress of your investigation. The aim of the investigation istoestablishifallreasonableactionwastakentoprevent such an accident occurring.

3.3.6TheHSEmaydecideto‘triangulate’anyresponse the Service might provide on an issue. This process entails them visiting other work places e.g. firestations,andaskingquestionstheretoseeiftheanswerstheyreceivematchtheofficialresponsefrom the Service. Experience suggests there are oftenvariancesbetweenpolicyandpractice.

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3.4 Representative Bodies/Trade Unions

3.4.1 The Fire Brigades Union (or other representativebodies)willcarryouttheirownaccident investigation. Under the terms of the Safety Representatives and Safety Committees Regulations 1977,tradeunionsafetyrepresentativesarepermitted to carry out an inspection of the workplace followinga‘notifiableaccident(occurrenceanddisease)’,forthepurposeofdeterminingthecause.

3.4.2Outofcourtesy,thePoliceshouldbeinformedif the Trade Union indicates their wish to undertake their own investigation.

3.4.3 Early consultation with the representative bodiesisessentialtoagreeprotocolsforliaisonandinformationsharing.Protocolswillbeinfluencedby:

•TheDataProtectionActandFreedomof Information Act •Servicelegaladvice •ServiceInsuranceprocedures •Servicepoliciesandprocedures •ThePolice’sstanceoninformationsharing.

Experience suggests that whilst the Police may share information with the Service, it is unlikely that there will be any direct information sharing protocol between the Police and the Representative body. Any information required by the Representative Body will almost certainly have to be requested via the Service.

3.4.4IfagreedbytheServiceandtherepresentativebody,ajointinvestigationwillgreatlyavoidthepotentialforduplicationofeffort,interviewsandconflict.Protocolsshouldbeestablishedtoinclude:

•Agreementonasinglelineofcommunication with a named individual •Correspondencetobeaddressedtoasingle point of contact •Requestsforinformationtobewithinlegal limitations •Provisionofanyinformationtobetoanagreed practical timescale •Regularmeetings.

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3.4.5 Health and safety specialist legal advice needs tobesoughtpriortoanycommitmenttoajointinvestigation to identify and address any areas where aconflictofinterestbetweentheServiceandtheemployee representatives could arise.

Experience shows that regular, open and honest dialogue between the Service and the Representative Body can be incredibly effective in building mutual trust and reducing the potential for unnecessary conflict.

3.5 Inter-Agency Liaison

3.5.1 The investigation will require close and ongoingliaisonwiththePolice,theHSEandotheragencies.Animportantfirststepinensuringthis liaison is managed and effective is the early production of an agreed Memorandum of Understanding (MoU) with the other agencies. An examplemaybefoundasAppendixH.InadditiontothoseagreedwiththePoliceandtheHSE,FRSareadvised to agree an MoU with the appropriate trade union.

3.5.2 If the accident was one that took place in an operational environment the Police and HSE may require advice on FRS procedures and practices to assist them in understanding the pertinent issues. The FRS might consider requesting another FRS toassistthePolice/HSEintheirunderstanding,anexampleofthismightbesubcontractingtheinvestigation into the cause and development of the fire.Itislikelythatinsuchcircumstancesthe‘subcontractedFRS’maylevyachargefortheirservices.

3.5.3ItisvitallyimportantthatarobustandeffectiverelationshipismaintainedbetweentheServiceandthePolice,HSEandrepresentativebodies.

Experience shows that where mutual trust exists, there are more opportunities for issues to be resolved without the need for a more formal prescriptive approach.

3.6 Crown Prosecution Service (CPS)

3.6.1TheCPSwilldecidewhetherthereissufficientevidencetowarrantprosecutionformanslaughter,murder or other criminal offence. The Police will work closely with the CPS and full co-operation is expected from the employer of the deceased.

3.7 The Chief Fire and Rescue Advisers Unit (CFRAU)

3.7.1CFRAUmustbeinformedattheearliestopportunity of relevant details surrounding the fatality.CFRAUaretheobviouscontactforpassinginformation to other FRS appertaining to the incident.

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4.1 Appointment of Accident Investigation Team

4.1.1Tocarryoutaninvestigationintoevents,theService will need to appoint a Service Accident Investigation Team (AIT). The size and makeup of the teamwillreflectthecomplexityoftheincidentunderinvestigationbutwouldtypicallyrequirethefollowingskills as a minimum:

•Detailedandcomprehensiveknowledgeof Operational activities •Detailedandcomprehensiveknowledgeof Training activities •Effectivereportwriting •Administration.

Experience has shown that the investigation of a death in the workplace is a protracted process often taking several years to complete, this should be factored into staff planning and logistical considerations.

4.1.2TheAITshouldbeheadedupbyaseniorofficer/managerempoweredtomakeexecutivedecisionsonbehalfoftheChiefOfficer.TypicallythiswouldbeaprincipalofficerofAssistantChiefOfficerrank or equivalent.

4.1.3 The Health and Safety Executive (HSE) and the Police recognise that organisations haveanobligationtocarryouttheirowninternalinvestigations to identify the cause of the accident. Liaisonwiththeseniorinvestigatingofficersofthesetwo organisations is a key role for the Head of the Service AIT.

4.1.4Followingappointment,anearlyconsiderationwillbetheproductionofTermsofReferencefortheService Accident Investigation Team (an example maybefoundasAppendixB).Itisimportanttoagreethe content with the other principal investigatory bodiesi.e.thePoliceandtheHSE.

4.1.5 The Service should consider the production of an agreed Memorandum of Understanding with the Police(anexamplecanbefoundasAppendixH),theHealth and Safety Executive and the Representative bodies.

4.2 Involvement of Other Agencies (FRS) to Undertake Specific Roles e.g. Fire Investigation

4.2.1 Where the death under investigation occurred duringafire,theServicehastheoptiontorequestanother FRS to assist with the investigation. This mightincludeproductionofafireinvestigationreport(including cause and development).

4.2.2 Where the incident is likely to involve the investigation of FRS processes and procedures it remains an option for the Police to engage the services of another (independent) FRS to assist them in their investigation.

4. FRS Accident Investigation (Organisation)

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4.3 Logistics and Equipment

4.3.1TheAITwillrequireadedicated,privateandsecureoffice.ItmustbeofadequatesizetoaccommodatetheAITandideallyprovidesufficientspace for meetings and private consultations. It will needtelephone,computerandprinterlinks.

4.3.2 Equipment required to ensure the smooth runningoftheofficeandsystemsincludes:

•Computers •Printer •Scanner(essentialfortheelectronicfiling of documentation) •Fax •Dictationequipment •Projectionfacilities •DVD/CDplaybackfacilities •Memorysticks •Headphones,etc.

4.4 Finance and Budget Issues

4.4.1AcostcentrewillberequiredtofacilitateAITspending on:

•Equipment •Accommodation •Printing •Research&scientificanalysis •Transport/Travel •Salaries •AnyfeesfromsubcontractedFRS/Consultants •ScientificAnalysis •CostsassociatedwithWelfareprovision •Consumables.

A dedicated cost centre provides an audit trail of AIT costs.

4.5 Confidentiality Clause for AIT Members

4.5.1AllmembersoftheAIT(andotherpartiesinvolved in the Service Investigation e.g. Fire BrigadesUnion)mustcompleteaconfidentialityagreement,(anexamplecanbefoundasAppendixC). The importance of information security and confidentialitymustbecommunicatedtoallpersonshandling investigation information.

4.6 Legal Advice/Assistance

4.6.1 A death in the workplace will entail an Inquest whereaCoroner,withtheassistanceofajury,willdecideonthecauseofdeath.Duringthisprocess,usuallyaftertheInquest,theremaybeaclaimforcivildamagesbyrelativesofthedeceased.Itisvitallyimportantthereforethatrobustandeffectivelegal advice is sought at the earliest opportunity.

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4.6.2 Often provision of such advice is included in theInsurancecovertakenoutbytheFRS.Thereforeassoonasthedetailsofthedeathareknown,theService should contact its Insurers to arrange the provision of legal advice.

Attendance at a jury inquest involving death in the workplaceusuallyrequirestheinclusionofbarristersto present (and defend) the views of the FRS. Legal costscanbeconsiderableandFRSshouldchecktheir policy provision with regard to legal cover. Specificadviceshouldbesoughton:

•disclosureofdocumentation •liaisonwiththePoliceandHSE •liaisonwithfamiliesandrelatives •liaisonwithemployeerepresentatives/Trade Union Representatives •preparingstaffforattendanceatCoronersCourt •productionofCoronersreport •recordsmanagementandmaintenanceofan auditabletrail.

4.6.3TheService’sinsurerswillwanttoknowthecircumstances of the death/s to assist the next of kin withinterimpaymentsfromanyEmployersLiabilityarrangements.

4.6.4 Civil legal process may follow at a much later stage,usuallyaftercompletionoftheInquest,withclaims for compensation.

4.7 Contemporaneous Notes

4.7.1 Service personnel involved in the incident shouldbeinstructedtorecordtheirpersonalaccountoftheiractionscontemporaneously.Theyshouldbeadvised to ensure they have a copy in the event that theirnotesareseizedbythePolice.

4.7.2Personnelshouldbeencouragedtoprovideacopy of these notes to the Service AIT.

4.8 Access to Evidence held by Police

4.8.1Duringtheinitialphaseoftheinvestigation,the Police will seize any and all items they feel are conducive to their investigation. This may include diaries,contemporaneousnotes,logbooks,trainingrecords and equipment. This list is not exhaustive. It is very important to keep a detailed record of all times seizedbythePolice.

4.8.2 Police will not release evidence until their investigations are complete and any legal action has beencompleted.ItshouldbenotedthattheHSEhave greater powers to seize items relevant to an investigation under Section 20 of the Health and Safety at Work Act.

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4.9 Interview of Service Personnel

4.9.1 The Police will interview any potential witness under the Police and Civil Evidence Act 1984 (PACE).

The Police may choose to interview witnesses formally(undercaution),alternativelytheymaychoose a more informal route. Whatever form the interviewtakes,thePolicemustrecordwhatissaideitherbyaudioorvideo.ThePoliceshouldexplainthebasisfortheinterviewandtherightsofthewitness.Ifthewitnessisnotbeinginterviewedformallyandnotundercautionthewitnessshouldbeadvised that they may leave the Police facility at any time.

4.9.2 The HSE will advise the Service what informationtheymayneed,thismayincludeinterviewing witnesses themselves under Section 9 of the Criminal Justice Act 1967. This provides that a writtenstatementsignedbythepersonwhomadeit,isadmissibleasevidencetothesameextentasoralevidencegivenbythatperson.

4.9.3 Alternatively under Section 20 (2) (j) of the Health and Safety at Work Act1974 the HSE Inspectors have powers to interview individuals as part of their investigation into workplace death. This requires individuals to answer questions and to provide information as required. The individuals willberequiredtosignadeclarationofthetruthoftheir answers. A refusal to answer questions shall beadmissibleinevidenceagainstthatpersoninanyproceedings.

4.9.4However,underSection28oftheHealthandSafetyatWorkAct1974,noinformationobtainedunderthispowerwillbedisclosedwithouttheconsentofthepersonbutthisdoesnotpreventdisclosuretotheHSE,agovernmentdepartmentorany other enforcing authority.

4.9.5Stafftobeinterviewedmaybeeitherwitnesses to the incident (that led to the workplace fatality) or to comment on Service procedures. AllServicewitnesseswillneedtobesupportedbothbeforeandaftertheeventbytheServiceandprovidedwithsuitablelegalrepresentation.

4.9.6 Where the interviews are not conducted under caution,theinterviewsmaybearrangedbytheFRS.Thepersontobeinterviewedcanbeaccompaniedbyacolleague,alegaladvisor,aseniorofficeroramemberofhis/herrepresentativebody.Anypersonaccompanying an interviewee must understand theirresponsibilitiestowardsthepersonbeinginterviewed,steppinginwheretheyfeelitnecessarytorequestabreaktodiscussapoint.Theyarenotthere to sway the witness in what is said in evidence.

4.9.7 The format for the interview will normally start with the individual giving a short account of theirservicelife,experienceetc.TheServicecanrequest that its own questions are incorporated into theinterviewbuttheycanonlybeincludedwiththe permission of the Police. The interviews are usuallyrecordedeitheraudiblyorviavideo(Policepreferred media). This form of interview permits the interviewee with the right to leave the process at any point.Theintervieweecanrequestbreaksatanytime.

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4.9.8 Interviewees should note that the Police statementsmaybe‘summarised’andnotbeaverbatimrecordoftheactualinterview.Accordinglysomeoperationalinformationcouldbeomitted.(TheAITshouldrequest‘full’DVDcopiesofallinterviews.)

4.9.9Allstaffrequiredforinterviewshouldbebriefedontheformat,theexpectationsofthePoliceandtheirrights as a witness. The Police will do all they can to relax interviewees and reduce stress.

4.10 Evidence Gathering Including Statements, Hard Timeline Occurrences

4.10.1 The Police are legally empowered to seize any evidence they feel necessary for their inquiries and will require the original items e.g. actualdocuments,notcopies.Shouldthisinvolvedownloadingdatafromaharddrive,thePolicewillwishtobepresentwhenthisisdone.

4.10.2 Initial Police evidence gathering and impounding of equipment may have taken place prior totheFRSAITbeingsetupi.e.atthetimeoftheincident.

4.10.3TheServiceshould,whereverpossible,ensure it takes (with the permission of the Police) copies of all documents seized.

4.10.4 The working arrangements with the Police will includetheuseofanEvidenceRequestFormwhich,oncompletionbythePolice,willprovidearecordofall evidential items passed to the Police.

4.11 Filing System

4.11.1Thefilingsystemwillneedtobecomprehensive and cross-referenced to provide an auditabletrailforfuturereference.Itisessentialthatinformation is managed and maintained for evidential purposesandthereforenumbered,datedandcatalogued.

4.11.2Itshouldbeensuredthatthefilingsystemmeets the need of the AIT team and not the person thatsetsitup.Itneedstobesimpleandintuitiveso that one naturally goes to the correct section. Considerthatthefilesmayrequiretobeaccessed

yearsonfromtheincidentbypersonnelunfamiliarwiththefilingsystem.AppendixDsuggestsafewheadings.

4.11.3Duringtheinvestigation,lockablestorage,filingcabinetsetc.areessentialforsecuringresearchdocumentation and correspondence. The need for thesecanbeavoidedwiththeprovisionofasecureoffice.

Experience has shown that ultimately all documents can be scanned and stored electronically on a secure drive.

4.11.4Exhibitsandimpoundeditemsmayneedlarger storage facilities such as a designated secure roomorlargercabinetwhichshouldbelockable.

4.12 Security

4.12.1 Security is a fundamental requirement of the investigation if the evidence/ statements etc are nottobecompromised.AllmembersoftheAITwillhavesignedaconfidentialityagreement.AllDatastoragemustbesecureandaccesslimitedtotheInvestigationTeam.Electronicdatamustbestoredonasecuredriveandbacked-upondiscs(securelystored)onaregularbasisincaseofsystemfailure.AccesstotheAITofficemustbebyinvitationonly.

4.13 Exhibit Inventory

4.13.1ArecordofallexhibitsheldbytheServiceAITshouldbemaintainedtopermiteasyaccesswhenrequired.Anexampleofasuggestedlayoutcanbefound as Appendix J.

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4.14 Organisational Improvement Steering Group (OISG)

4.14.1 The Service should consider the introduction of an Organisational Improvement Steering Group. The purpose of this group is to consider and act on safetycriticaloperationalpracticeissuesidentifiedbyandreferredfromtheAITaheadofthepublicationofthefinalreport,andtotakeactiontoaddressthemas part of continuous improvement.

4.14.2 These issues might include operational procedures,communications,breathingapparatusprocedures,incidentcommandandcontrolandoperational policy and directives.

4.14.3Amajorbenefitoftheworkofthisgroupistherobustaudittrailofactionittakestoaddresseachissue. An example of a typical terms of reference for anOISGcanbefoundasAppendixI.

Experience shows that the Health and Safety Executive are particularly interested in any work undertaken to prevent a re-occurrence.

4.15 Data Protection

4.15.1Allfireandrescueserviceshaveaccesstoexpertguidanceondataprotection,freedomofinformation and disclosure.

4.15.2Advicemustbesoughtonthedisclosureofinformation (including personal information) to third parties (including the media and representative bodieswhoareendeavouringtocarryouttheirowninvestigation,orotheremployees).

4.16 Media Strategy

4.16.1 The Service should draw up a Media Strategy in liaison with the AIT and the Service Legal Adviser. It should consider the following issues:

•Uncertaintyofinvestigationoutcomeandwhat actions,ifany,otherinterestedpartiesmaytake - potential for prosecution.

•Preplanninganoverallapproachto communicationswhichcanbeadaptedto changes in circumstances.

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4.16.2 StatementsfromtheService,whetherinresponse to direct queries (reactive) or sent out to the media (proactive) may include:

•Expressingsympathyforthefamilies/relatives •Payingtributetotheindividuals •Emphasisingprevioussafetyrecord (ifapplicable) •Explaining(nameofService)aimtolearn lessons for the future •Emphasising(nameofService)willingness to co-operate.

4.16.3 Statements should not:

•Providedetailaboutindividualactions •Criticiseanyindividual •Debateanyissues •Pre-emptthefindingsoftheCoroner; Police or any other agency.

4.16.4 Good practice recommends that:

•Statementsarepreparedforarange of scenarios •Servicestaffareadvisedtoreferallcalls/ enquiries from the media to the Service PressOffice.

4.17 Fire and Rescue Service Welfare

4.17.1 The Service Welfare Adviser (SWA) or OccupationalHealthManager(OHM)mustbeinformedofthedeathassoonasthefactsareconfirmed.

Experience has shown that after any traumatic incident, such as a death in the workplace, enormous emotional pressure is felt by the workforce. This is particularly so amongst those working with the deceased at the time of the accident.

4.17.2ConsiderationshouldbegiventothesupportavailablefromtheFireFightersCharity(FFC)whocanoffer a wide range of supportive measures including counselling and respite care.

4.18 Bereaved Family Liaison and Welfare

4.18.1TheServicehasamoralresponsibilityforthewelfareofthebereavedfamily.EarlyappointmentofaFamilyLiaisonOfficerwillassistinthehealingprocessbyensuringthewishesofthefamilyarepassedspeedily to the Service.

4.18.2ThePolicehaveestablishedFamilyLiaisonStrategiesandtheirFamilyLiaisonOfficers(FLOs)areselected and trained for the role. Police FLOs gather and provide information to the Senior Investigating Officer,aswellasprovidingsupporttothefamily.Itisimportant that Fire FLOs make and maintain contact with the Police FLOs and this relationship forms part of the MoU outlined in 3.5.1.

4.18.3 The Service should consider how the anniversaryoftheaccidentwillberecognisedandindeedforhowmanysucceedingyears.ThismaybeaffectedbythetimingoftheInquestwhichcouldtakeplace several years after the death(s).

4.19 Other Financial Matters

4.19.1TherewillbeotherfinancialmatterstoconsiderregardingPension,compensationandothers.Oftentherewillbeafundraisingresponsetothesetypesofincident,soearlyconsiderationshouldbegiventothemanagementofotherfinancialmatters,includingthepossibleestablishmentofatrustfundandtrusteeswithproperadviceonfinancialmatters.Anytrustfundwillrequireanaccount,publicinformationontheaccountand management of that account. It is important to liaisewiththefamilyorfamiliesonthesematters,althoughtrusteesdohavetheirownlegalobligations.Itispossiblethatotherorganisations,suchastheFireBrigadesUnion,willestablishsimilarfunds.

4.20 Inter-Agency Meetings

4.20.1 All agencies involved in the investigation will findregularjointmeetingsusefulinordertotrackprogress,removeduplicationandidentifyoptionsforimprovement.

4.20.2AgencymembershipofthemeetingwillbestbeservedbyGOLDstatusmemberswhohavetheexecutiveauthoritytomakedecisionsonbehalfoftheirorganisation.

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5.1 AIT Guidance

5.1.1GuidancehasbeenproducedbytheHealthand Safety Executive to provide a framework for carrying out an accident investigation:

•HSG65SuccessfulHealth&Safety Management •HSG245InvestigatingAccidentsandIncidents •HSG48ReducingErrorandInfluencing Behaviour •MemorandumofUnderstanding (Death at Work).

5.1.2Additionally,therearethreedocumentswhichemphasise the importance of working together to thoroughly investigate work-related deaths:

Work-Related Deaths (ACPO,HSE,CPS,BTP,LGA)

- A Protocol for Liaison http://www.hse.gov.uk/pubns/wrdp1.pdf

- Investigators Guide http://www.hse.gov.uk/pubns/wrdp2.pdf

- Guidance on the timing of Criminal proceedings http://www.hse.gov.uk/pubns/wrdp3.pdf

5.2 Impound and Collect all Equipment Immediately

5.2.1 Unless the Police or HSE have previously removedevidentialitemsasexhibits,theServiceshould impound all equipment pertinent to the investigatione.g.BABoard,BALogbooks,trainingrecordsetc.Detailedrecordsshouldbemaintainedofwheretheitemswerelocated(possiblywiththeaidofaphotograph),whentheywereimpounded,whoimpoundedthem,wheretheyarebeingheld,when they were handed over to the Accident Investigation Team etc.

5.2.2Assoonaspracticable,theequipmentshouldbeexaminedandsentforscientificanalysisif deemed necessary. The Police and HSE must beconsultedbeforetakinganyactiononitemsofpotential evidence. Delay can cause deterioration in the condition of equipment etc.

5. FRS Accident Investigation (Methodology)

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5.3 Evidence Sources

•ControlTapes-recordingsoftheradio messages,telephonecallsandother communications e.g. call out sheet

•Contemporaneousnotesofallstaffinvolvedin the incident

•CCTV-manybuildingshavethisinstalledboth internally and externally - the Police may already haveseizedthisbuttheymayprovidethe Service AIT with copies if requested

•Statements-copiesofPolicewitnessstatements (publicandFRSemployees)maybegiventothe ServicebythePoliceprovidingthe witnesses agree

•ConsiderconductinginterviewsofService personnel - take into account the potential for emotional overload of staff. Seek the agreement ofthePoliceandtheHSEbeforecarryingout any interviews

•FireInvestigationinformation(ifdeathwas atafire)

•RoadCrashInvestigation(ifdeathinvolvedan RTC the Police will carry out a detailed road crashInvestigationbutmaynotshare information due to criminal case preparation)

•MedicalreportsfrompostmortemviaPolice on cause of death (assists with ascertaining PPE performance etc.)

•Photographs,CCTV,mobilephonepictures (Serviceandpublicifprovided)

•Trainingrecords,internalmemorandaand correspondence,promotionrecords

•StandardTestrecords

•Photographs/videotakenattheincidentscene

•Serviceproceduresandpolicies.

5.4 Rationale for Conducting Interviews of FRS Staff

5.4.1AnydeathintheworkplacewillbeinvestigatedbythePoliceandtheHealthandSafetyExecutive.This investigation will almost certainly require personneltobeinterviewed.InsomecasestheHSE may delegate the interview phase of their investigationtothePoliceandmay,asaresult,monitor the interviews themselves.

5.4.2 The interview statements may or may not bereleasedtotheService.Objectionsfromtheindividual,perhapsunderinstructionfromtheTradeUnion,maymeanthatthePolicewillnotreleasethe statements. If they do decide to release the statementstotheServiceAITitmaybemanymonthsbeforetheydothis.

5.4.3Anearlydecisionwillthereforeneedtobetaken as to whether or not the AIT interview their staff. In their considerations the Service will take into account:

•Thepotentialforincreasingtheemotional loading of personnel

•Theview/permissionofthePoliceforconducting such interviews

•Theopportunitytoaskquestionsonareasnot coveredbythePoliceinterviews.

Death in the Workplace

5.5 Interview Process - Police

5.5.1 It is likely that the Police will wish to interview Service personnel regarding the events leading up tothefatality.ThereareanumberofissuesfortheService to take into account regarding the interview process:

•ThePoliceandHSEhavelegalpowersto interview witnesses as part of their investigation

•Interviewtypecanrangefrominformalchats through to interviews conducted under the Police and Criminal Evidence Act 1984 (PACE)

•Intervieweeswillbeaffordedtheopportunity to have a legal representative support them. Alternativelytheymaychoosetoaskamember of their Trade Union to accompany them. The Serviceshouldrobustlyadvisetheinterviewee toaccepttheofferofanOfficertoaccompany them during the interview.

5.6 Projected Timeline of Investigation

5.6.1 The FRS investigation timeline will usually startwiththetimetheincidentoccurredandfinishwiththesubmissionofitsreporttotheCoroner.ThereforetheinterveningperiodisthetimeavailabletotheFRStoconductitsinvestigation.DifficultymaybeencounteredinestablishingwhentheinquestisscheduledtobeheldandcloseliaisonwiththePolicewill assist in a realistic estimation of the likely date.

5.7 Produce a Timeline of Events

5.7.1 The investigation process will require the production of an action chart to plot the movements and actions of all personnel for each minute. Commonlyreferredtoasa‘STEP’analysis-Sequential timed event plotting. There are several options.

5.7.2 STEP is a proven method of accident investigation which provides a method for plotting the sequenceofeventsinanaccident,tounderstandtheinteractionsbetweenpeopleandthecircumstancesthat gave rise to the accident within a given time frame.

5.7.3Oneoption,forincidentswithasmalltimeframeandwithfewpeopleinvolved,istouse‘postit’notesstuckonthewall.Thisisveryflexibleandallowsactionnotestobeeasilymovedasmoreinformation comes to light. This approach has worked effectively for several FRS. For the larger scale incident the use of Microsoft Word offers certainadvantagesincludingelectronicfileandeaseof circulation to other agencies.

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5.7.4Usingtheevidenceandinformationavailableto construct the accident sequence will reveal the factorsthatinfluencedthecriticaleventsduringthespecifiedtimescale.Thegridwill:

1. Establish a time period: e.g. from time of initial 999 call to FRS to removal of casualty from the incident ground.

2. Map the time:acrossthetop,ideallyinone minute segments. Individual actions should beinsertedintotheappropriate‘box’.Hardtimes aretypedonaplainwhitebackgroundwhereas estimated times (estimated time is the time attributedtoanontimedoccurrencethatbest fitswithintheeventsthathaveknownand accurate timings from accredited sources e.g. FireControlTapeorCCTV.)mightbeshadedina different colour to aid clarity.

3. List all personnel: initially involved directly in theincident.Latterlyitwillprobablybepossible to remove those personnel that had no part in the criticalactions.Thenamesshouldbelistedinthe left hand column.

4. Identify significant occurrences from timed sources:Thesecanbeobtainedfrom theFireControllog/tape,CCTV,BATelemetryetc. Theseshouldbeinsertedacrossthetoprowin the appropriate minute segment. To aid clarity it isusefultouseadifferentcolouredbackground for these entries.

5. Establish the actions: of each individual involvedbetweenthesetimeslotsfromtheir contemporaneous notes and statements. Cross- referencingthenotesofanindividual’sactions will also assist in providing details of other people’sactionsi.e.whattheysawandwitnessed going on around them.

Fig 1: Example of electronic formatted STEP attached to wall to provide full picture of events.

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Death in the Workplace

5.7.5OncetheactionshavebeenagreedandplottedontheSTEPchart,thenextstepistostartconstructingatimeline/chronologyofevents.Initiallyitwillbeusefultoincludethreecolumns.Columnonewillbeforthetime(eitheractualorestimated),thesecondcolumnisfortheeventoccurringandthethirdwillbeusedtodetailtheevidencesource.Theevidencecanbedeletedfromthefinalreportbutservesasausefulindicatorofhowthetimeandeventwereidentified.

5.7.6Anexampleofadraftchronologylayoutcanbefoundbelow.

Time Occurrence

Athirdpump,theWaterTender(46WT)fromRiverdale,booksinattendance.

WMHatcher,FfsDollery,andThomasdescendthestairstothe7thFloor.FfWilliamsstaystoflakeout2lengthsofhoseinthe9thfloorlobby.

FfsTrokeandJeynesareinstructedbyCMMaynardtocommence an ICS log.

A second crew (Red Team 2) comprising of Ffs Stephens and Scarlett are sent to the Bridgehead.

A second crew (Red Team 2) comprising of Ffs Stephens and Scarlett are sent to the Bridgehead.

Fire is growing slowly behind the bottom left lounge window. Black smoke emissions are blowing in a westerly direction.

08:56

08:58 Est Time

09:08 Est Time

09:15

09:15

08:57

Fire Control Tape and LA CCTV

Statements P2B(26-32) W231 (3)

Statements 873 (1)S853 (1)

LA CCTV 02 Frontlobby

LA CCTV 02 Frontlobby

LA CCTV

Evidence Source

Fig2:ExampleofadraftchronologyshowingTime,OccurrenceandEvidencesource.

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The four principal areas for research as part of the accident investigation include:

•OperationalPoliciesandProcedures •TrainingandCompetence •EquipmentandPPE •SupervisionandManagement.

(NBwhereafireinvestigationisbeingundertakenorotherprofessionalinvestigation,thismayrevealotherassociated indirect or direct causes to the accident).

6.1 Operational Policies and Procedures

6.1.1 It is important to secure copies of all pertinent guidance/service orders/policy documents etc in force at the time of the incident. Identify the date these documents were last updated and if the current editions were held in the workplace.

6.1.2 Consider if the current procedures and policies adoptedbytheServiceweresuitableandsufficienttoensure personnel could deal with this incident safely.

6. Research Modules

23

Death in the Workplace

6.1.3Ascertainwhatprocedureswereadoptedbypersonnel at the incident and whether they were in accordance with Service Policy and procedures.

6.2 Training and Competence

6.2.1 Review individual training records to ascertain if and when personnel were trained in the current policies and procedures required during the incident.

6.2.2 Consider if the existing systems and processes within the Service were adequate and appropriate to ensure personnel were competent to deal with the incident.

6.2.3Ifappropriate,identifythefrequencyofsitespecificinspectionstothepremisesinvolved.

6.3 Equipment and Personal Protective Equipment (PPE)

6.3.1 Identify what equipment was in use at the incident. Consider whether adequate and appropriate plant,substancesandequipmentwereavailableand/or used to control the risks relating to this incident.

6.3.2 Identify the clothing and any personal protectiveequipmentegfirekitwornbythedeceasedandimpound(ifnotalreadydonesobythePolice).

6.4 Supervision and Management

6.4.1 What risk assessment process or safe systems of work were followed and what management systems were in place?

6.4.2 Consider if the existing arrangements within theorganisationweresuitableandsufficienttoensure personnel could deal with this incident. Thissectionwillincludeoperationalmanagement,incidentcommand,dynamicriskassessmentandsupervision.

6.5 Statutory Responsibilities and Legislative Requirements

•HealthandSafetyatWorketc.Act1974 •Subordinatelegislation:Regulationsand Approved Codes of Practice •BritishStandards •CEandinternationalstandards.

6.6 National Guidance

6.6.1Nationalguidancemaybeissuedin the form of:

•FireServiceCirculars •DearChiefOfficerLetters •FireServiceTrainingManuals •ManualofFiremanship •GenericRiskAssessments •OperationalGuidanceManuals.

6.7 Service Policies and Procedures

•ServiceInformationSysteme.g.Service Orders/Bulletins •SafeSystemsofWork&TechnicalGuidance •RiskAssessments.

6.8 Health and Safety Executive Guidance Documents

6.8.1 Within HSG65 a methodology for investigation - Analysing the causes of accidents and incidents - suggests looking at the Failures in Risk Control Systemstoestablishimmediateandunderlyingcauses.

6.8.2Oncethisinformationhasbeencollected,verifiedandevidencedasfactual,thebasisoftheinvestigationreportcanbestartedbycomparinglocalpoliciesandprocedures,againstnationalguidance and any legislative requirements.

6.8.3Considerwherethesedonotmatch,identifypotential gaps in local policy and procedures and areas for change and improvement. Produce a learning log of these gaps.

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This is a sample of the detail an incident investigation report might include:

7.1 Synopsis

• Introductionandnameofinvestigatingofficers

• Summaryofbackgrounddetails:date,time,location,nameofinjured,namesofwitnesses,incidentnumber/type/crewsattending,detailsofseniorofficersetc

• Précisofwhatoccurred.

7.2 Report Body

• Provideafactualaccountofeventsleadinguptoaccident - using the STEP chart or a narrative

• Historyandpreviousnearmissesorincidents-consider national events

• Considerstatutoryandlegislativerequirements-employer/employeeresponsibilities

• Comparenationalguidance(fireservicecirculars,trainingmanuals,ACOPsetc)againstlocal FRS procedures

• Provideseparatesectionsontheanalysisofeach of the research areas using the HSG 65modeltoestablishtheadequacyof:

• Operationalprocedures,policiesandsafe systems of work

• Training,instruction,competence

• Equipmentusedandpersonalprotective clothing

• Supervision,managementandincidentcommand including dynamic riskassessment.

7.3 Findings and Conclusions

• Summariseboththedirectandindirectcause- if known

• Includeanyapparentdeficienciescontributingto the accident.

7.4 Recommendations and Action Plan

• Makethefinalrecommendations,inagreementwith the Service Leadership Group/Management Team

• ProduceanActionPlanwithtimescalesbasedon the assessment of risk and allocated tonamed individuals.

7.4.1 If the Health and Safety Executive have served an Improvement Notice on the organisation some actionswillalreadybeinprogress.

7.5 Promulgation of Information Internal/External

7.5.1Itisessentialthatthelearningpointsidentifiedduring the investigation are promulgated as soon aspracticable.WithintheServicethiscanbeundertaken in a variety of ways:

• OperationalBulletins• RoutineOrders/Notices• TrainingNotes/Drills/Exercises.

ExternallytheissuesmustberaisedwiththeChiefFire and Rescue Advisers Unit (CFRAU). (Issues mayalsobereferredtoCFRAUviaaCoronersRule43 letter -please see paragraph 8.12). In addition tothis,itisbeneficialforacopyoftheinvestigationreport(includingthefindings),tobesenttoeveryfireandrescueservicewithintheUK.Thisreleaseis dependent on no pending legal action and the necessarylegalpermissionshavingbeengranted.

7. Investigation Report

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Family members should also receive a copy of any investigation reports following legal clearance to do so.

Death in the Workplace

8.1 The Purpose of an Inquest

8.1.1 Inquests are held in specialist Coroners Courts presidedoverbyaCoroner.Theproceduresandpowers differ from those of other courts. There are about140Coronersdistricts.Acoroner’spowersand duties are set down within a modern statutory framework,intheformoftheCoronersAct1988andthe Coroners Rules 1984 (as amended).

8.1.2Inquestsarefact-findinginquiries,whichaimtoestablishtheidentityofthedeceasedandwhere,whenandhowthedeceasedcamebytheirdeath.Theanswerstothefirstthreequestionsareoften known or are answered relatively easily. The focusofthemajorityofinqueststendstherefore,tobeonestablishinghowthedeathoccurred.Thisquestionisnotlimitedtoestablishingthemedicalcause of death and may involve an examination of the circumstances in which the death occurred. The verdictmustbeinaprescribedformandmustmakethefollowingfindings:

• Thenameofthedeceased(ifknown)• Theinjuryordiseasecausingthedeath• Thetime,placeandcircumstancesatorin

which injury was sustained• TheconclusionoftheCoronerorjury(asthecasemaybe)astodeath• Theregistrationparticulars.

8.1.3Theproceedingsareintendedtobeinquisitorial rather than adversarial. It is not the Coroner’sroletoapportionblameagainstanindividual or an organisation for the death. An inquest does not involve opposing parties setting out to prove that their version of events is correct as in a criminal or civil trial. The strict rules of evidence that apply in criminal courts do not apply at inquests.

8.2 How the Coroner is Informed of a Death

8.2.1 A coroner will consider holding an inquest whentheyareinformedthatthereisadeadbodyof a person within their jurisdiction and there is reasonablecausetosuspectthatthepersondied:

• Aviolentorunnaturaldeath• Asuddendeathofunknowncause• Inprison• Insuchplaceorundersuchcircumstancesthatan inquest is required under Coroners Act 1988.

8.2.2TheCoronerwillusuallybeinformedofadeathbythelocalRegistrarofBirthsandDeaths,adoctoror,moreunusually,amemberofthepublic.

8.2.3ItisnormalpracticefortheCoroner,onreceiptofaninterimreportfromthePolice,toopentheInquest and immediately close it pending further enquiries. These consist of further reports which are requestedfromotheragenciesincludingthePolice,HSE and the Service prior to reconvening.

8.3 Time Limits

8.3.1Therearenotimelimitsforholdinganinquest,although the Coroner must hold an inquest as soon asisreasonablypracticableonbecomingawareofthedeath.Therefore,iftheCoronerdelayedunduly,andcouldnotshowgoodcause,theHighCourtcould order him to proceed with it expeditiously.

8.3.2Aninquestcannotbeheldifthereisanongoing criminal investigation into the death with thepossibilityofchargesthatmaybeheardintheCrownCourt.Thespecifiedoffencesaremurder,manslaughter(corporateorindividual),infanticideandcausingdeathbydangerousorcarelessdriving.If the CPS proceed with such charges and a trial is held then the coroner may consider that there has beenasubstantivehearingaboutthedeathandthata full inquest is unnecessary. This decision is at the coroner’sdiscretion.

8. Coroner Inquest Process

26

8.4 Pre Inquest Review

8.4.1Increasingly,Coronersareholdingpre-inquestreviews or case management conferences to deal withissuesthatifnotaddressedbeforethehearing,mightrequiretheinquesttobeadjourned.Issuesforpreinquestdebatemightinclude:

•Jury •Disclosure(extentandtiming) •Experts •Timing •Location •Issuesrelatingtoanonymity •Photographs •Realevidence(suchastaperecordings,video evidence,anduseofreconstruction) •Forensicevidence.

8.5 Submission of Reports

8.5.1 Prior to commencement of the inquest the Coroner will call for reports from those investigating agencies he feels pertinent. These normally include reportsfromthePolice,theHSE,theemployerandtherepresentativebody.ThesereportsformthebasisoftheinquestandareusedbytheCoronertoanswerthequestionsdetailedin8.1.2above.AllreportsconsideredbytheCoronerwillbecirculatedtotheother agencies.

8.6 Notification of an Inquest

8.6.1AninquestmustbeheldinpublicunlesstheCoronerconsidersitnecessarytoexcludethepublicintheinterestsofpublicsecurity.Itisnottechnicallynecessarytogivepublicnoticeoftheholdingofaninquest,althoughitisuniversalpracticetodoso,oftenbyansweringenquiriesfromthemedia.

8.6.2Thereis,however,arequirementfornoticeofthetimeandplaceoftheinquesttobegiventoany spouse or near relative of the deceased (or their personal representative) and any other person whom theCoronerconsiderstobeentitledtoexaminethewitnessesattheinquestandwhohasnotifiedtheCoronerofhisrequesttobeinformed.Thisclassofperson is referred to within the inquest proceedings asa‘ProperlyInterestedPerson’.

8.6.3 The Coroner must also give notice to any personwhoseconductislikelytobecalledinquestionsothatifnecessarytheycanobtainlegalrepresentationasthereisaspecificCoroner’srulepreventingapersonbeingallowedtoself-incriminate.There are also requirements to inform government departmentsunderRIDDOR,suchastheHealthandSafety Executive.

27

Death in the Workplace

8.7 Opening of an Inquest

8.7.1TheCoronerwillopentheinquest,whenthereisajury,byswearinginthejurymembers.Thecoroner will then provide an overview of the process andproceduresoftheinquest,theroleoftheCoroner’sCourtandaverybriefoutlineoftheissuesof the case.

8.7.2TheCoronerwilldecidewhatevidenceistobecalled and in what order. There are no strict rules of evidence.

8.8 Witnesses

8.8.1 The Coroner will decide which witnesses to callandhowbesttosecuretheirattendance.

8.8.2WitnessescanbecompelledtoattendanInquest provided they are within the United Kingdom. TheCoronercanobtainaninjunctiontorestrainsomeonefromleavingthecountry,ifthewitnesshasbeenproperlyserved.

8.8.3Allevidenceisgivenbyeitherswearinganoathoraffirming.Perjuryiscommittedifuntruthsaretold.TheCoronershouldbeaddressedassirormadam.

8.8.4Thefirstwitnessafterthefamilyidentificationevidencewilloftenbethepathologistwhoconductedthe post mortem and they will explain the medical causeofdeath.Thiswillbefollowedbyothermedicalevidence such as toxicology reports and paramedic witness statements. Witnesses of fact such as eye witnesseswillusuallycomenext,followedbyexpertwitnesses such as incident investigators or specialist HSE inspectors.

8.8.5WhilethelayoutofeveryCoroner’sCourtisdifferent,generallyspeaking,thewitnesswillsit/standatthefrontoftheCourtnexttotheCoroner’sbenchandfacingtheCourt.Thejurywillsittooneside of the Court and the representatives of the familyontheotherside,thewitnessesandanyother interested parties will sit in front of the family. MembersofthepublicandmediawillbelocatedtothebackoftheCourt.

8.8.6AnypersonwhosatisfiestheCoronerthattheyarewithinthecategorieslistedbelowwillbeentitled to examine any witness at any inquest either in person or through their legal representative. This caneitherbeasolicitororabarrister(referredtoasCounsel in the inquest proceedings).

•Aparent,child,spouseandanypersonal representative of the deceased

•Anybeneficiaryunderapolicyofinsurance issued on the life of the deceased

•Theinsurerwhoissuedsuchapolicyof insurance

•Anypersonwhoseactoromissionorthatofhis agent or servant may in the opinion of the Coronerhavecaused,orcontributedto,the death of the deceased

•Anypersonappointedbyatradeuniontowhich thedeceasedatthetimeofhisdeathbelonged, ifthedeathofthedeceasedmayhavebeen causedbyaninjuryreceivedinthecourseofhis employmentorbyanindustrialdisease

•Aninspectorappointedby,orarepresentative of,anenforcingauthorityoranyperson appointedbyagovernmentdepartmenttoattend the inquest

•TheChiefOfficerofPolice

•Anyotherpersonwho,intheopinionofthe Coroner,isaproperlyinterestedperson.

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8.8.7Allquestionsshouldberelevanttooneofthefour questions the inquest must answer.

8.8.8Itisnormalpracticeforwitnessestobegrantedpermissiontobepresentincourtwhenevidenceisgiven. If the Coroner decides to require witnesses towaitoutside,hecannotexcludeanyonewhohasarighttobepresentasaninterestedparty.Forexample,assomeonewhoseconductmaybecalledin question.

8.8.9 Witnesses are more than often released at the end of their evidence unless there is a good reason for not doing so. There is a provision for jurors to requirewitnessestoberecalledshouldtheyrequirefurtherclarificationonapointoffactascantheCoronerorotherproperlyinterestedperson,attheCoroner’sdiscretion.

8.8.10TheCoronerexaminesthewitnessesfirst,unless they otherwise determine. They are then examinedinwhateverordertheCoronerdetermines,savethatthewitness,ifrepresented,willnormallybeexaminedbytheirownlegalrepresentativelast.The Coroner is required to exclude or disallow any questionwhichtheyconsidernottoberelevant,orotherwise not a proper question.

8.9 Juries

8.9.1Ajuryiscomprisedofbetween7and11memberstakenfromtheCrownCourtJuryList.There are some circumstances in which the summoning of a jury is compulsory:

•Deathsinprison

•Deathsinindustrialaccidents

•Deathsoccurringincircumstancesthe continuanceorpossiblerecurrenceofwhichis prejudicialtothehealthorsafetyofthepublic

•DeathsoccurringinPolicecustodyorresulting fromaninjurycausedbyaPoliceOfficerinthe purported execution of his duty.

8.9.2 There is nothing to prevent the Coroner having ajuryinanyothercase,iftheybelievethereis‘sufficientreason’fordoingso.Practicevarieswidely.

8.9.3PersonsarequalifiedtoactasjurorsonlyiftheyarequalifiedtodosoattheCrownCourt,theHigh Court or County Courts and there are also some limited categories of additionally excluded persons such as people having connection with a prison where someone has died.

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Death in the Workplace

8.10 Summing Up and Decision

8.10.1 The Coroner must sum up the facts heard during the inquest if there is a jury. The Coroner must direct them on the law and on the standard of proof relating to those verdicts which the evidence iscapableofsustaining.ThisisfortheCoronertodecide,applyingmuchthesamecriteriaasajudgeinacriminaltrial.Thismaybethesubjectoflegalargument.Ifthereisnojury,thereisnolegalrequirement for the Coroner to sum up or state any factsthattheyhavefoundbeyondthosethataresetoutintheformoftheinquisitionbutitisalmostuniversalpracticetostatethefindingsoffactsandthe reasons for reaching the conclusions that have beenreached.

8.10.2Ifthereisajury,thejuryaloneretires,no-onemustaccompanythem,theycantakeexhibits,videos,etc,andtheymayreturntocourtforclarificationofdirections.Thisshouldbedoneinopen court with everyone present. It would appear thattheycanrecallwitnesses,evenaftertheyhavestartedtheirdeliberations.

8.10.3Thejuryshouldbeaffordedenoughtimetoconsider their decision. A Coroner does not have totakeamajorityverdict,however,thiscanbeaccepted provided that no more than two dissent. Thiscould,theoretically,resultina5-2decision.TheCoronermustacceptaunanimousverdict,evenifitappearstobeperverse,butmayaddressthejuryand seek to re-direct their considerations if they appeartobeonentirelythewrongtrack.Ifthejurycannotagree,theCoronermaydischargethemandafreshinquestwillhavetobeheld.

8.10.4Thefindingsofaninquestarethosesetoutonaformofinquisition.Thereisalistonthebackoftheinquisitionofpossibleverdictsbuttheyarenot exhaustive. There is nothing to prevent a verdict whichconsistsofasimplestatementoffact-‘thedeceasedwaskilledbyanattackbyananimal’,oranarrative verdict.

8.10.5 However,findingsmustnotbeframedinawaythatappearstodetermineanyperson’scriminalorcivilliabilities.

8.11 Verdicts

8.11.1 There is popular misconception that the verdict is the short conclusion often reported in newspapers.Infact,thetechnicalmeaningoftheverdictisalltheinformationrequiredbytheInquisition.Thenameofthedeceased,theinjuryordiseasecausingdeath,thetime,placeandcircumstances at or in which the injury was sustained otherrelevantregistrationparticulars,forexample,whetherthedeceasedwasmaleorfemaleandfinallytheconclusionastodeath.Thereareanumberof potential common conclusions as to death. For example,naturalcauses,industrialdisease,accidentormisadventure,suicide,unlawfulkillingandanopenverdict.Thereisnoexhaustivelistbecausethere are only suggested short form conclusions.

8.11.2 A Coroner or a jury can also return what is known as a narrative conclusion which is a factual statement of the events causative of death. The evidential test against which all conclusions have to besetisonthebalanceofprobabilities(i.e.thecivilstandard of proof) except in the cases of suicide and unlawfulkillingwherethetestisbeyondreasonabledoubt(i.e.thecriminalstandard).

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8.12 Rule 43 Recommendations

8.12.1OneofthepowersavailabletoaCoroneris the power to make a Rule 43 report (this is often referred to as a Rule 43 letter). If the Coroner feels that the evidence gives rise to a concern that circumstances creating a risk of other deaths will occurorcontinuetoexist,he/shemaymakeaRule43 report which is sent to the organisation which has responsibilityforthecircumstances.WhilsttherearenotimelimitsforaCoronertosendaRule43report,a recipient of a Rule 43 report must send a written response within 56 days of receipt.

8.12.2 There is no legal requirement to actually takethestepsproposedbytheCoronerbutanorganisationisobligedtorespond.Theresponsemustgivedetailsofanyactionwhichhasbeentakenorisproposedtobetaken,orprovideanexplanationwhennoactionisbeingproposed.

8.13 Article 2 Inquests

8.13.1 Article 2 inquests are an enhanced form of inquestflowingfromArticle2(1)oftheEuropeanConventiononHumanRights;therighttolife.TheCoronerhasanobligationtocarryoutaneffectiveinvestigation into cases where Article 2 may have beenbreachedwherethestateisinvolved.ThistypicallyincludesNHStrusts,LocalAuthoritiesandcanalsorefertofireandrescueservices.

8.13.2 The question of when Article 2 is triggered for the purposes of an inquest is a developing area of law. It is accepted however that an Article 2 inquest islikelytobeheldwherethereisanarguablecasethat the death was as a result of systemic failure rather than mere/operational negligence. There is no procedural difference in the way that an Article 2inquestisconducted,howeveritwillinevitablybea lengthier and more in depth investigation and the Coroner is likely to allow a wider range of questions and in some cases more leniency to the family in terms of the questions they raise.

8.14 Coroners Rules

8.14.1Detailsofthesecanbelocatedunderhttp://www.justice.gov.uk/downloads/burials-and-coroners/guide-charter-coroner.pdf

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Death in the Workplace

9.1 An early consideration following the death of a memberinservicemustbethearrangementsforany service involvement in the funeral. As soon as issensitivelypossible,theFLOshouldapproachthefamily to ascertain the service involvement. Every FRS will have its own arrangements for staging a full service funeral.

9.2Wherethefamilyrequestaservicefuneral,experiencehasshownthebenefitofsettingupa Post Incident Programme Board to liaise with thefamilyandotherinterestedparties,andtodrawupplansforapprovalbythefamily.Theplanningprocesswillcovermultifariousissuesbutexperiencesuggeststhefollowingmaybeworthyofconsideration.

•OpenServicecondolencebook(include electronic media)

•Regularbriefingforstaffonfuneral arrangements

•Mappingoffuneralrouteandreleasetopress

•Productionofmediapacks

•ChiefOfficerspre-recordedpressrelease thanking community for their support

•Permissionfromfamilytositecamerasinand/or near to the church.

9.3 It is also necessary to consider whether the familywouldlikeamemorialservicetobeheldtocommemorate the life of the deceased.

9.4 The marking of the anniversary is a sensitive issueandarequestsforsuchmayarisefromboththe family and personnel representing the station/location of the deceased. Typically these events mightbeheldonthefirstanniversaryofthedeath-iftheinquesthasstilltobeconvenedonthesecondanniversary,considerationmightbegiventoofficiallymarking that event.

9. Service Funeral / Memorial Service

32

CFOA wishes to gratefully acknowledge the significant contribution of:

•HampshireFireandRescueService

•HertfordshireFireandRescueService(andin particular Veronica Adlam) in the development of this guidance document

•BerrymanLaceMawer(andinparticularAndrew Relton) in respect of the guidance on the Inquest process.

Please also read the HSE’s Work Related Death Protocol and the firefighter fatality appendix (soon to be published).

10. Acknowledgements

33

Appendix A Glossary of Terms

Appendix B Service Accident Investigation Team: Sample Terms of Reference

Appendix C ServiceAccidentInvestigationTeam:SampleConfidentialityStatement

Appendix D Service Accident Investigation Team: Sample File Headings for Filing System

Appendix E Sample Communications Strategy

Appendix F Sample Media Strategy

Appendix G Sample AIT Check List and Summary of Considerations and Aide Memoire

Appendix H Sample Memorandum of Understanding (Fire and Police)

Appendix I Organisational Improvement Steering Group: Sample Terms of Reference

Appendix J ServiceAccidentInvestigationTeam:SampleExhibitInventory

11. Appendices

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Glossary of Terms

ACO AssistantChiefOfficer

ACOP Approved Code of Practice

ACPO AssociationofChiefPoliceOfficers

AIT Accident Investigation Team

BTP British Transport Police

CCTV Closed Circuit Television

CFO ChiefFireOfficer

CFRAU Chief Fire and Rescue Advisers Unit

CM Crew Manager

CPS Crown Prosecution Service

DCO DeputyChiefOfficer

DCLG Department for Communities and Local Government

DPO DutyPrincipalOfficer

CFRAU ChiefFireOfficersAdvisoryUnit

FBU Fire Brigades Union

FFC Fire Fighters Charity

FLO FamilyLiaisonOfficer

FoI Freedom of Information

FOA FireOfficersAssociation

FRS Fire and Rescue Service

HASW Health and Safety at Work Act 1974

HSE Health and Safety Executive

HSG 65 Health and Safety Guidance Document 65

LGA Local Government Association

MoU Memorandum of Understanding

OHM Occupational Health Manager

OISG Organisational Improvement Steering Group

PACE Police and Criminal Evidence Act 1984

PPE Personal Protective Equipment

RIDDOR ReportingofInjuries,Diseaseand Dangerous Occurrences Regulations 1995

RTC RoadTrafficCollision

Rule 43 Letter sent from Coroner raising Issues tobeconsidered

SIO SeniorInvestigatingOfficer(usuallyPolice)

STEP Sequential Timed Event Plotting

SWA Service Welfare Adviser

UNISON PublicServiceTradeUnion

WM Watch Manager

Appendix A

35

Fire and Rescue Service Accident Investigation Team: Sample Terms of Reference

Introduction

1. On (Date),(Name) Fire and Rescue Service attended an incidental (Address). During the course ofoperations,afirefighter(Name of deceased) sustained fatal injuries.

2. In accordance with the Health and Safety at WorkAct1974,andtheManagementofHealthandSafety at Work Regulations 1999 - Regulation 5 - 36(b),(Name of FRS) will complete an investigation regarding this incident.

Investigation

3. (Name)Constabularyarechargedwithdetermining the circumstances surrounding the deathsatworkinordertoinformthecoroner’sinquest.Additionally,theinvestigationwilldetermineifa‘criminaloffence’hasbeencommitted.

4.Deleteifnotapplicable:The(Name)Constabularyinvestigationisbeingsupportedby(Name) Fire and Rescue Service (technical advice) and (Name) Fire andRescueService(cause,originanddevelopmentofthefire)andisbeingmonitoredbytheHealthandSafety Executive.

5. (Name)FireandRescueService,onbehalfof (Name)Constabulary,willundertakethefireinvestigation.

6. The Health and Safety Executive (HSE) is responsibleforenforcingworkrelatedhealthandsafety legislation under the Health and Safety at Work Act 1974.

7.Jointagencytermsofreference,producedby(Name)Constabulary,havebeenagreedbetween(Name)Constabulary,theother(Names) Fire and Rescue Services and the HSE.

8. The Service has a duty to provide (Name) Constabularywithinformationasrequestedinorderto assist them with their investigation. To facilitate this,theServiceAccidentInvestigationPrincipalLead (Name)willmeetonaregularbasiswiththe(Name)ConstabularySeniorInvestigatingOfficer(SIO). The (Name) Accident Investigation Team consists of:

9. Phase 1 of the Service Accident Investigation is to gather,record,copyandloginformationrelevanttothe incident.

10. Phase 2willrunconcurrentlywithPhase1,and will construct a comprehensive record of what happened at the incident and how it happened. This approachwillbeinlinewithHSG65andHSG245guidance.

11. Phase 3willbetoestablishwhytheeventsoccurred and associated risk control measures. This processwillbeinformedbyPhases1and2.

12. Phase 4willbetheproductionofaninvestigation report incorporating an action plan and recommendations for its implementation.

13. The Service Principal Head of the AIT will manage strategic issues and liaise with other agencies,i.e.Police,ChiefFireandRescueAdvisersUnit(CFRAU),HSE,FireBrigadesUnion(FBU),regarding the investigation.

14.Therepresentativebodieshavebeeninvitedto work in partnership with the Service Accident Investigation Team in line with HSE recommended good practice for safety representative involvement in investigations into workplace accidents. The representativebodiesmaybeaskedtoundertakespecifictaskstosupporttheinvestigation.

Appendix B

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Sample Confidentiality Statement

(Name) Fire and Rescue Service Accident Investigation Team

1.Employeesshallnot,exceptasauthorisedbythe(Name) FireandRescueServiceorasrequiredbytheirdutiesundertheiremploymentcontractorasprovidedinlaw,usefortheirownbenefitorgainordivulgetoanypersons,firm,companyorotherorganisationwhatsoeveranyconfidentialinformationbelongingto(Name of Service). This relates to information or to dealings which may come to their knowledge during their employment. Thisrestrictionshallceasetoapplytoanyinformationorknowledge,whichmaysubsequentlycomeintothepublicdomainotherthanbyabreachofthisclause.AnymattersrelatingtohealthsafetyandwelfarewillbereportedtothePrincipalLeadoftheAccidentInvestigationTeamonthe‘issues’form.

2.Allrecords,documentsandpaperswhichreasonablycouldbeconsideredtobeconfidential(whetherdesignatedassuchornot),togetherwithanycopiesorextractsthereof,madeoracquiredbyEmployeesinthecourseoftheiremploymentordutiesshallbethepropertyofthe(Name of Service)andmustbestored,used,duplicated,managed,translatedandreturnedtothe(Name of Service),asdirectedor,intheabsenceofsuchdirection,inaccordancewith(Name of Service)policyandbestpractice.

3.Confidentialinformationshallinclude,butnotbelimitedto,allinformationwhichhasbeenspecificallydesignatedasconfidentialbythe(Name of Service),andanyinformationwhichrelatestothecommercialorfinancialactivitiesofthe(Name of Service),theunauthoriseddisclosureofwhichwouldembarrass,harmorprejudicetheFireAuthority,or(Name of Service) employees or their agents and partnerships.

4. Information relating to (Name of Service)employeesofaconfidentialnatureisnottobedisclosed.The(Name of Service)considersunauthoriseddisclosureofemployee’sconfidentialinformationaseriousmatterthat may lead to disciplinary action.

5.UndertheComputerMisuseAct(1990)andtheDataProtectionAct(1998),itisacriminaloffencetousecomputers without authorisation or tamper with data or computer equipment or divulge information stored therein.

6.MembershipofaTradeUnionoranyrelevantsocietiesororganisationswhichmayconflictwiththeinvestigationmustbedeclaredbelow:

…………………………………………………………………………………………....................……

I acknowledge that I have received, read and understood the above statements and agree for a copy of this document to be kept on my Personnel Record File (PRF).

Signed ………………………………………………………………………………….......……………

Print Name ………………………………………………………………………………………………

Date ……………………………………………………………………………………...........…………

To be returned to Director of Human Resources, Service HQ.

Appendix C

37

Sample File Headings for Filing System

File 1 AIT Reports

File 2 BriefingNotes

File 3 Briefing(Media)

File 4 Briefing(Public)

File 5 Briefing(Staff)

File 6 Barrister

File 7 Confidentiality

File 8 Control Room

File 9 Coroner/Inquest

File 10 Equipment

File 11 Exhibits

File 12 Families File

File 13 FBU

File 14 Finance

File 15 Fire Authority

File 16 Fire Investigation

File 17 Fire Safety

File 18 General Investigation

File 19 HSE

File 20 Information Request

File 21 Insurance

File 22 Investigation Notes

File 23 Learning Log

File 24 Legal Advice

File 25 OISG

File 26 Operational plans

File 27 Other Brigades Advice

File 28 Personnel Files

File 29 Photographs

File 30 Police

File 31 PPE Press

File 32 Research

File 33 Service Orders

File 34 Staff Interviews

File 35 Station (affected)

File 36 Terms of Reference

File 37 Training Analysis

File 38 Training / NVQ

File 39 Video Footage Info

File 40 Welfare

File 41 Witness Statements

Appendix D

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Sample Communications Strategy

A Communications Strategy is also required to ensure that the correct approach is taking in communicating withfamilies,watchmembersandcolleagues,authoritymembers,allinternalstaffandthewiderfireservicecommunity.

The Communications Strategy should consider:

•Issuingregularandtimelyupdatestoallstaffandmembers.HFRSissueddailyupdatesimmediatelyafter the incident and also during the period of the inquest

•Alwaysinformstaffofupdatesbeforethemedia,particularlypotentiallysensitiveones

•FacetofacebriefingsfromtheChiefOfficerandregularvisitsfromseniormanagerstostations.Faceto face communication during this time is very important

•Constantreminderofwelfaresupportandcontactdetails

•Guidanceonfundraising

•Developmentofintranetpagesrelatingtohonoursandtributes,investigation,donationsandcollections.

Appendix E

39

Sample Media Strategy

The Service should draw up a Media Strategy for the immediate response and media handling at the time of the incidentandalsoforthelongertermmediamanagement.AMediaStrategyisalsorequiredforpre,duringandafter the inquest.

TheMediaStrategyforimmediateuseshouldbedrawnupandagreedwiththeIncidentCommanderandChiefOfficer.Thekeymedialinestakenintheveryearlystagesoftheincidentandthetoneofthemessageswillsetthesceneforthedurationoftheincident,investigation,inquestandbeyondsoconsiderthemcarefullyandensureagreementwiththeChiefOfficer.ThelongertermMediaStrategyshouldbedevelopedinliaisonandagreement with the AIT and the Service Legal Advisor to ensure information given to the media is correct and does not jeopardise the investigation or reputation of the Service.

The Media Strategy should consider the following:

•Immediatemediamanagementatthesceneoftheincidentandbackupofficesupportfor48hoursafter the incident

•Theuncertaintyoftheinvestigationoutcome

•Beingflexibleasandwhennewinformationcomestolight,youmayneedtochangeyourapproach

•IdentificationofkeyServicespokespeople,ensuringtheyaretrainedtofieldmediaenquiresduringa major emergency

•EnsuretheServicemeetsitslegalresponsibilitiestowarn,adviseandinformmembersofthepublic

•Clearrolesandresponsibilitiesformembersofthecommunicationsteam

•24hourrotaforthemediaandcommunicationsteamfortheweekaftertheincident(atleast)

•Thetimingofconfirmationoffatalities,namesandphotographs

•Coordinationofinformationreleaseandmessageswithothernecessaryandkeyagencies

•Advicetothefamilies,watchandstaffonhandlingmediaapproaches

•Thesetupandmanagementofapressconference

•TimingformediainterviewswiththeChief.HFRSChiefOfficerledthepressconferencethedayafterthe incidentandthenonlydidpre-recordedinterviewsbeforethefunerals

•Pressofficersupportonaffectedstations

•Mediaapproachatkeymilestonepoints,suchaswreathlayingonthestation,oneweekonfromthe incident,funerals,memorialservice,oneyearon,endofPolice.investigation,outcomes of HSE investigation

•Regularmediamonitoringtoallowforinaccuraciesorsensitivitiestobepickedupandchallenged

•Alwaysrememberthereispotentialforthecrisistoescalateoradditional/newcrisestoemerge.

Appendix F

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WithintheMediaStrategy,alsoconsideryoursocialmediaplanandhowyouwilluseandmanageyourpresenceonsocialmediaintheimmediate,mediumandlongerterm.Yoursocialmediaplanshouldconsider:

•Managementofcondolences

•Approachtoinappropriatecomments

•TimelyandfrequentupdatesandmessagesfromtheService

•Constantmonitoringtogaugeopinion

•Adviceandguidancetostaffontheirsocialmediausage

•Linkingupwith‘unofficial’condolencepages.

Statements and interviews should use consistent and agreed lines that are used throughout the process. Statements and release of information on social media should:

•Expresssympathyforthefamilies,relatives,friendsandcolleagues

•Paytributetotheindividualsandthosetacklingtheincident

•Emphasiseanypositivepointssensitivelyifappropriatei.e.numberoflivessaved,nooneinjured,safetyof surroundingbuildingsmaintained

•CommitmentoftheServicetolearnlessonsforthefuture

•Emphasisefullcommitmentandwillingnesstoco-operatewiththeinvestigation

•Confirmlocation,timingsandactions,asappropriate

•Confirmthatfamilieshavebeeninformed.

Statements should not:

•Confirmfatalitiesornamesuntilfamilieshavebeeninformed

•Speculateonanyofthecircumstancesoftheincident-cause,failingsorprocedures

•Criticiseanyindividualoragency

•Pre-empt,speculateorcommentonfindingsofthePoliceinvestigation,HSEinvestigationorfindings of the Coroner.

41

Sample AIT Checklist and Summary of Considerations

Roles

•FireControltoinformDutyBrigadeManagerwhoinformsCFO,DCO&otherPO’s/Directors •FireControltoinformHSE,H&SOfficer,OccupationalHealth •TheBrigadeManagerarrangescontactwithfamilies–ensuringcloseliaisonismaintainedwiththePolice •ThePolicewillexpectasinglepointofcontactwithinthefireandrescueservice •PrincipalOfficerappointedtoleadtheServiceAccidentInvestigationTeam •AppointServiceAccidentInvestigationTeam-ensureliaisonwiththeSeniorPolice InvestigatingOfficer(SIO) •ServiceLegalAdvisortobeappointed-checkServiceInsurancelegalcover.

Head of Service Accident Investigation Team

•ConsiderationofmembershipoftheAccidentInvestigationTeam •LeadandmanagetheAccidentInvestigationTeam •LeadofficertoliaisewithteamappointedtoconducttheFireInvestigation •AppointOfficersforparticularroles: •AgencyLiaisonOfficer-FBU,Police,HSE •DevelopinteragencyMemorandumsofUnderstanding(MoUs)forinter-agencyworking

Welfare

•Initialcontactwithfamily-PoliceorPrincipalOfficer-considerchoiceofFLOprovisionforlonger term liaison •AppointaFamilyLiaisonOfficerforliaisonwiththeimmediatenextofkin •Posttraumaticstresscounsellingforthosedirectlyinvolvedintheincidentandalsotheremainder of Service •Provisionoflegaladvicefornextofkin-thisisoftentakenonbytherepresentativebody, Service to ascertain •InitiateDeathinServicegrantassoonaspossible •TrustFund-Thereshouldbeanagreementontheestablishmentandmanagementofthefund •NotifytheFireFightersCharity •Rehabilitationrequirementsofthosesufferingemotionallyorphysically •FamilytodecidearrangementsforaServicefuneral-FireServiceChaplain(Familydecision) •Ongoinginformation(updatingfamiliesthroughoutinvestigation-useofFLO) •Considerimplicationsforwhentheinvolvedcrewsarenextonduty •ConsiderthewelfareoftheInvestigationTeam.

Appendix G

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Representative Bodies

•Establishprotocols/MoUsforinteragencyworking •JointinvestigationwithFRSorseparateinvestigation(likely) •Considerregulations(consultationwithemployeesregulations;safetycommitteesandsafetyreps) •Interviewsaretobeheldawayfromservicefacilities •Informationrequestsrequiredinwriting(loggedandrecorded).

Health and Safety Executive

•EnsureearlyliaisonwithHSE •KeepHSEupdated •HSEmaymakewrittencontactwithfamilies •Releaseexhibits/analysisreports •EstablishcontactwithLocalAuthority/FireAuthorityasappropriate.

Police

•Haveprimacyforinvestigation-althoughtheywillreviewtheirroleastheinvestigationproceeds and may cede this to the HSE •LiaisewithCoronerreinvestigationprogressandoutcomes •Informfamilies/nextofkin(requestconsiderationofajointvisitwithServiceFLO) •Interviewwitnesses •Willrequirebreakdownoffireandrescueserviceterminology •ServiceshouldmaintainagoodrapportwithPolicetoensurethesharingofresourcesandinformation •UsePoliceinterviewsinlieuofadditionalServiceinterviews.

Legal Advice

•Seekadviceimmediatelyonlitigationissuese.g.inquestprocess •Obtainadviceon: •Reportdraftspriortosubmission •DataProtection&FreedomofInformation •Disclosurematters •ConsiderpotentialforCorporateManslaughtercharges •ConsiderpotentialforCriminalAction •Consideruseofexternalexpertlegaladvice(checkInsurancelegalprovision) •Whereappropriate,initiatehardshippaymentsassoonaspossible •Contactspecialistswithinthefield •AttendmeetingswithFBUandPolice •ExpectCivilclaimsfollowingCoroners/CriminalCourtproceedings •MaintaincloseandongoingliaisonwiththeServiceInsurancecompany.

43

Budget

Initiate Budget (and code) for costs associated with the investigation and the coroners inquest for:

•SecureAccommodation •Welfare(psychologicalhelp-counselling) •Considertemporaryreplacementofstaffwhereappropriate •Policeinterviews-photos/video/transcriptions •Consumables •AdditionalITcosts •Securestorage •Consultantfees •Transport •Scientificanalysis •Overtimeortime-off-in-lieuandwagescompensation-reimbursementforpart-timestaff •Inter-regionalsupportcosts(overborderassistance) •Contingencyplanforunforeseenexpenditure.

Administration

•Resourceappropriateforanticipateddemands •Separateadminofficetobeavailable-dataprotectionandF.O.I •StafftobefamiliarwithServiceterminology •Equipmentrequirementsincludecomputers,photocopiers,scannersandsecureIT •Audittrailandcontinuityofevidence-loggingphonecallsandforwardingmessages •Documentcontrol-gatherreceiptsandlogeverything •Setupfilingsystem,labelling,baggingandstoringinformation •Arrangemeetingsandorganiseinterviews-takeminutes •AssistCoronerandattendinquest •Potentialforextendedinvestigationtime •AdministrationoftheinterviewprocesswiththePoliceandHSE.

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Thisisintendedasachecklistforseniorofficers/managersimmediatelyfollowingtheincident.

Aide Memoire for Death in the Workplace

•Thefirstpriorityistoconsidertheemotionalneedsofthefamilyandthosecloselyinvolved.Itisveryeasy to fall into the trap of trying to separate out management of the incident from those emotional needs and you should not attempt to do that.

•Inclusionofthosepersonallyinvolvedinallcommunicationsiskeyintermsofthetributesandmedia strategy;particularlyintheinitialperiod,butalsoongoing(thosepersonallyinvolvedincludetheline managers,aswellasclosecolleaguesandfamily).

•Timingofthereleaseandearlynotificationofcommunicationstothosecloselyinvolvedis particularly important.

•Buildinganopen,trustingrelationshipwiththemediaisvital.Thishelpstocontrolaccesstothefamiliesby the media and avoids any speculation.

•Youneedtoworkhardtobuildyourrelationshipswithexternalagencies,particularlythepolice,maintaining a dialogue through testing times.

•SeekassistancefromthoseoutsidetheServicewhohaveexperiencedsimilarevents,don’tbeafraidto ask for help - people will give it willingly.

•Visible,clearleadershipisvitaltomaintaintheconfidenceoftheorganisation.Ensureyoucreatethe capacity to allow the Chief to constantly provide that role.

•Youwillbeemotionallyaffectedyourself,thereforedoublecheckyourdecisionmakingwithanobjective external view.

•Youneedtoacceptthattheinvestigationwilltakealongtime.Itneedstobeproperlyresourcedand sustainedandyouwillneedtolookforyourbesttalents;bothasleaders,investigatorsandadministrators.

•Doyourutmosttoagreeworkingprotocolswithotheragencies,particularlythePolice,HealthandSafety Executive,butalso,representativebodies.ThereareMoUsavailable.

•Intheinitialstage,dealwiththeeventandresponsethroughacommandstructure,butthenmanagethe transitiontoaclearbusinessfocussedstructure,usingprogrammemanagement.

•Rememberthatthisisabusinesscontinuityeventsouseyourexistingplanstoassistyou.

•Quicklydecideonwhatisnolongeracorporatepriorityandstopordelaydoingit.

•HRinformationneedstobeimmediatelyaccessible-ensureyouhavethosegatekeepersavailabletoyou.

•FamilyLiaisonOfficersareincrediblyimportantbothintheshort,mediumandlongterm-choosecarefully.

•Makesureyourstaffcompletecontemporaneousnotes.

•Don’tunderestimatetheresourcerequirementtoproperlymanagehonour,tributeandfundraising activities.Establishaboardoftrustees.

•Theresilienceofyourtopteam(SMT)willbeseverelychallenged-considerappropriaterosteringand/or sharing arrangements.

45

Sample Memorandum of Understanding

Memorandum of Understanding between (Insert Name) Constabulary Investigation Team and the (Insert Name) Fire and Rescue Service Investigation Team.

TheInvestigationIntoTheDeathofFirefighter(Insert Name) (Insert Date)

MEMORANDUM OF UNDERSTANDING BETWEEN (Insert Name) CONSTABULARY INVESTIGATION TEAM

AND THE (Insert Name) FIRE AND RESCUE SERVICE FRS INVESTIGATION TEAM

Introduction

Thismemorandumofunderstanding(MoU),agreedbetweenthe(Insert Name)Constabularyinvestigationteamappointedtoinvestigatethecircumstancesofthefireat(insert details) and the investigation team appointed by(Insert Name)FRStocarryoutaninternalinvestigationintotheincident,setsouttheprinciplesforliaisonbetweentheagencies.

The aim is to ensure that effective investigation and data sharing processes are in place in order to facilitate anindependentandtransparentinvestigationby(Insert Name)Constabulary.Although(Insert Name) Constabularyhasprimacyfortheinvestigationintothedeathsofthefirefighteritisacceptedthat(Insert Name) Constabularywillhavetocommunicatewithpersonnelfrom(Insert Name)FRSonaregularbasistorequestinformation and provide updates where appropriate.

ThisMoUhasbeendevelopedfromtheInvestigationStrategyandTermsofReferenceagreedbytheleadAgency on the (Insert Date).

TheSeniorInvestigatingOfficerforthePoliceinvestigationis(Insert Name).

The FRS Service Accident Principal Lead is (Insert Name).

Requests for Information by (Insert Name) Constabulary

(Insert Name) FRS have a duty to provide the Police with information as requested in order to assist with the Police investigation. The Police may request information from (Insert Name)FRSeitherverballyorinwriting.

If (Insert Name)FRSarenotpreparedtosupplyinformation,documentorexhibitasrequestedby(Insert Name) Constabulary,reasonsforthisrefusalshouldbegiveninwriting.

Appendix H

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Communication

The SIO will formally meet with the (Insert Name) FRS Service Accident Investigation Principal lead on a periodicbasistoprovideanupdateonthePoliceinvestigation.Theformatforthesemeetingswillbeasfollows:

•GeneralUpdateonPoliceInvestigation •UpdateonplannedPoliceactivityandtimescales •Significantsafetyissuesidentified •Localandnationallessonslearnt(subjecttodisclosurecriteriatest) •Requestsby(Insert Name)Constabularyforfurtherinformationdisclosureby(Insert Name) FRS •Requestby(Insert Name)FRSfordisclosureofmaterialbythe(Insert Name) Constabularyinvestigationteam.

Itisacceptedthatitmaybenecessaryformembersofthe(Insert Name) FRS investigation team to communicate withmembersofthePoliceinvestigationteamonaregularbasis(particularlyatthestartoftheinvestigationwheninformationisbeingrequestedandsecured).Althoughthisisacceptedprotectingtheindependenceoftheinvestigationisparamountanditisessentialthatthereshouldbeasterilecorridorbetweenthetwoinvestigationteams.

Allcommunicationbetween(Insert Name)Constabularyandthe(Insert Name)FRSinvestigationteamwillberecorded and retained in line with the disclosure provisions of the CPIA 1996.

AnydifficultiesincommunicationbetweenthetwoteamswillbedealtwithbytheSIOandtheserviceaccidentinvestigation principal lead.

Membersofthe(Insert Name) FRS investigation team should not attempt to communicate or request information fromfireservicepersonnelfrom(Insert Name) FRS who are working as part of the Police investigation. Allcommunicationandrequestsforinformationby(Insert Name)FRSshouldbetotheSIOorotherPolicepersonnel who are part of the team. This is to protect the integrity and independence of the investigation.

Destructive Testing of Exhibits/Equipment

ThePoliceinvestigationteamhasastatutorydutytopresenttoaCoroner’sCourtorCriminalCourtthe‘bestevidence’available.Onoccasionsthismaybeconsideredtobethephysicalevidenceinthestateinwhichitwasrecovered.However,inordertoestablishthecauseofthedeaththeteammayneedtoundertakefurtherteststodevelopfurtherevidencethatwillmodifytheconditionorpossiblydestroysomepartoftheitem.

IftheSIOplansanyforensictestingwhichislikelytomodify/destroytheconditionofanyexhibit(Insert Name) FRSwillbegivenpriornotificationofthistestinginorderthattheycanconsidersendingarepresentativetooverseethetesting.Theresultsofsuchtestswillnotnecessarilybedisclosedto(Insert Name) FRS immediately after the test is complete to protect the integrity of the on going investigation.

Inrelationtoplannedforensictestingortestingofequipmentwhichislikelytobenon-destructive,(Insert Name) FRSwillbeinvitedtomakerepresentationsastothetypeoftestingcarriedout.TheSIOwillgiveconsiderationtoanyrepresentationsmadebutwillhavethefinallydecisionwithregardtoanyforensicsubmissionsortestingof equipment.

47

Interviews of (Insert Name) FRS Personnel

AdetailedinterviewstrategyiscurrentlybeingpreparedbythePoliceinvestigationteaminliaisonwith(Insert Name) FRSandotherrepresentativebodies.Incarryingoutinterviewswith(Insert Name)FRSpersonnel,thegeneralprincipleswillbeadopted.Theyareasfollows:

•(Insert Name)Constabularyhasprimacyfortheinterviewofallwitnesses.The(Insert Name) FRS will notcarryoutinterviewsortakewitnessstatementsfromanymemberof(Insert Name) FRS without the prior agreement of the SIO.

•Onceallrelevantinformation/evidencehasbeenobtainedfromawitness,atanappropriatetime,theSIO will give consideration to disclose the content of the interview to (Insert Name)FRS.Ifhavingbeen provided with details of the witness account (Insert Name) FRS wish to carry out additional interviews with thewitnessaformalrequestmustbemadetotheinvestigationteamforthePolicetoconsider.

•AlistofallpersonswhothePolicewishtointerview/takestatementsfromwillbeforwardedtothe(Insert Name) FRS investigation team and the FBU in advance. (Insert Name) FRS (with assistance from the FBU)willarrangeinterviewsatsuitabletimes,facilitatethechangeofdutyrotasetc.inorderthatthese interviewscanbecarriedoutattheearliestopportunity.

•Allmembersof(Insert Name)FRSwhoareaskedtoprovideawitnessaccountcanbeaccompaniedby afriend,representativeand/oralegaladvisor.Witnesseswillbeaskednottoselectpersonswhoattended theincidentat(Insertaddressofincident)onthe(insertdate)assupporterstopreventanysubsequent allegations of collusion. (Insert Name) FRSwillnotinsistontheattendanceofaseniormemberofstaff whenfirefightersareinterviewed(aspernormalprotocol).Ifawitnessrequeststhattheyareaccompanied duringawitnessinterviewbyaseniormemberof(Insert Name)FRS,(Insert Name) FRS will supply aseniorofficerwhoisnotpartoftheinvestigationteamandhadnoinvolvementintheincidentunder investigation.Anyseniormemberof(Insert Name) FRS who attends an interview at the request of a witnesswillbeinstructednottodiscussthecontentofthewitnesstestimonywiththe(Insert Name) FRS teamoranyothermemberof(Insert Name) FRS.

•ThePolicewillrequestthat‘significantinterviews’(interviewswithkeymembersofstaffwhohadan important role in the incident) are conducted at dedicated Police witness suites and that the accounts given are visually recorded. The Police will facilitate any requests from a witness that the interview takes place atadifferentlocatione.g.fireservicebuilding.Awitnessinterviewwillnotbevisuallyrecordedifthewitness objectstothis.

•Detailsofinterviewswithindividualwitnesses(summaryofinterview,statementandtranscript)willnot bedisclosedto(Insert Name) FRS immediately after the interview of a witness. The SIO will determine an appropriatetimewhensuchdisclosureswillbemadeonthebasisofthestatusanddevelopmentsoftheon going investigation.

•ThesameprocesswillbefollowedifthePolicewishtointerviewawitnessundercaution.Insuch circumstances,thememberofstaffwillbeofferedlegaladviceaspernormalPoliceprovisions.

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The Sharing of Information

ItwillbethedecisionoftheSIOwhentoreleaseinformationandmaterialtothe(Insert Name) FRS investigation team.Anydecisiontodiscloseinformationwillconsiderthebalanceinsupportingthe(Insert Name) FRS investigation with protecting the integrity of the on going Police investigation. The principle that (Insert Name)Constabularyhaveprimacyfortheinvestigationwillbeattheforefrontofeverydecisiontodiscloseinformation.NoinformationwillbedisclosedwhichmaydamagetheongoingPoliceinvestigation.

The SIO will consider all written requests for disclosure from the (Insert Name) FRS investigation team. Followingsuchrequestsawrittenrecordwillbemadeofanyinformationdisclosedandanydecisionnottodisclose the information.

Whereappropriate,theSIOwillseekadvicefromtheforcelegaladvisorandtheCPSregardingwhethertorelease the information to the (Insert Name) FRS investigation team.

Safety considerations are of paramount importance and it is fully accepted that the investigation may uncover informationthatmayassistininformingtheFireServicesafetyprocedures.WheretheinvestigationidentifiesapotentialrisktoFireServicepersonnel,thepublicorseriousproceduralfailuresthatmayexposeotherstoharmadvicewillbesoughtfrom(Insert Name of any assisting FRS),HSEandChiefFireandRescueAdvisersUnit (CFRAU) regarding the most appropriate channels to communicate this information to provide advice and guidancetofireandrescueservicesandotherstatutorybodies.

Indecidingwhethertodiscloseinformationregardingsafetymattersthatariseduringtheinvestigation,thefollowingdistinctionwillbemadebetween:

(i)SafetyCriticalInformation-Immediatereleasewillberequired

(ii)SafetyRelevantInformation-Safetyinformationwherethereisnotanimmediaterisktofireservicepersonnelorthepublic.Whensuchissuesareidentifiedadisclosuretestwillbeappliedtobalancethebenefitsandrequirements of disclosure with the likely impact on the ongoing investigation.

Signatories

PoliceSeniorInvestigatingOfficer(Insert Name) ……………………………………………… (Insert Name)Constabulary

FRSAITLeadOfficer(Insert Name) ………………………………………..………..………….. (Insert Name) Fire and Rescue Service

Dated ………………..….

49

(Insert Name) Fire and Rescue Service Accident Investigation - Address of incident and Date (Sample) Organisational Improvement Steering Group Terms of Reference

TheManagementofHealthandSafetyRegulations1999,Regulation5,ApprovedCodeofPractice,Monitoring,Paragraph36(b)requiresemployerstoensuretheyadequatelyinvestigatetheimmediateandunderlyingcausesofincidentsandaccidentstoensurethatremedialactionistaken,lessonsarelearntandlongertermobjectivesare introduced.

Improvements made during the course of the investigation will demonstrate that the Service is acting proactively and learning from the accident.

ItisthereforeincumbentontheServicetomakeimprovementsassoonasreasonablypracticablewheninformationcomestolightthatsuggeststhatthehealth,safetyandwelfareofemployeesorothersmaybeaffectedbyrelatedactivities.

TheAccidentInvestigationTeam(AIT)may,throughtheirinvestigationprocesses,identifyissuesthatpromptconsiderationfororganisationalimprovementstobemade.Theseissuesmighteventuallyberaisedinthefinalinvestigationreportandrecommendations,however,itmightnotalwaysbeappropriatetowaituntilthefinalreport is issued to take action on making improvements.

Itisimportanttonotethatsomeoftheissuesraisedmightnotbedirectlyattributabletothecauseoftheaccident,buttheyareneverthelessconsideredasitemsforimprovementforthebenefitoftheService.

InordertoprogressthesemattersanOrganisationalImprovementSteeringGroup(OISG)willbeestablishedinvolvingkeymembersoftheServicewho,throughtheirrole,willconsideranyissuesraisedandallocateresourcesaccordinglytotheactionsthatareagreed.Thisisimportantbecausesomeactionsmayhaveanimpact across all areas of the organisation.

The Organisational Improvement Steering Group will consist of:

•(ServiceDelivery)-Chair •(ServiceDeliveryResponse) •(ServiceDeliveryProtection) •(HeadofTraining) •(HealthandSafetyManager) •(AITAdminSupport) •MemberofAITasappropriate

Note:Anominateddeputywillattendifanyoftheaboveareunavailable.

The purpose of the Organisational Improvement Steering Group is to:

1.IdentifyandreviewallissuesraisedbytheServiceAccidentInvestigationTeam 2. Agree and record the expected actions/outcomes for each of the issues raised and place on an issues log 3.Developaninterimactionplan,identifyingkeyobjectives,keytasks,resourceimplications,leadofficers and timescales for completion 4.MonitorprogressandupdatetheAITLeadOfficer,ServiceManagementTeamandRepresentativeBodies 5.Issueappropriateandtimelycommunicationstostaffontheimprovementactionsbeingtaken.

Appendix I

Death in the Workplace

50

(Insert Name) Fire and Rescue Service - Accident Investigation - (Incident address) Sample Exhibit Inventory

Appendix JSe

rial

NoEx

hibi

t No

Date

Desc

riptio

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mm

ent

Loca

tion

Stor

edDa

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@FR

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51

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