Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0311, written 31 Oct 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Oct 2017 |
|---|---|
| Reference | 2017-0311 |
| Deceased | Douglas McTavish |
| Coroner | David Lewis |
| Coroner area | North Wales (East & Central) |
| 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.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Whirlpool (UK) Appliances Ltd c/o Plexus Law, Joseph’s Well, Hanover Walk, Leeds 4 CORONER lam David Lewis, Assistant Coroner, for the coroner area of North Wales (East and Central) 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 20 October 2014 HM Senior Coroner commenced an investigation into the deaths of Bernard Hender and Douglas McTavish. The investigation concluded at the end of the inquest on 1 September 2017, when | announced my findings and conclusion following evidence | heard on 19-21 April and 16-17 August 2017. The conclusion of the inquest was a narrative in the following terms: Shortly after 06.15 on the 10% October 2014 the deceased and a friend were each retrieved by officers from North Wales Fire and Rescue Services from their home address at The Star, Llanwrst, which had been the subject of a major accidental fire. The deceased died later the same day due to smoke inhalation and carbon monoxide poisoning due to the effects of the fire. On the balance of probabilities the fire was caused by an electrical fault in a tumble dryer in the laundry room at the flat In the case of each of the deceased the medical cause of death was: 1 (a) Smoke inhalation with Carbon Monoxide Poisoning 1 (b) Dwelling fire. 4 | CIRCUMSTANCES OF THE DEATH The deceased and a... all present in the flat which they shared at the Star at Llanrwst on 10 October when a fire took place. The fire, which originated in the laundry room, was discovered at about 06:00. Within minutes the alarm was raised by a attempted to rouse both of the deceased before making good his escape. The Fire and Rescue Service responded promptly and appropriately. Although they were able to retrieve both of the deceased within minutes of their arrival, both succumbed the same day to the effects of smoke from the fire. The inquest heard a number of possible theories as to the cause of the fire. Some were easily discounted but four received lengthy and detailed attention from witnesses who were either experts in their field or possessed of such experience that their evidence amounted to quasi-expert testimony. Having considered the entirety of the evidence | found that whilst it remained a possibility that the fire had started as a result of one of four possible causes (a problem with the light fitting, a problem with the iron, a problem with the tumble dryer or spontaneous combustion of recently dried material) on the balance of probabilities the fire could be attributed to a problem with the tumble dryer; more specifically an electrical fault associated with the door switch assembly. | heard evidence confirming that the manufacturers of the dryer were aware of a significant number of others fires associated with similar appliances and door switch assemblies in which a problem with the door switch had either been identified or not ruled out as cause of the fire. 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 door switch assembly of interest in this case is used in literally hundreds of thousands of appliances manufactured by Whirlpool. | did not emerge from the hearing confident that Whirlpool’s risk assessment processed have fully identified or appreciated the extent of the risk of fire (and its potential consequences), My impression was that at least some of the evidence from those called at the request of Whirlpool was defensive and dismissive in nature. The description by the company’s former Global Product Safety Director of the company’s approach to what he described as ‘soft data’ from the field (meaning, amongst other things, reported instances of fires) was of considerable concern to me. | am concerned that the company’s reluctance to place due reliance on information coming forward in this way, and instead to prefer to take advice from itself, represents an obstacle to timely learning and a likely inhibitor to progressive steps which might prevent fires and — | (2) In the course of evidence’ spoke about his belief that the most likely cause of the fire being spontaneous combustion, and explained that he was aware of hundreds of fires of that origin. | was not sure that public awareness of the magnitude of the ."] and of the circumstances in which it might materialise reflects the picture painted by! | am concerned that not enough has been done historically to raise awareness of this risk. ACTION SHOULD BE TAKEN 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 26 December 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. COPIES and PUBLICATION | have sent a copy of my report to the Chief Coroner and to the following Interested Persons : The Families of Mr Hender and Mr McTavish c/o Leigh Day Solicitors, PY and Peterborough Trading Standards in their capacity-of Primary Authority | 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. ra) [DATE] 31.10.17 [SIGNED BY CORONER] / '
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.
WHIRLPOOL (UK) APPLIANCES LIMITED’S RESPONSE TO REGULATION 28: REPORT TO PREVENT FUTURE DEATHS) DATED 31 OCTOBER 2017 We are writing to provide Whirlpool’s response to the Regulation 28 Report to Prevent Future Deaths dated 31.10.17 arising out of the Inquest into the deaths of Bernard Hender and Douglas McTavish. May we first of all say again how truly sorry we were to hear of this tragic incident and would like to take this opportunity to repeat our deepest condolences to the families and friends of Mr Hender and Mr McTavish. We have reviewed carefully the comments of the Coroner set out in the Regulation 28 Report, and respectfully provide the following responses to the two “Matters of Concern” raised in that report. WHIRLPOOL’S PRODUCT SAFETY PROCESSES We understand that the Coroner was left with some concerns about Whirlpool’s systems based in particular on certain evidence that was received during the hearing when Whirlpool’s former Global Product Safety Director was being questioned. We think that aspects of that evidence would benefit from further explanation and expansion to avoid any misunderstanding of the position. We therefore welcome this opportunity to address the Coroner's concerns, and to provide fuller details of Whirlpool’s product safety systems, including as they relate to the risks of fire associated with the use of tumble dryers. Whirlpool has a comprehensive set of policies, procedures, and guidelines in place for field monitoring, field safety investigations, analysis, risk assessment, and reporting potential safety hazards associated with its products. These systems have been developed and refined over decades, and Whirlpool keeps those systems under review as part of its commitment to continual improvement. Whirlpool’s approach to product safety governance starts with senior leadership oversight, with a specially designated Executive Safety Committee. The membership of Whirlpool’s Executive Safety Committee includes members of the Whirlpool senior leadership team from a cross-section of the company. This team is responsible for the decisions regarding the need to undertake field corrective actions for potential product safety risks that have been identified. Whirlpool’s Governance Model is implemented through formal corporate policies which define Whirlpool’s position and philosophy on product safety, formally puts in place the product safety system, defines clear roles and responsibilities for all employees and functional groups, requires pre- market risk assessments, post-sale monitoring of product performance and safety, requires risk assessment of potential issues that are identified on units already with consumers, and defines required communication protocols for these risks. The Governance Model is supported and implemented through multiple corporate and functional policies and procedures. Another important aspect of product safety governance at Whirlpool is the built-in system of checks and balances. Whirlpool has established an independent Global Product Safety Team which operates separately from product development, engineering, and commercial teams. The independence from the product development, engineering, and commercial teams allows this team to make unbiased decisions that are focused first on safety. This team has a direct link to the Whirlpool senior leadership team. Whirlpool requires a continual assessment of risk of potential safety hazards throughout the lifecycle of the product, from product development to marketing to disposal. This includes a formal and comprehensive pre-market risk assessment and safety audit, and continuous field monitoring of field hazard incidents and allegations. Whirlpool’s approach to monitor product performance in the field is a broad approach, practiced globally, that considers all reports that we receive involving our product where the consumer perceives their safety may be at risk. Whirlpool receives information and data about potential product safety incidents from multiple sources, including among others, Consumers, Trading Standards, Fire & Rescue Services and insurance companies. When this initial contact occurs, every effort is made to gather as much information as possible regarding the appliance, the consumer and the alleged incident. This allows us to both assist the consumer wherever we can, and it also allows us to investigate the matter in more depth. Regardless of the source of the information, all such cases are channelled through to a dedicated team in the UK to ensure that we have a consistent approach with our initial investigation process throughout. We wish to make it clear that there is no reluctance on the part of Whirlpool to consider, and as appropriate, place due reliance on information received from sources external to Whirlpool. Indeed, information from external sources is vitally important including information received from experts not appointed by or on behalf of Whirlpool. If an alleged incident description, references any concerns of safety, efforts are made to arrange a visit to the consumer's home by a qualified service engineer: to further assess the reported experience, to gain additional facts and to better understand the alleged event. This access to the product allows for further assessment of the consumer's description and provides a_ better understanding and refinement of the physical facts to determine if our product may have behaved in a potentially unsafe manner. If the information provided continues to lead the team to believe that the product’s behaviour may have resulted in it failing in a potentially unsafe manner, then, wherever possible arrangements are then made to retrieve the product and return it to our Product Safety Team team for a detailed inspection, here in the UK. Retrieving the product allows Whirlpool to conduct a more robust engineering inspection in a laboratory environment with the intent to identify and confirm the root cause that may or may not be consistent with the consumer's reported experience. If retrieval of the product is not possible (for example where the product cannot be released to us for legal reasons), where appropriate, throughout the country Whirlpool routinely uses third party, ( independent) Forensic engineers to support this work and examine the appliance on our behalf. In some instances, the physical product may not be available or may not require a field replacement however, the details of the report is still documented in our system and can be used qualitatively when an engineering investigation is performed. Whirlpool’s process is structured to funnel, along with other pertinent information, all machine inspection reports into one central database, irrespective of whether the report was generated by a Whirlpool employee or an independent forensic expert. Every alleged incident that is reported to Whirlpool is investigated and at the end of the investigation, if safety-related in nature, is reviewed by the team of dedicated product safety engineers, and is judged on the merit of the information available, irrespective of the source of that information (be it internally or externally gathered information), including where appropriate with the further support of external experts. After this review, the incidents are categorized into a structured and searchable database so potential field safety hazards, that may require further action, can be identified, monitored, and assessed. Therefore it would be a misunderstanding of the intent of the explanations given at the hearing to conclude that Whirlpool did not have full regard for what was described as “soft data”. As explained, that kind of data is a vital component of Whirlpool’s product safety processes. These processes were applied in full to any reports of fire which may involve components such as door switch mechanisms, and have been applied to the incident reports that were drawn to the Coroner’s attention during the course of the Inquest. Action taken or proposed to be taken Whirlpool continues to apply the processes described above on an ongoing basis, and will continue to carefully monitor reports from the field, and from other sources, which may involve fire risks associated with its products. Furthermore, over the past weeks, we have responded to specific questions raised of us by Trading Standards following the delivery of the findings by the Coroner in this inquest. Whirlpool will continue to co-operate with Trading Standards in relation to such issues. We trust that this additional information and further explanation helps in addressing any concerns that were raised during the course of evidence at the Inquest. SPONTANEOUS COMBUSTION Spontaneous combustion of laundry materials dried using a tumble dryer is a known, avoidable risk in the industry that can arise in some circumstances. For example, in May this year the Devon and Somerset Fire and Rescue Service attended a fire at the Exeter Chiefs ground in Devon which local fire investigators indicated was most likely caused by tea towels which spontaneously combusted. Watch Manager Gareth Sydenham, of Devon and Somerset Fire and Rescue Service, said “/t may sound like a strange phenomenon but is actually more common than you might think. Cotton laundry can often be contaminated with organic cooking oils that can self-ignite if dried and stored.” The risk can be avoided, if consumers follow the user instructions provided with Whirlpool Tumble Dryers?. Action taken or proposed to be taken Whirlpool agrees with the Coroner that there is a benefit in increasing public awareness of the potential risks of misusing a tumble dryer, such as the risk of spontaneous combustion. This is an industry wide issue. Whirlpool is willing to support any initiatives that help raise consumer awareness of the risk. Whirlpool is willing to work with AMDEA, the Fire Brigade, Electrical Safety First and any other organisations concerned with consumer safety to discuss the ways in which these issues can be best communicated to the public. Since the delivery of the Coroner's Regulation 28 Report, Whirlpool has already taken positive steps in this regard. Whirlpool reached out to AMDEA and arranged for relevant usage instructions to avoid the risk of spontaneous combustion to be added to the “Register my appliance” website®. 1 https://dsfire.gov.uk/News/Newsdesk/PressReleaseArticle.cfm?ReleaselD=1993&siteCategoryld=3& T1ID=26&T2ID=36 ? See for example Hotpoint Aqaultis AQc9 4F7 Tumble Dryer Instruction Booklet http://www. hotpoint.eu/hotpoint/_pdf/manuals/19510399205 GB.pdf, at page 4. 3 https://www.registermyappliance.org.uk/care-performance/appliance-care/ PUBLICATION OF THIS RESPONSE As the Regulation 28 Report was published, Whirlpool thinks it appropriate for this Response to be published. For and on behalf of Whirlpool UK Appliances Limited Dated: 22 December 2017
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