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A coroner has criticised the Royal Navy for ''a culture of cutting corners'' regarding health and safety on its warships at the conclusion of an inquest into the death of an officer who fell 40ft to his death from a suspended landing craft.
Lieutenant Joshua Woodhouse was serving as an engineering officer on board the helicopter carrier HMS Ocean which was visiting the Mayport naval station in Jacksonville, Florida, USA, on August 6 2010.
The 25-year-old from Portsmouth died in hospital four days later from a severe head injury suffered in the fall.
The Portsmouth inquest heard that Lt Woodhouse had gone on to the landing craft vessel personnel (LCVP) without a safety harness as it was suspended in its bay at the side of the warship, the second largest in the Navy.
He then fell from the craft, landing on another LCVP which was moored in the water together with another craft next to HMS Ocean.
The jury returned a narrative verdict at the end of the two-week inquest in which they suggested a lax health and safety culture and a ''can-do'' nature had contributed to Lt Woodhouse's death.
They also stated that he should have been wearing a safety harness which would have saved his life.
Portsmouth Coroner David Horsley said that he would be preparing a report for the MoD highlighting his and the jury's concerns.
He said that despite efforts by the Navy to reinforce health and safety regulations, not enough had been done.
He described how during a visit this summer to HMS Ocean by himself and counsel for the MoD and family, a sailor had said to them he did not wear a harness because it was ''a nuisance and cumbersome''.
Mr Horsley said: ''Having heard the evidence in its entirety, there are a couple of matters of concern to me.
''The jury have highlighted one of them in their verdict and that is a culture they feel existed on board the ship which resulted in corners being cut in relation to health and safety procedures.
''My suspicion is that this does not relate to just that little boat section or that ship but it is throughout the entire naval fleet.''
He added: ''I want the MoD and the Navy to look further at what can be done to enforce awareness of the value and purpose of health and safety regulations.''
He called for the Navy to adopt more standardised risk assessments across its warships.
The inquest heard that Lt Woodhouse had gone on board the small craft with a colleague, Petty Officer Matthew Fulton, with the intention of checking some flexible hoses when the accident happened.
But despite the LCVP being suspended at height, Lt Woodhouse was not wearing a safety harness or helmet.
The inquest heard that PO Fulton did not see the fall with the only witnesses being on board a USS warship which was sailing past.
Lieutenant Commander Geoffrey Wilson, of the RN special investigations branch, told the inquest:
''He was seen to slide down from the bridge roof and lose his footing as he reached the next level.
''He was seen to grab for the handrail before falling.''
Lt Cdr Wilson said that Lt Woodhouse had gone ashore the previous night and consumed a number of alcoholic drinks and added that a colleague, Lt Lisa Pitman, had described him as ''appearing slightly shabby and with slightly bloodshot eyes'' on the morning of the fall.
Another colleague, Lt Jennifer Hayes described him as being ''bright and happy'' that morning and did not appear ''dishevelled''.
Lt Cdr Wilson said that concerns had been raised in a report in December 2008 about health and safety procedures on board HMS Ocean but which did not appear to have been addressed, only leading to ''confusing advice'' for the crew.
Lt Cdr Wilson said that there did not appear to be a consistent working at height policy followed by crew members, meaning that colleagues took differing precautions when using the LCVPs.
He described how, following the accident, two further members of the ship's company had also gone on to the suspended LCVP without safety gear to take photographs of the scene.
Lt Cdr Wilson also described how the surface of the LCVP was greasy, possibly caused by oil on the davits being disturbed by recent tropical weather.
He added that there were no suspicious circumstances surrounding the fall or suggestion of suicide.
Lt Woodhouse began his officer training at the Britannia Royal Naval College in Dartmouth in January 2007 before carrying out his initial sea training on HMS Illustrious.
He went on to serve on HMS Edinburgh, HMS Nottingham and HMS Scott before he joined HMS Ocean in January 2010.
A Royal Navy spokesman said:
''First and foremost our thoughts remain with the family of Lt Woodhouse at this very difficult time.
''We acknowledge the professionalism of all those involved in the detailed examination of the circumstances surrounding the tragic death of Lt Woodhouse.
''We welcome the jury's verdict and the coroner's additional comments and will respond in full once we have received his letter and considered what further action is required.
''The naval service is fully committed to making the Royal Navy a workplace where safety and risk are properly managed and the Royal Navy is taking steps to improve health and safety generally.
''We have implemented the navy safety improvement programme, which has been designed to ensure there is a cultural and behavioural change to safety and risk management issues across all areas of the navy service.''