“As part of our review, we identified a discrepancy, between the information supplied by the UKPN engineer and HSE’s specialist inspector, on the distance between the high voltage line and the tree. To understand that discrepancy, we went back to the specialist inspector and, in doing so, identified that HSE held photographs that we had not previously identified as held ie within the organisation. This is because the photographs were not held within HSE’s corporate document repository. In the interests of transparency, having identified these photographs, we are including them now as part of our reply. However, after a careful consideration of the information that you have provided, we remain of the view that there is insufficient evidence to demonstrate a breach, beyond a reasonable doubt, of the Electrical Safety, Quality and Continuity Regulations (ESQCR 2002) in relation to the death of your husband.”
“(5) In determining whether to initiate, continue or discontinue an investigation under this Act, the Commissioner shall, subject to the foregoing provisions of this section, act in accordance with his own discretion; and any question whether a complaint is duly made under this Act shall be determined by the Commissioner.”
“(3) It is hereby declared that nothing in this Act authorises or requires the Commissioner to question the merits of a decision taken without maladministration by a government department or other authority in the exercise of a discretion vested in that department or authority.”
““Maladministration” is not defined in the 1967 Act. It will cover “bias, neglect, delay, incompetence, ineptitude, perversity, turpitude, arbitrariness and so on”
“i) The Ombudsman has no duty to determine questions of law. He/she is not acting as a surrogate of the court in determining whether there has been unlawful conduct, but rather, investigating a complaint of maladministration under the powers conferred on him/her by statute. ii) Maladministration is a different concept from unlawfulness; consequently in determining whether the conduct complained of amounted to maladministration, the Ombudsman is not constrained by the legal principles which would apply if they were determining whether that conduct was unlawful; iii) Unlawfulness is neither a precondition of, nor concomitant to a finding of maladministration; there may be maladministration without unlawfulness, and vice versa. iv) Even if, with the benefit of hindsight, it may seem obvious that the public body got something wrong, the Ombudsman must look at the question of maladministration on the basis of the information that the public body had at the relevant time, and not with the benefit of hindsight;”
“v) It is for the Ombudsman to decide and explain what standard he or she is going to apply in determining whether there was maladministration, whether there was a failure to adhere to that standard, and what the consequences are; that standard will not be interfered with by a court unless it reflects an unreasonable approach. vi) However the court will interfere if the Ombudsman fails to apply the standard that they say they are applying; vii) The question whether any given set of facts amounts to maladministration or causes injustice to a complainant is a matter for the Ombudsman alone. Whatever it may think about the conclusion reached, and even if it fundamentally disagrees with that conclusion, the Court may not usurp the statutory function of the Ombudsman. It can only interfere if the decision reached was irrational. viii) An Ombudsman’s report should be read fairly, as a whole, and should not be subject to a hypercritical analysis nor construed as if it were a statute or a contract.”
“Therefore, even if what the relevant public body (in this case Ofqual) did or said turns out in hindsight to have been based on a misunderstanding of the law, it will not necessarily lead to a finding of maladministration by the Ombudsman, especially if the legal issue is not entirely straightforward and the mistake was an understandable one for a layman to have made.”
“Fatalities (or serious incidents) not reportable under RIDDOR which should be considered for investigation 9. In these cases, initial enquiries may be necessary, and decisions on whether or not to investigate must be endorsed by a Head of Operations. To proceed to investigation, all the following criteria need to be met: (a) the incident resulted in death (or where the injuries are so serious that death might have resulted); and (b) there are, in relation to the circumstances that caused the incident, expected health and safety standards that are defined and known by the industry/sector in question; and (c) a clear and likely causal link has been established between a failure to achieve those expected standards and the resulting harm (it may be appropriate to wait for a postmortem to confirm causality); and (d) admissible evidence is likely to be available. Admissible evidence may not be available, for example where there is a significant length time delay before HSE is involved, or where witnesses are unlikely to be traceable.”
“We have looked at how the HSE reached its decision that part C of the FOD was not met. The primary evidence available to the HSE was the condition of the line at the site of the incident, and the HSE says this was assessed by the inspectors. The HSE explained that, following a review of the OHPL, the specialist inspectors and the principal specialist electrical inspector concluded that UKPN had taken reasonable precautions to control the risks of an electrical incident in the specific area where the incident occurred because it had acted in line with the requirements of the ESQCR 2002 cited above.”
“44. We enquired whether the HSE would expect any additional precautions to be in place for an uninsulated cable in a heavily wooded area. The HSE advised that the need for additional precautions depends on the specific location of the line, and the site visit established that there was no reason to expect any additional measures based on those already in place. 45. With regards to the most recent review of the case, Mrs [Wills] provided HSE with the information she had obtained from her civil mediation case. Of particular focus was the differences in opinion between UKPN, HSE, and Mrs [Wills] on the OHPL clearances from the trees. 46. In reviewing this evidence, the HSE held a discussion regarding the distance of the OHPLs from the trees. The HSE says the distance was measured by eye, as no mobile elevating work platform (MEWP) was available. The HSE re-reviewed a collection of photos of the area, which it considers demonstrates that clearance distances were met. 47. The HSE has acknowledged there is some discrepancy of opinion in relation to this distance and puts this down to the lack of MEWP, meaning both HSE and UKPN made an estimate measurement by eye. 48. We asked HSE about the process of measuring the distance of the lines from the trees by eye, and it confirmed that an assessment of this type would be normal practice. The visual inspection conducted at the time reported that the clearances of the trees to the OHPL were sufficient, concluding they were far enough away from the trees that there was no danger. 49. The HSE concluded that the line was not reachable as it was above minimum standards, and a distance away, had the required ‘danger of death’ notices in place, and did not have climbable branches in proximity. 50. It also reflected that the damage to the metal line being thrown from the garden over the tree branches was consistent with electrical arcing. In this context, it concluded that the line likely made loose contact with the OHPL, rather than jumped a distance between the line and the overhead powerline. 51. Therefore, the HSE concluded that the evidence gathered did not show, beyond reasonable doubt, that there was an identifiable breach of the ESQR 2002 standards for OHPLs that led to Mr [Wills’] death and allowed it to take further action. 52. After considering all the relevant evidence available to us, we have not seen any indications of maladministration in the way HSE has applied its guidance and standards in this case. The evidence available indicates the HSE followed the relevant guidance, policy, and requirements of the legislation when determining whether there was a failure to achieve the expected standards for OHPLs set out in the ESQCR 2002.”
“As you may know PHSO is the latest stage in the complaints process and our decisions are final. If someone can show us reasons to think our decision may be wrong, we can use our discretion to carry out a review. But a review is not a further stage in the complaints process. It is something we do on cases where we can see there is a good reason to look at our decision again to be assured it was the right one. PHSO has guidelines which help us decide whether a case should be reviewed. For example, we need to see evidence that our decision may be wrong, and the impact of the events complained about was potentially serious. After I had looked at your letter, I asked our Ombudsman Assurance Team (OAT) to consider whether PHSO should review the decision. OAT considered your complaint about our decision independently. OAT do this by looking at the complaint about our decision, rather than the original complaint, to see whether, under PHSO’s guidelines. It should be reviewed. Following their review, OAT has decided we do not need to review PHSO’s decision because your review request has shown no reason or new evidence that calls into question our decision on your complaint.”