Joseph Allison

lan Wade QC

Assistant Coroner

Eastern District of London
Walthamstow Coroners Court
Queens Road

Walthamstow

London E17 8QP 15 May 2015

Dear Mr Wade
Re: Inquest touching upon the death of Joseph AuW Son

Thank you for drawing our attention to your investigation and conclusions with regard to the
above case.

To address your points:

1 and 2 - we are satisfied that Handicare has adjusted internal process and training to
ensure that appropriate training is provided to the in-house engineers on an ongoing
basis. BHTA will remind all its manufacturer members that if training is necessary to
address a field safety issue the training must continue to be provided until such time as all
the products have been traced and the necessary action taken.

3 BHTA has been concerned for some time that there is no national alerting system for
notification of product recalls and field safety work for products such as stairlifts. We have

noted that is currently leading a review into the recall system for unsafe
products to which we will be responding:

https://Awww.gov.uk/ overnment/news/consumer-

product-safety-review

Clearly there is a need for a national system, but we are also conscious that costs and
effectiveness might be barriers. There is a well-established system run by the Medicines &
Healthcare Products Regulatory Agency (MHRA) for alerts regarding medical devices and
this ensures wide circulation throughout the health and care sectors. We will recommend
that the Health & Safety Executive talk to the MHRA and see if they might tap into the same
alerting system for alerts regarding products which are not medical devices but which have
been sold into the care sector, provided to social services, or sold direct to frail elderly
people for the purpose of maintaining independence, preventing falls, and / or enabling

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mobility.

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British Email: bhta@bhta.com

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British Healthcare Trades Association
A company limited by guarantee
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4 The business did raise the matter at one of our meetings (minutes of which are distributed
to all relevant members) and we have discussed how to improve notifications and co-
operation throughout the supply chain. We will reiterate to manufacturers the need to have
written agreement with their dealers setting out what will be expected of them in the event of
a recall or the need for field safety work; and that they should make full use of ourselves and
the publications read by businesses in the sector to raise awareness.

If we may be of any further assistance please do not hesitate to contact me.

Yours sincerely

Director General

& handicare

Handicare

82 First Avenue
Pensnett Estate
Kingswinford

West Midlands DY6 7FJ
Me len Wale QC United Kingdom
Assistant Coroner
Eastern District of London a i”
Walthamstow Coroner’s Court F
Queens Road enquiries@handicare.co.uk

Walthamstow www.handicare.co.uk
London E17 8QP

12” June 2015 -
fo) :

Dear Sir

Re: Inquest touching upon the death of Mr Joseph Allison

We write further to your Regulation 28 Report to prevent future deaths sent under
cover of your letter of 25th March 2015 and subsequent exchanges of
correspondence regarding an extension of time in which to submit a response.

This letter constitutes the response to your Regulation 28 Report.

Before addressing the section of your Report which deals with "Matters of Concern"
it is felt appropriate to deal with two matters which arise out of our consideration of
the section headed "Circumstances of Death" which we feel, as currently worded,
may have the capacity to mislead Someone reading the Report who did not have the
benefit of the full background or having heard all of the evidence given at the Inquest.

The first matter relates to Paragraph 4(3) where it is respectfully submitted that the
use of the following phrase has the potential to mislead:

"Moreover the manufacturer's internal record of compliance was completed so as to
falsely show that the necessary work had been carried out."'

Our concern is that the word "falsely" in the context of the sentence as constructed
has the capacity to be interpreted in a way which suggested some deliberate act or
act of dishonesty on the part of the company was involved in the factual narrative.
Plainly that is not the case, was not the evidence given in writing or orally at the
Inquest, and no witness was questioned on the basis that such could have been the
case, as should have been done, really, if such a matter was to be in question.

In our view the sentence would be more reflective of the actuality and the evidence
given were it to read "Moreover the records compiled by the manufacturer to capture

Mobility

Stairlifts, Moving & Handling

The second matter relates to the sentence appearing at paragraph 4(5) which reads:

“Furthermore no information regarding this defect and remedial actions was released
to appropriate third parties such as independent installer or dealers.”

Again, in our view, and respectfully, we say that this is capable of being misleading.
As was clear from the evidence submitted in writing and the evidence given orally at
the Inquest Bulletins 55 and 66 were mailed to our trade customers at the time of
issue. This would include independent installers and dealers, and, in fact, as was
explained, all those to whom we knew the business had supplied a stairlift or who
were regularly maintaining stairlifts.

What was not done at the time, and what we understood the concern to be directed
to during the course of the Inquest, was to distribute such information to other
independent installers and maintainers, outside of the group reached, in order to
cover the potential scenario whereby a stairlift had been sold or installed second-
hand outside the knowledge of the business or was being serviced by someone
outside our known and identifiable network of installers, dealers, and maintainers.

In our respectful view the sentence would more reflective of the evidence if it read
"Furthermore whilst efforts were made to provide information on the defect and
remedial actions to those to whom the manufacturer had supplied stairlifts or it knew
maintained stairlifts such information was not supplied to others who might have sold
or installed stairlifts second-hand or who were maintaining stairlifts outside the
manufacturers identifiable network of businesses which maintain stairlifts."

We will now address the matters set out in the section of your report entitled
"Matters of Concern".

“5(1) In-house service engineers have not been specifically trained to be aware of the
defect in the Minivator 2000, nor issued with feeler gauges to implement the
appropriate safety check.”

Action Taken

Handicare engineers have been made aware of the potential defect, issued with feeler
gauges and have received a face to face briefing with regard to its use to carry outa

trunnion inspection as detailed in Bulletin 66. The content of Bulletin 66 has also been
issued to them.

They have also been issued with a list of recall batch serial numbers.

Training with the feeler gauge anda briefing on the top trunnion issue has been
added to the new engineer training programme together with a list of the recall batch
serial numbers, to ensure that any new employees are made aware of the issue as
part of their induction training.

It will be recalled that Bulletin 66, which formed Appendix B to the statement of Mr

explained what needed to be done to identify the defect and what action
should be taken immediately if a defect was found.

“5(2) In-house and third party service engineers are thereby exposed to the same
risks which end users face if they test ride serviced stairlifts themselves”

Action Taken

In relation to in-house service engineers please see the response to paragraph 5(1)
above.

We are contacting all dealers that have ordered stairlifts or spares since 2005 to raise
awareness of the defect and upgrade programme. We are issuing the recall batch
numbers with the request to contact us if they come across any of these units in the
field.

We have also purchased a list of UK mobility retailers and are sending a similar
communication to any of these dealers not already registered with us and covered by
the communication referred to in the Paragraph immediately above.

First class mailing of these communications took place 11” and 12” June 2015.

A communication covering similar ground will also be included as an insert, for ease
of extraction and retention, in THIIS (stands for "The Homecare Industry Information
Service") magazine, the primary trade publication. This is planned for the July issue of
this monthly magazine.

We attach examples of the communications which are being sent to our dealer
network, are being sent to the list of dealers who are not part of our established
dealer network, and are to be inserted into THIIS magazine marked as TM1, TM2 and
TMS respectively.

“5(3) No nationally publicised safety recall campaign has been undertaken to alert end
users to the danger, or request that such users contact the manufacturer for access
to the remedial programme.”

Action Taken

We will be conducting a national advertising campaign in the Publications identified to
us by external specialists as having the highest readership and best national
coverage. This will run between Monday 15" June and Sunday 4" July. Adverts will
run on various days in the following publications: The Sun (National), The Scottish
Sun, the Daily Mail and the Mail on Sunday.

We are also mailing all Local Authorities to raise awareness of this recall in case they
have had an affected stairlift installed by a third party. First class mailing of these
communications took place 11" and 12" June 2015.

We attach examples of the adverts which are to appear in the national newspapers

and the communications to be sent to local authorities marked TM4, TM5 and TM6
respectively.

The Group function is also in the Process of reviewing the viability of incorporating a
section on the Handicare website, to be accessible by any visitor to the website,
listing safety upgrades, including the Minivator 2000 trunnion upgrade. This site is
managed by Handicare Group’s central marketing department not a local UK team

and serves a number of divisions so changes like this go through a consultation
process. As matters stand we cannot confirm whether or not this is something for
which we will get authority to proceed.

“5(4) No adequate initiative has been taken to advise the stairlift industry generally of
the risks inherent in unimproved Minivator 2000 Stairlifts.”

Action Taken

In relation to the generality of the concern expressed please see the responses/action
taken in relation to paragraphs 5(2) and 5(3) above.

As regards the topic of all manufacturers or all leading manufacturers sharing
information on such issues within the sector generally, from our recollection, this was
tabled by our representative at a meeting of the stairlift section of the BHTA once the
original trunnion upgrade programme was initiated, to highlight the need to share
safety information between companies. At the time some manufacturing members of
the section were opposed to creating a formal system due to concerns about the
requirement to share data or information which may be commercially confidential or
commercially sensitive in its nature, and therefore this was rejected.

We have raised the matter informally with the BHTA again, both before and following
the Inquest. There is a BHTA stairlift section meeting planned for the 9" July 2015, the
first such meeting following the Inquest, where this will be tabled once more for
consideration. We will raise the issue again with all manufacturers at this meeting to
try to highlight the importance of sharing such information in order to reduce the risks
to users of stairlifts with potential safety issues. A letter will also be sent to these
manufacturers during the week commencing 15” June 2015,

We believe we have done all that we can to address the concerns identified in the
Regulation 28 Report. As will no doubt be readily understood the safety of users of
our products and of our staff who maintain them is of the utmost importance to us
and that is why we always seek to review our processes to identify areas for risk
reduction and improved accident prevention. We are, therefore, appreciative of your
drawing our attention to the matters highlighted in the Regulation 28 Report.

At the risk of repeating what has already been said Publicly at the Inquest we must
reiterate how deeply saddened we were at the circumstances of the accident
involving Mr Allison following what was thought to have been a successful initial
upgrade programme.

If there is anything further with which we can help, or if any clarification is required,
please get in touch.

Yours faithfull

Sales & Marketing Director
For and on behalf of Handicare Accessibility Ltd

Encs: TM1 to TM6