Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0256, written 5 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2014 |
|---|---|
| Reference | 2014-0256 |
| Deceased | Sophie Allen |
| Coroner | Derek Winter |
| Coroner area | Sunderland |
| 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.
Derek Winter Senior Coroner for the City of Sunderland REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Rt Hon Dr Vince Cable MP Secretary of State for Business, Innovation and Skills 1 Victoria Street London SW1H OET CORONER 1am Derek Winter, Senior Coroner for the City of Sunderland 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. legislation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 1* May 2014 | commenced an investigation into the death of Sophie Allen, aged 2 years. The investigation concluded at the end of the inquest on 4th June 2014. The conclusion of the inquest was an Accident the cause of death having been confirmed as: - 1a Diffuse Profound Hypoxic Ischaemic Injury CIRCUMSTANCES OF THE DEATH On 21* April 2014 Sophie was found by her mother at their home address with a blind cord wrapped around her neck. After transfer from Sunderland Royal Hospital to the Royal Victoria Infirmary Newcastle, Sophie was pronounced dead at 03:39 hrs on 26" April 2014. CORONER’S CONCERNS Sophie's death was yet another example of the dangers that blind cords pose to the lives of young children. | understand that since 1999 there have been 28 such deaths in the UK due to looped cords (15 of them since 2010). | am aware that following reports from Coroners and other representations the new EN13120 released in February 2014 strengthened the child safety elements of the standard and that your Department continues to actively support safety campaigns which would include the distribution of leaflets and the provision of cleats and cord shorteners. Sadly and despite these efforts public awareness and the need to act promptly to eliminate the risks associated with blind cords not only needs to continue but perhaps should be extended to cover a greater element of the population including parents, grandparents and carers. Although the new standard applies to new installations there will be millions of blind cords already fitted in homes occupied (or visited by children) that pose a very real risk of death as in Sophie's case. It may be that Sophie's family may also write to you. Civic Centre, Burdon Road, Sunderland, SR2 7DN Tel 0191 5617843 | Fax 01915537803 | DX 60729 Sunderland www.sunderland.gov.uk/coroner | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you have 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 4th August 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 the Family. | 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 this 5" of June 2014 A Signature_ -~ an Senior Coroner for the City of Sunderland
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.
- - Mr Derek Winter Her Majesty’s Senior Coroner for the City of Sunderland Room 2.108 Civic Centre Burdon Road Sunderland SR2 7DN BIS Ref: REG28/SophieAllen Your Ref: 30 July 2014 Dear Mr Winter, REGULATION 28 REPORT TO PREVENT FUTURE DEATHS Thank you for your Regulation 28 Report to Prevent Future Deaths dated 5 June 2014 following your investigation and inquest into the death of Sophie Allen, aged 2 years by accidental death caused by an internal blind cord. May I first say how sorry I was to hear of this tragic accident, and if you have the opportunity would you please convey my deepest sympathies to her family. In your report you note that, despite the safety campaigns already in place, more needs to be done to increase awareness, especially in homes where blinds are already installed. You also say that you believe the government has the power to take action to prevent future deaths. However, I believe there is an already established and effective network of partners who are well placed to take preventative action forward, led by the British Blind and Shutters Association (BBSA) and the Royal Society for the Prevention of Accidents (ROSPA). Below I outline some of the campaigns planned or already underway. BIS supports the BBSA’s “Make it Safe Campaign” which is run primarily with RoSPA through widespread distribution of the Make It Safe brochure, press releases, TV and radio programmes and interviews and use of social networking. Since 2011 the BBSA has produced and distributed 1.6 million Make It Safe leaflets (many through RoSPA). They have also produced a video, poster, vehicle and shop window stickers – more information can be found on their website http://www.makeitsafe.org.uk/ The leaflet has gone to every local authority in Wales and to the main children’s organisations (statutory and NGOs). Business & Local Growth Orchard 1, Fourth Floor, 1 Victoria Street, London, SW1H 0ET http://www.bis.gov.uk/ RoSPA has spearheaded an awareness-raising campaign since 2011 with more than 150 radio and TV broadcasts. They also have a dedicated campaign page (BIS provides some funding) http://www.rospa.com/about/currentcampaigns/blindcords/ and promoted the issue on breakfast television programmes, such as BBC1’s “Breakfast” and ITV’s “Daybreak”. There has been widespread information promoted across social networking sites including Twitter, Facebook and Linkedin. In September 2013, the four UK Chief Medical Officers (CMOs) agreed that the CMO in Northern Ireland would lead a group of their respective public health agencies and The Royal Society for the Prevention of Accidents (RoSPA) to look at ways in which to reduce blind cord injuries and deaths. The organisations identified for representation on the group are: Department of Health, Social Services and Public Safety (DHSSPS), Northern Ireland Public Health Agency, Northern Ireland Health and Social Care, Scottish Government Public Health Wales Public Health England Royal Society for the Prevention of Accidents (RoSPA) British Blind and Shutter Association (BBSA) In addition the devolved authorities are taking a wide range of actions to ensure that the message gets across. These include: The Make It Safe leaflet has been disseminated to every local authority in Wales and to the main children’s organisation (statutory and NGOs). Children in Wales (CiW) run an accident prevention network for over 500 professionals, policy makers and practitioners. Blind cord risks are included in the bulletins on a regular basis. Every health visitor in Wales has also received a copy of the Keep In Mind (KIM) home safety leaflet which includes blind cord safety. In Northern Ireland all health visitor contact with families incorporates awareness-raising around accident prevention, including blind cord safety. A pilot programme has been established in Northern Ireland whereby Council Registrars raise awareness on blind cord safety when parents register a birth. The Registrar issues a BBSA blind cord safety leaflet and cleats if required (See reference to case study below). The Public Health Agency (PHA) in Northern Ireland have placed articles on blind cord safety in various publications including Birth to Five, Parenting NI, District Council Page 2 / 3 magazines as well as on the PHA website. PHA has also had the Make It Safe leaflet translated into appropriate languages for Northern Ireland. In Northern Ireland a 10-year strategy for home accident prevention, which includes particular reference to blind cord safety, will be launched for consultation in the coming weeks. It is expected that the strategy will be published before the end of the year. Information on blind cord safety is included in the Health Scotland publication Ready Steady Baby which is distributed to all new parents. The Good Egg Guide to Home Safety is distributed by Health Visitors at the ten-day visit to new mums and it too contains information on blind cord safety. The Scottish Government’s Community Safety Policy Unit and Child and Maternal Health colleagues jointly funded a specific prevention campaign to reduce blind cord strangulation in young children. The campaign was launched during Child Safety Week 2010 and saw the distribution of 10,000 leaflets across Scotland. A further 2,000 cleats (these are safety apparatus that are fixed to the wall for cords to be wound round and kept out of reach of young children and are generally retrofitted for blinds already in homes) were distributed, initially in North Lanarkshire. Following evaluation, further funding was made available and the campaign has now been rolled out to a total of 10 Local Authorities. To continue the prevention programme RoSPA has also offered the service to all the remaining Local Authorities across Scotland for a small charge. RoSPA in Scotland plan to re-launch the Make It Safe campaign and to roll it out to new areas while still supporting those who have covered the issue already. Regular reminders are placed in RoSPA Scotland’s weekly newsletter and disseminated to practitioners. The Child Accident Prevention Trust (CAPT) include blind cord safety on their website in their resources and newsletters In summary, BIS is committed to promoting blind cord safety. We believe the most effective way of achieving it is through the partnerships and networks I have described above, using all available resources as effectively as possible at local, regional and national levels to reach as much of the population as possible. We are grateful for your report and I would like to assure you that we will continue to work with a wide range of partners to prevent future deaths. Yours, MICHAEL PORTER Page 3 / 3
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