Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0214, written 8 May 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 8 May 2014 |
|---|---|
| Reference | 2014-0214 |
| Deceased | Anthony Lapping |
| Coroner | Karen Dilks |
| Coroner area | Newcastle Upon Tyne |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
Karen Dilks Senior Coroner for the City of Newcastle Upon Tyne REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Indesit Company, Morley Way, Peterbrough, PE2 9JB CORONER lam Karen Dilks, Senior Coroner for the City of Newcastle Upon Tyne CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. leqislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 29/08/2013 | commenced an investigation into the death of Anthony Lapping aged 48 years. The investigation concluded at the end of the inquest on 24 March 2014. The conclusion of the inquest was Accidental Death. CIRCUMSTANCES OF THE DEATH On the 24" August 2013 Mr Lapping consumed approx. 7-8 pints of beer. He returned to his home of 47 spoor Street, Dunston. A report of a fire at the premises was made by a third party. Fire and Rescue Services found Mr Lapping on the settee in the living room. Although Mr Lapping was successfully rescued and provided with emergency medical treatment he died to the effects of Carboxyhaemoglobin which caused Cardio Respiratory arrest and his death. The evidence of the Fire Investigation Officer was that his investigation led him to the conclusion that a cooker in the kitchen of the premises was switched on and that either a pan or the pans contents had ignited spreading to a Hotpoint Fridge Freezer adjacent to the cooker. Insulation material within the fridge freezer caused an extremely rapid development of the fire. This substantially reduced Mr Lapping’s prospects of (a) escaping the fire or (b) avoiding the effects of Carboxyhaemoglobin. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — [BRIEF SUMMARY OF MATTERS OF CONCERN] (1) Opportunities for escape from the fire and from the effects of Carboxyhaemoglobin were significantly reduced due to the rapid spread of the fire. (2) The rapidity of the spread was attributed to the insulation material used in a Hotpoint fridge freezer. (3) There is a clearly identified risk of further deaths if manufacturers do not address the risks posed by the highly flammable nature of the insulation material used in the manufacture of kitchen equipment (fridge freezers) in common use by the public at large. (4) Urgent review of the manufacturing process and the use of appropriate insulation materials in fridge freezers is required. Lord Mayor’s Gallery, Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE1 8QA Tel 0191 2777280 | Fax 0191 2612952 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 25 June 2014. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons: (a) Tyne and Wear Fire and Rescue Service and (b) Environmental Services at Newcastle City Council may find it useful or of interest. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated 8 May 2014 = Signature JO Bue. Senior Coroner for the City of Newcastle Upon Tyne Lord Mayor’s Gallery, Civic Centre, Barras Bridge, Newcastle Upon Tyne, NE1 8QA Tel 0191 2777280 | Fax 0191 2612952
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
(1) inDesit € company q A | 27 June 2014 Coroner’s Court Civic Centre Barras Bridge Newcastle upon Tyne NE1 8PS Dear Michael Allen, Further to your letter of g'" May, on behalf of the Company may | first of all say how truly sorry we are to hear of this tragic incident and we would like to take this opportunity to extend our deepest condolences to Mr Lapping’s family and friends. In response to your specific points regarding Hotpoint Refrigeration appliances, having reviewed the matter in some detail, we can advise as follows: Our understanding is that the original product is no longer available for examination and so having only the information provided in your letter/report, we were unfortunately unable to identify the exact model of refrigerator owned by Mr Lapping. However, from the photograph of the compressor label, we are led to believe that the appliance was most probably manufactured at the end of 1998/beginning of 1999. Whilst this product was produced in accordance with the regulations/Standards in force at the time, we believe that it is worth noting that the Safety Standards and component specifications have evolved significantly since 1998 and we would like to take this opportunity to outline some of the key improvements to you: Introduction of the Glow Wire Test The glow wire test is the fire protection requirement created to evaluate the rate of flammability of materials used within an appliance. It measures the risk of fire ignition due to the contact between live electrical parts with no insulation and plastic parts, which could arise due to a possibility of over current or short circuit failures. The actual test is described in the picture below. Glow Wire 7 Element —~ Product Tissue Paper Indirect Method (IEC Method) Indesit Company UK Ltd Morley Way, Woodston | Peterborough PE2 9)B Telephone: +44(0)1733 568989 | Fax: +44(0)1733 341783 | indesitcompany.com Registered Office: Peterborough PEZ 918 - Registered in London No 106725 - VAT No 513936740 |) INDESIT company Glow wire testing is performed by heating an element to a pre-determined temperature. The heated element is referred to as the glow wire. The sample to be tested is fixed in place and tissue paper is positioned directly below the sample. After reaching the pre-determined temperature, the element is then pressed into a sample material under a set force of 1N for 30 seconds. If ignition occurs, recordings are made to note the duration, flame height, and whether drips of the material ignite the tissue paper. GWEI stands for Glow Wire Flammability Index (IEC 60695-2-12). This is a property associated with raw material used in the end product. This property is determined by conducting the glow wire test ona test plate of a raw material of a given thickness. The Glow Wire Flammability Index (GWFI) is the highest temperature at which the material does not ignite or self-extinguishes within 30 seconds after removal of the heated element. The limit admitted is 850°C GWIT stands for Glow Wire Ignition Temperature (IEC 60695-2-13). This is a property associated with raw material used in the end product. This property is determined by conducting the glow wire test ona test plate of a raw material of a given thickness. The Glow Wire Ignition Temperature (GWIT) is the lowest temperature at which the material ignites and burns for longer than 5 seconds while the heated element is in contact with the test plate. The limits admitted are 750°C for the parts as compressor connection box or electronic board components (I>0,2A) and 650°C for parts as light switch, light box (I<0,2A) The Glow Wire test limits above were introduced in 2002. Run capacitor — Alternative Design Starting from 2009, we have changed the capacitors used in the production of our refrigeration appliances from type ‘PO’ to type ‘P2’. This change was not mandatory/driven by changes to the Standards but as we felt that an improvement in Safety Levels could be obtained, we unilaterally decided to make this change. The main differences between the ‘PO’ and ‘P2’ run capacitors are as follows: e Both have a plastic cover e Both inciude a Zn-Al film e The Zn-Al film in the PO run capacitor has a flat active surface. The film in the P2 capacitor is divided in zones and there are fuses between those zones. The fuses insulate the zone if there is a short circuit and as a consequence the P2 design prevents the capacitor from rupturing. Testing of light boxes To increase the severity of the test, from 2008 the test was changed such that the door is now in the most unfavorable condition of being closed, (previously the test had been carried out with the door open). The light remains switched on continuously and the temperature is measured until it has stabilised. At the measured temperature the plastic on the light box must not soften. Indesit Company UK Ltd Morley Way, Woodston | Peterborough PE2 9|B Telephone: +44(0)1733 568989 | Fax: +44(0)1733 341783 | indesitcompany.com Registered Office: Peterborough PE2 9/8 - Registered in London No 106725 - VAT No 513936740 InDeSIT company Future Developments Currently, we are assessing proposals to reduce the potential flammability of cooling products even further, through the possible introduction of an aluminized cardboard covering for the key insulation areas, Unfortunately due to constraints within the design that we have in production now, particularly the fact that our insulation is quite convex, introduction of this material today is not feasible. However, we are studying methods of introducing such a material on our new 60cm product platform which is under development. In summary, for Hotpoint, product safety is of paramount importance and every product sold under our brand is fully compliant with the Safety Standards in force at the time of manufacture, and so irrespective of the model, this was certainly the case for Mr Lapping’s appliance. Additionally, since the appliance in question was manufactured in 1998/99, both the Safety Standards and where appropriate, Hotpoint’s own component specifications have moved in the general direction to which you refer and hence have reduced any possible risk levels even further. Going forwards you have our absolute assurance that as we have always done, Hotpoint will continue to design our products in line with any appropriate technological/market developments that become available, or changes to the Standards that occur. We do hope that this information will be sufficient to satisfy your requirements, but obviously given the circumstances behind these questions Hotpoint will remain at your disposal should any further clarification be required. Finally, on behalf of all at Hotpoint we would like to emphasise again how sorry we are to hear of the tragic death of Mr Lapping as a result of this incident Yours sincerely Quality and Claims Manager Indesit Company UK Ltd Indesit Company UK Ltd Morley Way, Woodston | Peterborough PE2 9jB Telephone: +44(0)1733 568989 | Fax +44(0)1733 341783 | indesitcompany.com Registered Office: Peterborough PE2 9)B - Registered in London No 106725 - VAT No 513936740
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