AN INQUEST jury has found that multiple failures by Chippenham man Shaun Carter's employers contributed to his death when he was crushed by his dumper truck as toppled over the side of a large spoil heap.

In a narrative conclusion, the jury of seven women and four men at Gloucester coroner's court also found that safety communication on the building site where he was working was inadequate.

Mr Carter had been told to use another spoil heap on the site and dump the spoil at ground level, the inquest heard.

Workmates told Deputy Gloucestershire Coroner Caroline Saunders they had no idea why he had gone to the one where he met his death, as it was further away and not in use.

Following the conclusion of the two-day hearing late on Wednesday (jul 19) afternoon, Mrs Saunders made recommendations under the coroner's investigation regulations to Mr Carter's Swindon-based company, Tonic Construction, and to the Health and Safety Executive (HSE).

She said she was impressed by the steps taken by Tonic to improve safety since the accident, which were exemplary.

But before the tragedy, risk assessments were not followed she said, and were not even seen by all personnel on the site.

"I would like an assurance that this has been addressed," she went on.

"I will also make a report to the HSE about putting guidelines in place to reduce the danger of dumper trucks overturning."

Dumpers were designed to protect their drivers in dangerous situations, she said, but drivers could nonetheless feel exposed, causing them to try and jump clear when they were toppling over.

"I will ask the HSE if there should be changes to the design of dumpers as we have heard discussed today," she added.

Those discussions centred on Tonic Construction's adoption of a new type of dumper since the accident, complete with a full safety cab around the driver.

The inquest heard the company was now actively promoting the new vehicle to other construction companies in the hope that lives would be saved.

Mr Carter, 29, of Great Mead, Chippenham, was declared dead at the scene of the accident on a Barrett and David Wilson Homes site in Cirencester on May 31 2016.

A pathologist who carried out a post mortem found that he had suffered extensive damage to his head and chest from a crushing impact, and had probably died instantly.

Ground worker and dumper driver Mr Carter had been working for Tonic Construction, the groundworks contractor on the site, putting in roads, drainage and house foundations.

Fellow worker Jonathan Kosma said spoil heaps were created as a firm and safe place for waste soil, stone and rock, and as they got higher, a ramp was built for dumpers to get to the top.

"Since the incident, dumpers are no longer allowed onto the heaps, which are built up by excavators," he said.

"I saw Shaun in the dumper on the top of soil heap two and one of the rear wheels was just lifting off the ground. The front end started to go over the edge and I saw him try to jump clear.

"The dumper disappeared over the edge and I ran over. The dumper was upside down and the heap had a sheer face where it had landed.

"Shaun wasn't breathing. The ambulance operator told me to pull him away from the heap so that I could start chest compressions."

Excavator driver Paul Sorrell was working with Mr Carter that day. He said he thought the spoil heap where the incident happened was no longer in use.

"I thought we were supposed to use spoil heap one, but we weren't given any information about heap two's safety," he went on.

Mr Sorrell and supervisor Richard Hibberd both told Mr Carter to go to heap one.

Contract excavator driver Michael Reeves told the court that he had been told to make a start on removing heap two about ten days before Shaun's death.

But he said he had never been part of the safety briefings on the site, which were held first thing every morning.

"I removed spoil to make a small platform for the excavator, so that it would be easier to load the lorries," he said.

"It's normal to make heaps safe when you finish but I was given other work to do and there was no time to do it before the end of that day."

In her summing up, the coroner said various aspects of site safety had been discussed during the hearing, one of which was that Tonic's own safety procedure for spoil heaps was to build a bund, or low barrier, around the top to stop dumpers getting too close to the edge. But in practice, she said, this was never done.

Supervisors accepted that site safety was part of their role, she said, but no-one noticed that spoil heap two was dangerous.