Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0447, written 16 Oct 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Oct 2014 |
|---|---|
| Reference | 2014-0447 |
| Deceased | David Thomson |
| Coroner | Andre Rebello |
| Coroner area | Liverpool |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. 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 1 | CORONER lam André Rebello, Senior Coroner, for the area of Liverpool 2 | 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. 3 | INVESTIGATION and INQUEST On 11th August 2014 | commenced an investigation into the death of David Alan THOMSON, Aged 62. The investigation concluded at the end of the inquest on 15th October 2014. The conclusion of the inquest was la Severe Chronic Obstructive Pulmonary Disease and Coronary Artery Atherosclerosis On 5th August 2014, David Alan Thomson was certified as having died at his home. He suffered from Chronic Pulmonary Disease and Coronary Artery Atherosclerosis. He had been charging an e-cigarette when the battery exploded, causing damage to an oxygen pipe attached to the oxygen concentrator, causing the pipe to ignite. Mr Thomson is likely to have reacted to the risk and his exertions have proved fatal. 4 | CIRCUMSTANCES OF THE DEATH The deceased suffers from chronic obstructive pulmonary disease and is on home oxygen. The oxygen tank is located in the living room and he is located in bed in a bedroom on the same floor. There is an extensive length of hose between the tank and his bedroom. He has reportedly attempted to re-charge his E Cigarette but the charger / cigarette has been resting on the oxygen pipe, burnt through it and causes the oxygen to catch fire. He had attempted to get to the oxygen tank to turn it off but has collapsed and died. There was no fire damage in the property. History of Chronic obstructive pulmonary disease . 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. — It is understood that e-cigarettes rely on Lithium-lon batteries, which are charged using standard micro usb chargers. Unfortunately, any chargers with a micro usb plug will fit and, if the wrong current is fed to the e-cigarette, the battery will “explode”. This issue is brought to your attention for solution. 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 11th December 2014. I, 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 who may find it useful or of interest. The Family of Mr Thomson | 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. André Rebello Senior Coroner for the City of Liverpool Dated: 16" October 2014
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