Author Archives: Bespoke Safety

About Bespoke Safety

Food and health and safety regulatory advice

Training Programme

For the first time I have planned a programme of training sessions as follows:

The closed events are just for information, however all other sessions can be booked via Eventbrite, just follow the link.

Excellent course delivered in a fun and engaging way, I knew very little about PACE before I started the course and now I feel I have a good understanding of the process and pitfalls.

Really enjoyable day, went really quickly and lots of interesting and useful information delivered by a very personable and obviously knowledgeable trainer

Local Authority Officer

IOSH Webinar

I am speaking at my IOSH Branch Meeting webinar tonight…

When: Thursday evening, 12 May 2022 between 19:30 and 20:30hrs (UK time), directly after our Branch AGM.


A Coroners Inquest can be highly charged and emotive, considering the final circumstances of someone’s death. In the context of a work related death and breaking it down into the various components, this session will explore the purpose of the Inquest, the various roles of those attending including the Coroner, Jury and ‘interested person’, the chronology, the Conclusion and finally ‘Preventing Further Death‘ reports.

Being prepared to attend or give evidence in an Inquest is crucial given their public nature. This session aims to give an insight into the practicalities of an Inquest and to assist those who may have cause to attend a Coroners Inquest for both personal or professional reasons.

The event registration link is: 

IOSH Coroner’s Inquest Link


I have been working with a local authority recently, helping them with a fatal accident investigation and advising on Coroners Inquests. I’ve attended quite a few over the years assisting officers and families and I run training sessions for officers giving evidence. Unless you have been to one, it’s difficult to fully understand the process and so here are my top ten facts to help families, fatal accident investigators, health and safety practitioners and anyone who may be interested.

Please feel free to share with colleagues and if you have any questions or want any further information please get in touch.

Bespoke Safety


Although held in open court, an inquest does not seek to blame individuals or organisations, merely to determine:

Who the person was
When did they die (date and time)
Where did they die
How did they die
Generally, the Inquest is taken up with ‘how’ as the who, when and where is usually known. It is not unusual for lawyers to ask searching questions, especially if it is likely a health and safety prosecution may be considered. The Coroner will normally step in and remind all parties that this is an Inquest and not a trial. Even so, be aware, tensions can run high.


Coroners will be a barrister, solicitor or medical practitioner with not less than 5 years standing. They are appointed by the Crown but funded by the local authority in which they operate.


No, only those meeting the following. The death was violent or unnatural, cause of death was unknown or the person died in prison, police custody or another type of state detention. Work related deaths fall into the unnatural / violent death bracket and also include any death where an industrial disease is recorded. On notification from a doctor, police or Registrar, the Coroner then decides whether an Inquest is appropriate – it is not automatic. Coroners Officers will assist in the investigation to determine whether an Inquest is necessary, but it will remain the decision of the Coroner.


No. It is for the Coroner to decide whether a PM is necessary and this forms part of the initial investigation to determine whether an Inquest is needed. Other options available include MRI (magnetic resonance imaging) or CT (computerised tomography) scanning and toxicology reports. The Coroner does not have to ask permission to require a PM and there are 2 types, a general PM and a forensic PM. The majority are general PMs, but where a more detail is required a forensic PM is carried out although it is unlikely that this will be the case for a work related death.


No, the majority of Inquests will be heard without, however, a work related death will be heard with a jury. The Coroner may pose questions at the start of the Inquest for the jury to answer including how the person died and likely cause of death. They retire at the end of the Inquest to agree a response and can be directed by the Coroner in matters of law. The jury can ask questions or ask for clarification and so in that sense, it is similar to a Crown Court environment.


This is what makes an Inquest different. Before the Inquest, the Coroner will hold a pre Inquest review where the scope of the Inquest is set out and the Coroner decides who to call as a witness. All witnesses must attend and will receive a formal summons to attend. At the pre Inquest, the Coroner will identify ‘Interested Persons‘. These are the only people allowed to ask questions during the Inquest (besides the Coroner and Jury) and can include lawyers acting for Interested Persons, the Interested Person themselves as well as the family of the deceased. This is what makes an Inquest different. As a witness in the past, I have had to answer difficult questions from the family as well as barristers acting for 3rd parties and it’s that open court environment that makes an Inquest different. Given the nature of an Inquest, emotions can run high and they can be very tense affairs. All witnesses giving oral evidence do so on ‘oath’ (swearing on a religious book) or on affirmation (a promise to tell the truth). It is a criminal offence to lie in an Inquest. Witnesses are legally entitled not to answer any questions that may self incriminate.


At the end of the Inquest, the Coroner will set out the Inquest Conclusions (no longer called a verdict). For work related deaths, the most common Conclusions are:

  • Accidental death
  • Death by misadventure
  • Industrial disease
  • Unlawful killing

Other Conclusions include:

  • Alcohol/drug related
  • Lawful killing
  • Natural causes
  • Open (insufficient evidence to decide on a conclusion)
  • Road traffic collision
  • Stillbirth
  • Suicide

The Coroner concludes the Inquest stating who, when, where and how the person died on a prescribed form and stating one of the above. Where the Inquest has been more complicated or involves additional complex issues, the Coroner can also give a narrative Conclusion to further explain the circumstances leading to a death. The narrative provides a longer explanation of the facts surrounding the death and can include the Coroners or Jurys comments. The narrative is not confined to the 11 Conclusions above but can include other factors e.g. neglect. The narrative can also include answers to the questions that the Coroner posed to the Jury at the start of the Inquest.


The simple answer is no. It is for the Coroner to decide when to hold an inquest, however it is likely that the Inquest will be opened as soon as possible, for it to be adjourned pending an investigation. It is best practice for an HSE / local authority investigation to wait until the Inquest has been concluded before a decision is reached as to any further / legal action. This means, the HSE / local authority will provide an interim report to support the Inquest, but it is unlikely that a final report is provided as the investigation is still ongoing (more to come in Part 2).


At the end of an Inquest, the Coroner can issue a ‘Report to Prevent Future Deaths’ also known as a ‘Reg 28 Report’. Self-explanatory, this is a request made to relevant parties, including HSE / local authorities asking them to provide clarification on how the circumstances contributing to the death could be prevented in the future. For example, a death following a failure of lifting equipment may result in the Coroner asking if arrangements to ensure regular inspection of lifting equipment nationally are adequate. All parties receiving the request must provide a written response within 56 days. Copies of reports can be found HERE


Challenges to the Inquest Conclusions can be made to the High Court via ‘judicial review’.


I hope you are all well and negotiating the Covid-19 lockdown landscape.

As I am not able to deliver face to face training sessions, I am helping to support health and safety regulators with online training. I am providing this 40 min virtual session PACE in a Health and Safety Context free of charge to help you to maintain your CPD. It’s a session that I recently gave to IOSH South Midlands Branch members and I hope you will find it interesting and useful.

Although it is health and safety related, because it deals with PACE, it is relevant to all involved in criminal investigations including food safety, trade standards, planning, environmental crime etc.

It covers in general…

1. Origins of PACE

2. Using PACE in your investigations

3. Interviews under caution

4. CPS Code for Crown Prosecutors

5. Top tips!

Please feel free to share with colleagues and check web pages for future CPD sessions.



The fight against Covid-19 is not just about social behaviour, besides the UK Govt Rule of 6, we also have our own Practitioner Rule of 6. We should consider these as a minimum when drafting or assessing risk assessments or safe systems of work.


I keep seeing risk assessments that refer to social distancing without qualifying what they mean. Please state whether your are maintaining 2m, if not, state the circumstances when this drops below 2m and state the RISK MITIGATION measures at 1m+. You need to be clear as the term ‘social distancing’ is meaningless. Try to maintain 2m, but justify the decision to drop to <2m.


State the measures that you have in place, if necessary, room by room. Confirm what specialist equipment you are using. UVC lamps, electrostatic sprays, high touch point cleaning, frequency of cleaning, cleaners or staff cleaning etc. Set this out in you ‘Enhanced Cleaning Policy’. Consider how shared equipment will be managed/cleaned. General rules are clean and disinfect all shared equipment in between users or quarantine for 72 hours.


Quote the UK Govt/NHS guidance on hand washing/coughing/sneezing etc. and be clear about where your sanitising stations are and how are you ensuring they are topped up. What are you doing off site for mobile workers?


Increase fresh air circulation and shut down recirculated air. Review mechanical ventilation needs depending on activities e.g. gym vs office. Open windows and doors, but (in general) keep fire doors closed. It’s not good enough to state ‘we are increasing ventilation’, consider a separate ventilation section in your risk assessment to acknowledge the significant role ventilation plays.


What information are you communicating to staff and others (contractors/visitors)? How will it be shared, by who and when? The risk assessments are the starting point for content. Returning staff need Covid-19 induction clearly setting out the measures to ensure safety.

6. PPE

Last but not least…PPE. Remember, cloth coverings are not PPE. General rules are at 2m social distancing, respiratory protection is unnecessary. Less than 2m you have options depending on the activity, contact time and risk. Cleanable face visors and/or face masks for close contact work. Options include Type II surgical masks, Type IIR surgical masks, or FFP2/N95 (remember KN95 masks have been discredited by HSE so check). Disposable gloves where there is a risk of contamination from equipment/surfaces etc. Remember, there’s no point wearing any of this if staff don’t know how to use it/wear it/put it on safely.

Sponsoring CIEH COVID-19 Webinar

Very proud to have been asked to sponsor this event. There is a lot of discussion about how regulators will assist in keeping workers safe after lockdown. Will the Health and Safety at Work etc. Act 1974 play its part?? Hopefully this will be discussed along with a range of other topics.

Can improvement notices be used to tackle poor management of social distancing or might a prohibition notice be used in extreme circumstances?? Register to watch or catch up later. 7 May 10.30am

Looking Back on 2019

Looking back it’s been a busy 12 months. I finally got round to launching my Working With PACE day long course designed specifically for local authority officers. Those attending worked in health and safety, food safety, planning, trading standards, licensing, housing etc. I had ex police officers attending and commented on how useful the course was as it explained how local authorities apply PACE. I also got round to sorting out my logo and began publishing articles on practical application of PACE (I’ll make these widely available on my website). I inspected food traders at Glastonbury and continued to assist colleagues with more complex investigations.

Please click here to read more