Prevention of Future Deaths reports · 2020

Joey Walker

Regulation 28 report to prevent future deaths, reference 2020-0226, written 9 Nov 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Nov 2020
Reference2020-0226
DeceasedJoey Walker
CoronerChris Morris
Coroner areaManchester South
CategoryChild Death (from 2015)
Sourcejudiciary.uk record · original PDF
Responses published2

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.

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO

The Rt. Hon. Robert Jenrick MP, Secretary of State for Housing,
Communities and Local Government.

}_ —

CORONER

| am Chris Morris, Area Coroner for Greater Manchester South.

| 2

—e |

a

+

CORONER'S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and
_Justice Act 2009 and regulations 28 and 29 ofthe 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 1st May 2020, Alison Mutch OBE, Senior Coroner for Manchester
(South), opened an inquest into the death of Joey Jenson Walker who
died at the Royal Manchester Children’s Hospital on 23rd April 2020. The
investigation concluded at the end of the paves, which | heard on 29th
October|2020.

The court heard evidence that Master Walker died as a consequence of: -
1) a) Hypoxic brain injury;

b) Out of hospital cardiac arrest;

c) Accidental strangulation. !

The inquest concluded that Master Walker died as a consequence of an
accident.

CIRCUMSTANCES OF THE DEATH

On 5th April 2020, Master Walker was found unresponsive in an upstairs
bedroom of the private rented house he shared with his mother, having
become entangled by the neck in a roller-blind cord.

Master Walker was freed and resuscitation efforts commenced before he
was taken to the focal hospital by ambulance. From there he was
transferred to the Paediatric Intensive Care Unit at Royal Manchester
Children’s Hospital where he tragically died 18 days later.

A police investigation concluded there were no suspicious circumstances
surrounding Master Walker's death. The investigation established the
blind cord (which had probably been installed by a previous tenant) was
not a functioning safety cord which would break if undue pressure was
put on it.

| CORONER'S CONCERNS

—— | Itis‘a matter of concern that-residential landlords are not currently subject
~—~|-to- any obligation to inspect window coverings such as roller blinds ~ =

tenants.

The MATTER OF CONCERN is as follows. —

installed at private rental properties, or to otherwise ensure that only
safety cords are used on blinds in-use in properties let out to residential

“TACTION SHOULD BE TAKEN

In my opinion, action should be taken to prevent future deaths and |

believe you and your organisation have the power to take such a
4

| YOUR RESPONS

You are under a duty to respond to this report within 56 days of the date
of this report, namely by 4th January 2021. 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

7

COPIES and RUBTICATION

| have sent a copy of my report to the Chief Coroner and to Master

Walker's mother and father. | have also sent a copy of my report to
Tameside Metropolitan Borough Council and the British Blind and Shutter |

nN

Association, 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.

Signature: Lee
Chris Morris HM Area Coroner, Manchdster South.
Dated: 9th November 2020 )

rc eS ra I I RR ea I Se ee TE

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Responses

2 responses 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 British Blind and Shutter Association (PDF)
®

The British Blind and Shutter Association Limited

S> S SS A\N\ PO Box 232, Stowmarket, Suffolk, [P14 GAR

BRITISH BLIND & SHUTTER ASSOCIATION

1

Email: info@bbsa.org.uk

Supporting the industry since 19149 Web: www.bbsa.org.uk

Mr Chris Morris

HM Area Coroner
Coroner's Court

1 Mount Tabor Street
Stockport

SK1 3AG

13 April 2021

Dear Mr Morris,
Re: Regulation 28 Report into the death of Joey Jenson Walker

I am writing with an update to our joint letter with Royal Society for the Prevention of
Accidents of 8 January 2021.

The BBSA has worked with Trading Standards and RoSPA to produce some specific
guidance for Landlords highlighting their responsibilities and how to make existing blinds
safer. I am enclosing a copy for your information.

We have also updated our child safety website to include landlords in the menu options
and to signpost this guidance on this website - www.makeitsafe.org.uk.

I am pleased to report the National Residential Landlords Association are supporting the
dissemination of this guidance to their members. We are in contact with others in the
residential letting sector to do the same.

Please do not hesitate to contact me if you have any questions.

Yours sincerely,

Director of Operations
British Blind and Shutter Association co R

Openings a @ Es S-

Magazine

Registered in England No. 2584680 VAT Registration No. 233 3011 22

Landlord Advice on
Window Blind Safety

According to the Royal Society for the Prevention of Accidents since 1999 there have been at least 35 fatalities where
babies and young children have become accidentally entangled in internal window blind cords and chains.

Some of these accidents have occurred in rented homes.

Advice from Trading Standards states:

e Landlords have a duty of care to their tenants, including keeping their rented properties safe and free from health
hazards: https://www.gov.uk/renting-out-a-property/landlord-responsibilities

Landlords therefore have a responsibility to ensure all blinds installed anywhere in their properties which contain
cords or chains (which may be hazardous) are safe

if the blinds cannot be made safe by the addition of a compliant safety device(s) they should be replaced

Blinds installed by the landlord or their agent after February 2014 must be compliant with the child safety
requirements of BS EN 13120:2009+A1:2014

Blinds installed by the tenant should be checked to ensure they are compliant as part of the landlord/agent
inspections

e Tenants should be advised of the child safety aspects of internal window blinds

¢ Compliance with the standard is required irrespective of the age of the tenants, including where no children are
present

e This advice covers all residential environments and will include (but is not exclusive to) homes, holiday homes,
mobile homes, caravans and boats

R@SPA|

make it
sefe

| Window blind standards

The child safety requirements of the internal window blind standards were changed in February 2014. The applicable
legislation is the General Product Safety Regulations 2005 and compliance with the standards provides a presumption
of conformity with these regulations.

¢ All safety systems and safety critical items of internal blinds to be tested

¢ All products to be either inherently safe/‘safe by design’ (contain no dangerous loops or cords) or for cords and
chains to be provided with safety device(s) at the point of manufacture

© All products containing cords/chains must be securely fitted with safety device(s) supplied during installation to
eliminate any potential hazardous loops or entanglement

© All safety devices must be securely fitted at least 1.5m from the floor except for breakaway devices — these must
be at least 0.6m from the floor

e Instructions must be left with the customer and all warning labels left on the product at the point of fitting. The
installer/ instruction leaflet must inform you why the safety device(s) are necessary, how and where they need to
be installed and how to correctly operate the blind

The BBSA strongly recommends that blinds which are inherently safe,
sometimes called ‘safe by design’, are used in rented properties as these
do not require any supplementary safety devices. As such these blind
styles do not need testing to the standards.

Watch the video on what to look for in new blinds here:
www.makeitsafe.org.uk/resource/look-new-blinds/

& :: vimeo

You can find your local BBSA member by searching on www.bbsa.org.uk.

| Existing Blinds

Blinds installed prior to 2014 may not include safety features but every style of blind can be made safer.

Roller
Blind

Vertical
Blind

Barrel at top of window, one sheet __If your blind has a continuous looped chain or cord securely
of fabric. fit a device to hold this taut as in the picture below.

Operated by a spring with a centre
pull cord (likely to be safe if cord is
less than 220mm).

or

Operated by a continuous chain or
cord on one side of the blind. —=p>

The BBSA does not recommend using new breakaway
chain connectors on old blinds as it is not possible to
guarantee the required breakaway tolerance when mixing

new and old.
Watch the video here:

www.makeitsafe.org.uk/resource/make-existing-roller-
blinds-safer/

Headrait at top of window, fabric {f your blind has a continuous looped chain and cord
Slats/louvres. securely fit a device(s) to hold these taut as in the picture

Operation by a wand to draw the —below.
louvres across the window anc tilt
the slats = inherently safe.

or

Operation by continuous chain to tilt
the louvres and continuous cord to

Craw the OUVrES. — >

span en we

HHI

Watch the video here:

www. makeitsafe.org.uk/resource/make-existing-vertical-
blinds-safer/

Venetian
blind

Headrail at top of the window, metal, plastic or
wooden horizontal slats.

Cords to raise/lower the blind. ——-—_-_=—= >

Wand to tilt the slats or cords to tilt the slats. =>

If your blind has cords to raise and lower
the blind these should be a mimimum of
1.5m from the floor with the blind in the fully
lowered position.

Fit a cleat at least 1.5m from
the floor around which the cords
can be wrapped after each and
every use of the blind.

if the tilt cords are excessiviey
long then consider fitting a cleat
to house the cords after each and
every use.

Watch the video here:

www.makeitsafe.org.uk/resource/make-
existing-venetian-blinds-safer/.

Roman
blind

Headrail at top of window, soft fabric covering which

folds as it is retracted.

This is probably the most difficult blind style to make

safer.

Operation tends to be cords to raise/lower the blinds or a
continuous cord or chain to one side of the blind. —=p

However, this style of blind also uses cords on the back
of the fabric to gather the fabric into folds. If the distance
between the folds is greater than 200mm then a suitable
cord breakaway system should be used. This is often

challenging to retrofit onto an old blind.

Front of blind

Back of blind

4]

If your blind has cords to raise and
lower the blind these should be a
mimimum of 1.5m from the floor with
the blind in the fully lowered position.

Fit a cleat at least 1.5m from
the floor around which the cords can
be wrapped after each and every use
of the blind as shown above.

if your blind has a continuous looped
chain or cord securely fit a device to
hold this taut as shown above.

If you cannot retrofit safety devices
to the cords on the back of the blinds
you should replace the blind.

Watch the video here:

www.makeitsafe.org.uk/resource/
make-existing-roman-blinds-safer/

| Pleated Headrail at the top of window on which lf your blind has cords to raise and lower the

| blind pleated (concertina) fabric is hetd. blind these should be a mimimum of 1.5m
| Operation tends to be cords to raise/lower the ‘Tm the floor with the blind in the fully lowered
blinds or a continuous cord or chain to one —~PASition.

side of the blind. aD Fit a cleat at least 1.5m from the floor around
which the cords can be wrapped after each and
every use of the blind as shown above.

If your blind has a continuous looped chain or
cord securely fit a device to hold this taut as
shown above.

Watch the video here:

www.makeitsafe.org.uk/resource/make-
existing-pleated-blinds-safer/

The same safety requirements apply for corded curtain tracks.

if a Available in 12 languages. Free to download.
este BBEA,

Where to get more information:
www.makeitsafe.org.uk

This leaflet is intended only to give general and preliminary guidance and is for information purposes only. It does not, and is not intended
to give, professional or technical advice. The reader should always seek specific advice from a professional. Unless arising as a result of the
BBSA’s negligence, the BBSA accepts no liability in contract or tort, and are not responsible for any loss (howsoever caused), and whether
arising directly or indirectly, as a result of any action taken based upon the information contained in this leaflet.

British Blind and Shutter Association
PO Box 232, Stowmarket, Suffolk, P14 9AR. © 2021 v1

0
Response from Secretary of State for Housing Communities and Local Government (PDF)
Le. Rt Hon Robert Jenrick MP
Secretary of State for Housing, Communities and

Local Government

Ministry of Housing,
Communities & Ministry of Housing, Communities and Local
Government
Local Government Fry Building
2 Marsham Street
London
SW1P 4DF

Coroners Court

.gov.uk/mhel
1 Mount Tabor Street www.gov.uk/mhclg
Stockport
Cheshire

SK1 3AG A
December 2020

— Dear Chas,

Thank you for your letter and accompanying Regulation 28 Report of 9 November. I’m deeply
sorry to hear of Joey Walker’s death and my sympathies are with his family. | am of course
reminded of a similar tragic incident last year where a child died having become entangled in
a blind cord. | would like to reiterate that | take the health and safety of all people, and
children in particular, very seriously.

| wanted to set out the relevant legal provisions which are already in place. Firstly, the
General Product Safety Regulations 2005 place a legal obligation on producers to ensure
that their products, including blinds and blind cords, are safe before they can be placed on
the market.

In addition, in February 2014 a harmonised European Safety Standard was introduced which
requires that new blinds must be ‘safe by design’ or be supplied with appropriate child safety
devices installed. The standards apply to blinds purchased or installed after February 2014 -
manufacturers and retailers of blinds who do not comply with the standard may be
prosecuted.

In the case of the two recent tragic accidents, both children’s families were private tenants.
However, the risks that these cases have highlighted will affect children in all tenures. This is
why, following the incident last year, | asked my officials to work with the Office for Product
Safety and Standards (OPSS), which is part of the Department of Business, Energy and
Industrial Strategy (BEIS). OPSS holds responsibility for regulation of the safety of consumer
products like window blinds. The Government, through OPSS, continue to fund the Royal
Society for the Prevention of Accidents (RoSPA) to raise awareness of safety risks, including
the importance of noting warnings and following safety instructions where they are included.

RoSPA are leading a campaign, supported by the Government, to highlight the potential
dangers of looped blind cords, particularly among families with small children.

My officials have worked with their colleagues at OPSS to further publicise this campaign,
through our newsletters to landlords and local authorities and our suite of guides for private
rented sector landlords and tenants that cover safety in rented properties. | will ask that they
continue this work with their colleagues in OPSS, in particular identifying more ways this
information can be disseminated to all housing tenures.

Thank you again for your letter and | hope my response provides reassurance about how
seriously |, and the Government, consider this matter.

Youn avy,

net L

RT HON ROBERT JENRICK MP

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