Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0224, written 11 Sep 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Sep 2017 |
|---|---|
| Reference | 2017-0224 |
| Deceased | Brian Betterton |
| Coroner | Ian Pears |
| Coroner area | Bedfordshire and Luton |
| 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.
for Bedfordshire and Luton
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
The Secretary of State for the Department for
Business, Energy & Industrial Strategy
1 Victoria Street
London
SW1H OET
CORONER
| am IAN PEARS, Acting Senior Coroner, for the Coroner Area of Bedfordshire &
Luton
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 24 February 2017 | commenced an Investigation into the death of BRIAN
DAVID BETTERTON aged 79 years. The Investigation concluded at the end of
the inquest on 24" August 2017. The conclusion of the Inquest was
ACCIDENTAL DEATH. The medical cause of death was:
| (a) Carbon Monoxide Poisoning
1 (b)
1 (c)
| | Atherosclerosis
|4 | CIRCUMSTANCES OF THE DEATH
At an unknown date an unknown person fitted a new fuse box to the property
Subsequently a Product Recall Notice was issued for Electrium Miniature
Circuit Breakers due to a potential risk of burning.
| On the morning of the 20" February 2017 the Electrium Miniature Circuit
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 {| Fax 0300-300-8267
Breaker at the deceased’s home began to short and a small smouldering fire
occurred resulting in carbon monoxide being released. The Deceased died in
his bedroom from carbon monoxide exposure. His body was discovered several
hours later when a passer-by noticed it was very dark in the deceased's kitchen;
in fact this was soot coating the glass. The fire had extinguished itself causing
relatively little damage.
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:
1. The Product Recall relates to a product supplied between April 2009 and
February 2010
2. The Product Recall did not come to the attention of the deceased.
3. In the majority of cases the end user of the product will not have
purchased or fitted the product.
4. The Product Recall therefore is dependent upon identifying the person
who actually purchased the product.
5. The purchaser is likely to be a professional electrician, yet is not required
to keep a register of such items that he/she purchased and fitted nor is
he/she required to inform the supplier/manufacturer of the details of the
end user.
6. As a consequence it seems that the Product Recall was always likely to
be ineffective. (It would be interesting to know how many products the
manufacturer thought were affected and how many responses they had to
the Product Recail Notice).
7. Itseems to me that these concerns are not unique to fuse boxes, but that
there are many potentially lethal products which are fitted into domestic
properties which are purchased by a third party rather than the occupier.
ACTION SHOULD BE TAKEN
| In my opinion action should be taken to prevent future deaths and | believe the
Department for Business, Energy & Industrial Strategy has 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 30 October 2017. |, the coroner, may extend the period.
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 | Fax 0300-300-8267
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.
a
COPIES and PUBLICATION
| have sent a copy of my report to the Chief Coroner and to the following
interested Persons] daughter of the deceased). I have also sent it
to Bedfordshire Fire and Rescue Service who may find it useful or of interest.
lam 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 11th September 2017
IAN PEARS
Acting Senior Coroner
for the Coroner Area of Bedfordshire & Luton
Senior Coroner, The Court House, Woburn Street, AMPTHILL, Bedfordshire, MK45 2HX
Tel 0300-300-6559 {| Fax 0300-300-8267
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.
@ Department for Business, Energy & lndustrial Strategy Mr lain Pears Acting Senior Coroner for Bedfordshire and Luton HM Coroner's Office The Court House Woburn Street Ampthill MK45 2HX *t* (\^^. ?a-øu.Å, Margot James MP Department for Business, Energy & lndustr¡al Strategy 1 Victoria Street London SWlH OET 1 +44 (0) 20 7215 5000 E enquiries@beis.oov.uk W www.qov.uk Our ref: BB17 Your ref: 42387-2017 XD November 2017 Thank you for your Regulation 28 Report to Prevent Future Deaths dated 11 September 2017 following your investigatíon and inquest into the death of Brian David Betterton, due to accidental death caused by Carbon Monoxide Poisoning. I am responding as the Minister responsible for the safety of consumer products. May I first say how sorry I was to hear of this tragic accident. lf you have the opportunity would you please convey my deepest sympathies to Mr. Betterton's family. I recognise that the public needs to be reassured that the system for consumer product safety is working and that where unsafe electrical goods are identified they are dealt with swiftly and effectively. Product safety is a priority of this Government and we already have comprehensive legislative regulation to ensure products are safe before being placed on the market. ln addition, in October 20161 set up the Working Group on Product Recalls and Safety to bring together product safety experts, the fire service and trading standards professionals to identify where improvements could be made to the system of product recalls and safety. The Working Group published its recommendation on how to improve recalls and reduce fires in white goods on 19 July. The Government will be responding shortly but we have already taken action to implement many of the Working Group's recommendations. We have supported the development of a new BSI (the British Standards lnstitution) code of practice on corrective action and recalls which was recently the subject of public consultation. We have also commissioned research to understand how to increase the impact and effectiveness of product safety messages, so that more consumers respond to recalls. The Government's recalls website at www nroci uctrecall.camoaion.oov uk has been further upgraded so that consumers can quickly check for the latest recalls and register their appliances to allow them to be contacted directly about any future recalls of their products These changes, while aimed at consumers, will also make it easier for tradespeople to check for any safety recalls of products they are installing. I have fed the important points that you raise into the development of the BSI code of practice and I have also asked my officials to share your concerns with colleagues in the Department for Communities and Local Government who are responsible for Buildings Regulations. As you will be aware a review of Building Regulations has been announced and is being undertaken by . I hope this helps to assure you that we are more determined to than ever to ensure that consumers can have confidence in the safety of the electrical products in their home. J.*ø +,.^ftd4 MARGOT JAMES MP Minister for Small Business, Consumers & Corporate Responsibility
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