Prevention of Future Deaths reports · 2016

Roy Lawton

Regulation 28 report to prevent future deaths, reference 2016-0441, written 9 Dec 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Dec 2016
Reference2016-0441
DeceasedRoy Lawton
CoronerAndrew Haigh
Coroner areaStaffordshire (South)
CategoryProduct related deaths · Community health care and emergency services related deaths
Sourcejudiciary.uk record · original PDF
Responses published1

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.

Andrew A Haigh
Senior Coroner for Staffordshire (South)

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT 10: <=) REGULATORY LAWYER, MARKS
& SPENCER, 10°" FLOOR EAST, WATERSIDE HOUSE, 35 NORTH WHARF ROAD, LONDON
W2 1NW

CORONER

lam Andrew A Haigh, Senior Coroner for Staffordshire (South)

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 the 6th September 2016 | commenced an Investigation into the death of Roy Frederick
Lawton, aged 85. The Investigation concluded at the end of the Inquest on 22nd November
2016. The conclusion of the Inquest was accidental death - the death resulting from burns.

CIRCUMSTANCES OF THE DEATH

Early on 23rd July 2016 Mr Lawton was sitting on a settee at his home in Gentleshaw having a
cup of coffee and smoking a cigar. He dozed off and dropped the cigar which ignited the
dressing gown and pyjamas that he was wearing. He put the fire out but had sustained serious
burns. He was taken to the burns unit at the Queen Elizabeth Hospital where, despite treatment,
he died on 31st August 2016.

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 MATTER OF CONCERN is as follows: Enquiries into this death included a fire investigation
report. The Fire Investigator informed me that the dressing gown that Mr Lawton had been
wearing was highly inflammable. He told me that this appears to be the case whether clothing is
100% cotton or a mixture of cotton and polyester. A short while has elapsed since the
conclusion of the Inquest as you have been kindly checking the production details. | now
understand these are T07/5288 manufactured by Quantum in Vietnam. | wonder if anything can
be done either in the production, importing or retail of this clothing either to reduce its
inflammability or to warn customers as to the danger .

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

3 February 2017. |, the coroner, may extend the period.

No | Staffordshire Place, Stafford, ST16 2LP
Tel 01785 276127/276126 | Fax 01785 276128

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:
| have also sent it to the Staffordshire Fire and Rescue Service who 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 9 December 2016

Signature bow A K

Senior Coroner for Staffordshire (South)

No 1 Staffordshire Place, Stafford, ST16 2LP
Tel 01785 276127/276126 | Fax 01785 276128

Responses

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.

Response from Ms (PDF)
M&S

EST.18684

Waterside House

35 North Wharf Road
London W2 1NW

Tal: 020 7936 4422
marksandspencer.com

Mr Andrew H Haigh

Senior Coroner for Staffordshire (South)
No 1 Staffordshire Place

Stafford

ST16 2LP

2 February 2017

Dear Mr Haigh

INQUEST INTO THE DEATH OF MR ROY FREDERICK LAWTON
Response to Report to Prevent Future Deaths dated 9 December 2016 (the “Report’)

| am writing on behalf of Marks and Spencer pic (“M&S"), in response to the Report which followed the
inquest into the death of Mr Roy Frederick Lawton on 22 November 2016 (the “Inquest’).

Firstly, M&S should be grateful if you would send our sincere condolences to Mr Lawton’s family. We
were not aware of Mr Lawton's death or the Inquest until we read about it in the press on 25 November
2016. Accordingly, this is the first appropriate opportunity we have had to convey our sympathies to his
family. We very much hope that your investigation into any steps which can be taken to minimise future
risks will bring them some comfort.

Our understanding from the Report is that the evidence at Inquest showed that Mr Lawton fell asleep
and dropped his cigar on to his M&S dressing gown (the “Gown") which resulted in a fire. The Report
sets out your concern, which we understand is based on the evidence given by f
Codsall Community Fire Station (the "Fire Investigator’) at the Inquest, that the Gown worn by Mr
Lawton at the time of the fire was “highly inflammable". in view of this, you have asked whether
anything can be done by M&S “in the production, importing or retail of this clothing either to reduce its
inflammability or to warn customers as to the danger.”

As you would expect, the concerns raised in the Report have been taken very seriously by M&S. The
company prides itself on having rigorous systems in place to ensure that our Products comply with (and
usually significantly exceed) all safety requirements and include all appropriate warnings.

Upon receipt of the Report, we immediately contacted the Fire Investigator in order to Properly identify
the Gown. Based on the limited information and fabric available, we concluded that it was most likely to
be the M&S “Mixed blue stripe coloured woven dressing gown" (the "Relevant Product’).

The Fire Investigator informed us that his investigations undertaken for the Inquest had not involved any
flammability testing of the Gown (or any similar dressing gown) by either the Fira Service or another
body. M&S therefore instructed external experts, Intertek, to carry out a flammability test. Intertek are a
global leader in the field of product testing, including flammability testing.

We were not provided with the remains of the Gown and accordingly provided intertek with the Relevant
Product from our-store room. Intertek recommended applying the standard testing procedure used for
bedding, which is amongst the most rigorous and stringent. The procedure involves placing a lit cigarette
on top of, underneath and in between a fold of material. We followed the recommendation and the
Relevant Product was subject to the testing procedure for bedding.

This testing closely resembled the circumstances of the fire in Mr Lawton's home. | attach a copy of the

Flammability Test Report issued by Intertek which sets out the results of the test. The Test Report records

that the cigarette burnt for between 17 and 19 minutes (depending on where it was placed on the Relevant

Product) and then went out. No flame was produced and the fabric of the Relevant product did not burn

or smonieer after the cigarette had gone out. The dressing gown therefore received a ‘pass’ for
jammability.

Given the enclosed test results, we could not understand how the Fire Investigator came to the conclusion
that the Gown was “highly flammable". This was particularly puzzling given that the Gown was not
subject to any flammability testing as part of the inquest process. We are also unaware of any testing
carried out to ascertain whether or not an accelerant, such as aftershave, was present on the Gown.

We therefore contacted the Fire Investigator again to seek further clarification. He explained that he made
the comment “highly inflammable" In the context of his concerns about industry wide legal requirements
for the flammability of adult dressing gowns, which he believes are inadequate and allow some retailers
to sell “highly flammable" adult dressing gowns. In the course of our communications, the Fire Investigator
informed M&S that he was satisfied that the Gown worn by Mr Lawton was fully compliant with all legal
requirements.

M&S does not have detailed information on the nature and extent of the concerns of the Fire Investigator
regarding regulation in this area. We suspect, however, that they may emanate from the lack of any legal
requirement to test adult dressing gowns for flammability before they are placed on sale.

Currently, the only requirement is to include a label on the gown stating: “Keep away from fire and
flames". M&S goes significantly beyond this legal requirement in its flammability testing of adult dressing
gowns, including carrying outa ‘flash flame’ test on its dressing gowns with raised fibres (which carry the
greatest risk) and refusing to sell any raised fibre fabrics which fail this test. We also have a strict audit
procedure to ensure that dressing gown labels contain the correct customer warning and that raised fibre
fabrics pass the ‘flash flame’ test. We are therefore satisfied that M&S goes significantly beyond what is
legally required to ensure the safety of its adult dressing gowns.

M&S has a great deal of sympathy for Mr Lawton's family who will understandably want to ensure that
any lessons from Mr Lawton's death are identified. It is, however, clear from our communications with
the Fire Investigator that his concerns Ile with the industry wide legal standards for the flammability of
adult dressing gowns. You will appreciate that, as a retailer, we do not have the power to carry out this
type of legislative review. What we can do is take every reasonable step to ensure that our own
customers are safe when wearing the products we sell. For the reasons set out in this letter, M&S is
fully satisfied that it does so.

We hope that the above information and enclosed report is of assistance.
Yours sincerely
Grt7

egulatory Lawyer
Marks and Spencer pic

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