ON APPEAL FROM CHESTER CROWN COURT
THE HON. MRS. JUSTICE MAY
Strand, London, WC2A 2LL |
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B e f o r e :
MRS. JUSTICE McGOWAN
and
MR. JUSTICE DOVE
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REGINA |
Appellant |
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- and - |
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WOOD TREATMENT LIMITED and GEORGE BODEN |
Respondents |
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Dominic Kay QC and Harry Vann for the 1st Respondent
Simon Antrobus QC and Sandesh Singh for the 2nd Respondent
Hearing date: 27 April 2021
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Crown Copyright ©
Note: publication of the judgment was postponed pending the conclusion of the trial, which has now taken place. The judgment may be published.
Lord Justice Edis:
Introduction
67 Reversal of rulings
The Court of Appeal may not reverse a ruling on an appeal under this Part unless it is satisfied—
(a) that the ruling was wrong in law,
(b) that the ruling involved an error of law or principle, or
(c) that the ruling was a ruling that it was not reasonable for the judge to have made.
The Indictment
STATEMENT OF OFFENCE
CORPORATE MANSLAUGHTER, contrary to section 1 of the Corporate Manslaughter and Corporate Homicide Act 2007
PARTICULARS OF OFFENCE
WOOD TREATMENT LIMITED, on the 17th day of July 2015, being an organisation to which section 1 of the Corporate Manslaughter and Corporate Homicide Act 2007 applied, namely a corporation, caused the death of a person, namely Dorothy Lorraine Bailey, because of the way in which its activities were managed or organised by its senior management and the way in which its activities were managed or organised amounted to a gross breach of a relevant duty of care owed by it to the deceased.
STATEMENT OF OFFENCE
MANSLAUGHTER
PARTICULARS OF OFFENCE
GEORGE BODEN, on the 17th day of July 2015, unlawfully killed Dorothy Lorraine Bailey.
Causation
3. The Prosecution case is that an explosion of wood dust caused the deaths of four employees. The experts instructed by both Prosecution and Defence agree that wood dust was the only fuel present in sufficient quantities to cause the explosion.
The range of credible mechanisms for the explosion include:
• A primary dust explosion within the process, failing the equipment and stirring up previously settled dust within the mill, leading to a large secondary dust explosion.
• A failure of a piece of equipment or pipe releasing a cloud of dust within the mill which found an ignition source leading to an explosion and stirring up previously settled dust within the mill, leading to a large secondary dust explosion.
• A large release from a piece of equipment within the mill leading to settled dust and an explosive cloud and which was then ignited, levitating the settled dust from the release into the explosion without a separate secondary explosion.
• An explosive failure of the high voltage switchgear within the mill, stirring up previously settled dust within the mill, leading to a large secondary dust explosion.
4. The most likely scenario is one of the first two, i.e. an explosion in previously settled dust leading to a much larger secondary explosion.
5. Relevant to the issue of causation are the following matters.
6. First, an excessive accumulation of dust:
a. Unacceptably high levels of dust (e.g. knee or even waist deep in the Riverside; up to a foot deep around the valves in the Main Mill; a couple of inches on pipework, ledges and the top of machines).
b. Location of dust (e.g. high level; floor level; regular leakage points (e.g. valves, sock filters); airborne; upon electrical cabinets and electrical motors).
c. Speed at which dust accumulated (failure of containment)
d. Type of dust (i.e. fine dust which was explosible).
7. Second, the excessive accumulation of dust was caused by:
a. Leakage from process and machinery. The failure of containment arose from:
i. Ineffective and inappropriate repairs as part of a reactive maintenance regime;
ii. Unavailability of spare parts due to a lack of investment;
iii. Introduction of lower quality raw materials;
iv. Failure to respond to warnings and advice from suitably qualified third parties e.g. the vibration analysis conducted by RJW Engineering and the reports on the failures of the Local Exhaust Ventilation (APS); and
v. Reluctance to employ approved contractors for specialised maintenance.
b. The efficacy of the cleaning regime:
i. Inadequate resources invested in housekeeping e.g. a sole individual unable to clean at high levels;
ii. Failure to implement a cohesive system for cleaning e.g. to give effect to the "Site Cleaning Works Instruction";
iii. Cleaning as a reactive measure i.e. visits by regulators;
iv. Use of deception to prevent regulators from discovering the true state of parts of the site e.g. the Riverside;
v. Confusion over the roles and responsibilities of employees re cleaning; and
vi. The lack of leadership shown by senior management, in particular Shingler.
8. Third, multiple sources of ignition, for example:
a. Valves, blowers and other machinery;
b. Electrical sources (6 potential sources of electrical ignition - see Kenneth Morton);
c. Equipment modified by employees e.g. the bypassing of temperature sensors;
d. Failure to service equipment in accordance with manufacturers' instructions e.g. Firefly; and
e. Fires and smouldering dust piles.
9. Fourth, interconnecting rooms and doors which provided the potential for propagation of the initial event.
2.1 Range of Credible Scenarios
2.1.1 WE AGREE that the cause of the damage to the Mill was a large dust explosion but that the precise nature of the early events will remain speculative. The point of difference is between the likelihood that can be given with respect to one of several mechanisms over the others.
2.1.2 WE AGREE that there are a range of credible mechanisms for the explosion, including:
• A primary dust explosion within the process, failing the equipment and stirring up previously settled dust within the Mill, leading to a large secondary dust explosion.
• A failure of a piece of equipment or pipe releasing a cloud of dust within the mill which found an ignition source leading to an explosion and stirring up previously settled dust within the Mill, leading to a large secondary dust explosion.
• A large release from a piece of equipment within the Mill leading to settled dust and an explosive dust cloud and which was then ignited, levitating the settled dust from the release into the explosion without a separate secondary explosion.
• An explosive failure of the high voltage switchgear within the Mill, stirring up previously settled dust within the Mill, leading to a large secondary dust explosion.
2.1.3 WE AGREE that it is impossible to differentiate beyond reasonable doubt between any of the above mechanisms.
2.1.4 WE AGREE that an explosive failure of the high voltage switchgear is the least likely of the above scenarios but DR KETCHELL considers that it remains more credible than MR SUMMERFIELD, who considers it the most unlikely by a large margin.
2.1.5 WE AGREE that the most likely scenario is a primary dust explosion stirring up previously settled dust and leading to a much larger secondary dust explosion; i.e. one of the first two scenarios above.
2.1.6 MR SUMMERFIELD favours a primary explosion within the process based on the history of ignitions within the process and previous incidents.
2.1.7 DR KETCHELL considers a primary explosion within the process would be most likely to vent safety, whereas a primary ignition of a dust cloud outside the process has no further safeguards to prevent a major explosion.
2.1.8 WE AGREE that it is highly credible that the main damage destroying the Mill was caused by a large explosion of a large dust cloud released within the main Mill, also levitating dust settled from that release before ignition. WE AGREE that there is no strong distinction between primary and secondary explosion for this type of scenario. WE AGREE that the release of sufficient material in the available time on the morning of 17th July 2015 appears credible. WE AGREE that a dust cloud of this size would be noticeable to anyone present but are aware of no witness evidence that could confirm or deny the presence of such a cloud.
The nub of the problem
The directions to the jury
The submissions of no case
1. At the close of the Prosecution case, Wood Treatment Limited ("WTL") submits that the evidence adduced by the Prosecution is incapable of proving to the criminal standard that any gross breach of duty on the part of WTL's Senior Management caused the deaths alleged in Counts 1 to 4. WTL is entitled to be acquitted of these Counts accordingly (R. v. Galbraith [1981] 2 All ER 1060).
2. Subsection 1(1) of the Corporate Manslaughter and Homicide Act 2007 ("the CMHA") provides as follows:
"(1) An organisation to which this section applies is guilty of an offence if the way in which its activities are managed or organised –
(a) causes a person's death, and
(b) amounts to a gross breach of a relevant duty of care owed by the organisation to the deceased".
3. WTL submits that on the evidence which the Court has heard, it is impossible for the Jury to exclude, so that they are sure, all realistic possibilities for the cause of the explosion and deaths on 17th July 2015 consistent with innocence on the part of WTL. It is impossible to prove the central element of causation of Corporate Manslaughter to the criminal standard and Counts 1 to 4 must be withdrawn from the Jury".
1. It is submitted on behalf of George Boden that there is no case to answer in respect of Counts 5-8 (Gross Negligence Manslaughter).
2. This is an extraordinary criminal case in terms of causation, even by the standards of prosecutions arising out of fires or explosions. Whilst it is uncontroversial that this was a wood dust explosion, the Prosecution acknowledge that they do not know where it started within Bosley Mill ("the Mill"), how it started or even why it started and, thereafter, how it brought about the subsequent collapse of the Mill and the deaths of each deceased.
3. As the Prosecution cannot establish such basic underlying facts as to the cause of the incident, they have been forced to seek to prove causation by inference through the presentation of a number of credible hypothetical causal scenarios. Without direct evidence as to how this explosion occurred, for there to be a case to answer, each of the credible scenarios must only be reasonably consistent with guilt. If any of the credible scenarios are reasonably consistent with innocence, the case cannot continue.
4. The Prosecution have mistakenly approached the case on the basis that, howsoever the explosion may have been initiated, it could not have resulted in such a devastating fatal explosion in the absence of fuel in the form of accumulated wood dust within the mill brought about by the gross negligence of Mr Boden (and the company). They have presumed each scenario is consistent with guilt on that mistaken basis.
5. This approach fails to recognise the significance of the concession made by Mr Summerfield during the course of the joint meeting with Dr Ketchell in October 2020, now confirmed on oath, that he cannot exclude the realistic possibility that this explosion did not arise from accumulated wood dust at all, but instead from a dust cloud rapidly created during the course of the morning of 17th July 2015 from some piece of equipment within the Mill (and ignited by some unknown source).
The judge's ruling
11. In a case where the prosecution invites the jury to draw an adverse inference from a combination of factual circumstances, the prosecution must be able to rule out any realistic, non-fanciful cause consistent with innocence: R v. G & F [2012] EWCA Crim 1756; R v. Broughton [2020] EWCA Crim 1093. In G&F Aikens LJ put it like this, at [36]:
"We think that the legal position can be summarised as follows:
(1) in all cases where a judge is asked to consider a submission of no case to answer, the judge should apply the "classic" or "traditional" test set out by Lord Lane CJ in Galbraith.
(2) Where a key issue in the submission of no case is whether there is sufficient evidence on which a reasonable jury could be entitled to draw an adverse inference against the defendant from a combination of factual circumstances based upon evidence adduced by the prosecution, the exercise of deciding that there is a case to answer does involve the rejection of all realistic possibilities consistent with innocence.
(3) However, most importantly, the question is whether a reasonable jury, not all reasonable juries, could, on one possible view of the evidence, be entitled to reach that adverse inference. If a judge concludes that a reasonable jury could be entitled to do so (properly directed) on the evidence, putting the prosecution case at its highest, then the case must continue; if not it must be withdrawn from the jury" (all emphasis in original).
12. The case of Broughton concerned the failure of a young man to seek help for a young woman to whom he had given a cocktail of drugs at a music festival. The Crown's case was that he owed a duty of care to secure timely medical intervention when her condition deteriorated to the point where her life was obviously in danger. At the close of the prosecution case the defence had argued that the prosecution evidence was insufficient to prove to the criminal standard that the defendant's negligence had been at least a substantial contributory cause of his girlfriend's death. The submission was based upon unchallenged medical evidence to the effect that at the relevant time the negligence had deprived her of a 90% chance of survival, or put another way that there was a 10% chance that she would have died even with medical assistance. The trial judge had allowed the case to proceed and the defendant was convicted.
On appeal his conviction was quashed, the court deciding that the necessary causal link between negligence and death had not been established. The medical evidence had left open a realistic possibility that the young woman would have died anyway and in those circumstances no jury could have been sure that the negligence, however gross, was a cause of death. At [23], referring to the case of R v. Gian [2009] EWCA Crim 2553, Lord Burnett CJ said this:
"[Gian] concerned a suggestion that there were theoretical or hypothetical possible causes of death which could not be excluded as a matter of theory but were entirely unrealistic. The jury must make judgments on "realistic not fanciful possibilities". To be sure that the gross negligence caused the death the prosecution must exclude realistic or plausible possibilities that the deceased would anyway have died."
At para 94
"We respectfully agree with the observation made by the single judge, reflecting the submission made by Mr Kamlish, that the only evidence dealing with causation was that of Professor Deakin. …It was Professor Deakin who gave the evidence relevant to the issue of causation."
And at para 100-103:
"100. It is unhelpful to attempt to contrast scientific certainty (put at 100%) with a different figure for legal certainty. Human beings asked the question whether they are sure of something do not think in those terms. In the context of causation in this very sad case the task of the jury was to ask whether the evidence established to the criminal standard that, with medical intervention as soon as possible after [her] condition presented a serious and obvious risk of death, she would have lived. In short, had the prosecution excluded the realistic possibility that, despite such treatment, [she] would have died?
101. In our judgment none of Professor Deakin's descriptive language achieved that. Even his description of a 90% chance of survival at 21.10, were medical help available, leaves a realistic possibility that she would not have lived…..
103. In our view, this is one of those rare cases… where the expert evidence was all the jury had to assist them in answering the question on causation. That expert evidence was not capable of establishing causation to the criminal standard."
Q. What mechanisms can a company have to prevent a plant failure of that kind?
A. It's really down to maintenance and repair. It's making sure that the kit is in good condition and making sure that it's properly connected, that the flexible connections are sound and not leaking, and with regard to reconnecting equipment after a period of maintenance, it's a question of having the procedural controls in place that enable you to check that everything important has actually been reconnected and this is something which goes back a long way in history. We've had these sort of incidents before, where people forget to reconnect pieces of equipment and so there are management, safety management control systems in place to actually check that everything has been reconnected that should be reconnected.
Q. And does that include, for example, a safe operating procedure for the sifter?
A. Yes.
Q. Does that include, for example, the proper training of the person who is concerned with the sifter?
A. Yes.
Q. And does it also include, for example, the proper use of sealants and assessment of them for the purpose of safety?
A. Yes, it's important whenever you are making any repair that the material…. I'm sorry, I'm going too fast. It's important whenever you're making a repair on a piece of equipment that the materials you use are specified as being fit for that purpose and that they're used appropriately.
Q. And so is the likelihood of an equipment failure informed by things of that kind?
A. It is.
24. In accordance with the Galbraith test I have asked myself whether the prosecution evidence, taken at its highest, is capable of establishing causation to the criminal standard of proof, ie making the jury sure that the defendants' negligence was at least a more than minimal cause of the explosion and the deaths. As indicated in G&F and Broughton, where the evidence on causation consists in drawing inferences from a variety of circumstances, the jury will only be able to be sure if it can rule out any realistic possibility consistent with innocence.
25. In this case, where the state of the Mill and remaining machinery after the explosion and rescue/recovery operation was such that no firm conclusions could be drawn about the mechanism of the wood dust explosion, the challenge for the prosecution was always going to be to link acts and omissions (principally omissions in this case) on the part of company and Mr Boden to the explosion itself. The prosecution has sought to make this link by using expert evidence to draw a series of educated inferences from the evidence in order to identify possible causes. Whilst the jury have a great deal of evidence going to breaches of health and safety at the Mill generally, the expert evidence is all they have regarding the possible causes of the explosion on the day in question.
26. Pointing to breaches of the various health and safety regulations, which thereby increase the risk of occurrence of a wood dust explosion, may be sufficient for demonstrating the Health and Safety offences. But the very serious offences of corporate manslaughter and gross negligence manslaughter engage the much more exacting requirement of making the jury sure that the (gross) negligence was a cause of the deaths; in this case a cause of the explosion which led to the deaths.
27. In circumstances where the experts could say, with certainty, no more than that it was a wood dust explosion, the prosecution have sought to make the jury sure of the necessary causative link by asking their lead expert to take into account all the evidence in the case, including the evidence of all the other experts, for the purposes of giving an opinion on possible causes of the explosion. Expert input was necessary as there are many and various technical aspects involved in wood dust explosions, such as: the size of dust particles required for suspension in air, the mass of dust combined with size of room, configuration of the room assessing the scope for any venting, and many others. No jury could be expected to make those calculations or assessments on their own, without the assistance of an expert. When that expert input generates a number of realistic ("highly credible") possible scenarios for the presence of a cloud of explosible dust in the Mill on the morning of 17 July 2015, as happened here, the jury cannot logically be sure of causation unless the prosecution is able to show by evidence that all the possibilities can be attributed, at least in part, to the alleged negligence. In other words, that the jury can exclude any realistic possibility consistent with innocence.
28. Where the Crown has sought to make its case on causation by reference to expert evidence raising and critically examining possible scenarios, and has moreover, specifically instructed its expert to do so taking account of ALL the evidence in the case, it is not open to the jury to reject what the prosecution's own expert has identified as a realistic possibility. This is not a case where there is any other evidence which the jury could use to test, temper or reject the expert opinion. The matters said by Mr Badenoch to be the premises upon which the Forest Fresh minisifter example was based, and which he said could easily be dismissed by a jury were not raised with the expert, nor were many of them addressed by the factual evidence: there was no evidence of who actually disassembled and re-built the Forest Fresh mini-sifter, what process they used, whether there even were any manufacturer's instructions, whether the sealant was in fact the wrong type, the list goes on. It seemed at some points in the argument as if Mr Badenoch was approaching this on the basis that it was for the defence to prove that the minisifter example was what in fact happened. But that is not so; the defence needed to do no more than raise a realistic possibility for the source of the dust which exploded. Once their expert has accepted the defence example as a realistic possibility, the Crown is obliged to make the logical causative link by demonstrating that the Forest Fresh minisifter example of Scenario 3 was attributable (at least in part) to negligence on the part of the company/GB.
29. As to this, the "wealth of evidence" referred to by Mr Badenoch amounted to a list of the ways in which the Crown say that WTL and GB breached Health and Safety legislation and regulations over the 6 years between 2009 and 2015. He asked Mr Summerfield to comment, in respect of each alleged failing, on the extent of the gap between what should have been done and what the company did do during that time. Mr Summerfield's evidence was that, in most cases, the gap was very wide. But the failings upon which Mr Badenoch invited such comment were put in general terms – the absence of a process design, of risk assessments, of written operating procedures, of plotted hazard areas in the mill, to name but a few. The furthest extent of Mr Summerfield's evidence, as illustrated by the exchange in re-examination set out above, was that these matters were very important in identifying and reducing/controlling risk such that, without them, the risk was very much heightened – "an accident waiting to happen", as Mr Badenoch put it. But as Mr Antrobus rightly pointed out, this is wrongly to elide risk with causation. Increasing the risk of something happening is not the same as causing it to happen. The fact that the risk of explosion may have been high cannot of itself demonstrate that the particular explosion occurred as a result of the negligence of WTL/GB. It is necessary to go further, to demonstrate how a risk assessment, or a written operating procedure or any other control measure which the prosecution say should have been in place but was not, would have acted to have prevented a breakdown of plant, as contemplated by Scenario 3 in general, or by the Forest Fresh mini-sifter example in particular. What is missing in relation to Scenario 3 is a forensic process linking the (possible) mechanism of dust generation/explosion to the alleged negligence. Mr Badenoch's approach would require the jury to jump between health and safety failings generally and the specific failure of plant posited by the experts under Scenario 3, without any evidence, in effect to speculate about what a risk assessment might have said/recommended, or how any change of procedure implemented as a consequence of a risk assessment or written operating procedure could have prevented a failure of equipment on the morning of 17 July 2015.
30. I have reflected on one further point arising from Mr Badenoch's answer to a question which I put to him in argument: did he accept that there were any circumstances under which there could have been a non-negligent explosion at the mill? He said that he did not accept this, that any wood dust explosion, under any circumstances, must have resulted from a negligent failure to observe Health and Safety regulations at the Mill; it could not have happened unless there had been such failings. Clearly this is a circular argument, but it also, to my mind, sets a dangerous precedent in cases like this: if this approach is right then it would be enough for the prosecution in a health and safety manslaughter case to point to breaches of health and safety duties and say that those breaches of themselves are sufficient to demonstrate causation. That would be to reverse the burden to proof, to lay upon the defence the obligation in a health and safety case of showing that the death was not the result of such breaches.
31. It is for these reasons that I am not satisfied that the jury in this case would be able on the evidence to be sure of the causative link between gross negligence on the part of D!/D2 and the explosion causing the deaths. The presence of Scenario 3 as a "highly credible" possible cause, taken together with the absence of evidence addressing the link between breach of duty and a machine failure/rupture on the morning in question, means that the jury would be unable to rule out a possible cause consistent with innocence".
The Appeal
Ground 1
The judge erred in her approach to the concept of factual and legal causation
Ground 2
The judge incorrectly proceeded on the basis that the expert evidence addressed the legal concept of causation
Ground 3
The judge was wrong to conclude there was no evidence beyond the expert evidence relevant to the issue of causation
Ground 4
The judge incorrectly proceeded on the basis that the defence version of Scenario 3 was synonymous with innocence
Ground 5
The judge incorrectly approached the "realistic possibility consistent with innocence" element of the test to apply when considering a submission of no case to answer, in that she conflated a multi-stage test into one stage without properly analysing the evidence
Ground 6
The judge was incorrect to conclude that there was an insufficiency of evidence to link the suggested failure of the mini-sifter to the acts/omissions of WTL.
Discussion
"In our judgment, the judge was correct in refusing to withdraw the case from the jury merely on the basis that Dr Jerreat could not exclude a theoretical or hypothetical possibility that the victim had died from cocaine poisoning. There is ample authority for the proposition that the mere fact that as a matter of scientific certainty it is not possible to rule out a proposition consistent with innocence does not justify withdrawing the case from a jury. Juries are required to consider expert evidence in the context of all other relevant evidence and make judgements based upon realistic and not fanciful possibilities. (See Bracewell [1979] 68 Cr App R 44, Dawson [1985] 81 Cr App R 150 and Kai-Whitewind [2005] 2 Cr App R 31 at paragraphs 88, 89 and 90). The Court of Appeal endorsed Boreham J's direction in Bracewell. In that case the defence raised the possibility that the victim had been strangled, recovered and then suffered a heart attack, a sequence of events which could not be ruled out as a matter of scientific certainty. The judge directed the jury not to judge the case scientifically or with scientific certainty but to decide whether, on the whole of the evidence, they were sure. The Court of Appeal endorsed that direction which correctly drew the distinction between scientific proof and legal proof. It pointed out that the medical evidence was only part of the material on the basis of which the jury had to reach a decision.."
Q. Absolutely, and so I am clear and I am perhaps repeating myself, I am not suggesting that we could in any way be sure of that. Simply, as you agreed a moment ago, that that is a realistic possibility that cannot be excluded?
A. Correct.
Q. Now there are a number of reasons how the release could have happened, just to complete the scenario. We know, do we not, that the sifters oscillate on flexible mounts over several inches as part of the sifting process?
A. Yes, we saw it on the video, yeah.
Q. The inlet and outlet connections are flexible, as we have seen?
A. Correct.
Q. They have to be because of the movement, and we know, do we not, that the sifter in the previous 24 hours had been taken apart as part of a maintenance or repair programme?
A. Yeah.
Q. And then reassembled?
A. Yes.
Q. It is perfectly possible that the plant malfunctions just after it has first started, having been taken apart and reassembled for maintenance or repair?
A. Yes, it's happened many times before.
Q. It happens. It happens often?
A. Yeah, Piper Alpha was the classic example.
Q. It could be because, for example, the inlet or the outlet pipes failed?
A. Yeah, or weren't connected.
Q. The release could be because the bindings on the sieves, at the corner of the sieve have failed?
A. Yeah.
Q. Or any number of other explanations?
A. Yes.
Q. And those are all as we have said realistic possibilities that cannot be excluded?
A. Yes. They will influence the source term, but yes.
Q. So those are the first two of those industries we talked about, but in the dust handling industries, explosion relief remains a widely used mitigation measure?
A. It does.
Q. And this is because it is often impossible to prevent, and this is something you were saying yesterday, the formation of dense dust clouds inside the process?
A. Yes.
Q. And again, something you were saying yesterday, the dust itself or mechanical moving parts in contact with the dust, often create ignition risks that cannot be eliminated completely?
A. That's correct.