Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0007, written 4 Jan 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 4 Jan 2024 |
|---|---|
| Reference | 2024-0007 |
| Deceased | Bobby Lee |
| Coroner | Ian Potter |
| 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 Bobby LEE otherwise known as Kim Sing Lee (died 6 July 2023) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Chief Executive Officer Office for Product Safety & Standards Cannon House 18 The Priory Queensway Birmingham B4 6BS 1 CORONER I am Ian Potter, assistant coroner, for the coroner area of Inner North London. 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 31 July 2023, an investigation was commenced into the death of BOBBY LEE, then aged 74 years. The investigation concluded at the end of an inquest, heard by me, on 19 December 2023. The conclusion of the inquest was accidental death, the medical cause of death being: 1a smoke inhalation, severe burn injuries 2 frailty, severe coronary artery stenosis and atherosclerosis, hypertension, severe chronic kidney disease, type 2 diabetes mellitus. 4 CIRCUMSTANCES OF THE DEATH Mr Lee died at home on 6 July 2023 from the effects of smoke inhalation and severe burn injuries, resulting from a house fire that commenced at approximately 06:56 that morning. The fire was found to have been caused by the over-charging of a lithium-ion e-bike battery that had no battery management system in situ. The e-bike from which the battery came, was owned by another member of the household. The bicycle had started off as a regular mountain bike, but was subsequently fitted with a ‘conversion kit’ which converted the bicycle into an e-bike. The e-bike was purchased second-hand, without a charger. A charger was subsequently purchased from an online marketplace. I found on the evidence, which included that of a London Fire Brigade Fire Investigation Officer (whose evidence included input from the Chief Scientific Adviser at the Fire Science Department, who had examined the remains of the converted e-bike, the lithium-ion battery and the charger) that the fire was started by the over-charging of the lithium-ion battery, using a charger which was not suitable for the battery in that the charger had a substantially different voltage rating to the battery. In addition, the battery was not fitted with a battery management system aimed at reducing the risk of over- charging. This set of circumstances led to thermal runaway and a catastrophic failure of the lithium-ion battery. Despite attempts from family members to assist Mr Lee’s evacuation from his ground floor bedroom, it was not possible to secure his safe evacuation from the premises. Mr Lee suffered severe burn injuries and the effects of the inhalation of toxic smoke and died as a result. 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: The evidence, in particular from the London Fire Brigade’s Fire Investigation Team, revealed that: • Mr Lee’s death was one of three in London in 2023 attributable to fire started by faulty lithium-ion batteries and/or chargers for e-bikes or e- scooters. • The number of fires in London attributed to electric powered personal vehicles (e-bikes or e-scooters) has risen significantly and consistently in the past four years (26 fires in 2020; 74 fires in 2021; 116 fires in 2022; and 169 fires up to mid-December 2023). • That lithium-ion batteries sold as part of, so-called e-bike conversion kits, tend to be of a significantly inferior quality and construction when compared to the battery packs manufactured and installed in purpose- built e-bikes. • Lithium-ion batteries sold as part of e-bike conversion kits are regularly sold/supplied without a charger, thereby increasing the risk of an unsuitable charger being purchased and used. • Chargers for sale on online marketplaces, in particular, regularly fail to meet appropriate standards. In this case, the charger purported to carry the European ‘CE’ mark, which should be an indication that the product conforms to European health, safety and environmental protection standards; however, the Fire Investigation Officer noted that the mark was slightly different and therefore not genuine. It was used instead to denote ‘Chinese Export’. • The presence of universal charging connectors across batteries of different voltages means that there is a significant risk that over-rated chargers can be inadvertently connected to lower power batteries, which was the case in the fire that led to Mr Lee’s death. • There is currently no British or European (e.g. BSI or PAS) standard specific to e-bike conversion kits and/or chargers and consequently: - It is relatively easy for people to buy, particularly from online marketplaces, e-bike conversion kits and/or lithium-ion batteries that are not of sufficient quality or otherwise not of an appropriate standard to charge safely. - There is an increased risk of people mixing and matching lithium-ion batteries with chargers that carry a different voltage rating. • 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 very quickly and explosively with the emission of sparks and toxic, flammable vapours. I am aware, from past ‘prevention of future death’ reports of a similar nature that the Office for Product Safety and Standards (OPSS) has planned to commission the British Standards Institute (BSI) to prepare a fast-track standard to cover technical and safety standards for e-bike conversion kits to help manufacturers to comply with existing safety regulations. However, to my knowledge this piece of work has not yet been completed. In addition to the above, I am also aware that the OPSS established a multi- disciplinary safety study to understand data and evidence of risks in this area, as well as commissioning new research into battery safety, including compatibility issues, from Warwick Manufacturing Group (part of Warwick University). However, I do not know the progress or timescales involved in this review and research. It is clear to me though that there is a substantial existing, ongoing and future risk of further deaths while it continues to be the case that there are no, or insufficient, controls and/or standards governing the sale in the UK of lithium-ion batteries and chargers for electric powered personal vehicles and e-bike conversion kits. It is my understanding that the OPSS is taking the lead and has the power to introduce such standards, which is the basis upon which this report is being sent to you. Insofar as that power may lie elsewhere, or other individuals and/or organisations may need to have input into the introduction of such a standard, I would request that you share this report with those individuals and/or organisations. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you 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 29 February 2024. 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. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Person: (a) (b) Brigade) (family member). (London Fire 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. 8 9 Ian Potter HM Assistant Coroner, Inner North London 4 January 2024
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.
Office for Product Safety and Standards Cannon House 18 The Priory Queensway Birmingham B4 6BS 29 February 2024 Ian Potter HM Assistant Coroner, Inner North London St Pancras Coroner’s Court Camley Street London, N1C 4PP Dear Ian Potter, Regulation 28: Prevention of Future Deaths Report Bobby LEE Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 4 January 2024, following your investigation and inquest into the death of Bobby Lee who died on 6 July 2023, as a result of smoke inhalation and severe burn injuries following a fire caused by a charging lithium-ion battery for a converted e-bike. I was very sorry to hear of Mr Lee's death. If you have the opportunity, please do pass on my deepest sympathies to his family and friends. In your report, you refer to previous Reports to Prevent Future Deaths, and I have outlined below further work that has been undertaken subsequently. I would like to reassure you that the Government is taking the safety risks associated with e-bikes, e-scooters, their batteries and chargers very seriously. Key Departments across Government, including the Office for Product Safety and Standards (OPSS) within the Department for Business and Trade, the Home Office, and the Department for Transport have joined forces as part of a taskforce to establish the root causes of fires, so we can determine the most effective actions to tackle the issue. The UK’s product safety laws already require that only safe consumer products be placed on the market. Manufacturers or importers are required to ensure their products, including e-bikes, e-scooters, their batteries or conversion kits, are safe and there are criminal penalties for those that don’t comply. In addition, distributors, including online marketplaces, must not supply products they know, or should know, are unsafe. These requirements are enforced by both Local Authority Trading Standards and OPSS. Action is being taken to remove unsafe or non-compliant products from the market. Ten separate product recalls and nine other enforcement actions for unsafe or non-compliant e- bikes or e-scooters have been published by OPSS since March last year. Last month, OPSS took enforcement action to remove from the market two dangerous models of e-bike batteries manufactured by Unit Power Pack (UPP), which posed a serious risk to users, including potential fatalities. OPSS has issued Withdrawal Notices to 20 distributors and one manufacturer, including major online marketplaces, requiring them to stop the immediate The Office for Product Safety and Standards (OPSS) delivers consumer protection and supports business confidence, productivity and growth. It is part of the Department for Business and Trade. gov.uk/opss supply of these products. OPSS has also published public safety information on gov.uk, advising consumers not to use the affected UPP batteries and how to dispose of them safely. OPSS is also assessing the compliance of 60 UK-based businesses involved in the supply chain of e-bikes, e-scooters or conversion kits. The product safety issues around these products remain complex: products may be safe and compliant with the law when sold, but not when they are modified, or when used in a combination which is not compatible, as appears to have been the case in this tragic fatality. Steps are being taken across Government to raise awareness among consumers of the risks from lithium-ion batteries, particularly for counterfeit, damaged or poorly modified e-bikes and batteries, or when an incorrect charger is used. In December, OPSS published a safety message highlighting the steps people should take when owning or thinking of buying an e- bike or e-scooter. This includes always following the manufacturer’s instructions for charging and using the products; checking and only using the manufacturer’s recommended battery and charger; never attempting to tamper with or alter the battery or charger; and unplugging the battery when charging has finished. The Department for Transport released new guidance on how to “safely purchase, charge, and use e-bikes and e-scooters” earlier this month which includes fire safety advice for users, owners, and transport operators. I am able to provide an update on a new fast-track standard for conversion kits. I can confirm we have held initial discussions with the British Standards Institution (BSI), the UK’s national standards-setting body responsible for introducing new standards, on the preparation of a publicly available specification (PAS) to cover technical and safety standards for conversion kits. This new standard will not change the existing legal requirements, and, like the vast majority of standards, it will be voluntary. However, it will function to create and communicate expectations in this important market area and assist businesses in meeting the existing legal safety requirements for conversion kits. All British Standards are drawn up by committees and made by consensus which necessarily takes time. But we are using a fast-track route and would hope that the standard could be in place for businesses to use within the next 12-18 months. In your report you refer to the research commissioned by OPSS from Warwick Manufacturing Group (WMG) into batteries used in e-bikes and e-scooters. This is a wide-ranging and comprehensive project and includes examination of compatibility issues. We are working with WMG to bring forward and share insights from this research as quickly as possible, while ensuring the evidence base is robust and rigorous. We expect WMG to deliver their final report later this year, but in the interim OPSS intends to share early insights from this work across government and through our stakeholder network so it can feed into our understanding of risk and our enforcement and policy priorities. We can write to you again and share this report once it has been published. The Government recently consulted on proposals, as part of a Product Safety Review, to modernise the product safety framework in the UK. One of the key aims is to address concerns regarding the ease with which unsafe products can be sold online, creating a fairer playing field so that shopping online is as safe as on the high street. We are currently analysing responses to that consultation and would expect the Government’s response to be published later this year. I hope that this demonstrates how high a priority the safety of e-bikes and lithium-ion batteries is for government, and the breadth of work taking place to address the issues you have raised. We can, and will, take further enforcement action where there is appropriate and proportionate evidence to do so. I would be grateful if you could share a copy of this letter with colleagues who may find it useful. Yours sincerely, Chief Executive
See every Prevention of Future Deaths report matching Product related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.