SINGAPORE - A 39-year-old retail and merchandising operations manager for a local bakery who died while at work in the early hours of August 2015, had slipped and fallen backwards on an oily and wet floor.
Ms Shella Lee Shin Shin, who worked for Swissbake, was wearing a pair of her own shoes with soles that were worn out, instead of safety shoes, at the bakery's baking premises.
She suffered severe traumatic brain injury from the fall and became unconscious.
She never regained consciousness, and was pronounced brain dead in hospital the next evening.
On Monday (Feb 22), State Coroner Marvin Bay said her death was due to "an accidental fall".
The coroner said the incident underscores "the vital importance of conscientiously adhering to a practice of wearing safety equipment whenever any worker or manager is at a production floor, or other work area".
"Falls and other industrial mishaps can occur in even the most innocuous of circumstances. The donning of appropriate safety equipment can do much to avert accidents, or mitigate the risk of injury or death, should accidents nevertheless occur," he added.
The coroner's inquiry heard that Ms Lee's job was to ensure enough ready-to-eat confectionary at the Swissbake bread shelves located at supermarket chain Cold Storage's outlets.
A power failure occurred on the night of Aug 20 at Swissbake's baking premises at Commonwealth Culinary Creations, in 348 Jalan Boon Lay.
At about midnight on Aug 21, Ms Lee, concerned that there would not be any ready-to-eat confectionary and pastries in the morning, arrived at the baking premises to ensure that operations ran smoothly.
Workers were mobilised to prepare bread at the packing area at the time.
They would need to spray an oil-based substance on the dough, before baking it into bread or pastries. Trays of the dough had been taken out from a freezer at the packing area and left out to be defrosted.
But the defrosting process made the floor wet due to condensation.
With oil and water, the floor around the packing area became slippery.
At about 1.15am, Ms Lee, who was 1.78m tall, was seen by a delivery driver walking past the entrance of the packing area towards a freezer, presumably to check on a batch of pastries that was being cooled.
The driver called out to greet her, and Ms Lee slipped and fell. Her head landed on the floor with a heavy impact.
A Swissbake director, who was in the packing room, called for an ambulance.
A Ministry of Manpower investigator found that the floor of the bread cooling area was wet.
But there were no anti-slip floor mats nor signs to warn workers of the wet floor.