Coroner's Finding: Clark, Guy Redman
Deceased
Guy Redman Clark
Demographics
59y, male
Date of death
2015-10-20
Finding date
2020-01-21
Cause of death
Electrocution
AI-generated summary
Guy Redman Clark, a 59-year-old facilities manager, died from electrocution while attempting to remove a coffee machine at a café. When the water hose dislodged during removal, he attempted to reconnect a glass washing machine's water pipe without turning off its power. The glass washer had multiple electrical defects: reversed polarity wiring that kept it live even when the standby switch was off, bare uninsulated terminals, and poor water pipe installation allowing water to leak into the electrical motor. No residual current device (RCD) protected the outlet. Lack of clear instructions about the coffee machine water supply location and the glass washer's electrical state contributed to the fatal chain of events. Emergency response was timely and professional. The investigation identified failures in training, equipment maintenance, electrical safety standards, and regulatory oversight.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Reversed polarity wiring on glass washer plug kept machine live despite standby switch being off
- Absence of residual current device (RCD) protection on outlet
- Poor installation of glass washer water pipe allowing water leak into electrical motor
- Lack of instruction to Mr Clark regarding coffee machine water supply location
- Lack of procedure for safe equipment removal and repair
- No training provided on equipment operation and safety
- Bare uninsulated spade terminal inside glass washer accessible without tools
- General electrical defects in glass washer including damaged heater element wires and incorrectly wired detergent solenoid
- Coffee machine plug ground down to fit socket (safety non-compliance)
Coroner's recommendations
- Installation of RCDs be mandated in all workplaces regardless of when the workplace was constructed
- AEDs be made more widely available for businesses remote from ambulance services, particularly isolated workplaces and tourist venues
Further listening
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