Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0267, written 30 Aug 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Aug 2022 |
|---|---|
| Reference | 2022-0267 |
| Deceased | David Honnor |
| Coroner | Stephen Nicholls |
| Coroner area | Dorset |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Secretary of State for Levelling Up. 2. Secretary of State for the Home Office. 1 CORONER I am Stephen John Nicholls, Assistant Coroner, for the Coroner Area of Dorset 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 the 25th April 2022, an investigation was commenced into the death of David Honnor, born on the 3rd March 1946. The investigation concluded at the end of the Inquest on the 24th August 2022. The Medical Cause of Death was: 1a Asphyxia. The conclusion of the Inquest recorded Suicide. 4 CIRCUMSTANCES OF THE DEATH The deceased was diagnosed with oesophageal cancer in 2021. He underwent radiotherapy treatment. His conditioned worsened in 2022, he had a stent fitted in March 2022. On the 21st March 2022 he attended hospital and had a chest X ray. He was asked to return to the hospital later that day. He had obtained a cannister, how and when is not clear. gas . with the intention of ending his life. 1 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows: 1. During the inquest evidence was heard that: i. Mr Honnor had researched on the internet how to obtain a gas cannister with a view to ending his life. ii. iii. iv. v. It is not known when or where he purchased this item. There is no restriction on members of the public purchasing these items. Separate consideration needs to be given to the labelling and colouring of gas cylinders to enable emergency services to respond to any risk arising at an incident. The police found the vehicle with Mr Honnor in and the cannister. They removed him to commence CPR. The officers put themselves at risk in entering the vehicle which contained the gas cannister. Evidence was heard at the inquest from a police inspector that officers attending emergencies need to be able to identify gas cannisters by colour coding. vi. The gas cylinder had the following labelling: and details the warnings of gas under pressure, odourless and asphyxiation- do not inhale. Non-in-flammable, Non -toxic Gas2 with an emergency phone number. 2. I have concerns with regard to the following: i. ii. iii. iv. I have concerns that members of the public are able to purchase . or acquire I have concerns that these products should be licensed. I have concerns that there is no colour coding of gas cylinders to assist first response emergency services. I have concerns as to whether the safety information on these gas cannisters is clear and sufficient. 2 6 ACTION SHOULD BE TAKEN In my opinion urgent 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, 25th October 2022. 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: (1) I 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. 9 Dated Signed 30th August 2022 Stephen J Nicholls 3
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.
Mr. Stephen J. Nicholls HM Assistant Coroner for Dorset The Coroner's Office for the County of Dorset Bournemouth Town Hall Bournemouth BH2 6DY Monday 10th October 2022 Your Reference: 23785928 Our Reference: TRO/0421116/22 Engagement and Policy Division Health & Safety Executive Mallard House 3 Peasholme Green York YO1 7PX Dear Mr. Stephen Nicholls, Thank you for your Regulation 28 report in relation to the death of David Stefan Honnor, dated 30th August 2022. Your report was addressed to the Home Office and the Department for Levelling Up, Housing and Communities, but was transferred to the Health and Safety Executive as a number of your concerns touch on areas for which we have responsibility. Before I address your concerns, may I take this opportunity to express my condolences regarding the tragic circumstances that gave rise to the report. Your report highlights the following areas of concern: (i) (ii) (iii) (iv) Members of the public are able to purchase or acquire Oxygen Free Nitrogen (OFN). These products should be licensed. There is no colour coding of gas cylinders to assist first response emergency services. Whether the safety information on these gas cannisters is clear and sufficient. A full response which addresses the above concerns and sets out applicable cross- government policy is provided below. I hope this information reassures you as to the seriousness with which we treat these types of incident. Purchase and licensing of oxygen free nitrogen products Under the retained Regulation (EC) No. 1907/2006 concerning the registration, evaluation, authorisation and restriction of chemicals (‘the UK REACH Regulation’), it is possible to place restrictions on a chemical substance, which limit or ban the use of the chemical or its placement on the market within Great Britain. Restrictions under UK REACH are reserved for chemicals for which the associated risks have been deemed unmanageable. As a chemically inert substance that is not intrinsically toxic to humans or the environment and cannot support combustion, OFN poses a minimum risk. As such, OFN is not restricted for supply or use under the UK REACH Regulation and is available for sale to consumers. OFN has a number of legitimate applications which warrant its availability on the GB consumer market. Such applications include pressure testing and leak detection in air conditioning units; automotive tyre inflation; and use in relation to beverages as a propellant. The UK has a robust legislative framework to protect UK consumers from unsafe products. The General Product Safety Regulations 2005 require all products to be safe in their normal or reasonably foreseeable usage and enforcement authorities have powers to take appropriate action when this obligation is not met. There is also sector-specific legislation where manufacturers and businesses have specific obligations to ensure they are supplying safe products. This includes the Simple Pressure Vessels (Safety) Regulations 2016 and the Pressure Equipment (Safety) Regulations 2016, as they apply to Great Britain. In Great Britain, local trading standards authorities have a duty to enforce the Regulations in relation to consumer goods, i.e. those intended for private use or consumption. Colour coding of gas cylinders to assist first response emergency services Your report does not contain details regarding the colouring of the gas cylinder found in Mr. Honnor’s vehicle. I have understood concern 2(iii) to mean that you are concerned that there is no system of colour coding in place for gas cylinders, and that such a system that would be of benefit to first response emergency services. A harmonised standard, BS EN 1089-3, exists across the gases industry in Europe (including the UK) and governs the colour coding of transportable gas cylinders. This colour coding system provides a method by which to easily identify the contents of a gas cylinder primarily via its properties, particularly in an emergency situation. Under BS EN 1089-3, some gases have a designated colour associated with them. Nitrogen is one such gas—BS EN 1089-3 requires gas cylinders containing nitrogen, and therefore OFN, to be coloured black. Please note that with the exception of acetylene and hydrogen gas cylinders, colour coding in line with BS EN 1089-3 will only apply to the shoulder of the gas cylinder. Safety information on gas cannisters The label located on the shoulder of a gas cylinder is intended to be the primary method of hazard identification. The label should contain mandatory information required under legislation such as the retained Regulation (EC) No. 1272/2008 on the classification, labelling and packaging of substances and mixtures (‘the GB CLP Regulation’), for which HSE, as the GB CLP Agency, has responsibility. Your report notes that the gas cylinder found in Mr. Honnor’s vehicle contained the following labelling: oxygen free nitrogen; warnings of gas under pressure, odourless and asphyxiation—do not inhale, non-inflammable and non-toxic gas 2; and an emergency phone number. This suggests a level of compliance with the GB CLP Regulation. The GB CLP Regulation facilitates a high level of protection of human health and the environment through the use of effective, harmonised hazard communication. The Regulation requires suppliers to provide hazard information through labelling before their substance or mixture is placed on the GB supply market. Such hazard information will be in the form of, but not limited to: Hazard pictograms; Signal words (e.g. warning or danger); Hazard statements (e.g. gas under pressure); and Precautionary statements (e.g. in the case of gases under pressure, store in a well-ventilated place). In your report, concerns were raised as to whether the safety information on gas cannisters is clear and sufficient. Your report does not detail the nature of the OFN gas cylinder found in Mr. Honnor’s vehicle, and as such I am unable to comment on whether the cylinder was fully GB CLP-compliant and thus, whether safety information was displayed on the cylinder to a sufficient degree. The domestic legislative framework around hazardous chemical substances provides an additional method of safety information communication. Whilst OFN is not restricted under the UK REACH Regulation, Article 31 of the Regulation does apply to OFN and requires the supplier of a chemical, whether a manufacturer, importer, downstream user, distributor or a representative, to provide customers with a Safety Data Sheet (SDS) if the chemical they supply is hazardous. In a workplace setting, the requirement to provide an SDS is also mandatory under the Control of Substances Hazardous to Health (COSHH) Regulation 2002, if a chemical product containing hazardous substances is being supplied. SDS provide information on chemical products that help users of those chemicals to make a risk assessment. They describe the hazards the chemical presents, and give information on handling, storage and emergency measures in case of accident. In relation to your concerns about the clarity of safety information on gas cylinders, the Department for Business, Energy and Industrial Strategy have advised that sector-specific legislation places obligations on actors within a supply chain to provide instructions and safety information that are clear, legible and in easily understandable English. I hope this response helps to address the concerns set out in your report and explains our position. Yours sincerely, Classification, Labelling and Packaging Policy Team Leader
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