Janet Jasper

Mrs Tankya Rawden 
Assistant Coroner 
Rutland and North Leicestershire Coroner’s Court 
Southfield Road,  
Loughborough  
LE11 2TR 

13 March 2020 

Dear Mrs Rawden 

Inquest touching the death of Mrs Janet Jasper 
Response to Regulation 28 Report – Prevention of Future Deaths 

Following the Inquest touching the death of Mrs Janet Jasper, this letter sets out the joint response 
to  the  Regulation  28  Report  from  the  Gas  Distribution  Networks  (GDNs),  namely  Cadent  Gas 
Limited, Northern Gas Networks Limited, Scotland Gas Networks PLC, Southern Gas Networks PLC 
and Wales and West Utilities Limited (the “GDNs”).  The sympathies of all GDN’s remain with Mrs 
Jasper’s family following this tragic accident.       

The Regulation 28 Report sets out two separate matters of concern: (1) that there are two hundred 
and fifty-four properties within the immediate area of the incident which are at risk of floors failing in 
a  similar  manner;  and  (2)  that  there  was  inconsistency  in  the  GDNs’  requirements  for  checking 
adjoining and adjacent properties when responding to reports of internal gas escapes.   

As explained during the inquest, the GDNs had a pre-arranged meeting with the Health and Safety 
Executive (“HSE”) on 23 January 2020 and had added to the agenda the consistency of procedures 
for  responding  to  reports  of  internal  gas  escapes  (and  specifically  the  checking  of  adjacent  or 
adjoining properties).   

This meeting was attended by the engineering policy leads for each of the GDNs, together with Steve 
Critchlow and Caroline Lane of the HSE.  At this meeting, it was agreed that the GDNs did not have 
any power to take action in relation to the two hundred and fifty-four properties which were at risk of 
floors failing and the HSE would consider this point separately.   

In relation to the GDN procedures, when the documents were reviewed as a whole and side by side, 
it  was  agreed  that  there  was  already  a  consistent  approach  to  checking  adjoining  and  adjacent 
properties  when  investigating  an  internal  escape.    However,  detailed  discussions  continued  in 
relation to whether the industry could clarify its existing procedures in this regard.     

The GDNs met again on 5 February 2020 at the Energy Networks Association and agreed an aligned 
form of wording, which would further clarify existing procedures in relation to investigating reports of 
internal escapes.   

Existing  procedures  already  require  operatives  to  consider  whether  gas  may  be  leaking  from 
alternative sources,  including from  adjoining  and adjacent  properties.  The  agreed  wording going 
forward is that operatives shall take all reasonable, practicable and proportionate measures to  

National Gas Emergency Service 
0800 111 999* (24hrs) 
*Calls will be recorded and may be monitored 

Page 1 of 2 

 
 
 
 
 
 
 
 
 
 
 
 
 investigate the possibility of gas leaking from external sources before confirming a “no trace” result.  
As part of this investigation, operatives must check immediately adjoined and adjacent properties 
where it could be reasonably assumed, based on site conditions, that they are a possible cause of 
the reported smell of gas.   

Where  it  is  not  possible  to  gain  access  to  immediately  adjoined  and  adjacent  properties,  gas 
detection checks will be undertaken at accessible building ingress points, such as letterboxes, air 
bricks, vents, windows etc.  A “no trace” result can only be recorded under the clarified procedures 
where  no  gas  has  been  detected  at  the  original  property  and  where  no  gas  has  been  detected 
following all reasonable, practicable and proportionate measures to investigate the possibility of gas 
leaking from external sources.     

In  February  2020,  the  GDNs  met  again  with  Steve  Critchlow  of  the  HSE  to  report  back  on  their 
proposed approach.  Steve Critchlow agreed with the proposed changes and considered that they 
would meet the Coroner’s aims. 

All  of  the  GDNs  will  be  briefing  their  operational  teams  on  the  revised  requirements,  which  are 
expected to be in place across all networks by mid-summer. 

Although it cannot be concluded that Mrs Jasper’s tragic death could have been prevented had these 
revised  procedures  been  in  place  at  the  time,  we  trust  that  the  approach  being  adopted  by  the 
industry going forward addresses any concerns that may have arisen during the Inquest.  

Yours sincerely 

Chief Safety and Strategy Officer 
Cadent Gas Limited 

Head of Engineering &  
Network Strategy   
Scotland Gas Networks PLC & 
Southern Gas Networks PLC 

Head of Asset Integrity 
Northern Gas Networks Limited 

Chief Operating Officer 
Wales and West Utilities Limited 

cc. 

HSE 

National Gas Emergency Service 
0800 111 999* (24hrs) 
*Calls will be recorded and may be monitored 

Page 2 of 2

Mrs T Rawden 
Senior Coroner’s Office 
Rutland and North Leicestershire Coroner’s Office 
Southfield Road 
Loughborough 
LE11 2TR 

Engagement and Policy Division 

Head of Manufacturing and 
Utilities Unit 
Foundry House, 
3 Millsands 
Riverside Exchange 
Sheffield 
S3 8NH 

http://www.hse.gov.uk/ 

Head of Division 

Date: 12 March 2020 
Reference: Janet Shirley Jasper Inquest 

Dear Mrs Rawden, 

I am writing in response to the Regulation 28 – Report to Prevent Future 
Deaths issued by you on 17 January 2020 in relation to the Janet Shirley 
Inquest. 

In your report you highlighted the following area of concern: 

The Court heard that there are two hundred and fifty four properties 
within the immediate area of the incident which are at risk of floors 
failing in a similar manner. 

The Court also heard that there is inconsistency in the policies of the 
four gas distribution networks with some requiring first call operatives 
to inspect adjoining properties for gas and some permitting the 
operative to make that decision based on the circumstances and 
findings on scene. 

In my opinion there is a risk that future deaths may occur unless the 
risk to the other properties within the immediate area of the incident is 
properly and quickly address, and a consistent approach to inspecting 
adjoining properties developed. 

I am writing to confirm the activity that has taken place and/or been agreed 
since the incident. 

 
 
 
 1.  GDN policies and procedures 

The Gas Distribution Networks met 5 February 2020 to review their 
current EM72 policies, the policies that describe the action that should 
be taken when responding to a callout about a possible gas leak. In 
particular, the meeting was looking at the policies in relation to “no 
trace” declarations when attending a reported internal smell of gas and 
whether these were -fit for purpose, consistent between each GDN, 
and consistent with their approach to investigating CO incidents. 

At this meeting all GDNs agreed, in principle, to adopt a new and 
consistent policy: 

If at an internal PRE and there is no trace at the reported 
address then the operative: 

 

  MUST check those properties which are immediately adjoined or 
adjacent including building line, points of ingress, letterbox and 
knock for entry. 
If access is gained ask questions about whether a smell of gas 
has been noticed. 
If no smell of gas reported, carry out gas detection checks 
(tightness test not required). 
If a smell of gas is reported or detected undertake a tightness 
test and follow normal gas escape procedures. 

 

 

If no readings are found either inside or via letterbox checks, 
then report work as no trace. 

This new policy will bring the policy in relation to reported internal smell 
of gas in line with those on external gas smells and for CO response, 
which in turn should provide a significant improvement in safety. 

Each GDN will now agree these new policies with their relevant 
Director’s and legal departments prior to implementation. 

HSE has agreed that if any changes are made to the revised policy 
prior to rollout this must be discussed and agreed with HSE first. 

2.  Other properties in the immediate area at risk 

HSE, along with the Gas Safe Register, undertook extensive 
communication activity with both residents and gas engineers in the 
local area to advise them of the cause of the incident, the risk to their 
own properties and the action the could take to mitigate this. This 
included: 

  Hosting a residents meeting, 
  Providing leaflets for residents to explain the potential risk and 
actions. These leaflets were dropped through the letterboxes of 
affected properties and additional copies were provided to the 
local authority. 

   Providing information from Gas Safe Register specifically for 
local gas engineers to explain what should consider and do 
when attending these properties 

  Providing additional briefing and material for HSE and Gas Safe 

Register staff that might deal with calls from concerned 
residents and/or engineers 

Both HSE and the GDNs have taken your concerns seriously and taken action 
to address the issues raised. 

Yours sincerely, 

Head of Manufacturing and Utilities Unit 

Operational Strategy 

Engagement and Policy Division 

Health and Safety Executive