Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0306, written 29 Aug 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Aug 2023 |
|---|---|
| Reference | 2023-0306 |
| Deceased | Mizanur Rahman |
| Coroner | Adam Smith |
| Coroner area | Inner North London |
| Category | Other related deaths · 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.
Regulation 28: Prevention of Future Deaths report Mizanur RAHMAN (died 09.03.23) THIS REPORT IS BEING SENT TO: Chief Executive Officer Office for Product Safety and Standards 4th Floor Cannon House 18 The Priory Queensway Birmingham B4 6BS 1 CORONER I am: Adam Smith Assistant Coroner Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009, paragraph 7, Schedule 5, and The Coroners (Investigations) Regulations 2013, regulations 28 and 29. 3 INVESTIGATION and INQUEST On 17 March 2023, E Buckett, HM Assistant Coroner for Inner North London, commenced an investigation into the death of Mizanur Rahman, aged 41 years. The investigation concluded at the end of the inquest on 17 August 2023. I made a determination of accidental death. The medical cause of death was: 1(a) Hypoxic brain injury 1(b) Thermal and smoke inhalation injury 1 2 Bronchopneumonia 4 CIRCUMSTANCES OF THE DEATH Mr Rahman died on 9 March 2023 at the Royal London Hospital from the effects of smoke inhalation during a fire which took place in the early hours of 5 March 2023 at the 4th floor multi-occupancy flat where he resided. The fire was found to have been caused by a faulty lithium ion e-bike battery which was charging at the time. The e-bike from which the battery came, which was owned by another occupant of the flat, had been heavily modified, notably including a retro- fitted additional battery cage and motor. I found on the evidence, which included that of a London Fire Brigade Fire Investigation Officer (whose evidence was in turn informed by input from the Chief Scientific Adviser at the Fire Science Department, who had examined the e-bike and remains of the charger\battery), that the fire started with a faulty lithium ion battery, probably a battery and charger which did not match and carried different voltage ratings, leading to thermal runaway and catastrophic failure of the lithium ion battery. Despite attempts by occupants of the flat to prevent the fire’s escalation, this was not possible and the flat quickly filled with toxic smoke necessitating its evacuation. Sadly, Mr Rahman did not successfully evacuate before he was overcome by the smoke, causing his death. 5 CORONER’S CONCERNS During the course of the investigation, including 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. I have received evidence, in particular from the London Fire Brigade’s Fire Investigation Team: • That Mr Rahman’s death is the ninth nationally in approximately one year, in six fires attributed to faulty lithium ion batteries. • That the number of fires in London attributed to electric powered personal vehicles has risen consistently and significantly over the last six years and now stands at well in excess of 100 per annum. 2 • That there is presently no British or European (e.g. BSI or PAS) standard to control what lithium ion e-bike batteries and chargers can be sold in the UK and that, consequently: o It is easy for people to buy (including online) lithium ion batteries that are not of sufficient quality or otherwise not of an appropriate standard to charge safely. o There is an increased risk of people mixing and matching lithium ion batteries with chargers that carry a different voltage rating. • That the OPSS has the ability to introduce such a standard. • Of how, when a lithium ion battery is charged using a charger with a different voltage rating, this can lead to thermal runaway and catastrophic failure of the battery - a build up of heat, failure of one of the cells within the battery, followed by a chain reaction as the remaining cells fail, all of which can happen quickly and explosively with the emission of sparks and toxic, flammable vapours. I understand that there is currently a product safety review underway, led by the Office for Product Safety and Standards (OPSS) and involving the Home Office (Fire Policy Team) (under the Minister for Crime, Policing and Fire, Chris Philps MP) and a number of other organisations. I do not know the timescale for this review, but it is clear that there is an existing, ongoing and future risk of further deaths whilst it continues to be the case that there are no controls or standards governing the sale in the UK of lithium ion batteries and chargers (and conversion kits) for electric powered personal vehicles. This report is being provided to you given my understanding that the OPSS has the ability to introduce an appropriate standard. Insofar as this power may lie elsewhere, or other individuals or organisations (whether or not involved in the current product safety review) would need to have input into the introduction of such a standard, you are requested to share this report with those individuals/organisations. 6 ACTION SHOULD BE TAKEN In my opinion, action should be taken to prevent future deaths and I believe that you have the power to take such action. 7 YOUR RESPONSE 3 You are under a duty to respond to this report within 56 days of the date of this report, namely by 24 October 2023. 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 following. • The Next of Kin of Mr Rahman • The London Fire Brigade • HHJ Thomas Teague QC, Chief Coroner of England & Wales I am 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 ASSISTANT CORONER 29 August 2023 4
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.
Adam Smith
Assistant Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London, N1C 4PP
Dear Mr Smith,
Office for Product Safety and Standards
Cannon House
18 The Priory Queensway
Birmingham
B4 6BS
24 October 2023
Regulation 28: Prevention of Future Deaths Report
Mizanur RAHMAN
Thank you for your Regulation 28 Report (Prevention of Future Deaths) dated 29 August 2023,
following your investigation and inquest into the death of Mizanur Rahman who died on 9
March 2023 as a result of smoke inhalation from a fire in a charging lithium-ion e-bike battery.
May I first say how sorry I was to hear of Mr Rahman’s death. If you have the opportunity,
please convey my deepest sympathies to his family and friends.
I would like to assure you that an urgent programme of activity is being carried out across
Government, including by the Office for Product Safety and Standards (OPSS); the Home
Office; and the Department for Transport, looking at the root causes to understand why fires
in e-bikes are occurring, so we can take action to tackle the issue.
OPSS has engaged with both the London Fire Brigade (LFB) and Tower Hamlets London
Borough Council Trading Standards in relation to the tragic fire on 5 March. LFB initially notified
OPSS of the fire in line with our agreed procedure under the terms of our Memorandum of
Understanding. Unfortunately, in this case, LFB has not been able to identify the specific
manufacturer or model of conversion kit or battery involved from the remains of the product.
UK product safety laws require all consumer products to be safe. E-bikes and e-scooters,
their batteries and chargers must comply with essential safety requirements set out in the
Supply of Machinery (Safety) Regulations 2008, the General Product Safety Regulations 2005
or Electrical Equipment (Safety) Regulations 2016. These require manufacturers to ensure the
safety of products before they are placed on the market and to provide consumers with
information on the safe use of these products, such as safe charging practices. In addition,
importers and distributors, including online, have obligations regarding the safety of the
products they import or distribute.
OPSS and Local Authority Trading Standards (LATS) have access to powers to enforce the
law and we are prioritising action to identify and test e-bikes, modification kits and chargers so
that products found to be unsafe are removed from the market.
The Office for Product Safety and Standards is part of the Department for Business and Trade. We strive to enhance
protections for consumers and the environment and drive increased productivity, growth and business confidence.
https://www.gov.uk/government/organisations/office-for-product-safety-and-standards
On 20 October OPSS published for designation, updated standard EN 15194:2017+A1:2023
for Electrically Power Assisted Bicycles. The previous version of this standard did not
adequately address the safe integration of batteries into battery packs and the incorporation
of battery packs into an end-device. As a result, it was designated by government with a
restriction that meant that manufacturers had to go beyond the requirements of the standard
to comply with the essential safety requirements in the law. Improvements to the standard have
been made by the standards bodies and we are satisfied that it now meets the essential safety
requirements with regards to battery safety. As a result, we plan to remove the restriction that
applied to battery packs so that manufacturers who follow the designated parts of the standard
would be presumed to comply with legal requirements for safety.
I can also confirm that OPSS is reviewing all relevant voluntary standards in this area to identify
any areas where additional or updated standards would be beneficial to support the essential
safety requirements in the law.
We have already identified e-bike conversion kits as an area where, although there are legal
safety requirements, there is no specific standard. We plan to commission the British
Standards Institution (BSI) to prepare a fast-track standard (a publicly available specification)
to cover technical and safety standards for conversion kits to help manufacturers comply with
existing safety regulations.
The issues involved in e-bike safety are complex as products may be safe when used alone
but not when used in combination or when modified or converted. We know from LFB, and as
you have mentioned in your report, that the e-bike involved in this fire was heavily modified
including a retro-fitted additional battery cage and motor.
OPSS has established a multi-disciplinary safety study to understand data and evidence of
risks in this area and we have commissioned new research into battery safety, including
compatibility issues, from Warwick Manufacturing Group (WMG - part of Warwick University).
We are seeking the input and expertise of stakeholders including Electrical Safety First, the
Fire and Rescue Services, the National Fire Chiefs Council, and the London Fire Brigade so
we can better understand and tackle the complex issues involved.
Ensuring consumers have access to clear and accurate information on safety issues is also a
priority. In September OPSS published information for consumers to raise awareness of safe
purchasing, use and charging practices and to draw attention to the new Fire England guidance
on safe charging published in August.
As you note in your report, the Government is also considering longer term reforms. A
consultation on the Product Safety Review was launched on 2 August and is inviting views on
the future approach to product safety regulation. As part of that consultation, the Government
is considering how to use regulations in future to enable a more agile and responsive regulatory
framework, particularly where new technologies emerge.
The Office for Product Safety and Standards is part of the Department for Business and Trade. We strive to enhance
protections for consumers and the environment and drive increased productivity, growth and business confidence.
https://www.gov.uk/government/organisations/office-for-product-safety-and-standards
Thank you again for sharing the findings of your report into Mr Rahman’s death. I can assure
you that the safety of e-bikes is a priority for government, and urgent work is taking place to
address the issues that you have highlighted.
Yours
Chief Executive
Office for Product Safety and Standards
The Office for Product Safety and Standards is part of the Department for Business and Trade. We strive to enhance
protections for consumers and the environment and drive increased productivity, growth and business confidence.
https://www.gov.uk/government/organisations/office-for-product-safety-and-standards
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