The document provides guidance on conducting thorough investigations following major accidents at work to balance risk management, legal liability, and responsibility. It outlines key steps like making the site safe, gathering evidence, supporting employees, controlling information, and cooperating with investigating authorities. The guidance emphasizes promptly notifying authorities, taking legal advice, and conducting an internal investigation while respecting the criminal investigation process.

1. Major accident tool kit
Issues forum – January 2009

2. 1
Major accident tool kit – January 2009

3. Serious accidents and fatalities at
work can trigger interventions from
enforcing authorities with significant
legal implications for firms and
senior managers. Following up
our November 2007 Issues Forum
on the Corporate Manslaughter and
Corporate Homicide Act, we have
prepared the following guide to help
employers carry out thorough
accident investigations.
A risk management A liability perspective
perspective
It is important to strike a balance between,
One of the main reasons for conducting using the accident investigation process
health and safety investigations is to as an opportunity to audit and modify your
build a better understanding of the risks systems and, protecting your legal position.
associated with particular work activities.
Such investigations can help develop and This guide aims to help you and your staff
refine a risk management system that through the potentially complex aftermath of
combines targeted risk control measures a serious or fatal accident on site. It covers
with effective supervision and monitoring some of the key areas of the law and offers
to minimise the risk of prosecution. practical guidance on what to do if you face
charges under health and safety or under
individual and/or corporate manslaughter
legislation or under individual and/or
corporate manslaughter legislation.

4. Health and safety Responsibility for enforcing health and safety Where a HSE inspector believes a breach
prosecutions legislation is shared between the Health and of health and safety regulations is ongoing
Safety Executive (HSE) and local authorities. or likely to be repeated, an improvement
Minor infringements of health and safety These regulatory bodies have a variety of notice may be issued requiring that the
legislation will not generally result in options open to them where they believe contravention be remedied within a specified
prosecutions. Self-regulation is the health and safety legislation has been period of time.
authorities’ primary mechanism for contravened:
managing workplace health and safety, Where an inspector believes a particular
with a strong emphasis on risk assessment. activity, or the use of a particular area, poses
1. No action
a risk of serious injury, a prohibition notice
Prosecutions are likely to be considered may be issued requiring that the activity be
where: stopped or the area restricted.
• there is a need to draw the attention Improvement or prohibition notices do not
2. Written warning
of the public, an industry, or a particular in any way preclude prosecution at a later
employer to the necessity of complying date. Most prosecutions follow earlier
with current laws and standards enforcement notices. Ignoring a prohibition
or improvement notice constitutes a breach
• prosecution is expected, for example:
3. Improvement notice of that notice, and can result in the company
where a breach of duty has led to death
being prosecuted or the individual
or serious injury
responsible receiving a prison sentence.
• there is, or has been, potential for
considerable harm resulting from a In the event of a subsequent prosecution,
breach of duty 4. Prohibition notice having failed to challenge a notice may be
regarded as tantamount to admitting unsafe
• the significance of the offence merits a
practices. If you are served a notice which
prosecution, for example: where there
you believe may be inappropriate to the
have been repeated breaches and a
circumstances, you should seek immediate
reckless disregard for the law 5. Formal caution legal advice from your QBE panel solicitor
on the merits of appealing.
The correct enforcing authority is
determined primarily by the type of activity
6. Prosecution
carried on in a particular workplace.
Further information on this can be found in
schedules 1 and 2 of The Health and Safety
(Enforcing Authorities) Regulations 1998.
A formal caution is an officially recorded
reprimand for specific failings prior to
notification of an incident. Should any further
breach occur this caution will be taken into
consideration.
3
Major accident tool kit – January 2009

5. The accident
The first indication of a serious incident will
often be a distressed call from one of your
managers or employees. What you do from
this moment on lays the foundations for the
investigation ahead. Your site could soon
become a designated crime scene while
the police, HSE or local authorities gather
and assess the evidence. This will clearly
have an immediate and significant impact
on your business.
Work related deaths Managing the investigation Acting in the best interests of your
organisation, its directors, and employees
The offence of manslaughter can only be Following a serious incident, it is important
involves striking a balance between
investigated by the police. There is no time for any organisation or individual faced with
a) protecting your legal position,
limit for such investigations. The Crown potential criminal charges to put themselves
b) making the necessary changes to prevent
Prosecution Service (CPS), or in Scotland in the best position possible to:
recurrence, and c) acting (and being seen
the Procurator Fiscal, will then decide
a) avoid prosecution to act) in an appropriate way towards the
whether a prosecution should proceed.
injured person and their family, your
b) defend themselves, should prosecution
employees, the authorities, and – important
Where there is an indication of a serious ensue
not to forget – the media.
criminal offence, such as individual or
c) diminish the severity of any sentence
corporate manslaughter, the police will
they may receive if convicted By providing an overview of the typical
conduct an investigation jointly with the
pattern of events following a death or
HSE or local authority, who will look
QBE recommends having detailed plans serious injury on site, this guide will help
specifically at health and safety offences.
and procedures in place for handling both you exercise strong leadership and good
internal and external investigations. judgement, and coordinate an investigation
The HSE, Police and Crown Prosecution
that does everything possible to protect
Service’s joint framework for effective liaison
all concerned.
is set out in ‘Work Related Deaths: A
Protocol for Liaison’ [HSE, March 2003]

6. Making the site safe
One of the first priorities will be to ensure the
site is safe and take any immediate remedial
actions such as isolating power sources.
In practice, however, the investigating
authorities will probably insist that everything
be left undisturbed. In which case, you
should touch nothing and ensure the area is
sealed or cordoned off, restricting access to
investigators only.
A picture, as they say, paints a thousand
words. Photographs taken at this stage may
well become crucial evidence in court. So it
is always advisable to have a camera on
site. Keeping a written record of what each
picture shows is also important. This should
include the date and time taken and the
identity of the photographer.
Visiting the site – gathering
essential evidence and
information
It is essential you visit the site as soon as Things to check at the accident scene To help capture a full picture of the
possible after an accident to collate all would include: events leading up to an incident,
relevant schematic drawings, plans and we recommend you:
photographs and so compile a clear picture • the condition and appropriate use
of the scene at the time of the incident. of tools and equipment • determine and describe the location of
The accident scene may be familiar to those involved and their respective roles
• the cause of any slip or trip claimed (avoid
those operating it, but will clearly be less and relationships
focusing solely on the immediate cause)
so to others. • determine and describe the events
• defects in the work environment e.g.
preceding the accident
Important clues or evidence of unsafe obstructions, holes, depressions or
conditions and/or actions may well be found slippery floors • if the injured person is not your
at the locus of the incident. The longer the employee, ascertain the name of the
• the suitability, position and effectiveness
delay in investigating, the greater the chance sub-contractor, the name and contact
of all necessary guards
conditions will have changed, evidence details of their most senior representative
been lost, and vital contributory factors
• the condition, location and dimensions of on site and of the relevant contact for
plant, lighting etc. (take measurements) further information and ongoing liaison
missed.
If there is no obvious reason for the
accident, then record this fact. Recording
a site in good order, is just important as
recording any faults.
5
Major accident tool kit – January 2009

8. Supporting your employees This person, or another senior person – Specialist legal advice
preferably someone with media skills –
It is clearly advisable to offer immediate should handle all press enquiries. Dealing Once your organisation – and potentially its
support and advice to any employees with the media can be a minefield. It is directors and employees – have become
involved in or affected by the incident. This important to provide journalists with the subject of a criminal investigation, it is
might include counselling, line management appropriate information and/or carefully essential you have access to legal advisers
support, or legal advice – depending on the worded statements in a timely fashion. with the right expertise and resources to
individual and how they have been affected. Inappropriate ‘off the record’ statements or guide you through what can be an intense
a poorly expressed comments in an and stressful process.
Having a director or a health and safety interview can seriously damage your
adviser present during the aftermath and reputation. The police and HSE inspectors investigating
the subsequent investigation can provide you will be trained and experienced in
invaluable support. It also shows you take Reporting to the HSE criminal procedure and law. So it is vital your
the incident seriously and care about your organisation can call on similar expertise. All
employees’ welfare, as does discussing the The Reporting of Injuries, Diseases and QBE’s panel solicitors are selected for their
incident with employees, even if you do not Dangerous Occurrences Regulations expertise in this field. Your own nominated
specifically require a witness statement 1995 (Riddor) impose a legal duty on the QBE panel solicitor should be your first point
from them. immediate employer or the company in of contact for legal advice.
control of the premises to report any death
Making contact with or serious incident to the relevant enforcing They can advise you, amongst other things,
a victim’s family authority forthwith, by the quickest about the concept of Legal Professional
practicable means. It is important you keep Privilege. This effectively protects you from
The people liaising most closely with the a record of your report. having to disclose documentation,
family will normally be the immediate statements and reports prepared in the
employer and the Police Family Liaison You can fulfil your legal duty to report the aftermath of an incident to the police or
service. But even if you are not the death or 'specified major injury' without HSE. This is something your own internal
employer, you may still have an important delay by contacting the Incident Contact investigation should be aware of from the
part to play in providing support and Centre directly by phone, via the internet, very outset!
information. If you do want to make contact by email, or by post.
with the family of someone killed or injured
on your site, you need not worry that helping Telephone: 0845 3009923
with funeral expenses or lost wages would
Internet: www.riddor.gov.uk (complete and
be seen as admitting blame.
submit the form online)
Controlling the flow of Email: riddor@natbrit.com (download the
information form, complete it then email it)
Fax: Downloaded or printed forms can also
Establishing clear lines of communication
be faxed to 0845 3009924
helps everyone, not least the authorities.
One senior individual should have sole Post: Incident Contact Centre, Caerphilly
authority to speak and act on behalf of your Business Park, Caerphilly CF83 3GG
organisation. All onsite employees should
be aware of this person’s contact details,
so they can pass them on to the authorities
or any other interested parties on request.
7
Major accident tool kit – January 2009

9. Your investigation Information sources The form and content of your report have
legal implications which could prove crucial
The exact location of persons and/or
Your internal accident investigator should if proceedings are subsequently issued. It is
equipment at the time of the incident will
be on site as soon as possible to begin important your ‘draft’ report is marked as
often be unclear. Equipment, barriers and
investigating the incident’s causes and such at all stages. Each page should also
other items can become displaced in the
identifying any necessary improvements be marked ‘without prejudice – prepared
process of helping the injured party –
to current working practices. It is essential, for the purposes of taking legal advice.’
creating confusion as to how an incident
however, that your investigation reflects the
occurred. Photographs or video footage of
fact that a criminal investigation is also The person undertaking your investigation
the scene can help avoid this – particularly
underway. Taking prompt and pertinent should have been trained for the task. If you
when accompanied by detailed notes.
legal advice can be critically important in need to use health and safety consultants
CCTV footage can also sometimes provide
this context. or other external providers to carry out your
valuable clues.
investigation, you should maintain close
Key considerations include: control over how they do so, and/or contact
It is important to preserve all relevant
your nominated QBE claims inspector/QBE
materials, plant, equipment and paperwork,
Witnesses panel solicitor. If the authorities ask for a
as these may be required much later as
Record the accounts of all witnesses copy of your report, take legal advice before
part of a civil or criminal investigation.
who are in a fit condition to be interviewed providing one and ensure you limit the
as soon as possible. Ensure those who circulation of your draft report to the fewest
It is also vital you notify your company's
are not, receive proper medical attention people possible.
directors, brokers and insurers of any
and arrange to see them at a more accident.
appropriate time.

10. 9
Major accident tool kit – January 2009

11. When the authorities call Evidence gathering: Witness interviews
The way you communicate with the
site documentation
The enforcing authorities will want to
authorities can significantly affect the Paper and/or computer records for the
interview eye-witnesses first, followed by
company's legal position, your employees' period prior to the incident may well be
anyone else involved in the lead-up to the
position, and your reputation. In the event requested or even seized. This could include
incident. They will aim to do this at the
of a death, both the police and HSE will method statements, risk assessments,
earliest opportunity and normally write up
normally arrive on your premises to inspection documentation, training records
witness statements on the spot. It is worth
commence their investigations. Both have and any permits to work. Before removing
remembering that the evidence provided by
a legal right to enter under Section 20 of from site, we strongly recommend taking
your senior managers will be central to any
the Health and Safety at Work Act 1974. three copies of any relevant documents. If
investigation into either individual or
the police or HSE take the only copy of a
corporate manslaughter charges.
Under the new corporate manslaughter document, there is a danger you may lose
legislation, the police are obliged to remain track of it.
If you think employees may not be fit to be
involved until they can eliminate the
interviewed, take legal advice – and be sure
possibility of bringing charges. It could take You should also:
to raise the issue with the authorities. Where
weeks, months, even years for them to
possible, interview all employees as part of
satisfy themselves that your senior • take legal advice on the categories of
your internal investigation before they speak
managers are not culpable. documentation seized or copied
to the authorities.
• keep a copy of everything removed from
The police and the HSE have different legal
your premises The HSE has powers to force witnesses
powers. If in doubt as the extent of their
to answer questions. Your solicitors can
respective powers, consult your solicitor. • record all documentation taken by the
establish the legal basis of employees'
authorities
interviews and advise accordingly. Your
The police will treat the site as a crime
• ask any contractor whose employee has QBE panel solicitor can offer general advice
scene. They may insist that all work stops
been injured on your site for copies of to your employees on the interview process.
in the area of the incident while they assess
any documents they provide to the For anything more detailed, however, it is
the scene and gather evidence. Equipment
authorities best to consult an independent solicitor.
in use at the time of the accident may be
seized and removed from your site. You may
It is important to keep all It is good practice, though by no means
be asked to help dismantle and transport
correspondence with your legal team the norm, for the authorities to provide your
this equipment.
separate and marked “covered by legal employees with a copy of any statement
professional privilege.” The authorities they have given. This helps by giving them
If possible, it is a good idea to make office
have no right to seize these documents. a record they can check should they have
facilities on site available to police officers
any concerns about misstatements or
and inspectors.
omissions. If a witness volunteers a copy
of their statement, it may help you identify
issues to address and prepare for any
interview under caution when the
investigation nears its conclusion.

12. Inquests
Any sudden death at work will trigger an
inquest. Those considered to be interested
parties will include the deceased’s family,
their employer, those in control of premises
where the fatal injury occurred, and anyone
else whose conduct is likely to be called into
question. Each is entitled to participate in
the inquest process.
Inquests are limited in their scope, but
provide allows all interested parties to
explore the relevant facts and observe
witnesses under questioning.
The Coroner's Court is only required
to establish:
1 who died,
2 when they died,
3 where they died, and
4 under what circumstances they died
Apportioning blame is not part of the In the context of an inquest, your QBE panel
Coroner's remit. The facts that unfold at solicitor can:
inquest, however, can strongly influence the
chances of prosecution. So it makes sense • ask the coroner what evidence he or she
to be represented at inquest – preferably by intends calling or reading
your QBE panel solicitor, who can also act • advise you on questioning witnesses
for you later, should proceedings be issued.
• help you alert the coroner to any
additional witnesses with relevant
testimony to add
• appear for you at inquest and make
appropriate representations on legal
issues
11
Major accident tool kit – January 2009

13. PACE – interview under Keeping out of trouble
caution(s) The best option, of course, is to take all
Once the authorities have finished gathering reasonably practicable steps to avoid having
evidence, they may well ask any employee(s) a serious incident in the first place. There is
suspected of an offence – and/or a some excellent guidance available on this
representative of their employer – to attend topic, and we strongly recommend you
an interview under caution. Separate familiarise yourself with the leaflet INDG417
interviews will take place for each party (leading health and safety at work) published
under investigation. in October 2007 by the Institute of Directors
(IoD) and The Health and Safety
Police and HSE interviews may be voluntary Commission (HSC).
in the first instance. In the case of
manslaughter investigations, however, the INDG417 contains guidance for boards and
police are entitled, if necessary, to arrest directors on how organisations of all types
suspects with a view to interviewing them can lead and promote health and safety,
under caution. structured around the core principles of
planning, delivery, monitoring and review. It
Taking legal advice is essential at this stage. features a useful checklist of areas in which
This both enables you to ensure the to benchmark your health and safety
interview complies with the law, and gives performance.
you the opportunity to present your position
in the best possible light – either as a denial In combination with the following action
of liability or an acceptance of fault with points, the approach outlined in INDG417
mitigation. should significantly reduce the potential for
prosecution.
At interview you can respond either by:
• Make sure your directors and senior
• answering the questions posed, or managers show strong and active
leadership and a visible commitment
• reading out a prepared statement
to health and safety
Being interviewed under caution does not • Get your employees involved, and
automatically mean an employee will be engage your workforce in promoting
prosecuted. But they will probably need health and safety in the workplace
separate legal advice. So multiple suspects
• Review your policies and procedures
may create a need for multiple legal teams.
in the light of our toolkit
It is a good idea to check your insurance
policies to establish whether your directors • Prepare a major incident response
and senior managers will have access to procedure
legal advice cover in the event of a fatal
• Train your accident investigation team
accident.
• Review your media and counselling
facilities
• If in any kind of doubt, seek legal advice
from your QBE panel solicitor.

14. Further information Disclaimer QIEL and the QBE Group have no obligation
to update this report or any information
You can find additional information on This Forum has been produced by QBE contained within it.
the HSE website www.hse.gov.uk Insurance (Europe) Limited (“QIEL”). QIEL is
a company member of the QBE Insurance To the fullest extent permitted by law,
and also on the following websites:
Group. QIEL and the QBE Group disclaim any
www.iod.com/hsguide responsibility or liability for any loss or
Readership of this Forum does not create damage suffered or cost incurred by you
www.hse.gov.uk/leadership
an insurer-client, advisor-client, or other or by any other person arising out of or in
business or legal relationship. connection with your or any other person’s
Author biographies
reliance on this Report or on the information
This Forum provides information about the contained within it and for any omissions or
Mike Barraclough, Liability Risk
law to help you understand and manage risk inaccuracies.
Manager
within your organisation. Legal information is
Mike joined QBE in 1998 serving as a not the same as legal advice. This Forum QBE Insurance (Europe) Limited and
Claims Inspector for nine years before does not purport to provide a definitive QBE Underwriting Limited are authorised
joining the Liability Risk Management team statement of the law and is not intended and regulated by the Financial Services
in 2007. Mike has spent 27 years in the to replace, nor may it be relied upon as Authority. QBE Management Services (UK)
insurance industry and he holds the Nebosh a substitute for specific legal or other Limited and QBE Underwriting Services (UK)
National Diploma in Occupational Safety professional advice. Limited are both Appointed Representatives
and Health. of QBE Insurance (Europe) Limited and QBE
QIEL has acted in good faith to provide an Underwriting Limited.
Steffan Groch, Partner DWF Solicitors accurate Forum. However, QIEL and the
Steffan qualified as a solicitor in 1995. He QBE Group do not make any warranties
is currently a partner with DWF Solicitors, or representations of any kind about the
based at their Manchester offices. Steffan contents of this Forum, the accuracy or
specialises in advising and representing timeliness of its contents, or that the
companies, directors, and managers in information or explanations (if any) given.
all types of health and safety prosecutions QIEL and the QBE Group do not have any
from the HSE, local authorities and the duty to you, whether in contract, tort, under
Environment Agency. Steffan and his team statute or otherwise with respect to or in
are experts in proactive health and safety connection with this Forum or the
management systems and procedures. information contained within it.
DWF, Centurion House, 129 Deansgate,
Manchester M3 3AA. Tel: 0161 603 5008
13
Major accident tool kit – January 2009

16. QBE European Operations
Plantation Place
30 Fenchurch Street
London
EC3M 3BD
tel +44 (0)20 7105 4000
fax +44 (0)20 7105 4019
differently@uk.qbe.com
www.QBEeurope.com
288/ISSUESFORUM/MAJORACCIDENTTOOLKIT/JANUARY 09
QBE Insurance (Europe) Limited and QBE Underwriting Limited are authorised and regulated by the Financial Services Authority. QBE Management Services (UK) Limited
and QBE Underwriting Services (UK) Limited are both Appointed Representatives of QBE Insurance (Europe) Limited and QBE Underwriting Limited.

17. Dear reader
Thank you for taking the trouble to read this publication.
QBE Risk Management believe that best practice organisations are those where senior individuals
facilitate and engage in the processes of sensible risk management. We make this document available to
all interest parties in an effort to share knowledge and promote good practise.
Our services are available only to clients insured by QBE in Europe. Our insurance products are sold
through insurance brokers. We cannot offer advisory services to anyone else, however we would be
delighted to hear if you have found this document useful or believe there are risk management issues that
do not receive appropriate attention in the media.
Regards
QBE Risk Management Team
email: RM@uk.qbe.com
www.QBEeurope.com/RM
Disclaimer
This document has been produced by QBE Insurance (Europe) Limited (“QIEL”). QIEL is a company member of the
QBE Insurance Group.
Readership of this Forum does not create an insurer-client, advisor-client, or other business or legal relationship.
This Forum provides information about the law to help you understand and manage risk within your organisation.
Legal information is not the same as legal advice.
This Forum does not purport to provide a definitive statement of the law and is not intended to replace, nor may it be
relied upon as a substitute for specific legal or other professional advice.
QIEL has acted in good faith to provide an accurate Forum. However, QIEL and the QBE Group do not make any
warranties or representations of any kind about the contents of this Forum, the accuracy or timeliness of its contents,
or the information or explanations (if any) given.
QIEL and the QBE Group do not have any duty to you, whether in contract, tort, under statute or otherwise with
respect to or in connection with this Forum or the information contained within it. QIEL and the QBE Group have no
obligation to update this report or any information contained within it.
To the fullest extent permitted by law, QIEL and the QBE Group disclaim any responsibility or liability for any loss or
damage suffered or cost incurred by you or by any other person arising out of or in connection with your or any other
person’s reliance on this Report or on the information contained within it and for any omissions or inaccuracies.
QBE European Operations
Plantation Place
30 Fenchurch Street
London
EC3M 3BD
tel +44 (0)20 7105 4000
fax +44 (0)20 7105 4019
QBE European Operations is a trading name of QBE Insurance (Europe) Limited, no.01761561 ('QIEL'), QBE Underwriting Limited, no. 01035198 ('QUL'), QBE Management Services (UK)
Limited, no. 03153567 ('QMSUK') and QBE Underwriting Services (UK) Limited, no. 02262145 ('QSUK'), whose registered offices are at Plantation Place, 30 Fenchurch Street, London, EC3M
3BD. All four companies are incorporated in England and Wales. QIEL and QUL are authorised and regulated by the Financial Services Authority. QUL is a Lloyd's managing agent. QMSUK
and QSUK are both Appointed Representatives of QIEL and QUL.