Synergy Housing Ltd, a Dorset based housing association was
fined £1million at Bournemouth Crown Court on 19 January 2019 for
breaches of health and safety legislation leading to the death of
Alexys Brown, a five-year-old girl, who became trapped while using
a lift at her home in Weymouth.
Following an investigation by the Health & Safety Executive
(HSE), Synergy Housing Limited of Poole in Dorset pleaded guilty to
breaching Section 3(1) of the Health and Safety at Work etc Act
1974 and has been fined £1m and ordered to pay costs of
The Association's lift maintenance contractor Orona Ltd of
Sheffield also pleaded guilty to breaching Section 3(1) of the
Health and Safety at Work etc Act 1974 and has been fined £533,000
and ordered to pay costs of £40,000.
Bournemouth Crown Court has heard how the family moved into the
property in 2009. The property had an internal lift used by the
five-year old's brother who suffers from a degenerative
neurological condition and is wheelchair bound.
On 13 August 2015, Alexys got into the lift to get her brother's
phone from upstairs. She put her head through a hole in the vision
panel and as the lift moved upward, the five-year-old's head got
stuck between the lift and the ground floor ceiling and she died as
a result of her injuries.
Findings by HSE during the investigation included:
- Tenants were not provided with safety critical information
concerning the operation of the lift;
- No risk assessment was carried out following the change of lift
user when the Brown family moved in;
- Concerns raised during service inspections were not addressed
- The Perspex vision panel had been damaged for up to 18 months
prior to the incident. On 12 May 2015, an Orona engineer completed
a service inspection and, in his report, wrote "Routine service
visit - Glass in door smashed!" but this was not fixed or
- Problems with the emergency lowering and lack of emergency hand
winding wheel during the whole of the Brown family's tenancy, and
which was shown in the documentation from at least January
- The key switch used to control operation of the lift had been
modified from factory installation to allow removal of the key in
any position. Because the switch was in the "on" position with the
key removed, it could be operated by anyone at any time.
- Concerns raised by Alexys' brother's health workers were not
taken seriously enough;
- According to HSE guidance, lifts carrying people should be
inspected every six months but, in this case, the lift was serviced
only four times between 2009 and 2015 and was not thoroughly
examined since 2012.
Full details of this tragic case can be found on the HSE website.
To ensure the safety of residents, ARCH member councils may wish
to review their own arrangements for maintenance of lifts in light
of the findings in this case, having regard to the HSE
Guidance on the Thorough examination and testing of