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recurance

Jack Saunders: Prevention of future deaths

31 Mar 2026 · Coroner James Newman · Lancashire with Blackburn and Darwen

The coroner's concerns

  1. 1. equipment without clear instructions

    “The equipment that had been borrowed had no instructions available as to their use, and although there were illustrations/instructions on the equipment itself warning against use in enclosed spaces, these were small and could have been clearer.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error