A tragic case sentenced this week is a stark reminder that a near-miss ignored can become a fatality. According to the HSE Media Centre, two major companies have been fined a combined £1.3 million after a window unit fell from the 26th floor of the luxury Corniche development on London's Albert Embankment, killing a man walking below.
What happened
Mick Ferris, a 53-year-old coach driver, was on his break and returning to his coach on 2 October 2018 when a bespoke window pane — one weighing 130kg — fell some 300 feet from the penthouses, killing him instantly. He was a father and grandfather; his wife Rachel described his death as "so sudden" and "out of the blue".
The HSE investigation found the windows had been changed at an early design stage from opening inwards to opening outwards, meaning that if they detached they would fall onto a pedestrian area. According to HSE, they were never effectively risk assessed. The safety of the windows relied on a single restrictor held in by a single screw, and none of the fittings had been confirmed by manufacturers as suitable for the bespoke curved penthouse windows.
Crucially, this was not the first warning. In August 2017 — more than a year before Mr Ferris died — a window left open in windy conditions fell from the same penthouses during construction and nearly hit two workers. An internal review followed, but HSE records showed key concerns "were not followed up effectively".
St James Limited (the developer, Principal Contractor and Principal Designer) was fined £1million plus £125,000 costs. Lindner Prater Limited, the specialist engaged to design the windows, was fined £300,000 plus £125,000 costs. Both were found guilty of breaching Section 3(1) of the Health and Safety at Work etc. Act 1974 at Inner London Crown Court.
Why it matters to contractors
HSE lead inspector Andrew Verrall-Withers said two companies "widely seen as leaders in their fields failed to respond to an obvious risk". His point about the wind is telling: "Both times a window fell, the wind speeds were not unusually high."
The lesson is not about penthouse windows. It's about three things every contractor deals with weekly: acting on near-misses, risk-assessing design changes, and not relying on a sign or a single fitting to hold back a serious hazard. HSE noted too much reliance was placed on adding a small sign, in effect hoping residents would remember to close windows. Administrative controls at the bottom of the hierarchy — a sign, a note, a warning — should never be your primary defence against something falling from height.
For anyone acting as Principal Designer, HSE was blunt: clarify exactly what services architects, designers and consultants will provide, then monitor their performance so risks are identified and improvements coordinated.
What to check on your site
- Do you record near-misses — and can you prove the actions from them were closed out, not just noted?
- When a design or spec changes, is the change re-risk-assessed, or does the original assessment quietly get left behind?
- Are you relying on signage or a single fitting where a physical control (edge protection, secondary restraint, exclusion zone) is needed?
- Have manufacturers confirmed fittings and components are suitable for the actual application — especially bespoke items?
- As Principal Designer or Principal Contractor, is it clear who is doing what, and are you actually monitoring it?
- Are pedestrian and public areas below overhead work protected and considered in your risk assessments?
Documents that help
Getting the paperwork right won't remove risk on its own, but it structures the thinking that stops incidents like this. A task-specific risk assessment forces you to consider what happens when things detach or fail, not just when they work as intended. Our near-miss and incident investigation forms give you a RIDDOR-ready structure to log a near-miss and, importantly, track the actions to close-out — the exact step that failed here.
For work at height and overhead risks, the site monitoring and inspection forms keep controls under active review, and the CDM 2015 guide sets out what Principal Designers and Principal Contractors are actually expected to coordinate and monitor.
Take five minutes today
Pull your last three near-misses. Can you show what changed as a result? If not, start there. Browse our full template library or grab the Risk Assessment Bundle and get your close-out process on paper.