When Unsafe Storage Turns Fatal: How ISO 45001 Could Have Prevented the Systagenix Pallet Collapse Tragedy

In November 2025, Scapa Healthcare Limited (trading as Systagenix Wound Management Manufacturing Limited) was handed a £600,000 fine - plus £15,637 in costs - after a worker was killed when an overloaded pallet stack collapsed at their Airedale Mills facility in Gargrave, North Yorkshire.

The incident itself happened in September 2020, but the Health and Safety Executive (HSE) investigation and prosecution concluded this year, revealing a series of fundamental safety failures that speak directly to the importance of a robust, well‑implemented Occupational Health & Safety Management System.

This is exactly the type of tragedy ISO 45001 is designed to prevent.

What Actually Happened

On 21 September 2020, 56‑year‑old employee Tony Snowden was working in a bulk storage area at the Systagenix site. Large pallets known as Nelipak pallets - three‑legged moulded plastic units commonly used in pharmaceutical and medical manufacturing - were being stored in tall vertical stacks.

One pallet in particular weighed approximately 592 kg and had been double‑stacked on top of another pallet - despite that type of pallet not being designed to be stacked vertically due to their inherent instability.

During routine operations, the upper pallet became unstable. Without warning, the 592 kg load toppled and crushed Mr Snowden, pinning him against a fixed ledge. Because the pallet was too heavy to lift, workers had to manually remove its contents before they could reach him. Despite their efforts, he had already suffered fatal injuries.

HSE investigators found damning evidence of systemic failings:

• No suitable or sufficient risk assessment had ever been carried out for pallet stacking, stability, height limits, or load weight.

• The pallets involved “should never have been stacked vertically”, yet vertical double‑stacking was common practice on site.

• Training was inconsistent and incomplete - Mr Snowden himself had not received the company’s own “Pallet Handling Policy” training.

• Supervision and monitoring were inadequate, with unsafe stacks allowed to develop in the bulk store area.

• The company had experienced a similar fatality risk in earlier years, yet had failed to learn from previous incidents and change storage practices accordingly.

HSE Inspector Kirsty Storer‑Cottrell summed it up starkly:“This tragic incident could have been easily prevented had a suitable and sufficient risk assessment taken place and the actions identified implemented.”

Where ISO 45001 Would Have Changed the Outcome

ISO 45001 isn’t a bureaucratic exercise - it is a framework specifically built to prevent incidents like this. Each failure identified at Systagenix maps directly to key ISO 45001 clauses.

Leadership & Worker Participation (Clause 5)

ISO 45001 requires senior leaders to actively promote safe working practices, eliminate hazards, and engage workers directly in discussions about risks.At Systagenix, unsafe stacking had become “normal”, suggesting leadership blind‑spots and a culture lacking accountability for health and safety.

With ISO 45001 in place:

• Leaders would have ensured pallet storage risks were understood, controlled, and reviewed.

• Workers would be empowered - and expected - to report unstable stacks or unsafe layouts.

Hazard Identification & Risk Assessment (Clause 6)

This is the clause at the very heart of the failure. ISO 45001 requires organisations to proactively identify hazards, understand potential harm, and introduce controls.

A compliant system would have flagged:

• Vertical stacking of Nelipak pallets = unstable

• 592 kg loads above head height = crush hazard

• Narrow aisles = additional entrapment risk

• Historical incidents = elevated risk category requiring immediate action

The risk assessment alone could have stopped unsafe stacking entirely.

Competence, Training & Awareness (Clause 7)

ISO 45001 requires proof that workers are trained, competent, and understand risks associated with their tasks.

HSE confirmed:

• Mr Snowden had not been trained in the pallet‑handling procedure

• Staff were unaware that certain pallets must never be double‑stacked

• Supervisors failed to enforce the controls that did exist

Under ISO‑aligned controls, this is unacceptable.

Operational Controls (Clause 8)

This is where the practical safeguards should have existed. ISO 45001 requires clear documented safe‑work controls, implemented consistently.

Proper operational controls at Systagenix would have included:

• A ban on stacking non‑stackable pallet types

• Safe maximum height limits for all pallet categories

• Mandatory racking for heavy or unstable loads

• Routine inspection of storage layout

• Segregation of high‑risk storage zones

• Prohibition of double‑stacking for heavy goods

None of these were reliably in place.

Performance Evaluation (Clause 9)

A mature OHSMS includes monitoring and inspection to spot deterioration before someone gets hurt.HSE stated that supervisors had not adequately monitored the stacking area, allowing extremely unsafe conditions to develop.

ISO 45001 would require:

• Regular inspections of pallet stacks

• Recording of near‑misses or unstable pallet sightings

• Escalation of risks to management review

• Trend analysis to identify recurring hazards

Incident Investigation & Continual Improvement (Clause 10)

ISO 45001 requires that when incidents happen - especially serious ones - the organisation must investigate root causes and ensure controls prevent recurrence.

Yet Systagenix had previously experienced a fatality with similar characteristics years earlier.The absence of effective corrective action demonstrates a complete failure of continual improvement obligations.

What a Different Future Could Have Looked Like

Under a robust ISO 45001 system:

• The Nelson pallets would NEVER have been stacked vertically - the risk assessment would forbid it.

• Heavy pallet stacking would require racking or engineered solutions.

• Every worker in the area would be trained and competency‑checked.

• Supervisors would perform daily visual inspections of pallet conditions and stability.

• Near‑miss reporting culture would identify dangerous stacks long before collapse.

• Leadership would monitor indicators such as “unsafe stack observations” and “pallet‑handling nonconformities”, enabling early intervention.

• A prior similar incident would have triggered system‑wide corrective action, preventing this tragedy entirely.

Instead, one man lost his life - and a company now carries a criminal record, a £600k penalty, and irreversible reputational damage.

Why This Matters for UK Employers Today

The Systagenix case is not an outlier. HSE statistics show 124 workplace fatalities in 2024/25 and thousands of serious injuries.Material‑handling environments - manufacturing, warehousing, logistics, food production, and waste - continue to experience disproportionate harm because pallet storage, stacking, and movement are often treated as low‑complexity tasks.

ISO 45001 transforms these “routine” tasks into controlled, risk‑informed processes - the kind that save lives.

If even one company reads this case and strengthens its controls, then this tragic loss can serve a purpose.

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