AN inquest jury found that multiple failures contributed to the death of a worker who was crushed by a dumper truck, after toppling over the side of a large spoil heap in Cirencester.

In a narrative conclusion, the jury of seven women and four men at Gloucester Coroner's Court, also found that safety communication on the building site where Shaun Carter was working was inadequate.

Mr Carter had been told to use a specific spoil heap on the site at Kingshill Lane, next to Corinium Via estate, and dump the spoil at ground level, the inquest heard.

But workmates told Deputy Gloucestershire Coroner Caroline Saunders they had no idea why he had gone to the one where he met his death, as it was further away and not in use.

Following the conclusion of the two day hearing, Mrs Saunders made recommendations under the Coroner's investigation regulations to Mr Carter's company, Tonic Construction, and to the Health and Safety Executive (HSE).

She said she was impressed by the steps taken by Tonic to improve safety since the accident.

But prior to the death of Mr Carter, risk assessments were not followed she said, and were not even seen by all personnel on the site.

"I would like an assurance that this has been addressed. I will also make a report to the HSE about putting guidelines in place to reduce the danger of dumper trucks overturning."

Dumpers were designed to protect their drivers in dangerous situations, she said, but drivers could nonetheless feel exposed, causing them to try and jump clear when they were toppling over.

"I will ask the HSE if there should be changes to the design of dumpers as we have heard discussed today," she added.

Those discussions centred around Tonic Construction's adoption of a new type of dumper since the accident, complete with a full safety cab around the driver.

Mr Carter, 29, of Great Mead, Chippenham, Wilts, was declared dead at the scene, on May 31 last year.

A pathologist who carried out a post mortem found that he had suffered extensive damage to his head and chest from a crushing impact, and had probably died instantly.

Fellow worker Jonathan Kosma said: "I saw Shaun in the dumper on the top of soil heap 2 and one of the rear wheels was just lifting off the ground. The front end started to go over the edge and I saw him try to jump clear.

"The dumper disappeared over the edge and I ran over. The dumper was upside down and the heap had a sheer face where it had landed."

In her summing up, the Coroner said various aspects of site safety had been discussed during the hearing, one of which was that Tonic's own safety procedure for spoil heaps was to build a bund (low barrier) around the top to stop dumpers getting too close to the edge.

But in practice, she said this was never done.

Supervisors accepted that site safety was part of their role, she said, but no one noticed that spoil heap two was dangerous.