Prevention of Future Deaths reports · 2020
Regulation 28 report to prevent future deaths, reference 2020-0274, written 7 Dec 2020. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Dec 2020 |
|---|---|
| Reference | 2020-0274 |
| Coroner | Geraint Williams |
| Coroner area | Cornwall and Isles of Scilly |
| 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.
Information Classification: CONFIDENTIAL REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) Re: Kevin David John BRANTON, Richard Lee SMITH, Audrey COOK, Alfred Henry COOK and Maureen Henrietta COOK, deceased REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. 2. Parliamentary Under Secretary of State, Department of Business Energy and Industrial Strategy , Office for Product Safety and Standards 1 CORONER I am Geraint Urias Williams assistant coroner, for the coroner area of Cornwall and the Isles of Scilly. 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 On 17/11/2010 an investigation was commenced into the deaths of Kevin David John Branton, 32 and Richard Lee Smith, 32. On the 01/03/2013 an investigation was commenced into the deaths of Maureen Henrietta Cook, 47, Alfred Henry Cook, 90 and Audrey Cook, 86. The investigations concluded at the end of the inquest on 23/11/2020. The conclusion of the inquest was accidental death as a result of carbon monoxide poisoning. 4 CIRCUMSTANCES OF THE DEATH The 5 deceased died in 2 separate incidents with a common feature namely that a gas cooker at their homes had an inherent defect which meant that if the grill was used with the door closed fatal levels of carbon monoxide were produced. 5 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 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) That there is no national or central database which contains details of gas appliances manufactured, supplied or fitted to homes in the UK which would 1 Information Classification: CONFIDENTIAL allow rapid identification and tracing of potentially dangerous items. (2) That communication between manufacturers, suppliers, wholesalers, fitters and householders in connection with the supply etc of gas appliances is hindered by the lack of mandatory recording of the said manufacture, supply and fitting of such appliances. (3) That the lack of a mandatory scheme for recording the supply etc of such items means that it is difficult and time consuming to trace potentially dangerous items when urgency is of the utmost importance. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] 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 1st February 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The next of kin of the deceased, Beko Plc, Hertfordshire County Council Trading Standards, Intertek, Arcelik. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. 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. 9 [DATE] [SIGNED BY CORONER] 07/12/2020 Mr G. U. Williams, Assistant Coroner 2
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.
Paul Scully MP Parliamentary Under-Secretary of State Department for Business, Energy & Industrial Strategy 1 Victoria Street London SW1H 0ET T E +44 (0) 20 7215 5000 enquiries@beis.gov.uk W www.gov.uk Our ref: 01 February 2021 Mr Geraint Williams Assistant Coroner Cornwall and Isles of Scilly Coroner’s Area H.M. Coroner’s Office Newquay Road Truro Cornwall TR4 9AA Email: Dear Mr Williams, INQUESTS INTO THE DEATHS OF KEVIN BRANTON AND RICHARD SMITH AND JOHN, MAUREEN AND AUDREY COOK, DECEASED: PREVENTION OF FUTURE DEATHS REPORT Thank you for your letter and Regulation 28 Report to Prevent Future Deaths, dated 7 December 2020, following your investigation and inquest into the deaths of Kevin Branton, Richard Smith and John, Maureen and Audrey Cook from carbon monoxide poisoning due to a design flaw in their cookers. You also sent a copy of the report to Standards (OPSS), which falls within my remit. I am responding as the Minister responsible for product safety policy for the Department for Business, Energy and Industrial Strategy (BEIS), including OPSS. , the CEO of the Office for Product Safety and I would first like to say how deeply saddened I was on hearing of these tragic deaths. If you have an opportunity, please pass on my condolences to the families. The Government is committed to ensuring that the UK has a product safety system that provides consumers with a high level of protection. This applies to the purchase of gas appliances as it does to all consumers products. I note that BERR (the predecessor to BEIS at the time of these deaths) took the initiative quickly to work with the European Commission, Member States, and through the CEN standard making process, to amend the standard relevant to the manufacture of gas cookers to include explicitly a closed-door test. In addition, the 2016 Regulation on gas appliances and fittings places clear responsibilities on manufacturers to ensure their products meet essential health and safety requirements before they are placed on the market. The findings of this inquest provide an opportunity to assess whether further lessons can be learned as we seek to ensure that the UK’s product safety system is continually improved. In particular, thank you for raising the importance of tracing owners and potentially dangerous appliances effectively. In 2018 the Government created the Office for Product Safety and Standards (OPSS) as a new national regulator for product safety. Since then, OPSS has taken significant steps to ensure the UK product safety system is one of the most robust in the world. This has included creating a new national capacity including technical and scientific advisors and experts in intelligence, enforcement and product recalls and publication of an Incident Management Plan and a new national Product Safety Database. The Incident Management Plan sets out how OPSS will support local authorities managing a product safety incident, and itself lead on an incident that is national in scale and a serious risk to health and life. The national product safety database has been designed to support regulators to capture and share information on unsafe goods, so that risks can be identified and action taken more quickly. Market surveillance authorities can report and share information relating to unsafe and non-compliant products, identifying the product, describing the risks involved, recording the nature and duration of measures taken or decided on and information on supply chains. OPSS supports and works with local authority Trading Standards on a day-to-day basis. Where an unsafe product results in a national incident, OPSS can designate this for investigation and enforcement at a national level. Where a local authority considers it does not have the expertise and resources necessary to carry out a complex investigation, it can ask OPSS for assistance. In 2019, Parliament enabled OPSS to use investigatory powers set out in Schedule 5 to the Consumer Rights Act 2015, and ensured these powers were available to OPSS and to local authority Trading Standards in relation to gas appliances, where products were deemed to be unsafe. OPSS has also developed a Strategic Research Programme to commission and assure high quality strategic science-based research to strengthen the evidence base for enforcement. In particular, OPSS has commissioned research to understand how consumers engage with the safety of the products they purchase and into how to encourage greater registration of products to facilitate corrective actions and recalls. I have asked OPSS to specifically to assess whether there is more we can do to research consumer behaviour in relation to safety in the gas appliance sector. In your report, you express concern that there is no national or central database, containing the details of gas appliances manufactured, supplied or fitted to homes in the UK, which would allow rapid identification and tracing of potentially dangerous appliances. You also expressed concern that the lack of mandatory recording of the manufacture, supply and fitting of gas appliances hinders effective communication between manufacturers, suppliers, wholesalers, fitters and householders and that it is difficult and time consuming to trace potentially dangerous products when urgency is required. In response to your report, I have asked OPSS officials to engage with manufacturers, retailers and consumer groups, and relevant bodies in Government to consider the concerns you have raised, including the options for effective and rapid communication between manufacturers, suppliers and owners to locate potentially dangerous appliances, should a design fault be identified. I have asked them to discuss your report, subject to your agreement, with members of the Cross-Government Working Group on Gas Safety and Carbon Monoxide in order to develop an action plan to address your concerns. To inform these considerations, I have asked OPSS to draw on analysis of the gas appliances market, assess consumer trends towards purchase and advise on whether further areas of research are needed to help identify and change consumer behaviour towards greater gas safety. Thank you again for bringing this matter to my attention. PAUL SCULLY MP Minister for Small Business, Consumers & Labour Markets Minister for London
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