Prevention of Future Deaths reports · 2014

Santosh Muthiah

Regulation 28 report to prevent future deaths, reference 2014-0476, written 5 Nov 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report5 Nov 2014
Reference2014-0476
DeceasedSantosh Muthiah
CoronerAndrew Walker
Coroner areaLondon (North)
CategoryProduct related deaths
Sourcejudiciary.uk record · original PDF
Responses published5

The report

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.

ag North London C Court,
Her Majesty's Coroner for the 29Wood Steet

Northern District of Greater London — Barnet ENS 4BE
(Harrow, Brent, Barnet, Haringey and Enfield) Telephone 0208 447 7680

Fax 0208 447 7689

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
a. Association of Manufacturers of Domestic Appliances (AMDEA) [I
HE Rapier House, 40-46 Lambs Conduit Street, London, WC1N 3NW
British Standard's Institute, Chairman of CPL/ 61 Committee, 389 Chiswick
High Road, W4 4AL.

b. The Trading Standards Institute, 1 Sylvan Court, Sylvan Way, Southfields
Business Park, Basildon, Essex, SS15 6TH;

c. Chief Fire Officers Association NNN, 9-11 Pebble Close,
Amington, Tamworth, Staffordshire, B77 4RD;

d, HEE Deputy Director, National Resilience and Fire Programmes,
Department for Communities and Local Government, 3/E1, Third Floor Eland
House, Bressenden Place, London, SW1E 5DU.

e. Association of British Insurers, 51 Gresham Street, London, EC2V 7HQ;

f. UK-AFI President, Mr J Galvin, 9 Bushey Bartrams, Shenley Brook End,
Milton Keynes, MK5 7HE;

g. Mr N. Gibbins, Company Secretary, The Institution of Fire Engineers, IFE
House, 64-66 Cygnet Court, Timothy's Bridge Road, Stratford-upon-Avon,
CV37 SNW;

h. Ann Priston, President, The Chartered Society of Forensic Scientists, Clarke
House, 18A Mount Parade, Harrogate, North Yorkshire, HG1 1BX.

Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

i. Mr M Proctor, Chief Executive Officer (trading), The British Retail
Consortium, 21 Dartmouth Street, London, SW1H 9BP.

j. Trading Standards Institute, 1 Sylvan Court, Sylvan Way, Southfields
Business Park, Basildon, Essex, SS15 6TH.

k. Beko pic, Beko House, 1 Greenhill Crescent, Watford, WD18 8QU.

I, | | Head of Product Regulation, Department for Business, Innovation
and Skills, 1 Victoria Street, London, SW1H OET.

m. Association of Manufacturers of Domestic Appliances (AMDEA), Rapier
House, 40-46 Lambs Conduit Street, London, WC1N 3NW (FAO:

HE Technical Manager)

n. British Standard’s Institute, Chairman of CPL/ 61 Committee, 389 Chiswick
High Road, W4 4AL.

0. British Standards Institute, Chair of PEL/ 33 (Power Capacitors) Committee,
389 Chiswick High Road, W4 4AL

p. Department for Business, Innovation and Skills, 1 Victoria Street, London ,
SW1H OET

i
1 CORONER

London

Hi

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| am Andrew Walker, senior coroner, for the coroner area of Northern District of Greater
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 the 23" day of November 2010 | opened an investigation into_the death of Santosh
2

Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

Benjamin Muthiah , 36 years old. The inquest concluded on the 26" September 2014
The conclusion of the inquest was "Narraitive’, the medical case of death was 1a
Cerebral Anoxia , and under paragraph 1 b Inhalation of Fire Fumes

4 | CIRCUMSTANCES OF THE DEATH

At some point during the night of the 10" to 11" of November 2010 the failure of the fridge
freezers defrost timer resulted in fire that spread from the fridge freezer to the house
whilst Mr Muthiah and his family slept upstairs. Fortunately EEE awoke and
efforts focussed on saving their children. Mr Muthiah's wife passed one of their two
children to a neighbour who had climbed the front of the house to the front bedroom
window. Their second child was rescued by another neighbour from a flat roof at the rear
of the house. The London Fire Brigade recovered from on the bed in the

front bedroom and Mr. Muthiah from the bathroom at the rear of the house.

Mr andi] Muthiah were taken to hospital where Mr Muthiah died as a consequence of

smoke inhalation in the fire at his home.

Pe

5 1. CORONER'S CONCERNS

2. 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.

Identification of cause of fires

2. \ heard evidence from various witnesses, including the LFB but also from Beko and
| formerly of Intertek, that there are often problems in identifying, not just
the specific cause of an appliance fire, but even the manufacturer, model and serial
number of the appliance in question due to the severity of the fire damage. This has
a knock on effect on Fire & Rescue Services’ ("FRS's’), Trading Standards’ ("TS")
and manufacturers’ ability to accurately identify a pattern or trend within fires from

appliances which may evidence a specific manufacturing or component problem.

manufacturer or particular appliance is not fully known and therefore underestimated
with the consequence that the risk to the lives of consumers may also be

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| 3, This creates a risk that the nature and extent of a potential problem with a particular
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Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

underestimated.

4. LFB witnesses gave evidence that if manufacturers were to mark their appliances
with the model and serial number of their products in such a way that the marking will
survive a fire, even if it were severe, this would enable any appliance believed to have
caused the fire to be properly identified so that accurate information can be provided
to the manufacturer and TS. More accurate information would assist manufacturers
when carrying out risk assessments and will serve to more accurately identify the
nature and extent of any potential problem and its consequent risk to the lives of
consumers and to TS in order that they can consider whether action should be taken.

5. l|address these concerns in this report to:
a. Association of Manufacturers of Domestic Appliances (aMOEA)
HE Rapier House, 40-46 Lambs Conduit Street, London, WC1N 3NW
British Standard’s Institute, Chairman of CPL/ 61 Committee, 389 Chiswick

High Road, W4 4AL.

Communication of Information

6. | heard evidence from the LFB witnesses as to the LFB's practice at the time of Mr

Muthiah’s death and the present practice in relation to the communication of

information gathered by their Fire Investigation Team ("FIT") concerning the cause of

appliance fires.

7. The LFB practice is to communicate information on an appliance fire to both the
manufacturer of the appliance and to TS where they have been able to identify the
manufacturer of the appliance and where the fire investigation has concluded that the
cause of the fire was that appliance. In other words, every time that an LFB fire
investigator determines that a fire has originated in a particular appliance the

manufacturer and TS are told.

8, This is not the case routinely elsewhere in the country. There may be a variety of

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Her Majesty's Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

9. Whatever the reasons there is a risk in existence where such information that is

reasons for this, including the difficulty in identifying the appliances due to fire
damage, and the more limited resources and expertise in the investigation of the
causes of fires that other FRS’s have in contrast to the fortunate position of the LFB.

gathered by FRS's in relation to fires involving domestic electrical appliances (where
the appliance can be identified) is not routinely passed to the appropriate TS Home or
Primary Authority or indeed to the manufacturer. TS is taking decisions on whether to
take any action in relation to a particular manufacturer or a particular appliance on
less than all the available information. If they were provided with more accurate
information about the incidences of appliance fires they would be in a better position

to take action where necessary.

1

oOo

. | address these concerns in my report to:
a. The Trading Standards Institute, 1 Sylvan Court, Sylvan Way, Southfields
Business Park, Basildon, Essex, SS15 6TH;
b. Chief Fire Officers Association MEN 9-11 Pebble Close,
Amington, Tamworth, Staffordshire, B77 4RD;

11.

=

At present the Department for Communities and Local Government (“DCLG”) does
not necessarily pass the data it collects from FRS's, relating to appliance fires (where

the make and model are recorded) to TS.

42. Again, there is a risk created where TS is taking decisions on whether to take any
action in relation to a particular manufacturer or a particular appliance on less than all
the available information. If they were provided with more accurate information about
the incidences of appliance fires they would be in a better position to take action

where necessary.
13. | address these concerns in my report to:

a, WEE Deputy Director, National Resilience and Fire Programmes,

5

Her Majesty's Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

Department for Communities and Local Government, 3/E1, Third Floor
Eland House, Bressenden Place, London, SW1E 5DU.

44. | heard evidence that companies and organisations which investigate fires, such as
insurance companies, legal firms, private fire investigators etc. do not, generally,
notify TS when the outcome of an investigation is that the cause of a fire is believed

to have been the result of a product failure.

15, There is a risk created where TS is taking decisions on whether to take any action in
relation to a particular manufacturer or a particular appliance on less than all the
available information. If they were provided with more accurate information about the
incidences of appliance fires they would be in a better position to take action where

necessary.

16. | address my concerns in this report to:

a. Association of British Insurers, 51 Gresham Street, London, EC2V 7HQ;

b. UK-AFI President, Mr J Galvin, 9 Bushey Bartrams, Shenley Brook End,
Milton Keynes, MK5 7HE;

c, MrN. Gibbins, Company Secretary, The Institution of Fire Engineers, IFE
House, 64-66 Cygnet Court, Timothy's Bridge Road, Stratford-upon-Avon,
CV37 ONW;

d. Ann Priston, President, The Chartered Society of Forensic Scientists, Clarke
House, 18A Mount Parade, Harrogate, North Yorkshire, HG1 1BX.

17. Major retailers also do not notify TS when they receive reports of failures, including

fires, in products reported to them by customers.

18. Again, there is a risk created where TS is taking decisions on whether to take any
action in relation to a particular manufacturer or a particular appliance on less than all
the available information. If they were provided with more: accurate information about

the incidences of appliance fires they would be in a better position to take actior

where necessary.

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Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

19. | address this concern in my report to:

a. Mr M Proctor, Chief Executive Officer (trading), The British Retail
Consortium, 21 Dartmouth Street, London, SW1H 9BP.

Second Hand Market

20. | heard evidence from the LFB witnesses who gave some evidence that defective

products on the second hand market pose a continuing risk to consumers.

21. There is no clear system in place to ensure that products subject to a safety notice or
recall are not sold, unmodified, on the second hand market. By way of example, the
LFB has recently identified several unmodified Beko fridge freezers which are subject
to the safety notice, for sale in a second hand retailer. This lack of regulation or
market surveillance of the second hand market poses a risk to consumers.

22. | address this concern in my report to:

a. Trading Standards Institute, 1 Sylvan Court, Sylvan Way, Southfields
Business Park, Basildon, Essex, SS15 6TH.

Beko Frost Free Fridge Freezers the Subject of the Recall

23. | heard evidence from the LFB witnesses of their concerns that serious failures in
Beko Frost Free Fridge Freezers ("FFFF’s”) manufactured between 2000 and 2006
are continuing resulting in a serious risk to the safety of consumers. PF
BEM gave evidence of the numbers of fires which the LFB FIT have investigated to

date, the appliance models and the causes of the fires.

24. The LFB submits that there remains a risk in relation to the lack of or minimal

awareness of the current safety notice in relation to these Beko models.

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Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

25. | address my concerns in this report to:

a. Trading Standards Institute, 1 Sylvan Court, Sylvan Way, Southfields
Business Park, Basildon, Essex, SS15 6TH;

b. Beko plc, Beko House, 1 Greenhill Crescent, Watford, WD18 8QU.

Risk Assessment

26. | heard a great deal of evidence concerning the process of risk assessment and the

27.

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factors to be taken into account when considering the potential seriousness of injury
and the likelihood of a risk eventuating.

It is the view of the LFB that the following matters should always be taken in to

account when carrying out a product safety risk assessment:

a. Sleeping risk — i.e. the fact that a person is more vulnerable to the risks of fire
when asleep;

b. The most serious consequence of a product failure i.e. in the case of fire,
serious injury or death;

c. The potential long term physical impact on persons who have suffered burns
injuries;

d. The possible psychological impact on persons who have suffered the trauma
of a fire.

It was clear from the evidence that there have been and continue to be different
approaches to risk assessment adopted. The evidence from P| and the
evidence from the face of the Arcelik and Intertek Risk Assessments (in documentary
form) made at the material times over a period of a number of years show that some
of these factors are not taken into account and some may be taken into account to a

variable degree.

. Failing to take these factors into account expressly creates a risk that the seriousness

of injury, and consequently, potentially the seriousness of the overall risk is

8

Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

30.

underestimated.

| address my concems in this report to:

a. P| Head of Product Regulation, Department for Business, Innovation
and Skills, 1 Victoria Street, London, SW1H OET.

Guidance

31.

32.

33.

34.

35.

| heard from Beko witnesses and, also, in particular, I that there are
inconsistencies between the EU Commission Guidance and the UK Trade
Association Guidance on corrective action and the requirement to notify an

enforcement authority.

The AMDEA guidance says that if the outcome of the risk assessment is that there is
a “moderate” risk, the manufacturer is not required to notify TS but the BIS guidance
says that a “moderate” risk outcome requires notification to TS,

Manufacturers therefore are in difficulty in consistently applying guidance and in
carrying out their notification obligations where there is the requisite level of risk to
consumers.

| accept the LFB submissions that such inconsistency creates a risk that of TS not
being notified and therefore action not being taken in circumstances when it arguably
should be highlighting a risk to consumers.

| address my concerns in my report to:

a. | | Head of Product Regulation, Department for Business, Innovation
and Skills, 1 Victoria Street, London, SW1H OET,

Construction of Refrigeration Appliances

36.

| heard evidence from the LFB witnesses who gave evidence concerning the inherent

9

Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

37,

38,

39,

risks that refrigeration appliances present due to their construction. The polyurethane
insulation material used in most refrigeration appliances represents a high fuel load,
is highly flammable and when on fire burns to create dangerous gases.

There is no legal requirement or industry standard that this insulation material is
isolated from or protected from ignition by a failure in another component within the
appliance, which represent a risk of ignition, such as the compressor, capacitor or

ancillary components. This represents a serious risk to the safety of consumers.

This is currently being considered by AMDEA and BSI and will be discussed at the
meeting to be held in Japan later this year.

The plastic materials which are used for filling, strengthening and insulating
refrigeration appliances are highly flammable and increase the fuel load of these
appliances posing a continuing risk to consumers. It is possible to use alternate, non-
flammable or less flammable materials. It is also possible to better contain such
combustible components or insulation, There is no such requirement at present

which creates a risk to the safety of consumers,

40. | address my concerns in this report to :

a. Association of Manufacturers of Domestic Appliances (AMDEA), Rapier
House, 40-46 Lambs Conduit Street, London, WC1N 3NW (FAO: I
fr Technical Manager);

b. British Standard’s Institute, Chairman of CPL/ 61 Committee, 389 Chiswick
High Road, W4 4AL.

Capacitors
41. | heard evidence for the LFB witnesses, in particular who gave

evidence about the serious concerns they hold about the ongoing risk posed by
capacitor failures resulting in fires. These concerns are twofold, relating generally to
capacitors and the industry standards and in relation to Beko appliances.

10

Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

42. Paragraph 24.8 of British Standard BS EN 60335-1:2012 ‘Household and similar
electrical appliances; Safety; Part 1 - General requirements.’ applies to the type of
capacitors used in refrigeration appliances. It states that they shall not cause a
hazard in the event of failure.

43. This requirement is considered to be met by one or more of the following conditions:

a. The capacitors are of a class of safety protection P2 according to IEC 60252-
1;

b. The capacitor is housed within a metallic or ceramic enclosure that will
prevent the emission of flame or molten material resulting from failure of the
capacitor;

c. The distance of separation of the outer surface of the capacitor to adjacent
non-metallic parts exceeds 50mm;

d. Adjacent non-metallic parts within 50 mm of the outer surface of the capacitor
withstand the needle-flame test of Annex E;

e, Adjacent non-metallic parts within 50 mm of the outer surface of the capacitor
are classified as at least V-1 according to IEC 60695-11-10, provided that the
test sample used for the classification was no thicker than the relevant part of
the appliance.

44, | accept and agree with the concern raised by the LFB that the above requirement
does not ensure that capacitors do not pose a hazard. This creates a risk to the
safety of consumers.

45, The LFB FIT has experience of failures of P2 capacitors and failures leading to

ignition of metal casing capacitors (contrary fo a. and b. above).

46. Further, it is clear that the mechanisms of failure of a capacitor can bypass the
required 50mm distance (contrary to c. above). Furthermore, in the case of a
refrigeration appliance, the base of the compressor compartment is offen two metal
bars used for mounting components, leaving the floor surface exposed (for example a
flammable carpet).

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Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

47, The LFB believes that the requirements regarding capacitors referred to in paragraph

50 above (citing paragraph 24.8 British Standard BS EN 60335-1 : 2012) are not
robust enough to prevent capacitors from presenting a hazard, which creates a risk to
the safety of consumers.

48. | address my concerns in this report to:

a. The British Standards Institute, Chairman of CPL / 61 Committee, 389
Chiswick High Road, W4 4AL.

b. British Standards Institute, Chair of PEL/ 33 (Power Capacitors) Committee,
389 Chiswick High Road, W4 4AL

49, | heard evidence from LFB witnesses who gave evidence of their concerns that

50.

51.

serious failures in Beko Frost Free Fridge Freezers ("FFFF's’) manufactured between
2000 and 2006 are continuing resulting in a serious risk to the safety of consumers.
HE 212 evidence of the numbers of fires which the LFB FIT have
investigated to date, the appliance models and the causes of the fires. The LFB have
written to Beko concerning these fires and the risk the appliances represent. This
concer relates in large part to capacitor failures.

Although it is right to say that there was some evidence that there may be an
“industry wide problem” i.e. that this risk is not specific to Beko, this alone does not
address the risk which exists in Beko products and nor have the LFB been concerned
enough in relation to the risk presented by other manufacturer's products to write fo
any of them.

The LFB were provided with a risk assessment from Beko dated 26 April 2012 which
states that the risk is “low” such that no action is necessary or proposed. The LFB is
concemed that this underestimates the risk to the safety of consumers, particularly as
Beko witnesses’ own evidence seemed to highlight that they consider the capacitor
as a potential ignition source in fires.

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Her Majesty's Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

52. | address my concerns in this report to :
a. The Trading Standards Institute, 1 Sylvan Court, Sylvan Way, Southfields
Business Park, Basildon, Essex, $S15 6TH;
b. Beko plc, Beko House, 1 Greenhill Crescent, Watford, WD18 8QU.

52. | have concerns that there should be consideration given to the creation of a
simple, easy to use, Government funded/National website where aif product recalls can
be registered and accessed by consumers (and retailers) and ;

53. that there is no the mandatory placement on all domestic “white goods”
appliances of the manufacturer, make, model number, serial number/batch number
in flame resistant material.

54. | have concerns that consideration should be given to Legislation that offences
relating to the “failure to notify" duties in Reg 7 and Reg 9 of the General Product
Safety Regulations 2005: (GPSR’s)

(i) to become "either way" offences

(ii) maximum penalties on summary conviction to be increased to a level 5
fine and/or 6 months imprisonment

(iil) maximum penalties on conviction in the Crown Court, to include an
unlimited fine and/or 2 years imprisonment (in line with many other "trader
offences").

iv) the removal of time limits for the institution of criminal proceedings or an
extension to the existing time limits

55. | have concerns that there is no mandatory requirement that retailers must obtain
the name, address and/or telephone number and/or email address of
consumers at the point of sale of domestic “white goods” appliances.

56. and that this information is not stored for a minimum period of time.

57. | have concerns that there is no Code of Practice on product recalls to include:
minimum standards, prominence guidelines for recall notices at point of sale and
advertising (with a view to improving consistency of approach by manufacturers
and retailers)

| address these concerns to :

a. Department for Business, Innovation and Skills, 1 Victoria Street, London ,
SW1H OET

13

Her Majesty’s Coroner for the

Northern District of Greater London
(Harrow, Brent, Barnet, Haringey and Enfield)

3. ACTION SHOULD BE TAKEN

4. In my opinion action should be taken to prevent future deaths and | believe you
[AND/OR your organisation] 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 Monday 30" 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;-

The solicitors representing the family, The London Fire Brigade, Hertfordshire Trading
Standards ,

| 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.

Responses

5 responses 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.

Response from Amdea (PDF)
The Association of Manufacturers of Domestic Appliances

Mr Andrew Walker

Senior Coroner

HM Coroner for the Northern District of Greater London
North London Coroner's Court

29 Wood Street

Barnet

EN5 4BE

22 December 2014

Dear Mr Walker
Response from the Association of Manufacturers of Domestic Appliances

Further to your report dated 5 November 2014, AMDEA wishes to reply to the points 2 to 4 of
your report as follows.

We accept that there are difficulties in identifying products and components that fail but in most
cases the fire officers with specialist knowledge (such as are found in the London Fire Brigade)
with assistance from company specialists can overcome the difficulties preserited when a
product is burnt out and only a carcass remains. Over the past few years industry and the fire
service have held regular meetings at AMDEA and we ensure that the fire services are supplied
with contact details for all our members.

The idea of marking the product in some way that will survive a fire has been discussed in this
group. It is accepted that such a marking would have to be a separate marking in the steelwork
at the base of the product, whereas the rating plate needs to be at a level easily accessible to
the consumer. This marking would only have value in event of a catastrophic fire which is an
extremely rare event. The location would have to be known to the fire services and with the
manufacturing products being sourced throughout the world this would need world-wide
agreement. Also the metal structure of these appliances can be used across a range of
appliances and a range of brands, some of which are retailers own brands and some of which
are the brands of other manufacturers. It would be very difficult to set up a standard for this with
international acceptance since it would not be considered to be a safety matter by IEC.

LFB have argued that manufacturers who provided such a marking would also avoid the
situation of their products being misidentified, as has happened in the past. This is now
understood and discussions are continuing both in UK and European industry fora.

AMDEA Rapier House

40-46 Lambs Conduit Street London WC1N 3NW
t.+44 (0)20 7405 0666 f. +44 (0)20 7405 6609
info@amdea.org.uk www.amdea.org.uk

Chairman: Maurizio Pettorino
Chief Executive: Douglas Herbison

A company limited by guarantee.
Registered in England No. 1465823

VY

With reference to the construction of refrigeration appliances (36 to 40):

EE fhe Technical Manager on Refrigeration within AMDEA, together with

industry safety specialists prepared a basic proposal for change to the international standard
IEC 60335-2-24 to cover these points. This work arose because of a previous fire incident. This
proposal was placed before the BSI committee CPL61 and, was accepted as a UK proposal for
change at international level in 2014.

FP in his role as Chairman of BSI committee CPL/61 and UK delegate at the
recent International Electrotechnical Commission (IEC) meeting in Tokyo, Japan, presented the
UK proposal which was subsequently accepted by the meeting.

Full details of this standards activity are_contained in the correspondence to yourself from the
BSI. We have included an extract from! report for completeness.

With regard to point 39 the insulation material used in refrigeration appliances: whilst this is
highly flammable it has been successfully used for at least 30 years and is currently the only way
to meet the performance requirements of the Ecodesign Regulation as part of the industry's
commitment to reduce greenhouse gas emissions. We believe that their continued use, with
slight changes in the materials used to contain them, will be satisfactory.

It is vital that any change to refrigeration products is accepted at international level since there is
no major manufacturing of household refrigeration products in the UK.

We believe that we have taken note of the recommendations in the Coroner’s report and will
continue our dialogue with industry colleagues worldwide to address these concerns.

Yours sincerely

Douglas Herbison
Chief Executive
Response from Bsi (PDF)
bsi
) Sl. ..making excellence a habit?

22 December 2014

Mr Andrew Walker

Senior Coroner

HM Coroner for the Northern District of Greater London
North London Coroner’s Court

29 Wood Street

Barnet

EN5 4BE

Our ref: CPL/61 and PEL/33

Dear Mr Walker

Response from British Standards Institution on behalf of BSI Committees CPL/61 and
PEL/33

Further to your report dated 5 November 2014, BSI is now in a position to advise that the Committees
CPL/61 and PEL/33 have reviewed points 36 to 48 therein in relation to the following British Standards:

BS EN 60252-1: AC motor capacitors - Part 1: General - Performance, testing and rating - Safety
requirements - Guidance for installation and operation;

BS EN 60335-1: Household and similar electrical appliances; Safety Part 1: General requirements;

BS EN 60335-2-24: Household and similar electrical appliances. Safety. Particular requirements for
refrigerating appliances, ice-cream appliances and ice makers

As you will be aware these are British Standards which are based on European harmonized
standards which are in turn based upon International IEC standards. Any change we wish to make
to the British Standard must be submitted by way of a proposal to the International Committee
and/or the European Committee and is then subject to formal voting procedures.

The response from BSI to the points in the report which were addressed to CPL/61 and PEL/33 is as
follows:

Construction of refrigeration appliances (36 to 40):

Item 36) The high fuel load from the polyurethane insulation material is necessary to achieve the high
level of performance required by the Eco-design Directive.

BSI Group T: +44 20 845 086 9001 British Standards Limited

389 Chiswick High Road F: +44 20 8996 7400 Registered in England no: 07864997 x xy

London, W4 4AL cservices@bsigroup.com Registered address: 389 Chiswick High Road M4 i INVESTORS
: / IN PEOPLE

t \
United Kingdom *y bsigroup.com London, W4 4AL, United Kingdom ed

bsi
Sl. making excellence a habit?

(37) Regarding the matter of protecting foam insulation from the risk of ignition, the UK has put in a
proposal on this to the International committee IEC SC 61C and in November 2014 this was agreed to
be progressed to a Formal Vote. The proposal requires a flame retardant covering to be put over foam
insulation. We believe that if this proposal is accepted internationally and in the EN then item 37 will be
resolved. Relevant text from the UK delegate’s report from this meeting is attached to this letter.

(39) See response to (36) above regarding the first two sentences. The last two sentences are
addressed by the UK proposal which was agreed to progress at the IEC SC 61C meeting in November
which improves the testing to ensure the fire resistance of the outer materials of the fridge/freezer.
Relevant text from the UK delegate’s report from this meeting is attached to this letter.

Capacitors (41 to 48)

It is important to note that the capacitors standard was amended in 2013 and is now designated as BS
EN 60252-1:2011+A1:2013. This includes new features’ associated with segmented metallised
dielectrics, Clause 3.22.4 and a revision of the destruction test, Clause 5.16.

In this amendment, a new identification was introduced replacing the old safety classes PO, P1 and P2.
This was done to make sure that any capacitors could be clearly identified as meeting the new classes
S0, $1, S2 and $3.

NF

Class SO (formerly PO) does not have any specific safety protection.

Class $1 (formerly P1) is protected against fire and shock hazard but may fail in the open-circuit or
short-circuit mode.

Class $2 (formerly P2) is protected against fire and shock hazard but must fail in the open-circuit mode
only.

Class S3 is a new category covering segmented film construction and has protection against fire and
shock hazard. Capacitors in this class are required to fail with low residual capacitance (<1% CN).

The recommendation of PEL/33 is that:

1. BS EN 60335-1:2012 should be amended to refer to BS_EN_60252-1-2011 +A1-2013 which has.
the new safety classes $0, Si, S2 and $3; “
2. IEC/TC 61/SC 61C has the option of specifying the highest level of safety protection for

applications such as refrigeration appliances. In the new amendment, this is referred to as S2 and

$3.

CPL/61 can advise that as a result of the UK raising the general fire issue both of these
recommendations are currently under consideration in the international committee IEC TC 61/SC 61C.

We trust that the above demonstrates that where possible BSI is taking on board the recommendations
contained in the Coroner’s report but we have to advise that we cannot guarantee that our position will
prevail at international level. Additionally, it is important to be aware that the whole process of changing
the standard and manufacturers changing their designs will take some time. Finally, changing the
standard will not eradicate the problem which might exist with products already in use.

Yours sincerely

Geraldine Salt
Programme Manager, Manufacturing and Services

Nest

bsi
Sl. ..making excellence a habit"

Extract from the report of the UK delegate to the IEC SC 61C meeting held on 13 November
2014

The proposal presented was accompanied by a presentation from the UK explaining the problem as we
saw it together with a video clip of an ITN news broadcast about the incident that resulted in multiple
deaths in north London. Videos of tests carried out by Bureau Veritas on behalf of London Fire Brigade
on various types of insulated panels from the rear of a typical European style refrigeration appliances
were also part of the presentation.

The national comments from various nations were discussed. The modifications proposed by New
Zealand supported the British stance but they felt that the text could have been written in a simpler
form and include an alternative procedure in dealing with abnormal heat and fire tests which appear in
appliance standards. This had general support of the meeting. The vote was close with some major
countries having a brief to oppose change including Germany, Japan, Brazil Turkey and Italy but there
was enough support to continue to the next stage.

Normally this would go to a further stage of comment and discussion before being proposed as a Final
Draft International Standard where national committees only have a yes/ no vote before publication.
However on this occasion we had enough support from the national delegates present to include this in
the amending FDIS that was being agreed at the meeting on other topics.

Assuming that the combined FDIS goes forward to publication it is likely that the international standard
with Amendment 2 could be published in 2015. Thus regional standards such as the European EN60335-
2-24 should change shortly afterwards with all products using the standard for compliance with
European Safety Legislation meeting the requirements in about 2018. However since we have been
discussing the matter, major manufacturers have been reviewing their constructions and many believe
that changes they have been making will comply with this change though this will need to be confirmed
once the standard is published.

The final text agreed has been through the editing committee of which the UK delegate is a member.
We are awaiting formal publication by IEC and then via the BSI committee responsible CPL/61.

The editing committee text is as follows:

Extra warnings to be added to the instructions provided with all appliances:

The instructions for refrigerating appliances and ice-makers shall include the substance of the
following:

WARNING: When positioning the appliance ensure the supply cord is not trapped or damaged.

WARNING: Do not locate multiple portable socket-outlets or portable power supplies at the rear
of the appliance.

bsi
Sl. ..Making excellence a habit”

A new test to be carried out on all appliances where relevant

30 Resistance to heat and fire
Add the followng new subclause.
30.2.4 Addition:

Accessible non-metallic material having any dimension exceeding 50 mm that covers the thermal
insulation on the rear surfaces of an appliance, excluding non-metallic material that is within 50
mm from the top surface of the appliance,

is subject to the needle-flame test (NFT) of Annex E; or
shall comprise material classified as V-O or V-1 according to IEC 60695-11-10 provided that the
test sample used for the classification was no thicker than the relevant part of the appliance.

Accessible non-metallic material of the appliance within 150 mm of the motor-compressor and its
electrical controls

is subject to the needle-flame test (NFT) of Annex E; or

shall comprise material classified as V-0 or V-1 according to IEC 60695-11-10 provided that the
test sample used for the classification was no thicker than the relevant part of the appliance.

This extra test requires that non-metallic material used to cover thermal insulation on the rear of
appliances, considered to be the cause of fire problems reported in the UK, will be subjected to a small
flame test called the needle flame test which is used for similar material testing near to connections in
other appliances. Also this will apply to all non-metallic material in an area close to the compressor and
its controls. What is different is the allowance to meet the requirements using a pre-selection option of
using materials with a known fire resistance which has always been an option in appliance standards
and is the method favoured in US national standards by Underwriters Laboratory.

RECEIVED
24 DEC 2014
Response from Chief Fire Officers Association (PDF)
CFOA
Chief Fire Officers
Association The professional voice of the UK Fire & Rescue Service

Contact:
Humberside Fire and Rescue Service

Summergroves Way, Hull, HU4 7BB
Tel: a

Ema es

Our Ref: CB/KLF
‘a 29h December 2014

Mr Andrew Walker

Senior Coroner

Northern District of Greater London
North London Coroners Court

29 Wood Street

Barnet

ENS 4BE

Dear Mr Walker
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS —- SANTOSH BENJAMIN MUTHIAH

jlam writing in response to your letter of 5? November 2014, under Regulation 28 of the Coroners
(Investigations) Regulations 2013, relating to the inquest into the tragic death of Mr Santosh Benjamin
Muthiah.

Before responding to your earlier correspondence, | would first like to express and place on record my
deepest condolences to Mr Muthiah’s family.

Firstly, by way of an introduction | am the Deputy Chief Fire Officer of Humberside Fire and Rescue
Service and, also the Chief Fire Officers Association (CFOA) Lead Officer for Fire Investigation. In this
capacity | also chair CFOA's Fire Investigation Strategic Steering Group (FISSG).

CFOA is a charity whose purpose is to promote and increase efficiency amongst the UK's Fire and
Rescue Services (FRS) for the benefit of the public and all communities across the Country. It is important
to note that my CFOA role does not authorise me to mandate any FRS to undertake a particular course
of action. Whilst this is the case, | can produce guidance and recommend to the CFOA Board that this
be issued to FRS in order to support the Association's purpose.

Page 1 of 3 7

Chief Fire Officers Association | 9-11 Pebble Close | Amington | Tamworth | Staffordshire | B77 4RD Regi
Telephone +44 (0)1827 302300 | Fax +44 (0)1827 302399 | www.cfoa.org.uk Registered in England as a

ed in England as a Limited Company: No 03677186
rity No 1074071 VAT Registration No: 902 1954 46

|
|

|
|

As your lefter relates to the sharing of information following investigations into the origin and cause of a
fire, it is also important to note thai whilst the Fire and Rescue Services Act 2004, in particular Section 45 of

~., that Act, does give the FRS powers to obtain information and investigate fires, it does not place a specific

iduty on them to do so. Therefore, whilst all UK FRS currently investigate fires fo an extent, it cannot be
guaranteed in the absence of a statutory duty, the level that FRS will continue to investigate [fires] in the
future.

Despite that fact, | would assert that Fire Investigation remains an important aspect of FRS work and,
there is no doubt that the findings from various investigations have helped secure and safeguard both
communities and firefighters alike.

This has been achieved through the identification of trends and emergent issues and, sharing information
with partners and stakeholders. in this regard | acknowledge that there would be benefits in Trading
Standards (TS) and manufacturers being provided with more of the information that was available
relating to appliance fires.

In this respect, | can report that there has been work on going since early 2014, initiated by the
aforementioned CFOA FISSG, to improve the ability for the FRS to share information and intelligence with
TS. Following a meeting in June 2014, hosted by the Government's Business Innovations and Skills
Department (BIS), there was agreement by all stakeholders, including CFOA, the Department of Local
Government (DCLG) and the Association of Trading Standards Officers {ACTSO) that information sharing
“Yoetween the FRS and TS was important and, as a result, BIS undertook to carry out exploratory research

“an how that might be achieved most effectively through web based means. CFOA continue to engage

proactively on this project and are currently awaiting an update from BIS.

| also note that in your letter you address a number of concerns iii” DCLG Deputy Director
National Resilience and Fire Programme. lt appears that those concerns are around a similar area of
data sharing. On this matter, | would comment as follows.

All UK FRSs provide information as to the cause of fires and the extent of damage caused by fire, to
DCLG via their incident Recording System (IRS). This is provided for every fire attended by the FRS and is
generally gathered by frontline crews at the scene, rather than dedicated Fire Investigators who are
mobilised depending on local circumstances but mostly where incidents are likely to be protracted or
complicated. In respect to the subject matter, these routine reports will include the make and model of
the appliance where that information is available. | have discussed the overlap between fhe two areas
that we are responding to with i and some of her colleagues. Whilst | am not in a position to
comment upon the capacity for DCLG to change any processes, | do believe that there may be
opportunities to work to enhance some of the information gathered for IRS. As a result it may be possible
to consider the ways that information is currently recorded and accessed thereby providing a more

~ sustainable method to inform both TS and manufacturers of the information that you suggest on a regular

basis. CFOA are already engaged with a working party developing the replacement IRS system,

moreover there is an FISSG member to provide specific inputs on FI related matters.

On this matter, my opinion is that if a system was developed to extract information on those fires where
the FRS had reported to DCLG in 8.1 of the IRS as being caused by “fault in equipment or appliance" and
the manufacturer and/or model number was known and reported to DCLG in 8.2 of the IRS, then even
that limited information may be useful to both TS and manufacturers.

There are clear benefits in such a system being administered centrally using existing means rather than
relying on the potential discrepancies caused by local inputs associated with a revised individual FRS
arrangement. To illustrate this point, | would refer to the lack of statutory duty around the investigation of
fires and the current variations across the UK in respect to how information is gathered and disseminated.
Whilst this is the case, the requirement for each FRS to complete the IRS as described above is one which
DCLG can continue to demand under Section 26 of the Fire and Rescue Services Act as it places a duty
upon Fire and Rescue Authorities to “submit fo the Secretary of State any reports and returns required by
him."

3
é

‘Page 2 of 3

Chief Fire Officers Association | 9-11 Pebble Close | Amington | Tamworth | Staffordshire | B77 4RD R
Telephone +44 (0)1827 302306 | Fax +44 (0)1827 302399 | vayw.cfoa.org.uk Registered in England cz

Limited Company: No 08677186
No 1074571 VAT Registration No. 962 1954 46

}

Proposals for further action by CFOA

CFOA will continue io engage proactively with the work which BIS are progressing regarding
information sharing between FRS and TS. As the nominated person for that work | will ensure that
CFOA provide any support within the timescales required by BIS.

CFOA will continue to engage proactively with DCLG to help develop the future IRS, and the
ease by which this type of information can be gathered, accessed and disseminated. The
timetable for that work is outside of the conirol of CFOA but the Association has nominated an
officer to be part of the working group and will support as required.

CFOA will provide guidance to FRS by April 2015 to help ensure that the information provided on
IRS is as accurate and meaningful as is possible to facilitate the ease by which DCLG could
provide it to TS and manufacturers if they decided to do so.

If DCLG determine it is not feasible to provide meaningful information to both TS and
manvfacturers on a periodic basis then CFOA, in consultation with DCLG, will provide guidance
to each UK FRS on the methods to be used in order to identify appliances involved in fire and the
manner in which this is to be recorded and information shared with other partners; including TS
and manufacturers. It must be acknowledged that this cannot be mandated, or indeed
monitored by CFOA going forward. Depending on the response from DCLG this will be provided
to FRS, even only as an interim measure that they may decide to adopt, by 15! April 2015.

Once again please allow me to express my deepest condolences to Mr Muthiah's family. CFOA are
committed to working with its members and partners in order to reduce the tragic incidences of deaths
caused by fire in the UK and | would welcome sight of the responses from the other organisations that
you have written to in order for us to best understand how to achieve our aims.

Yours sincerely

"Page 3 of 3

Chief Fire Officers Association | 9-11 Pebble Close | Amington | Tamworth | Staffordshire | B77 4RD Regstered in Englar

Chris Blacksell
Lead Officer for Fire Investigation
Chief Fire Officer’s Association

3 a Lintect Company: No 08877186

Telephone +44 (0)1827 302300 | Fax +44 (0)1827 302399 | vavw.cfoa.org.uk Registered in Eng’and as a Charity No 1074071 VAT Registration No: 902 1954 46
Response from Department for Business Innovation Skills (PDF)
Department
for Business 1 Victoria Street
~~, . London
Innovation & Skills SW1H OET
Mr A Walker T +44 (0) 20 7215 5000

: E enquiries@bis.gov.uk
Senior Coroner

North London Coroners Court
29 Wood Street
Barnet EN5 4BE

www.gov.uk/bis

% January 2015
Spor Mr Linlicer,
REGULATION 28 REPORT- SANTOSH BENJAMIN MUTHIAH

Thank you for the copy of your Regulation 28 Report to Prevent Future Deaths, which you have
addressed —_, Head of Product Regulation and the Department for Business,
Innovation and Skills. | am replying as this maiter falls within my portfolio. The death of
Santosh Benjamin Muthiah in November 2010 was a tragic incident and | share your interest in
preventing a reoccurrence.

The first two concerns you have addressed to me relate to differences in approach to
undertaking risk assessments of products (paragraphs 26-29), and inconsistencies in the
related guidance (paragraphs 31-34). My view.on this is that the legislation itself is clear, and
that this is underpinned by equally clear guidance (produced by Prosafe, a non-profit making
organisation which draws together European Market Surveillance Authorities to spread and
develop best practice, with support from the UK). The Government plays a leading role in
discussions on risk assessment and corrective action in the EU, and we will continue to promote
best practice and draw attention to the Prosafe guidance on this basis.

However, we are aware that there may be additional guidance in the public domain that is not
fully consistent with Prosafe advice. Whilst it is important to note that risk assessment is an
inherently subjective activity, | share your concern that any apparent divergence in approach
could cause confusion for manufacturers in relation to their obligations. As a result, consistency
of guidance and sharing of best practice is something that will be considered as part of the
independent review of consumer product recalls recently announced by Baroness Neville-Rolfe
during a House of Lords debate on the Consumer Rights Bill. The review will incorporate views
from a range of Market Surveillance Authorities and other business and non-government
stakeholders. The output will be a report to BIS Ministers highlighting the strengths and
weaknesses of the current system and making recommendations on how it might be improved.

You also raise a series of concerns in paragraphs 52-57. The first of these relates to the
creation of a website where all product recalls can be registered and accessed by consumers.
There are already a number of initiatives in this area including AMDEA’s ‘Register my
Appliance’ site launched on 15 January, as well as the online list of product recalls maintained

Jo Swinson MP
Minister for Employment Relations and Consumer Affairs

by the Trading Standards Institute. Nevertheless, the usefulness and feasibility of such a
website will be considered as part of the aforementioned independent review.

Your second concern in this section relates to white goods carrying key information on a fire-
resistant plate or similar. | understand that this idea has a number of practical challenges
associated with it, but | believe that industry are looking into it in some detail and are seeking to
make a proposal with the aim of securing global agreement. BIS will continue to support their
efforts in this area.

Your third concern covers the “failure to notify” offences under the General Product Safety
Regulations 2005 and, in particular, whether the range of penalties is sufficient and whether the
time limits for instituting criminal proceedings are too short. In my view, the general scheme of
offences in the 2005 Regulations operates in a proportionate and effective manner. In relation to
penalties, it is important to appreciate that a producer or distributor who commits an offence
under regulations 7 or 9 (the “failure to notify” offences), will very frequently also have

committed an offence under regulations 5 (generai safety requirement) or 8 (obiigations of
distributors), to which higher penalties can be applied. In addition, you may be aware that the
Ministry of Justice is currently working on commencing section 85(1) of the Legal Aid, (
Sentencing and Punishment of Offenders Act 2012, which would have the effect of permitting a ~
fine of any amount to be given in respect of the “failure to notify” offences. In relation to time
limits, | agree that the system must allow sufficient time for effective prosecutions to be brought.
However, the system must also be proportionate and certain. Therefore, | do not propose to
address the range of penalties or the time limits applying to the “failure to notify” offences under
the 2005 Regulations any further at this time.

Your fourth concern centres on collection and storage of consumers’ contact details by retailers.
As you will appreciate, there are some challenging issues here in relation to data protection, as
well as customers’ general willingness to give their contact details. This is why BIS’s approach
focusses on encouraging consumers to register their appliances and helping them understand
why this is beneficial, rather than forcing them to do so. This is exactly what AMDEA’s Register
my Appliance site is designed to do, and we will continue to support that initiative.

Finally, you raise concerns about the absence of a Code of Practice on product recalls. |
believe that much of the content that one would expect to see in a Code of Practice is covered
by the Prosafe guidance mentioned above. In addition, it is difficult to set out firm criteria for
preduct recalls, since each one must be tailored according to a huge number of factors including
the nature and age of the product, the nature of the risk, the number of products on the market
and the consumers affected. Once again, however, the potential for a Code of Practice will be
considered as part of the independent review.

In addition to the points above, | would like to highlight that the independent review of product
recalls will also consider a number of the other concerns you have raised elsewhere in your
report. | understand that views will be sought from coroners as part of the evidence gathering
that underpins the review. | would of course be happy to send you details of the review’s
findings when it concludes later in the year.

JO SWINSON MP
Minister for Employment Relations and Consumer Affairs

RECEIVE
29 JAN 201:

TARR ene me
Response from Forensic Sciences (PDF)
Supporting forensic practice worldwide The

Chartered
Society of
Forensic

Sciences

: The Hon. Mr Justice Sweeney

Andrew Walker

HM Coroner for the Northern District of Greater London

North London Coroners Court

29 Wood Street

Barnet

ENS 4BE 24 December 2014

Coroners Concerns - Inquest - Santosh Benjamin Muthiah

Dear Sir,

I have been passed a copy of your report dated 5 November 2014 raising questions and seeking
a response from the Chartered Society of Forensic Sciences.

The objects of the Society are to advance the study, application and standing of forensic
science and to facilitate co-operation among persons interested in forensic science throughout
the world. It is also the professional body for forensic science practitioners.

Forensic Scientists outside academia are usually employed / contracted by a third party for
their services by the police or other emergency services, including the fire service; solicitors;
private businesses or individuals for criminal, civil and other investigative work or advice.
Their reports are therefore delivered direct to whoever has engaged them and, depending on the
circumstances and purpose, are not always available for wider circulation and may be sensitive
or confidential.

A forensic scientist will not be called to assist at the scene or even with any aspect of the
majority of fire investigations. They are rarely involved in any but the most serious fires and /
or unexplained or suspicious deaths. Reasonably straightforward cases where the cause of the
fire is readily assessed will usually be investigated by the fire service and / or police without an
external forensic scientist’s involvement.

They are not therefore, in my opinion, best placed to be able to report, or be required to report,
information such as a specific appliance or apparatus that may have been the cause of a fire.

The fire service, I understand, have a duty to investigate every fire and the police will be
involved in fatalities. Scientific evidence may be available to assist them to reach a conclusion
or suggest lines of enquiry but not necessarily involving input from a forensic scientist.

The Chartered Society of Forensic Sciences | Clarke House | 18a Mount Parade | Harrogate | HG1 1BX
Tel: 00 44 (0)1423 506068 or 00 44 (0)1423 566973 | Fax: 00 44 (0)1423 566391 | Email: info@csofs.org
Website: www.charteredsocietyofforensicsciences.org
Registered Charity No.1156052 Company No.RC000869

Supporting forensic practice worldwide The

Chartered
Society of
Forensic

Sciences

Patron: The Hon. Mr Justice Sweeney

In order to provide consistent and accurate data to a central monitoring body such as Trading
Standards I believe responsibility should rest with a single agency that will always be involved
and already has a duty to investigate, i.e. The Fire and Rescue Services / Local Authority.

Please do not hesitate to contact me should you need further information or if I can assist in
any way.

Yours Sincerely

Colin Ratcliff

Vice President.

The Chartered Society of Forensic Sciences | Clarke House | 18a Mount Parade | Harrogate | HG1 1BX
Tel: 00 44 (0)1423 506068 or 00 44 (0)1423 566973 | Fax: 00 44 (0)1423 566391 | Email: info@csofs.org
Website: www.charteredsocietyofforensicsciences.org
Registered Charity No.1156052 Company No.RCO00869

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