UK senior coroner Kevin McLoughlin on the changing nature of work-related fatalities and the challenges of getting a true picture.
The UK Justice Committee’s 2021 recommendation to make better use of coroners’ Reports to prevent future deaths (PFD) highlighted that harnessing the knowledge and experience of this group of professionals in conversations around work-related deaths is vital. One thing Kevin McLoughlin (inset, right), senior coroner for West Yorkshire in the UK, has witnessed in recent years is a change in the nature of fatalities among workers – particularly since COVID-19.
‘A generation ago, we used to think only about the risks to construction workers and people who worked in manufacturing plants. But now, office-based mental health issues are more recognised,’ he says. ‘Employers should be aware of the pressure they may be putting people under by imposing demanding targets on individuals who may be isolated and deprived of the camaraderie of having supportive workmates around them.’
For some, tragically, it’s too much to bear. ‘Suicide is one of the things that I’ve increasingly looked at,’ says Kevin. ‘I saw a statistic recently that between 2009 and 2019 about 67,000 people killed themselves in the UK (NCISH, 2022). It’s heartbreaking and beyond astonishing .’
However, the ability to study trends and pinpoint those at higher risk of suicide more accurately brings hope of improving the situation, Kevin adds. ‘In Leeds – part of my patch – we’ve got maps for particular areas of the city where suicide is prevalent and, lo and behold, they coincide with poverty. We can even see which tower blocks have a higher incidence of self-harm. So people are trying to drill down into this.
‘Currently we have to deal with things as one-off cases, but it shouldn’t stop us trying to look at the overall patterns and what we do about it.’
Kevin, whose background is in OSH (he is a Chartered Fellow and a former IOSH trustee) and who practised as a barrister before taking up an appointment as a senior coroner, also observes trends among his own cases. ‘It shines through on the suicide cases that young males are more impulsive. Three-quarters of those who take their own lives are male. This suggests that if someone had been able to intervene at the moment of crisis, it could have been averted.’
There are also barriers to reporting on deaths accurately – which became all too familiar during the pandemic. ‘The legacy of COVID is one that everybody is wrestling with,’ says Kevin. ‘How many people died due to COVID, as opposed to dying with COVID from pre-existing disease? The more you look at the issue, the more complicated it becomes, in that a lot of the people who died of COVID came into hospital with multiple comorbidities and may have died anyway. Equally, there may be cases where just the reverse is the case.
we’ve got maps for areas of the city where suicide is prevalent. We can even see which tower blocks have a higher incidence of self-harm
‘So trying to delve into the statistics and work out the true picture is challenging – and it may take years to clarify the situation.’
And for all the potential benefits around sharing – and learning from – PFD reports, the reality isn’t quite so simple. ‘Coroners are conscientiously making these reports. The problem at present is analysing them and identifying the learning priorities on a national basis. I think a lot more work is needed to analyse and codify these reports to determine the lessons that society should learn.’
Improvements in practice
Happily, Kevin has been able to see the role his personal reports have played in improving health and safety practices. He recalls two separate cases where workers had died while unloading large glazing units.
‘I made PFD reports to say that this is an industry-wide problem. When heavy glazing units are tightly packed in containers or bound together on stillages, those unloading them need instructions on the sequence in which to cut securing straps. Moreover, the instructions need to be presented in such a way that people speaking a variety of languages can follow them.’
He says the recipients of his reports in the glazing industry responded in an exemplary way, forming groups that devised constructive ways of dealing with the issue. ‘It was rewarding for me to have identified a problem and seen such a positive response from the particular industry concerned.’
Learning from tragedy
Kevin has also seen an improvement in risk assessments within organisations over the years. ‘In the early days, risk assessments classifying a hazard as low risk were sometimes exposed as embarrassing following a fatality. But over the years, the quality of risk assessments has improved. I take this as a demonstration of the contribution made by OSH professionals to workplace safety.
Kevin’s hope for the future is that inquests following workplace fatalities will be approached by the lawyers involved in a less adversarial manner, less preoccupied with the possibility of a prosecution. ‘When someone has lost their life, the dominant thought should be “How do we learn from this painful tragedy?”’
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Healthcare Quality Improvement Partnership. (2022) National Confidental Inquiry into Suicides and Safety in Mental Health. (accessed 10 December 2022).