Ian Ebbs, 43, from Morton near Bourne, was killed on 6 October 2008 while working on a Manroland Lithoman press on the night shift at St Ives Peterborough.

Following the verdict, the man’s widow, Jackie Ebbs, said she would take legal action against St Ives, which she claimed had let her husband down.

She accused both the HSE and line managers at St Ives of failing to fully acknowledge "a total lack of set guidance for reporting incidents at the factory".

The inquest heard that Ebbs was killed after a paddle wheel on a Manroland press he was trying to fix moved and landed on his chest. He had gone inside the press to diagnose a problem after it stopped working when staff tried to adjust the paper size.

Colleagues worked for 15 minutes using metal bars and a forklift truck to try and save Ebbs before the fire brigade arrived and freed him. A post-mortem exam revealed he died of asphyxiation caused by the crushing.

At the inquest, it was revealed that an engineer who had previously tried to fix the machine in the same way as Ebbs narrowly avoided being hurt as the paddle wheel swung down. The incident was not reported and staff were not warned of the danger.

Following the three-day inquest at Peterborough Town Hall last week (13-15 October), the coroner ordered St Ives Web to improve some of its working practices.

Coroner Gordon Ryall said: "The evidence shows that there were other instances whereby those working on the press had experienced unexpected movements of the parts of the machinery.

"There is no evidence that those instances were reported or investigated. If they had been, the possibility that the problem which ultimately became known following Mr Ebbs’ death would have been identified earlier."

Taran Hewitt, a specialist mechanical engineering inspector for the HSE added that the faults which had led to the accident were foreseeable.

He said: "I have heard of discussions or conversations that might have covered risk assessments, but I haven’t seen anything that says there’s a specific system in place that makes sure somebody looks at all the situations that may take place."

A spokesman for the HSE added that the organisation would "review the evidence heard at the inquest and consider whether any further action needed to be taken".

Following the inquest, St Ives chief executive Patrick Martell said: "The company deeply regrets the death of Ian Ebbs. No workplace accident is acceptable and the company accepts that it has a legal obligation to take all reasonable steps to provide a safe place of work.

"The company accepts the verdict of the inquest which was concluded. Out of respect to the family, friends and work colleagues of Ian Ebbs and in view of ongoing investigations by the HSE, it would not be appropriate to make any further comment at this time."

A Manroland statement said: "Our first thoughts are with the family and friends of Ian Ebbs. Safety for Manroland is a top priority."

According to the HSE investigation into the incident, the press stoppage was caused by a safety pin that had failed to retract fully, preventing the machine arm from descending.

Engineers at the site, including Ebbs, believed it was safe to enter the press because an emergency stop button had been pushed and the interlocking doors were open.

However, a build up of hydraulic pressure meant that the paddle wheel swung down violently when the pin was removed, rather than in the slow, steady manner normally seen.