It is my belief that taking the evidence in the Inquest and Review together it appears there was:
1.. Gross breach of duty of care creating very high risk of death
2.. Action or lack of action due to financial or other inappropriate motive(s).
3.. Marked or endemic corporate culture encouraging or producing tolerance of breach of duty of care.
4.. Exposing vulnerable employees to unsafe practices.
5.. Breaches of the duties under sections 2 and 3 HSWA involve failure to take all ‘reasonably practicable steps to ensure the safety of employees and/or the public'.
6.. There was a disregard of the duty of care, and that disregard amounted to recklessness.
Anyone agree/disagree ?