Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0261, written 16 Aug 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 16 Aug 2017 |
|---|---|
| Reference | 2017-0261 |
| Deceased | Isabella Pritchard |
| Coroner | Peter Bedford |
| Coroner area | Berkshire |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Classification: OFFICIAL-SENSITIVE REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State: Department of Communities and Local Government, 2 Marsham Street, Westminster, London, SW1P 4DF. The Secretary of State: Department of Business, Energy and Industrial Strategy, 1 Victoria Street, Westminster, London, SW1H 0ET. 1. CORONER I am Peter James Bedford, Senior Coroner, for the coroner area of Berkshire. 2. CORONER’S LEGAL POWERS I 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 I was informed of the death of 6 year old Isabella Pritchard who died at Wexham Park Hospital, Slough, Berkshire on the 7th July 2012 from catastrophic head injuries suffered when the marble mantelpiece in the lounge of her home at fell and struck her. Following a lengthy investigation involving the Health & Safety Executive and Thames Valley Police, a conviction was secured against the contractor who originally installed the mantelpiece. Having opened and adjourned my Inquest Investigation into this young lady’s death under Schedule 1 of the Coroner’s and Justice Act 2009, as a result of the prosecution I was not required to resume the Inquest as the criminal proceedings stood in its stead. However, it is clear that a Coroner’s powers under Regulation 28 to issue a Report to Prevent Future Deaths are not restricted to matters revealed in evidence at an Inquest. The matter giving rise to concern may be something revealed at any stage of a Coroner’s Investigation. Classification: OFFICIAL-SENSITIVE -1- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 4. CIRCUMSTANCES OF THE DEATH Isabella Pritchard was found in the lounge with fatal head injuries and with three pieces of a marble mantelpiece lying around her. The incident was not witnessed but it is clearly understood that the mantelpiece had come away from the wall and struck her. A forensic post mortem examination revealed the cause of death of “severe head injury.” Despite lengthy and detailed Investigations, only the contractor who installed the mantelpiece could be prosecuted under the existing regulations and legislation. The information supplied to me raises concerns with regard to a potential faulty design of the fireplace that was not required to be mechanically fixed to either the wall or some other part of the fire surround and also the apparent situation whereby installation of fireplaces are completely unregulated. 5. CORONER’S CONCERNS During the course of gathering evidence following this tragic death, the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could 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) It appears to me that both the manufacturer and installation of stone fireplaces are an unregulated industry. (2) There appears to be no quality/safety standard that applies to fireplaces. The British Standards (BS1251) appears to relate purely to flues and combustible properties of the chimney itself. I am aware of no BSI kite mark applicable to fireplaces. It therefore seems possible to design and manufacture a product with dangerous design features that are cosmetically attractive but inherently dangerous. The fireplace that struck and killed Isabella Pritchard incorporated a stone mantle weighing 86kg with a design relying on gravity and adhesive to keep it in place. In addition, the installation instructions provided by the manufacturer by their own installer were vague in detail, generic and covered their whole range of products. I understand that most high street DIY warehouses sell fireplaces, some weighing as much as 125kg where the design, if untested, could have the same design faults. (3) I understand that there is no regulation or building control around the installation of fireplaces. I believe building regulations do not cover this area as they are deemed to be a decorative item. While I understand that Classification: OFFICIAL-SENSITIVE -2- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS the NHBC now mandatorily require the use of mechanical fixings, this does not cover every instance. Also, that the Stone Federation issued guidelines but are guidelines only. Further, they are a non-regulatory trade body where membership is optional and adherence to their guidelines is entirely voluntary. (4) I understand that building regulations are the responsibility of the Department of Communities and Local Government. I would invite consideration of an amendment to building regulations that might not only ensure safe installation at new builds but could also encompass installations where a fireplace is retrofitted, for example, in the course of the renovation. Might it also be possible to include installation of fire surrounds into the GasSafe or HETAS Scheme? (5) I understand that general product safety, including safe design and products requiring to be marked as compliant, fall under the Department for Business Energy and Industrial Strategy. I ask if powers under that sphere of responsibility could be considered in the context of the circumstances of Isabella Pritchard’s death with a view to taking steps to prevent the risk of a repeat tragedy in the future. 6. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe your departments have the power to take such action. 7. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by MONDAY 16th OCTOBER 2017. 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. 8. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and also to the family of Isabella Pritchard. You are also under a duty to send the Chief Coroner a copy of your response. Classification: OFFICIAL-SENSITIVE -3- Classification: OFFICIAL-SENSITIVE REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 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. 9. 16th August 2017 Peter J. Bedford Senior Coroner for Berkshire Classification: OFFICIAL-SENSITIVE -4-
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.
| The Rt Hon Sajid Javid MP Secretary of State for Communities and Local i Department for Government Communities and Department for Communities and Local Local Government Government Fry Building 2 Marsham Street Ae . - London Mr Peter Bedford SWIP 4DF Senior Coroner for Berkshire Reading Town Hall Tel: 0303 444 3450 Blagrave Street Fax: 020 7035 0018 Reading www.gov.uk/delg Berkshire . RGI 10H Our Ref: 3465158 Your ref! PIB/PRITCHARD I 25 October 2017 Da Me Bedynd ; Thank you for your letter of 18 August following your investigation into the death of six year old Isabella Pritchard in 2012 who was struck by a falling stone mantelpiece. You have provided me with a copy of your Regulation 28 Report calling for my response that sets out actions taken or proposed to prevent future deaths, May I stress at the outset how sorry I was to hear about the tragic death of this young girl. Although such events are thankfully rare my department is aware of a small number of similar instances and has previously considered and worked with others to act upon this. The Building Regulations do not control fixtures such as decorative fireplace surrounds. The issue was previously considered by the Building Regulations Advisory Committee, industry experts and technical specialists from my department who looked at options for revising the statutory guidance in relation to compliance with the Building Regulations’ requirements on structures ( Approved Document A). At the time, it was considered unlikely that regulation would be the most effective way of controlling this type of work, much of which is decorative in nature and is often carried out by householders rather than professionals. It was felt that it would be difficult to enforce requirements on householders and awareness of building regulations amongst this group is low, Instead it was considered that there was a need to get more general guidance on the fixing of fireplace surrounds to a wider audience so my department has worked with others to make such good practice guidance on fireplace installations more widely available. Agencies and external partners who have published guidance include: e The Royal Society for the Prevention of Accidents has promoted the importance of safe installation of stone fireplace surrounds. e In April 2013, the Health and Safety Executive issued a safety alert aimed at suppliers of stone fireplace surrounds of the need to provide adequate fixings as well as instructions on safe installation. ® In Qctober 2013, the National House Building Council issued standards in relation to fixing fireplace surrounds for new homes. « In 2012, the Stone Federation of Great Britain made best practice guidance on the fixing of stone fireplace surrounds publicly available on its website and updated this guidance in January 2015. ¢ The Standing Committee on Structural Safety (SCOSS) issued Report 145 drawing structural engineers’ attention to the issue. A lot has been done to raise awareness however; given the tragic nature of this incident lL will ask the Building Regulations Advisory Committee to re-consider their previous advice not to regulate for stone fire surrounds (and other heavy decorative items that require substantial fixings for their safety, such as large mirrors). Additionally 1 will make arrangements through authorised schemes, including the Gas Safe Register and HETAS, to alert their registered installers of gas fires and wood burning stoves to good practice guidance on the fixing of stone fireplace surrounds. L will also ask my officials to continue to work with other agencies and external partners to keep guidance on fireplace installations up to date and available. Lnote that your report was also sent to the Rt Hon Greg Clark MP, Secretary of State for Business, Energy and Industrial Strategy and his office responded separately on 29 August 2017. I would be grateful if you could convey my sympathy onto Isabella’s family. _ Crit a RT HON SAJI 1 MP
See every Prevention of Future Deaths report matching Product related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.