Governance of health and safety – the need to ensure safe systems of operation and to carry out risk assessments

David Halcki MBE (, independent health and safety consultant and former NHS safety professional, believes that NHS boards and managers should learn lessons from the following industrial laundry incident. In particular, he is urging boards to ensure that NHS organisations have safe systems of operation in place and carry out risk assessments both in relation to any laundry services they might have, and in relation to wider organisational health and safety matters.

The Health and Safety Executive (HSE) is urging laundry companies to ensure that they have safe systems of operation in place and carry out risk assessments after a worker was left in a coma, following an incident at a factory in Balham, Wandsworth. This follows the successful prosecution (Thursday 24 September) of a major UK laundry company at Southwark Crown Court, following an incident in October 2007. OCS Group UK Limited of Limpsfield Road, Sanderstead in Surrey was fined £80,000 and ordered to pay costs of £33,059, after pleading guilty to breaching section 2(1) of the Health and Safety at Work etc Act 1974, after Joseph Pathmananthan, a worker at the site, was injured in a serious incident.

OCS Group UK Limited provides commercial laundry services at industrial processing plants across the UK, including Balham. This plant had approximately 150 workers. 

On 2 October 2007, Mr Pathmananthan, a 61 year-old employee from Sutton in London, was working at the company’s Boundaries Road site in Balham. He was repairing the hopper unit which loads roller towels into the top of a continuous batch washer, which is an industrial washing machine costing more than one million pounds. The hopper unit needed repairing after a towel had become entangled in a lifting belt. After several different methods had been used by Mr Pathmananthan and four other colleagues to dislodge the towel, he entered the hoist’s protective cage to continue to try to remove the towel. Mr Pathmananthan was standing underneath the suspended large steel hopper. As the towel became free the hopper fell two meters onto the victim, crushing him. He suffered from multiple broken bones and internal injures and was in a coma for 19 days.  He stayed in hospital for three months and has not been able to return to work for two years since the incident.

OCS Group UK Ltd carried out an internal investigation into the incident and almost all the blame fell on a number of employees on the Balham site, including the victim who was disciplined. Despite the HSE subsequently prosecuting OCS, the company’s own internal investigation made little criticism of the company’s policies or of senior management. The HSE investigation showed that OCS Group UK Ltd did not have a sufficiently effective system for ensuring the machinery was safe to be operated and maintained, and that there were no checks on the machinery after its repair.  Also, the Balham site engineering team had not been provided with a manual which would have clearly shown how to raise the hopper safely for someone to work beneath it.  The court heard that two years prior to the incident, an HSE Inspector had attended the site and had identified that Mr Pathmananthan needed more support.

The HSE gave direction on necessary improvements including the need to risk assess the continuous batch washer, but there was no evidence this had been followed by OCS Group UK.  The HSE also found the site had inadequate controls in place to stop people slipping and tripping and that the movement of vehicles at the busy site was disorganised and dangerous.

While sentencing the company, Judge Taylor criticised OCS Group UK Ltd for what she said was a systemic failure and its complacency during monitoring. If the company had not pleaded guilty at the earliest opportunity Judge Taylor, said the fine would have been £40,000 more. Andrew Verrall-Withers, Health and Safety Inspector, said: “I was pleased the company co-operated with the investigation and made good efforts to improve after the incident, but I was surprised and disappointed that their own internal investigation failed to identify so much of what the company had got wrong.  “I hope this case sends out a message to other companies, including large ones, that it is vital they make sure that they are protecting their employees effectively. It is no good to anyone if problems are only found after it is too late.”

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