What happened
On 2 October 2018, Mick Ferris, a 53-year-old coach driver, was returning to his coach after a break when a window unit fell from a penthouse at the Corniche development on Albert Embankment. The window weighed 130kg and fell around 300 feet. He was killed instantly.
St James, part of the Berkeley Group, was the developer, Principal Contractor and Principal Designer for the scheme. Lindner Prater Limited was the specialist company engaged to design the penthouse windows. After a five-week trial, both were convicted of breaching Section 3(1) of the Health and Safety at Work etc. Act 1974. St James was fined £1 million and Lindner Prater £300,000, each with £125,000 costs.
HSE found that early in the design process the windows had been changed from opening inwards to opening outwards. That meant a detached window would fall onto a pedestrian area, but the change was never effectively risk assessed. Safety depended on a single restrictor held in by a single screw, and none of the fittings had been confirmed by their manufacturers as suitable for the bespoke curved windows.
In August 2017, more than a year before Mr Ferris died, a window left open in windy conditions fell from the same penthouses during construction and narrowly missed two workers. St James carried out an internal review, but HSE found key concerns from that review were not followed up effectively. The windows were only redesigned to open inwards after the fatal incident. HSE's lead inspector noted that on both occasions the wind speeds were not unusually high, and that too much reliance had been placed on a small sign asking residents to close the windows.
Why it matters
This is an important case for anyone involved in design under the Construction (Design and Management) Regulations 2015, whether as a client, Principal Designer or specialist designer. It shows that design decisions made years before an incident can lead to conviction, and that a change in design needs the same scrutiny as the original concept.
It also shows the limits of warning signs and reliance on end users. Asking occupants to remember to close a heavy window is not an engineering control. Where a foreseeable failure could kill someone below, the design itself needs to remove or reduce that risk.
HSE specifically called on Principal Designers to be clear about exactly what services architects, designers and consultants are providing, and then to monitor their performance so risks are identified and improvements co-ordinated. For anyone appointing or acting as a Principal Designer, that is a direct prompt to check appointment scopes and how design risk is tracked across the team.
Practical takeaways for employers and duty holders
- Treat every significant design change as a new design risk assessment, particularly where it changes what happens if a component fails or who could be affected.
- When a near miss involves a design feature, close it out with a design review and a documented decision, not a sign or an instruction to users. Make sure actions from internal reviews have owners and are verified as complete.
- If you appoint a Principal Designer or specialist designers, set out clearly in writing who is responsible for which design risks, and check that bespoke components have been confirmed as suitable by their manufacturers.
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