A care home in Bristol has been fined for not doing enough to keep people safe from vulnerable patients who posed a danger to themselves and others.

The complex Health and Safety Executive (HSE) investigation and prosecution follows the death of Melissa Mathieson at Alexandra House on 12 October 2014. Jason Conroy murdered the 18-year-old and was jailed for life the following year, following a Crown Prosecution Service case.

Alexandra House on Wells Road, Bristol is one of three homes run by Alexandra Homes (Bristol) Limited. It’s a specialist residential care service for adults with Asperger syndrome and autism spectrum disorders and registered with the Care Quality Commission (CQC).

Both Melissa and Jason were fairly new residents at the home having both moved there in August 2014, Melissa from Crawley, and Jason from a school in Shropshire.

Prior to moving to Alexandra House, Jason Conroy had strangled a member of staff at his school rendering her unconscious. This and several other incidents highlighted the need for close monitoring.

Alexandra House was identified as a suitable place for Jason when he turned 18. Information was passed from his school to Alexandra House warning of his behaviour. This included a risk assessment that said he posed a risk to others and that he had demonstrated sexual aggression towards women. A report also said that he could be violent to others and posed a threat of sexually harmful behaviour to staff and younger peers.

In 2015 Jason Conroy was jailed for life and ordered to serve a minimum term of 19 years for the sexually motivated murder of Melissa.

Following Melissa’s death, the HSE investigation found Alexandra House did not have suitably trained and qualified staff in sufficient numbers to adequately deal with Jason Conroy.  In addition, they were not sufficiently informed of the risks he posed.  He was not adequately monitored and there were insufficient control methods in place to ensure the safety of people in Alexandra House, particularly at night.

At Bristol Crown Court on 1 December, Alexandra Homes (Bristol) Limited of Kingswood, Bristol, pleaded guilty to breaching Section 3(1) Health and Safety At Work Act 1974 and the Management of Health and Safety at Work Regulations 1999. They were fined £125,000 and ordered to pay £41,000.

Melissa’s father James Mathieson said: “Melissa was a lovely daughter, she was friendly, loved her cuddles, energetic and fun to be with. Everybody loved her and many hearts were broken when she was allowed to be murdered in her sleep.

“When Melissa found a place at Alexandra House, we made it clear to representatives at Alexandra Homes just how vulnerable she was. We were putting her safety into their care and to me they disregarded this.

“They told us they would look after her, she would be safe and they would help her live a full life. That was not true, as they failed on all accounts, and we lost a beautiful daughter, sister, and granddaughter.

“Although Jason Conroy murdered our daughter, I feel he was another failure of Alexandra Homes as he was in the wrong place with the wrong supervision.”

Speaking after the hearing, HSE inspector Caroline Coleman said: “This has been a complex and sensitive investigation. It has taken time, but we now have the right outcome.

“Alexandra Homes was given clear warning signs about Jason Conroy’s behaviour but simply didn’t act upon them. As a result, Melissa Mathieson, a vulnerable young woman lost her life in a setting that was meant to protect and help her.

“While the Care Quality Commission is now the regulator for patient health and safety matters, the legislation is there to help keep people safe and must be followed. Our thoughts remain with Melissa’s family and friends.”

This HSE prosecution was led by HSE lawyer Krystal Savoie.

Notes to Editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.
4. Following the Mid Staffordshire NHS Foundation Trust Public Inquiry and the publication of the Francis Report, the Care Quality Commission (CQC) was given powers to carry out criminal investigations and bring prosecutions. These took effect in April 2015. Since that time, in England, the CQC has been the regulator for patient health and safety matters, with HSE regulating health and safety for workers and members of the public. A revised memorandum of understanding reflecting these changes and setting out areas of responsibility was agreed by the two organisations which is available on HSE’s website. MoU between the Care Quality Commission (CQC) and HSE

A cider manufacturer has been fined after a much-loved grandfather was killed on his 65^th birthday.

Tommy Manns, from Dymock, Gloucestershire, was driving for H Weston and Sons Limited, the manufacturer of Henry Westons Cider, when he was killed by the end of a security barrier on 28 September 2020.

H Weston and Sons Limited was fined £1.4 million on Thursday after the company was prosecuted by the Health and Safety Executive (HSE).

The van was being driven out of the firm’s site at Bounds Farm, March Marcle, Ledbury, when the end of a security barrier speared through the vehicle’s windshield and fatally crushed Tommy.

Two of Tommy’s grandchildren had called him up to wish their grandad a happy birthday just hours before the accident.

Tommy, who had two children as well as three grandchildren, was a farm manager at H Weston and Sons Limited and had started working at the company in 2008.

A HSE investigation into the incident found H Weston and Sons had installed the barrier a month earlier, and failed to undertake a suitable and sufficient risk assessment. The company also failed to implement a safe system of work to ensure the barrier could be secured safely when open and closed.

HSE guidance can be found at: Advice on horizontal swing car park barriers.

Tommy’s wife Rose Manns said: “I am still in shock following the death of my husband. I’ve never been an emotional person, but since the accident I am nervous and reliving the accident all the time. In the beginning I couldn’t even drive because my husband was driving at the time of his accident and I couldn’t face driving again for a long time.

“I’ve always been a people’s person and now I have no confidence. People stop and ask me how I feel and how I am. I don’t feel confident to talk to people about what happened and people don’t know what to say to me.

“Tommy loved his grandchildren so much. He spoke to the two grandkids who were four and six on the day of his death. They rang to sing happy birthday to him in the morning. He never got the chance to open his birthday cards.

“We had put a deposit down on a motorhome. My son had to ring the company a couple of days after Tommy died to cancel the order.

“Tommy has left a great legacy. He was so loved, he was my rock, my soulmate.”

Oliver Hunter, Tommy’s stepson, added: “As a parent there are many memorable moments you want to keep hold of, however trying to explain to my four-year-old son (now seven) and six-year-old daughter (now nine) that their Grampy Tom had died on his birthday and that he is no longer with us, is one I wish I could forget.

“Both of our children were outgoing, happy little people with a love of life, but since Tommy’s death their behaviours have changed, they are more weary of life, can be more angry and upset over various things. They live with a constant fear that their loved ones maybe taken away from them which consequently means they are both struggling daily with separation anxiety on different levels.”

H Weston and Sons Limited, of Much Marcle, Ledbury, Herefordshire, pleaded guilty to breaching Regulation 3(1) of the Management of Health and Safety  at Work Regulations 1999 and Section 2(1) of the Health and Safety at Work etc. Act 1974. The company was fined £1.4 million and ordered to pay £26,756.50 in costs at Kidderminster Magistrates’ Court on 30 November 2023.

HSE inspector Sara Lumley: “This is a sad and devastating case that is made all the more tragic as the incident took place on Tommy’s birthday. It was also his day off. Rosemary and Oliver have made clear the impact that Tommy’s passing has had and our thoughts remain with them and their family.

“Horizontal barriers can be dangerous – but deaths are extremely preventable. The guidance for those operating barriers like this at car parks is clear and it’s vital to make sure the barriers are adequately secured at all times whether open or shut.”

Notes to Editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise. hse.gov.uk
2. More about the legislation referred to in this case can be found at: legislation.gov.uk/
3. HSE news releases are available at http://press.hse.gov.uk

A further two companies have been fined after a dad died following a fall from the roof of a building site in Warrington.

Father-of-one Dennis Vincent, 36, and another worker were using ropes to install a lightning protection system to the front of an office block being converted into flats.

Mr Vincent, who was from Stoke-on-Trent, Staffordshire, was lowering the access equipment from the roof, using a rope attached to a frame at roof level and a handrail at ground level. As he did so, both he and the frame fell from the roof to the ground.

The incident happened on 24 February 2021 at Palmyra House, Palmyra Square in Warrington.

Inco Contracts Limited and Prestige Security Installations Limited were fined on Thursday after a Health and Safety Executive (HSE) investigation.

The companies were found guilty of breaching health and safety regulations following a three-week trial at Liverpool Crown Court earlier this year. In February, PTSG Electrical Services Limited, Mr Vincent’s employer, was fined £120,000 after the company failed to adequately assess the risks associated with the working at height.

The HSE investigation found that Inco Contracts Limited, the principal contractor for the project, and Prestige Security Installations Limited, the contractor in control of the electrical installation package, failed to ensure that the lightning protection work was properly planned and failed in their duties to manage and monitor the work to ensure it was carried out safely. Due consideration had not been given to safer methods of working at height, such as the use of scaffolding or a mobile elevating work platform (MEWP), and the workers had been given no instruction or safe means of getting their equipment down from the roof.

HSE guidance can be found at: Work at height – HSE

Inco Contracts Limited, of Dunston Business Village, Stafford Road, Dunston, Stafford, Staffordshire, was found guilty of breaching Regulation 13(1) of the Construction (Design and Management) Regulations 2015. The company was fined £600,000 and ordered to pay £58,448 in costs at Liverpool Crown Court on 30 November 2023.

Prestige Security Installations Limited, of Sycamore Lane, Great Sankey, Warrington, was found guilty of breaching Regulation 15(2) of the Construction (Design and Management) Regulations 2015. The company was fined £30,000 and ordered to pay £15,000 in costs at Liverpool Crown Court on 30 November 2023.

HSE inspector Sara Andrews said: “It is vitally important that work at height is properly planned; where it isn’t, the risks can lead to the most serious of consequences.  As such, duties are placed on all those involved in construction work to ensure that the risks are properly assessed and suitable control measures are implemented.

“Principal contractors and contractors should be aware that appointing subcontractors with specific specialisms does not remove the duty that they have to ensure the work has been properly planned and can be undertaken safely.

“Had Inco Contracts Limited and Prestige Security Installations Limited properly reviewed PTSG Electrical Services Limited’s proposals for carrying out the work, they could have ensured suitable controls were in place prior to work starting and this tragic incident could have been avoided.

“Our thoughts remain with the family of Dennis Vincent, a husband and father, who did not return home on 24 February 2021 because of the significant failings of these three companies.”

Notes to editors 

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.

A premium yacht makers has been hit with a £600,000 fine after one of its workers suffered life changing injuries at its shipyard in Plymouth.

Mark Gillen’s wife Sarah said she is lucky to still have her husband around after he sustained a catalogue of injuries, including 12 broken ribs and a severed right arm, when a staging platform weighing approximately one tonne, toppled over and fell on top of him.

The 54-year-old, who had worked for the company for 26 years, also suffered bleeds on the brain and remained in hospital for several months.

A Health and Safety Executive (HSE) investigation found the platform fell due to one of the front wheels hitting a divot in a concrete surface. Mark had been part of a team working on a 72-foot vessel at the company’s Southyard site when the incident happened on 9 November 2021.

Sarah Gillen said: “Our worlds were turned upside down the day Mark had the catastrophic crush accident, leaving him with life changing injuries. He simply went to work that morning, and while he was eventually able to come home, our lives will never be the same.

“We are incredibly lucky to still have him with us but there is no denying that the road to recovery has been, and continues to be, extremely difficult and challenging.

“We are very grateful to the team at the HSE for all the work that has gone into holding Princess Yachts to account. However, the sad reality is that no fine, no matter how significant, will ever truly reflect the pain and ongoing suffering that Mark and our family has been through.”

HSE enforcement lawyer Andy Siddall told Plymouth Magistrates’ Court how on the day, finished mouldings were being moved from the firm’s Southyard site to their one on Newport Street for fit-out.  Staging platforms were used extensively by the company to form a safe and stable work at height platform that surrounds a moulding and later a boat whilst it is the manufacturing stage. As Mark and two of his colleagues began to push the platform, one of the front wheels hit a divot in the concrete surface, causing it to topple and fall on top of him. Due to the seriousness of his injuries, Mark was then airlifted to hospital.

Sarah went on to say that before the incident Mark had been a fit, healthy strong and determined man.

“He had enjoyed weight training, boxing gym, cycling and playing golf with friends and a very active social life” she said.

“Now though, he is in constant chronic nerve pain which affects his ability to participate in the things he once loved, which in turn has a huge detrimental impact on his health and wellbeing.

“It is our hope that today’s outcome will act as a wakeup call to Princess Yachts and other companies about the devastating and serious consequences of health and safety failings in the workplace, and that lessons are learnt that could prevent others being injured, or worse, in similar circumstances.”

The HSE investigation found that there was a failure to assess the risks associated with moving staging platforms manually through the external yard. Had this been done, it would have identified the uneven ground as a hazard that required controlling. The risks could have been further eliminated by prohibiting the manual moving of the platforms and requiring any external movement to be carried out by forklift trucks.

Princess Yacht Limited of Newport Street Plymouth pleaded guilty to breaching the Health and Safety At Work Act 1974 2 (1). The company was fined £600,000 and ordered to pay costs of £9,146.

HSE inspector Paul Mannell echoed the comments made by Mark’s wife Sarah: “Mark Gillen is lucky to be alive.

“The company should have had measures in place to ensure that mobile staging was never pushed through the yard by hand.

“As the measures taken post-accident clearly show, it would have been reasonably practicable to have had them in place when Mr Gillen was injured.

“They were implemented immediately after the accident at no cost to the company.

“The failure to have in place a safe system of work resulted in a life changing injury to a loyal employee who had worked for the company for 26 years.”

Notes to Editors:

1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. We prevent work-related death, injury and ill health through regulatory actions that range from influencing behaviours across whole industry sectors through to targeted interventions on individual businesses. These activities are supported by globally recognised scientific expertise.
2. More information about the legislation referred to in this case is available.
3. Further details on the latest HSE news releases is available.

Philip White, HSE’s Director of Building Safety (DoBS), will continue in his current role leading the Building Safety Regulator (BSR) on a permanent basis.

Philip has been leading the work to fully establish the BSR in HSE since taking over from Peter Baker in April 2023.

Ahead of the BSR becoming fully operational next year, the permanent appointment will ensure continuity for the programme as well as strong and experienced leadership at a vital stage of developing the new regulatory regime.

As HSE’s DoBS, Philip will continue to perform the duties of the Chief Inspector of buildings working closely with BSR’s statutory industry and resident committees to ensure both industry and residents are heard at the heart of the new regime.

He will keep the programme on course to deliver against agreed timelines and milestones including championing the need for culture change in industry and highlighting the need for collective responsibility to improve building safety.

Philip’s extensive regulatory experience and proven leadership will be vital to the success of the BSR ion the coming years, ensuring the strength of HSE continues to be brought to bear in creating an effective regulator that’s fit for purpose for the future.