Adam Brunskill

rooflights or to prevent a fall through the rooflights. The Jury found there were no designated walkways. The Jury found there was no safety netting inside the warehouse to mitigate a fall. On the morning of 14/7/20 Adam was allocated the job of laying down bars on the roof of the building in preparation for over cladding. Around 9 am Adam was discovered to be absent from the roof. A broken glass rooflight was identified. The evidence was that Adam had fallen through one of the glass rooflights approximately 8 metres to the concrete floor below. The exact circumstances of the fall are unclear. He sustained a devastating brain injury and died the following day 15/7/20 in the Queen Elizabeth Hospital, Birmingham. The Health & Safety Executive had conducted an investigation and the inquest was aware that no decision had been made at the time of inquest by the Health & Safety Executive about prosecution of either Wayne Clarey Roofing and Cladding had been made in relation to any criminal offences. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The Coroner heard at inquest that Adam had been employed by Wayne Clarey Roofing and Cladding to work on a roof with no prior experience of working on a roof and no CSCS card nor had he completed a mandatory one-day Health & Safety course; (2) On day 13/7/20 and 14/7/20 there was no evidence of a designated supervisor responsible for Adam on site and/or responsible for Adam’s practical on the job training; (3) The Coroner did hear in evidence that one of the Principal Contractors who provided regular work to Wayne Clarey Roofing and Cladding would undertake to train any future unqualified employees of Wayne Clarey and provide access to an accredited training qualification and training matrix. The Coroner also heard that Mr Clarey had legal responsibilities under the Health & Safety at Work Act and the Construction (Design and Management) Regulations 2015. However, there was no evidence of any clear designated structured training programme in place by Wayne Clarey Roofing and Cladding for new and/or unqualified employees; (4) The Coroner did hear in evidence that one of the Principal Contractors who provided regular work to Wayne Clarey Roofing and Cladding would undertake to train any future unqualified employees of Wayne Clarey and provide access to an accredited training qualification and training matrix. The Coroner also heard that Mr Clarey had legal responsibilities under the Health & Safety at Work Act and the Construction (Design and Management) Regulations 2015. However, there was no evidence of any clearly identifiable supervisor and/or supervisory arrangements in place by Wayne Clarey Roofing and Cladding for new and/or unqualified employees;