Blood on the tracks: why did it take Cormac two years to update its accident reporting form? Forensic examination of four-year-old incident at Grampound Road, and the subsequent cover-up, now destined for major political showdown at County Hall

Posted By on 8th November 2020

By Graham Smith

Cornwall councillor Bob Egerton has written to all of his 121 colleagues urging them to demand an independent inquiry into a serious accident which curtailed the working life of a Cormac employee.

The case has long been chronicled by Cornwall Reports, and appears now to be reaching a political peak with the prospect, in the months ahead, of the full council being invited to vote on the need for an inquiry.

The Labour, Mebyon Kernow and Conservative groups have already called for such an inquiry.  But the Liberal Democrat-Independent administration continues to hold out.

Everyone concerned in this story accepts that accidents happen.  It is also accepted that full details of what caused the serious injury at Grampound Road, in December 2016, will probably never be known.

But as is so often the case in politics, it is the subsequent cover-up which is potentially explosive.  Who knew what, and when did they know it?

The story has also called into question the opaque relationship between Cornwall Council, the group of companies which it owns, and between the political and executive leadership at County Hall.  At some point between 20th and 24th April 2020, council officials refused to comply with an instruction from council leader Julian German.

This is a story which refuses to go away.

Dramatis personae:

Andrew = Andrew Richards (right) the Cormac worker whose head injury in 2016 was so severe that he was forced into early retirement on medical grounds.  Mr Richards was initially referred to as “Joe” but later agreed to be identified, and to speak to reporters .

Kate = Kate Kennally, chief executive of Cornwall Council

Cath = Cath Robinson, chief executive of Corserv

Julian = Julian German, leader of Cornwall Council

Mel = Mel O’Sullivan, Cornwall Council’s top lawyer

Below is Mr Egerton’s email to every councillor.  Attached to the email is a list of “exhibits” which you can download here: Exhibits to accompany email-compressed

Dear colleagues

I am writing to you again about the ongoing saga of the health and safety incident that took place at a Cormac depot in December 2016 and the life changing injuries that were suffered by a Cormac employee, namely Andrew Richards of Tregony.

I think that it is important that you understand the extent of the false statements that Cormac/Corserv have made in relation to this incident. Not only have they told untruths to the Health and Safety Executive but they have also provided false information in a response to an FOI request that I made. You, as members accountable to the public, need to decide if you are happy for the political leadership and senior management of the Council to turn blind eyes to the actions of Corserv. Is it acceptable for a company wholly owned by the Council to cover up a serious health and safety incident and to repeatedly tell untruths about the facts in order to try to maintain that cover up?

You have been assured by the Leader of the Council that he has looked into the issue and he sees no need for any inquiry. He says that there is no evidence of wrongdoing. Whilst the Conservative, Labour and MK groups have asked for an independent investigation of the incident, most of the Lib Dem and Independent councillors have been prepared to accept the Leader’s assurance. Loyalty to your group is one thing; refusal to even countenance that there could be something seriously wrong in the organisation is another matter. Later in this lengthy email, I will explain what exactly the Leader’s “investigation” consisted of. On reading this, you may feel that it was not quite as thorough as he led you to believe.

 

The untruths told by Cormac to the HSE

Phase 1 (December 2016-January 2017)

The incident occurred on 16 December 2016. Andrew was working alone at the Cormac depot at Grampound Road. He was seen looking fine at 1.55 p.m. At 2.20 p.m. he was found by colleagues slumped over a desk in the office on site, barely conscious, there was a pool of blood on the ground in the yard. An ambulance was called and he was taken to hospital. The Highways Manager arrived on the site, took a few notes in his notebook then told the other Cormac employees to sweep up the blood. The police were not called.

That evening, the Highways Manager was advised by Andrew’s wife that he had a fractured skull. A fracture of that nature is a reportable category of injury. It must be reported to the HSE using the RIDDOR process (reporting of injuries, diseases and dangerous occurrences regulations) as soon as practicable. The fact that Andrew had a fractured skull was acknowledged in a Cormac internal email on 16 January. [Exhibit A.]

The health and safety manager of Cormac, a man with a job that you would think would mean that he had a reasonable knowledge of health and safety reporting processes, submitted a RIDDOR report to the HSE on 23 January 2017, i.e. over 5 weeks after the incident.

The report contained 3 falsehoods:

1) “Mr Richards passed out and sustained a head injury” - there is no evidence that he “passed out”.

2) “a work colleague who took him to hospital” - he was taken to hospital in ambulance - an obvious and deliberately wrong account of what happened.

3) “What was the severity of the injury? Injury preventing the injured person from working for more than 7 days” - the severity should have been reported as a fractured skull. Failure to report such an injury is a criminal offence.

[See exhibit B.]

Those 3 falsehoods were clearly designed to lead the HSE to believe that the incident was relatively minor and would not warrant an HSE investigation. If Cormac had told the HSE that Andrew had suffered a fractured skull and bleeding on the brain in an incident in a Cormac depot and that there was no explanation of how it happened, it is possible that the HSE would have investigated and they would certainly have asked questions such as “why were the police not notified on the day?”. The untruths succeeded in that the HSE did not investigate and neither did anyone else ask any questions. The incident might never have come into the public domain if I had not come across it by chance several months later.

Andrew never returned to work and he was subsequently medically retired. He will never work again; he will never drive again.

 

Phase 2 (August-October 2017)

After I found out about the incident, I met with Kate Kennally and later the same day with Tony Barnett, then M.D. of Cormac. Both said that they were unaware of the incident. Barnett promised an investigation.

An investigation was carried out by the health and safety manager of Cormac, the same person who had provided false information to the HSE about the incident. Cormac refused to show me a copy of the incident report. It was two years later before I finally managed to see a copy of the report and also copies of the emails that the health and safety manager sent to the HSE to “make amendments to the detail of one of our notified incidents”.

In that email, it was admitted that "there is no evidence that he actually lost consciousness” and “Mr Richards was taken to hospital by ambulance.”

But the email also said “there has been no change to the injured person’s condition, or the category of injury”, i.e. it was still classified as an “over 7 days” injury despite the fact that the health and safety manager had just completed a report that expressly said that Andrew suffered a fractured skull. [Exhibit C]. Another blatant falsehood.

The HSEQ director of Corserv endorsed this update to the HSE in an email that he sent to a number of Cormac employees. In other words, he knew that the Cormac health and safety manager had misled the HSE about the injury again and he wanted to make sure that they were all telling the same story. [Exhibit D]

 

Phase 3 (September 2019 - April 2020)

It was only two years later that I finally obtained a copy of the Cormac incident report and copies of the internal emails that showed how Cormac had misled the HSE. With this evidence, I met Kate Kennally and Cath Robinson on 4 September 2019 and demanded that Cormac should report itself to the HSE and confess to giving them false information. I said that, if they were not prepared to do that, then I would report the matter to the HSE. On 17 September, Cath wrote to the HSE and admitted that their reporting of the nature of the injury had been incorrect but claimed that there had been conflicting information from the GP fitness to work certificates and the evidence from elsewhere. This was also untrue. It was absolutely clear to Cormac both at the time of the incident and at the time of the “correction” of the RIDDOR report that they knew that Andrew had a fractured skull.

On 29 September, I contacted the HSE and told them of my concerns that Cormac had told them untruths about this incident.

On 15 November, I met the HSE inspector in her Plymouth office. When I signed in at their office, I saw that the HSEQ director of Corserv had been to the office before me on 31 October. It was fairly clear to me from the atmosphere of my meeting that the HSE were likely not to take any formal action against Cormac. This was confirmed to me in subsequent correspondence from the HSE.

It was only after I went through a 2 stage complaints process with the HSE that they finally wrote formally to Cormac advising them that they had breached RIDDOR processes but that "there have been significant changes to your health and safety management systems in the intervening years which have improved your incident reporting policy and procedure making the issue of an IN [improvement notice] unnecessary”. [Exhibit E]

 

The evidence provided by Cormac to the HSE regarding improvements to policy and procedure

At the meeting that the HSEQ director had with the HSE in October 2019, the written evidence that Corserv provided was, according to the response (17 June 2020) to an FOI enquiry that I made of Corserv [Exhibit F]:

  1. a) A RIDDOR reporting flowchart showing people how to complete the necessary process.
  2. b) A copy of the incident report prepared by the Cormac health and safety manager in August 2017, slightly amended from the version that I had previously seen. In the version that I had seen, the contents page referred to "section 4 recommendations” although there were no recommendations in the report. In the version provided by Cormac to the HSE the reference to recommendations had been deleted. [Exhibit G]
  3. c) Copies of doctors fitness to work reports.

The HSE inspector took no notes of the meeting and did not write a report on the meeting. She was sufficiently persuaded by a RIDDOR flowchart and the smooth words of the Corserv HSEQ director that all was now well in Cormac/Corserv and she concluded that there was no need to take any action against the company. Incidentally, the HSEQ director of Corserv used to work for the HSE as an inspector in the south west.

 

The falsehoods surrounding the RIDDOR flowchart

The RIDDOR flowchart was the only written evidence that Corserv provided to the HSE that supposedly supported their claim that there had been significant changes to health and safety systems. In the FOI response to me dated 17 June 2020, Corserv said, "You asked whether any changes in health and safety reporting procedures or RIDDOR reporting procedures have been made as a result of investigating this incident. Corserv and Cormac have strengthened their incident reporting systems; documented through use of the enclosed RIDDOR reporting checklist. This document provides guidance to employees on how to correctly identify and subsequently notify a reportable injury sustained at work. The form includes facility for checks at senior level by the HSEQ team at Corserv.” [Exhibit F]

Since the incident report relating to Andrew’s accident was produced in August 2017, one would have expected that the new RIDDOR system would have been implemented within, at most, a few months of that report. However, when I asked Corserv the date on which the RIDDOR reporting checklist was first published, I was told (in an email of 13 October 2020), "The Corserv RIDDOR checklist was introduced in July 2019, in order to bolster the existing reporting arrangements for health and safety incidents across the Corserv Group of Companies.”  [Exhibit H] This date was nearly two years after the incident report and now it was being labelled as a more general updating of processes, not related to the Andrew Richards event. In response to my question about who it was distributed to, the response was "The RIDDOR checklist was issued to the Corserv HSEQ team; being the team responsible for the reporting of health and safety incidents to the Health and Safety Executive.” No longer was it guidance to employees, but merely confined to the HSEQ team.

By chance, therefore, according to Corserv, this new system was introduced in July 2019 which meant that when Corserv had to provide evidence to the HSE, they had this form available, produced just a few weeks before - very handy!

However, when I examined the metadata of the RIDDOR form pdf that had been sent to me, I found that it had been created on 18 September 2019, not July as Corserv had told me. [Exhibit I]

Since the original form had been set up in Microsoft Visio, it was possible (although highly unlikely) that the Visio form had been created in July and been converted to a pdf in September. Therefore, I asked Corserv to provide a copy of the Visio file so that I could check that it had been created in July and not September 2019.

Once again, Corserv changed their story in an email on 30 October 2020:

"Unfortunately, we are unable to provide a copy of the Microsoft Visio digital file as it was not required after its conversion into the interactive PDF file following its development and was therefore deleted when the PDF version was finalised.

As we continually seek to improve our quality management systems, for which we are audited bi-annually by our external verifiers; BSI, the form was conceived to bolster our existing safety systems and demonstrate continual improvement required by the ISO quality and safety standards. The document was initially discussed and developed informally by the HSEQ team during late July and August 2019, culminating in the interactive digital form being produced during early September, to a final version as provided to you; dated the 18th September 2019.” [Exhibit J]

In other words, another untruth from Corserv. The obvious conclusion is that this RIDDOR checklist, supposed evidence for improvements in procedures, was actually fabricated by Corserv after I had my meeting with Kate and Cath on 4 September in a desperate ploy to have something to present to the HSE as an improvement in processes. It was sufficient to take in the HSE inspector who probably never thought to ask the Corserv HSEQ director when he had produced the form.

 

The role of the Leader in this scandal

I presented my initial report on the incident to Cabinet colleagues at a meeting on 9 March 2020. Cabinet colleagues were reluctant to take immediate action to instruct the chief executive to sort the matter out, i.e. to force Corserv to apologise and to offer compensation to Andrew. Julian said that he would consider the matter and take legal advice.

Later that day, Julian and I exchanged emails. [Exhibit K]

On 22 March, I spoke to Julian and he advised me that he was seeking answers from Kate.

On 28-29 March, I exchanged emails with Julian again asking him for an update of how we was doing with regard to this matter. [Exhibit L]

On 17 April, when I spoke to Julian, he was clearly still hesitant to tell Kate to do something.

Cabinet members have a Cabinet pre-brief, just members, not officers, most weeks on a Monday. On Saturday 18 April, two days before the next pre-brief meeting, I texted Cabinet colleagues asking them to make a decision at that meeting as to whether or not they were going to force action from the chief executive and warning them that I would resign from the Cabinet if they did not act. [Exhibit M]

On the morning of 20 April, Julian phoned me to say that he had instructed Corserv chair and Mel to sort the matter out and to do the right thing for Andrew Richards. Julian emailed the rest of the Cabinet to tell them that I would be attending that afternoon’s meeting. I then attended that meeting because I thought that the matter would be resolved satisfactorily. [Exhibit N]

On 24 April, Julian phoned me to say that the officers were refusing to do what he had asked.

In the more than 6 weeks from the time that I first presented my report to the Leader and other Cabinet members, at no time did the Leader sit down with me and go through the report and question how I had reached the conclusions in it.

This is the “improved” Cormac RIDDOR flowchart, first produced as a PDF file in September 2019 – nearly two years and nine months after Mr Richards’s accident.  Cormac claimed the flowchart had been produced as a Microsoft Visio file in July 2019 (so only two years and seven months late) but now says that the original file has been deleted.

Cornwall councillor Bob Egerton resigned from County Hall's ruling cabinet in protest at what he saw as deliberate obstruction of his attempts to dig out the truth.  The Health and Safety Executive has confirmed that it never investigated the accident because Cormac failed to report it.

During this time, he never said to me that he had doubts about anything that I had put in the report.  He never suggested to me that he thought that I was mistaken in my conclusions.

On 25 April, I emailed Julian to say that I had resigned from the Cabinet with immediate effect.

On 27 April, I emailed all members to advise them of what I had done and why.

In the afternoon of 27 April, the Leader emailed all members of the Independent Group to tell them that "I would like to reassure you that I have investigated this matter fully and have found that Bob's accusations do not stand up.” [Exhibit O]

I was somewhat surprised that Julian was saying this as it was only a few days after he had assured me that he was trying to resolve the issue in favour of Andrew. But, as they say, a few days is a long time in politics.

At the Full Council meeting of 7 July, I asked a question of the Leader, requesting that he publish a copy of his investigation into the incident. He refused to do so on the grounds that it contained confidential information.

I then submitted a FOI request to the Council asking for release of the investigation, and, if necessary, redacting personal information.

On 21 July, I received the first reply to my FOI request. The Council refused the request completely citing three grounds for exemption. But they did say that “the Leader’s findings were in line with those of the employer and he was satisfied with the actions and learning undertaken however, it is considered that documentation relating to this matter is exempt …” [Exhibit P]

I asked for an internal review of the decision.

On 18 August, I received the second FOI reply that put a different slant on the Leader’s investigation. It said, "After reviewing the case as an independent reviewer, my conclusion is that there is not a copy of an investigation report held. Whilst there are reports pertaining to the incident, the Leader did not produce a further report. He assessed the information within the existing reports and had meetings and conversations to question them. He then assimilated all of this information and came to a conclusion about the accusations that were made.” [Exhibit Q]

I then made another request for what “actions” and “learning” had been undertaken and also what other reports there were beside the August 2017 incident report. I made that request to both CC and Corserv.

On 17 September, I received the third FOI response from Cornwall Council. [Exhibit R] Once again, there was a change from the previous reply. This time it was admitted that the Council had not produced any more reports. The FOI response from Corserv on the same date confirmed the same. [Exhibit S] In other words, the earlier reference in an FOI response to “reports” in the plural was wrong and that, in fact, only one report has ever been produced, i.e. the incident report prepared by the health and safety manager of Cormac in August 2017. The CC response then went on to say, "Meetings and conversations took place regarding the matter, but where these took place as part of other matters, conversations or catch up meetings, these are not recorded and therefore details not held. However, it can be confirmed that calls took place on the matter with Mel O’Sullivan, Monitoring Officer on the following dates: 29 April, 5 May, 19 May, 29 May 2020.”

So, what conclusions can we draw about how thorough the Leader’s investigation was? He had four conversations with the Monitoring officer on the dates shown above. These were allegedly part of his process of investigation. But all those meetings were after the date on which he sent out the email to members, 27 April, saying that he had “investigated the matter fully”. Unless the Leader has access to a time machine, it is difficult to see how these conversations could have aided his investigation. Furthermore, the only action that Cormac had supposedly taken as a result of the incident was to produce a RIDDOR reporting checklist. As explained above, this document was fabricated in order to mislead the HSE. But it seems that it was enough for the Leader to give Cormac a clean bill of health.

The role of the Monitoring Officer in this scandal

On 27 April, after I had sent out my email to members and officers, the Monitoring Officer emailed me and her email included,

"You have published on your website and made available to the public:

(1) statements of a potentially libellous nature,

(2) confidential information and documentation potentially not already in the public domain, and

(3) personal information that could easily be used to identify members of the public where consent to the sharing of personal information has presumably not been given.”

And

"Please also note and continue to bear in mind that the release of confidential information to the public is a breach of the council’s code of conduct.”

At the end of August 2020, a Cornwall Councillor submitted a complaint to the Council alleging that I had breached the code of conduct in making libellous comments about Cormac/Corserv and the Council. After two months, the Assurance team are still refusing to accept it as a potential breach of the code of conduct. In an email from an officer in Assurance, it says, "Prior to processing this matter further, I seek clarity from you in respect of what you consider particularise exactly who has been defamed and by what statements. Your complaint, at present, is too imprecise for us to respect.  It should be noted that robustly pushing an issue for a constituent isn’t itself a code breach and it would need to be demonstrated that another element had been breached.”

So, at one time, the Monitoring Officer was telling me that I have made libellous statements and that I am in breach of the code of conduct, but when a complaint is made, her team are refusing to accept it. It is apparently now fine for me to accuse Cormac of lying because that is just "robust pushing for a constituent."

It should be noted, of course, that should the Assurance team accept it as a potential breach of the code, they would have to refer the matter to an independent person to assess whether or not it was a breach. I can only conclude that they are worried that the independent person would carry out an proper investigation into the affair and reach a different conclusion from that which the senior management and political leadership of the Council would like you to believe. Better, therefore, to kick the can down the road and pretend that it is not a breach of the code of conduct.

 

The claim that Corserv is a sovereign body and cannot be scrutinised by Cornwall Council

The Leader claimed in his email of 27 April that he had fully investigated the issue and found that there was no substance to my allegations. But he refuses to explain how he reached that conclusion. He does not explain why he thinks that it is acceptable to tell untruths. Or is it that he thinks that filing a report to the HSE that says that the injured man was taken to hospital by a colleague was not a deliberate falsehood? Does he think that failing to call the police on the day was the right thing to do? Does he think that telling the HSE that the injury was an “over 7 day injury” when they knew that it was a fractured skull is acceptable?

When four of my residents who were very concerned about the incident tried to ask public questions at a Cabinet meeting, suddenly the position changed. These questions were ruled out of order because, it was said, the issue was not a matter for Cornwall Council. So why did the Leader say that he had carried out an investigation if it was nothing to do with Cornwall Council?  It seems that Cornwall Council says whatever it thinks is expedient at the time that questions are asked: they are making it up as they go along. On one day, everything is fine, they have investigated the matter and there is nothing to see here; on another day, it is nothing to do with the Council and we should not investigate Corserv’s actions.

The indisputable fact is that Cornwall Council is the 100% owner of Corserv. If Cornwall Council really wanted Corserv to do something, or not to do something, they have the power to enforce their will. If they don’t do use their ownership powers in relation to Corserv, it is because they have chosen not to do so.

 

The threat of legal action by Corserv

On 30 April, three days after I published the reasons for my resignation, I received a letter from Stephens Scown demanding that I retract all my statements, take them down from my website and apologise.

I replied to say that I would see them in court.

On 19 June, I emailed Cath Robinson as follows,

"Dear Cath

It is now more than 6 weeks since I wrote to you about your threat of libel action against me.

I have heard no more. Would you please confirm that you are proceeding with the action and advise when I can expect to receive the court papers. I am looking forward to this matter being resolved once and for all in a court of law.

Yours sincerely

Bob Egerton”

Cath did not reply to me. Instead, I received a further email from Stephens Scown as follows:

"We refer to your email dated 19 June 2020 which was sent to Ms Robinson direct. We request that you refrain from contacting our client in respect of this matter. Any future correspondence should be directed to this firm.”

There was a time when chief executives would proudly have on their desks signs saying “The buck stops here”. No longer it seems. Now it seems that the sign says “I need to have my lawyer with me before I can answer any questions.”

Six months after the threat from Stephens Scown, I have heard no more about any court case.

 

Summary

On 16 December 2016, an employee of a company 100% owned by Cornwall Council suffered life-changing injuries in an unexplained accident at work in premises owned by Cornwall Council. I don’t know how the injury occurred. The doctors who treated Andrew at Treliske said that the injuries were unlikely to have been caused by a simple fall from ground height. They looked more like the type of injuries seen in motor vehicle accidents. Cormac probably don’t know how the injury occurred. They may have suspicions about how it happened but, rather than making every effort to try to find out how it happened, they have deliberately covered up even the occurrence of an industrial injury. They have told untruth after untruth in a desperate attempt to cover it up. I cannot explain why they have done this. All I can do is show you the evidence that this is what they did.

When I have made FOI requests to both Cornwall Council and Corserv, the responses have been economical with the truth and when I have asked follow-up questions, the stories have changed.

Cornwall Council’s political and officer leadership has been complicit in allowing this cover up to continue.

 

What happens next?

What happens next is primarily down to the members of the Liberal Democrat and Independent groups. The Conservatives, Labour and MK groups have all asked for an independent inquiry into this affair. The Leader has refused, confident that he has the backing of the Lib Dems and Independents. With a combined number of 66, these two groups can, if they stay united, block any attempt to have an inquiry.

The choices facing these group members are, I would suggest:

1) Persuade the Leader to hold an independent inquiry into this matter. If they do so, it is likely to take a few months and any report from that would be published early in the New Year, shortly before the May elections.

2) Persuade the Leader that, having reviewed the evidence in this email, they are sufficiently convinced that an injustice was done to Andrew Richards and that the Leader should simply instruct the chief executive of Cornwall Council, sole owners of Corserv, to apologise to Andrew on behalf of the company and to offer a reasonable sum in compensation for the wrong that has been committed.

3) Double down and decide that loyalty to the Leader is paramount and refuse to countenance any apology or compensation.

 

I will wait to see what you decide to do.

 

Best wishes.

Bob

This article has 1 comment

  1. Sir Walter Scott, Marmion, 1808:
    “Oh, what at tangled web we weave
    When first we practise to deceive”

    William Shakespeare, Julius Caesar, 1599:
    “beware the Ides of March”

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