Terrence Taylor

HM Coroners Officer 

Cambridgeshire & Peterborough Coroner Service, 

Lawrence Court, Princes Street, Huntingdon, PE29 3PA 

BY EMAIL  

Email: 

Your reference:

12 August 2024  

Dear Sir, 

Terrence Taylor: Prevention of future deaths report 

I. 

Introduction  

1.  This letter constitutes BSI’s response to your regulation 28 report arising out of the death 

of Mr Terrence Taylor (“the Report”).  

2.  BSI would like at the outset to express its deepest sympathy and condolences for the 

family of Mr Taylor.  

3.  The Report includes the following:  

______________________________________________________________________________________________________________________________________________ 

BSI Group The Netherlands B.V. 
Say Building John M. Keynesplein 1-27  
Amsterdam Bergen 1066 EP 
Netherlands 
bsigroup.nl 

BSI. All rights reserved. © 2024 

 
 
 
 
 
 
 
 
 
 
 
 
 
            
 
 
 
 
 
 
 “Action is required to ensure operators of care homes are provided with reliable, up to date 

guidance and to ensure that the limitations of the British Standard are widely known and 

understood by operators of residential care homes. 

Action is required to review the British Standard relating to window restrictors to consider 

whether some different standard or qualification to the existing standard is required in respect 

of residential care homes and/or deliberate acts to disable window restrictors.” 

4.  In accordance with its usual practice, BSI passed the Report to the responsible expert 

committees, who have replied as detailed below. We believe that constitutes compliance 

with the required actions, but would be pleased to assist if the coroner has any further 

questions.  

II. 

The role of BSI  

1.  BSI’s role as the NSB is established by Royal Charter. BSI has several governing documents 

(available online at  

https://www.bsigroup.com/en-GB/about-bsi/governance/standards-governance/):  

a.  BSI’s Royal Charter and Bye-laws 1981;  

b.  A  Memorandum  of  Understanding  (MoU)  of  20  June  2002  between  the  United 

Kingdom government and BSI in respect of BSI’s activities as the United Kingdom’s 

NSB;    

c.  BS 0: 2021 ‘A standard for standards – Principles of standardization’ (BS 0) 

2.  Article 1.2 of the MoU provides that BSI’s role as the NSB should be interpreted to include 

the management, co-ordination and understanding of: 

a)  “British Standards” and “other standardization products”;  

2 

© 2024 BSI. All rights reserved. 

 
 
 
 
 
 
 
 b)  participation  by  BSI  in  European  and  international  standards  bodies,  and  other 

international activity undertaken in the interests of BSI as the United Kingdom’s NSB;  

c)  promotion, marketing, distribution and information activities concerned with British 

Standards, BSI’s other standardisation products, and standardisation generally;  

d)  support any corporate infrastructure activities intended, wholly or in part, to enable 

paragraph 9(a) to (c) above.  

The  Director  of  Standards  has  the  primary  responsibility  for  the  activities  set  out  in 

paragraph 9(a) to (d). BSI’s present Director of Standards is 

 (his full title 

is ‘Director–General, Standards’, which incorporates the role of Director of Standards).  

3.  BSI develops and distributes standards in response to the needs of UK stakeholders, which 

include  UK  Government  and  business.  Standards  are  technical  documents  representing 

good industry practice. They are voluntary documents drafted by independent experts.  

III. 

Standards committee structure  

4.  Each  individual  standard  is  the  responsibility  of  one  technical  committee.  A  technical 

committee  may  be  responsible  for  more  than  one  standard,  and  may  establish 

subcommittees to deal with individual standards or other discreet areas of its work.  

5.  Technical  committees  and  sub-committees  consist  primarily  of  experts  who  are 

independent  of  BSI,  and  who  are  often  nominated  by  trade  associations,  professional 

bodies,  research/scientific  institutions,  government  or  other  entities  (see  BS  0,  para  7.2). 

They have an independent chair and BSI provides a committee manager and other support 

including an editorial project manager for each standard.  

6.  The committees referred to in this letter are examples of such committees.  

3

© 2024 BSI. All rights reserved. 

 
 
 
 
 
 
 
 
 IV. 

Status of Standards  

7.  The  defining  characteristic  of  standards  is  that  they  are  voluntary,  agreed  by  industry 

experts and users, including manufacturers, health and safety representatives, regulators 

and  consumer  groups.    They  do  not  have  the  status  of  legislation  or  regulation  (unless 

specifically referred to in a statute or regulatory instrument), although they may be used as 

one  means  of  demonstrating  compliance  in  appropriate  circumstances.  They  may  also 

become  privately  enforceable  between  individual  entities  by  being  incorporated  into  a 

contract (see paras 4.14 and 9.2 of BS 0).   

V. 

BSI expert committee feedback 

8.   BSI considered the following committees would have relevant expertise: 

a.  B/538, Doors, windows, shutters, hardware and curtain walling 
b.  B/538/1, Windows and Doors 
c.  B/538/4, Building Hardware 

9.  Representatives of all those committees have jointly considered BS 6375-2. Their response 

is as follows, which we are quoting in full:  

“A committee was formed of members from, 

B/538, Doors, windows, shutters, hardware and curtain walling 

B/538/1, Windows and Doors 

B/538/4, Building Hardware 

We were all saddened to hear of the death of Mr Taylor under what must have 

been such difficult circumstances for everyone concerned and we are determined 

4 

© 2024 BSI. All rights reserved. 

 
 
 
 
 
 
 
 
 
 
 to make appropriate changes to standards to reduce the risk of deaths under 

similar circumstances in the future. 

Amendments to BS 6375-2 

Our proposal is to amend clause 5.3 of BS 6375-2:2009 so that it includes a 

requirement for situations when the window is to be used for the purposes 

described in the Coroner’s report. We will need a descriptive term for the mode of 

use. We have considered, “deprivation of liberty,” but this may be too severe and 

not appropriate for our purpose.  

The test will be undertaken on a sample of the window to be used to ensure that 

the window, the restrictor and any fixings securing it to the window will be tested 

as a system. 

When open, with the maximum opening gap limited to 89mm by a restricting 

device, the window shall be capable of resisting a load of 850 N applied anywhere 

on the window in a manner intended to open the casement or sash with the 

objective of obtaining egress. 

This load shall be applied via a 50 mm x 50 mm pad and can be located at various 

places on the casement or sash, for example  

• 

• 

• 

at the location of the restrictor 

at the hinge points 

at a point the maximum distance from the restrictor 

The load shall be applied, for example 

5 

© 2024 BSI. All rights reserved. 

 
 
 
 
 
 
 
 
 • 

• 

perpendicular to the plane of the open casement or sash 

parallel to the direction of opening of sliding sashes. 

As BS EN 14609 does not cover loads applied to restricted sliding sash windows we 

will need to introduce a new annex to BS 6375-2 describing the test method to be 

used for such windows. 

If loads are to be applied to the casement or sash then it will be necessary to 

upgrade the glazing so it can withstand comparable loads. We therefore propose 

that the glazing should be able to support the 850 N point load (applied via the 

pad) but also be grade 1(B)1 or 1(C)1 when tested in accordance with BS EN 12600. 

This will reduce the risk of egress being achieved by breaking the glass. 

Steel-framed windows 

Clause 12.2, safety device loading, of the national product standard for steel 

windows, BS 6510, will be amended so that it refers to clause 5.3 of BS 6375-2 and 

doesn’t refer directly to a load of 350 N supported for 60 S as it does now. 

The other material specific product standards for windows, BS 644, BS 7412 and BS 

4873 refer to clause 5.3 of BS 6375-2 without stating loads or durations. 

6 

© 2024 BSI. All rights reserved. 

 
 
 
 
 
 
 
 
 
 
 
 
 Existing European Standards 

BS EN 14351-1, the European product standard for windows and external 

pedestrian doors, doesn’t, as appears in for example the HSE report RR1150, limit 

the load bearing capacity of a safety device to 350 N but instead sets 350 N as the 

minimum, or threshold, value for such devices. It would be for the EU member 

state, or country in which the product is used, to set the national requirements for 

such products. 

The load bearing capacity of safety devices is an essential characteristic of windows 

(reference Table ZA.1) therefore, when such a device is fitted to a window the 

loadbearing capacity of the window, when tested in accordance with BS EN 14609, 

must be stated on the manufacturer’s declaration of performance in accordance 

with article 4 (2) of the assimilated EU Regulation 305/2011 (The Construction 

Products Regulation). 

However, as this characteristic falls under AVCP System 3, it is possible that, the 

function of a restrictor as intended in BS EN 14351-1 is not life-safety-critical 

because, if it was, it would fall under AVCP System 1 as is the case for fire 

characteristics. This could mean that our proposed amendment to BS 6375-2 would 

not conflict with existing European Standards. This will, however, need to be 

checked. 

BS EN 14609, is referred to by BS EN 14351-1 as the test method to determine the 

load bearing capacity of safety devices, but it only covers casement windows not 

sash windows, clause 7 calls for the restrictors to be disengaged and figures A.1 to 

A.6 show the movement of the casement to be limited by a “block” stopping the 

movement of one corner.  We will discuss the possible need to amend EN 14609 

7 

© 2024 BSI. All rights reserved. 

 
 
 
 
 
 
 with the European working group CEN/TC 33 WG1 that is responsible for this 

standard. 

List of standards 

•  BS 644:2012, Timber windows and doorsets. Fully finished factory-assembled 

windows and doorsets of various types. Specification 

•  BS 4873:2016, Aluminium alloy windows and doorsets. Specification 

•  BS 6375-2:2009, Performance of windows and doors - Classification for 

operation and strength characteristics and guidance on selection and 

specification 

•  BS 6510:2010, Steel-framed windows and glazed doors. Specification  

•  BS 7412:2024, Windows and doorsets. Unplasticized polyvinyl chloride (PVC-

U) extruded hollow profiles. Specification 

•  BS EN 12600:2002, Glass in building. Pendulum test. Impact test method and 

classification for flat glass 

•  BS EN 14351-1:2006+A2:2016, Windows and doors. Product standard, 

performance characteristics - Windows and external pedestrian doorsets 

•  BS EN 14609:2004, Windows. Determination of the resistance to static 

torsion” 

10. Please  note  that  the  committee’s  proposals  will  have  to  be  implemented  by  the  usual 

standards development process (as set out in BS 0), which among other things means there 

will be a period of public consultation. The final version of the standard will  therefore be 

informed by that consultation and may differ from the committee’s proposals accordingly. 

Nonetheless the intention of the process will be to improve the standard, informed by the 

Coroner’s Report and the committee’s expertise.  

8 

© 2024 BSI. All rights reserved. 

 
 
 
 
 
 
 11. BSI believes that the above is self-explanatory and constitutes a full reply to the Coroner’s 

Request. Again, however, if the Coroner has any further questions or requires clarification, 

BSI would be pleased to assist.  

Yours sincerely, 

Head of Standards Governance  

BSI, 389 Chiswick High Road, London, W4 4AL, UK 

We support the UN Sustainable Development Goals, so please consider the environment before printing this email 

The British Standards Institution is a member of BSI Group and is incorporated in England under Royal Charter. Its principal address is 389 Chiswick High Road, 
London, W4 4AL, United Kingdom. 

9

© 2024 BSI. All rights reserved.

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

4 September 2024 

Keith Morton KC 
Assistant Coroner 
Cambridgeshire and Peterborough Coroner's Service 
Lawrence Court 
Princes Street 
Huntingdon 
Cambridgeshire 
PE29 3PA 

Care Quality Commission 

Our Reference: 

By email: 

Dear HM Coroner Keith Morton KC, 

Prevention  of  future  death  report  following  the  inquest  into  the  death  of 
Terrence Roy Hubert Taylor. 

We write to acknowledge receipt of the Regulation 28 report of 21 June 2024, sent to 

the  Care  Quality  Commission  (CQC),  in  relation  to  the  death  of  Mr  Terrence  Roy 

Hubert Taylor.  

Firstly, the CQC would like to express our deepest sympathy and sincere condolences 

to the family of Mr Taylor. 

We understand that you want action taken to ensure that;  

(1) Operators of care homes are provided with reliable, up to date guidance on the 

use of window restrictors; and  

(2) Operators  of  care  homes  are  made  aware  of  the  limitations  of  the  British 

Standards  in  that  they  were  developed  to  prevent  accidental  falling  from 

windows as opposed to deliberate attempts to bypass window restrictors. 

1 

 
 
 
 
 
 
 
 
  
 
 As you are aware, the CQC is the independent regulator of health and social care in 

England. The CQC publishes guidance on how providers and managers can meet the 

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the 2014 

Regulations”) and the Care Quality Commission (Registration) Regulations 2009 (“the 

2009  Regulations”).  There  is a  link  on  our website  to  the  2013  guidance,  and  then 

further  information  and  guidance  on  meeting  the  specific  regulations  can  be  found 

under  separate  headings.  Under  the  heading  of  Regulation  12:  safe  care  and 

treatment, there is a link to guidance issued by the Health and Safety Executive (HSE) 

on Health and Safety in Care Homes www.hse.gov.uk/pubns/books/hsg220.htm. 

Chapter  7  of  this  guidance  specifically  addresses  Falls  from  Height.  In  addition,  to 

accidental falls, this guidance also refers to;  

•  Falls arising out of confused mental state, including where an individual is trying 

to escape from an environment they perceive to be hostile, and 

•  Deliberate self-harm.   

It sets out control measures that may be taken by care homes to ensure that people 
are kept safe. In 2022, CQC published a ‘Learning From Safety Incidents’ page on our 

website on the use of window restrictors. This can be found, alongside relevant, up to 

date  guidance  on  complying  with  the  relevant  health  and  safety  precautions,  here: 

www.cqc.org.uk/guidance-providers/learning-safety-incidents/issue-7-falls-windows. 

This  webpage  also  has  links  to  the  latest  HSE  guidance  on  risks  to  vulnerable 

members 

of 

the 

public 

from 

falling 

from 

height 

from  windows; 

www.hse.gov.uk/safetybulletins/windowrestrictors.htm. 

This guidance repeats that which is set out in Chapter 7 (see above) and also makes 

reference  to  the  Department  of  Health  Building  Note  00-10  Part  D  Windows  and 

associated hardware.  

In August 2024 we published a note in our bulletin to providers (a regular update for 

providers and professionals working in adult social care) highlighting the tragic loss of 

life  following  a  deliberate  attempt  to  bypass  a  window  restrictor  and  to  remind 
providers of the CQC’s ‘Learning From Safety Incidents’ webpage.  This publication 

has been updated on the CQC website to reflect the Health Building Note published 

2 

 
 by NHS England, which highlights that the British Standard for window restrictors does 

not factor in deliberate attempts to defeat the restrictor using impact forces. 

We are currently undertaking work to improve how we signpost providers to sources 

of good practice, to support our Single Assessment Framework. Good practice that is 

applicable across all sectors is already available, and we signpost to the HSE 2012 

information sheet on Falls from windows or balconies in health and social care under 
the  Quality  Statement on  ‘safe  environments’,  under  the Safe  key question.  In  time 

this will be supplemented by guidance that is applicable to specific sectors (such as 

ASC or health), or to specific service types (such as care home).  

Whilst the CQC will publish and expect providers and registered managers to be aware 

of, and follow, best practice when it comes to British safety standards, the CQC relies 

upon guidance issued. If either HSE or The British Standards Institution update their 

guidance around window restrictors, the CQC will take steps to ensure providers are 

signposted to it both through our website and published bulletins to providers. 

We hope this response is helpful but if you have any questions arising, please do not 

hesitate to contact us.  

Yours sincerely, 

Deputy Director for Local Authority and Adult Social Care Policy (Interim) 

3

Our ref: 

Keith Morton KC  
Assistant Coroner 
Cambridgeshire and Peterborough Coroner’s Office  
Lawrence Court   
Princes Street   
Huntingdon   
PE29 3PA  

By email: 

Dear Mr Morton, 

From 

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

16 August 2024 

Thank you for the Regulation 28 report of 21st June 2024, sent to the Department of Health 
and Social Care (DHSC), about the death of Mr Terrence Roy Hubert Taylor. I am replying 
as the Minister with responsibility for adult social care. 

Firstly, I would like to say how saddened I was to read of the circumstances of  Mr Taylor’s 
death, and I offer my sincere condolences to his family and loved ones. The circumstances 
your report describes are very concerning, and I am grateful to you for bringing these matters 
to my attention.  

The report raises concerns over:  

1.  Current  guidance  for  residential  care  homes  on  the  British  Standard  for  window 
restrictors.  The  guidance  does  not  factor  in  situations  where  a  resident  deliberately 
attempts to defeat the restrictor. 

2.  DHSC and NHSE’s best practice guidance, Health Building Note 00-10 Part D: Windows 
and  associated  hardware.  This  guidance  does  highlight  that  the  British  Standard  for 
window restrictors  does  not  factor in  deliberate  attempts  to  defeat  the  restrictor using 
impact forces. However, Health Building Notes are written for the design and planning of 
new healthcare buildings and/or the adaptation or extension of existing facilities. As such, 
this guidance, though relevant, has not been directed to residential care home providers 
and was not known or understood by care home operators, manufacturers, or suppliers 
of window restrictors. 

3.  Research by the Health and Safety Executive (HSE) in 2019, which is not known by care 
home operators or window restrictor manufacturers and suppliers, advises that window 
restrictors should withstand forces greater than the British Standard.   

  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
     
  
  
  
 
 
 Regarding  these  concerns,  you  had  two  requests  for  action.  The  first  related  to  raising 
awareness of the latest guidance regarding window restrictors, including the limitations of 
the British Standard, amongst residential care home operators. Your second request was to 
review the British Standard to consider whether changes were required. 

In preparing this response, Departmental officials have made enquiries with the Care Quality 
Commission (CQC).  

In response to your first request, CQC are a named responder to this case. CQC’s separate 
response will address concerns related to raising awareness amongst residential care home 
operators of the latest guidance on window restrictors. 

CQC expect providers and registered managers to be aware of, and follow, best practice 
guidance. In 2022, CQC published a ‘Learning From Safety Incidents’ webpage on window 
restrictors. This can be found, alongside relevant, up to date guidance on complying with 
relevant  health  and  safety  precautions,  here:  www.cqc.org.uk/guidance-
the 
providers/learning-safety-incidents/issue-7-falls-windows.  The  webpage  also  links  to  the 
latest HSE guidance on risks to vulnerable members of the public from falling from height 
from windows. It can be found here: www.hse.gov.uk/safetybulletins/windowrestrictors.htm.  

Having discussed the case of Mr Taylor with CQC, they have updated their ‘Learning From 
Safety Incidents’ webpage with a link directing providers to the Health Building Note 00-10 
Part D: Windows and associated hardware. CQC have also committed to publish a note in 
their bulletin to providers in August 2024 to remind providers of the CQC’s ‘Learning From 
Safety Incidents’ webpage.  

In response to your second request for action, reviewing the British Standard is not within 
the scope of my Department's responsibilities. However, my officials have contacted HSE 
on this matter and await their reply. 

I hope this response is helpful. Thank you again for bringing these concerns to my attention.   

Yours sincerely,