Catalogue of failures responsible for five-year-old’s death

Two companies have been sentenced following the death of a five-year-old girl who became trapped while using aHSE logo
lift at her home in Weymouth.

Bournemouth Crown Court was told how Alexys Brown’s family moved into the property in 2009 of which Synergy
Housing Limited, as part of the Aster Group, became the owner. The property had an internal lift used by Alexys’
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. Alexys died as a result of her injuries.


To ensure the lifts were maintained and repaired, Aster Property Limited managed a contract with Orona Limited on
behalf of Synergy Housing Limited. The contractual relationship was that Synergy Housing Limited had an agreement
with Orona Limited for the maintenance and repair of lifts, including the lift at the property in which the Brown family
lived. Synergy Housing also had an agreement from June 2013 with Aster Property Limited, another company from the
Aster Group, to arrange the maintenance and repair of lifts and to control the work.
When one of the Perspex vision panels in the lift became damaged in early 2013, this was not fixed or replaced. In May
2015 an Orona engineer visited the property to inspect the lift and noted the vision panel was damaged.
The HSE’s investigation found a catalogue of failures by the three companies: Synergy Housing as the Brown family’s
landlord which had primary responsibility for the safety of the lift at the property; Aster Property as the company to
which responsibility for arranging lift maintenance issues fell; and Orona who were responsible for the relevant lift
maintenance and repair work.


Synergy Housing Limited of Link House, West Street, Poole pleaded guilty to breaching Section 3(1) of the Health and
Safety at Work etc Act 1974 and was fined £1m and ordered to pay costs of £40,000.

Synergy Housing accepted that its duties were not to be delegated and that the failings of Aster Property were part of
its breach. The charge against Aster Property Limited of Sarsen Court, Horton Avenue, Devizes, was ordered to be left
to lie on the court file and was not separately sentenced.

Orona Limited of Europa View, Sheffield Business Park, Sheffield pleaded guilty to breaching Section 3(1) of the Health
and Safety at Work etc Act 1974 and was fined £533,000 and ordered to pay costs of £40,000.

Speaking after the hearing, Lorraine Brown, the mother of Alexys Brown said:

“The last three years have been unimaginable; the loss of Alexys has impacted our lives and our children’s lives
immensely. To have this investigation brought to an end has now offered us some closure. Despite this part of our
story coming to an end, the outcome will never be what we all wish for, nothing will ever bring Alexys back to us.
“Lexi was a loving, care free, angelic little girl who was full of energy, love and laughter. I hope that what has happened to our family sheds light on others in order to avoid anything like this ever happening again. “We are now looking forward and raising our children with memories, photos, videos and stories of their sister.”


HSE inspector Leo Diez commented:

“These companies failed in their duties to put systems in place to ensure the lift in the Brown’s family home was kept safe – more could have been done by Synergy, Aster and Orona. As a result of their negligence, a wholly avoidable tragedy, under horrific circumstances, has occurred where a five-year-old child has lost her life and a family have been left utterly devastated at the loss of their little girl.

“Companies should know HSE will not hesitate to take the appropriate enforcement action against those who flout
health and safety law.
“Safety-critical aspects of the use and maintenance of the lift were also missed. From December 2013 until 12 May
2015, the lift was not inspected at all – even though safety critical problems had previously been identified they were
not rectified. In 2015, when the call-out report contained a warning, there was still a failure to act. Those breaches
went unchecked over a long period of time during which the lift became more dangerous for the Brown family to use.”


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 including: •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 replaced.
  • 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 2011.
  • 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.