Prevention of Future Deaths reports · 2024

Abdul Oryakhel

Regulation 28 report to prevent future deaths, reference 2024-0343, written 25 Jun 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report25 Jun 2024
Reference2024-0343
DeceasedAbdul Oryakhel
CoronerMaria Voisin
Coroner areaAvon
CategoryOther related deaths · Product related deaths
Sourcejudiciary.uk record · original PDF
Responses published3

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

M. E. Voisin  
 Her Majesty’s Senior Coroner 
Area of Avon 

25 June 2024 

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

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 

 – Head of private E-scooter Regulation, Traffic and Technology 

Department for Transport, Great Minster House, 33 Horseferry Road, London, SW1P 4DR 

 – Metro Mayor 

The West of England Combined Authority, 70 Redcliff Street, Bristol, BS1 6AL 

1 

CORONER 

I am M. E. Voisin HM Senior Coroner for Avon  

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. 
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 

3 

INVESTIGATION and INQUEST 

On 28/9/2022 an investigation was commenced into the death of Abdul Jabar Oryakhel. The 
investigation concluded at the end of the inquest on 25/6/2024.  

The conclusion of the inquest was - Accident. 

The brief circumstances are as follows:  

The deceased died on 25 September 2022 at Twinnell House, Stapleton Road, Bristol. He had 
fallen from the window of his flat on the top floor when he was trying to escape from a fire in 
the flat caused by the overheating and ignition of a lithium-ion battery pack which caused the 
fire. The battery was used for an E-bike stored in the cupboard of the flat.  

The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 

  
         
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 4 

CIRCUMSTANCES OF THE DEATH 

132, Twinnell House is a Bristol City Council owned property and was rented by the deceased’s 
cousin. His cousin had an E –Bike which was stored in the cupboard in the hallway. 

The fire started when the occupants were asleep in the flat on 16th floor. Mr Oryakhel died, 1 
received significant burns whilst escaping and the other 2 escaped by crawling out the kitchen 
window and being rescued by the emergency services.  

The deceased, according to another resident, who lives on the 4th floor of Twinnell House, fell 
past his window at around 2.15am, he called 999, and the police, ambulance and fire services 
arrived on scene.   

 from Avon Fire and Rescue explained that the first 999 call was received at 
02.19hrs on 25th September, it was subsequently confirmed that the fire was on 16th floor of 
the building and it was initially declared a major incident. The fire was contained in the flat as 
was intended by the building design and fire safety measures.   

A fire scene investigation was commenced the next day and 
circumstance of the fire based on the investigation of the scene was ... the accidental ignition 
caused by local overheating and catastrophic failure of a Lithium-ion battery pack which in turn 
caused a thermal runaway and significant fire development in a short space of time. The E- bike 
and charging equipment was the only possible source of ignition.   

 confirmed that the 

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 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.  –  

There appears to be a lack of understanding of the dangers with Lithium-ion batteries used for 
e-bikes and e-scooters.  

I understand that there is currently 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. 

From what I am told there is an increase in the number of people buying and using e-bikes and 
e-scooters.  

I am aware that other coroner’s have written similar reports but this only goes to emphasise 
that preventable deaths continue.   
ACTION SHOULD BE TAKEN 

6 

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 

The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL 

  
         
 
 
 
  
 
 
  
  
  
  
 
 
 
 
 
 
 
 
 
 
 You are under a duty to respond to this report within 56 days of the date of this report, namely 
by 12th September 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. 

8 

COPIES and PUBLICATION 

I have sent a copy of my report to the chief coroner and to the following interested persons – 
the family of the Deceased and Bristol City Council 

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 

25th June 2024 

M. E. Voisin 
HM Senior Coroner for Avon 

The Coroner's Court, Old Weston Road, Flax Bourton, BS48 1UL

Responses

3 responses 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.

Response from Department of Transport (PDF)
From the Parliamentary  
Under Secretary of State 

Great Minster House 
33 Horseferry Road 
London 
SW1P 4DR 

Tel: 
E-Mail: 

Web site: www.gov.uk/dft 

Your Ref: 

M.E. Voisin  
His Majesty’s Senior Coroner for the Area of Avon 
Old Weston Road 
Flax Bourton 
BS48 1UL 

          30 July 2024 

Dear Mrs Voisin, 

Thank you for your Regulation 28 report of 25 June 2024, regarding the death 
of  Mr Abdul Jabar Oryakhel.  I  was very sorry  to  hear  about  his  death, and I 
send my sincere condolences to his family and friends.  

I have considered your report carefully and the matters of concern you raised 
to help prevent similar deaths in the future. I set out my thoughts below. 

In your report you state that:  

“There appears to be a lack of understanding of the dangers with 
lithium-ion batters used for e-bikes and e-scooters. I understand that 
there is currently 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. From what I am told there is an increase in the number of people 
buying and using e-bikes and e-scooters. I am aware that other 
coroner’s have written similar reports but this only goes to emphasise 
that preventable deaths continue.”  

The Department for Transport, the Home Office and the Office for Product 
Safety and Standards have worked together to understand the issues with 
lithium-ion batteries and have all published guidance for users of e-cycles and 
e-scooters on battery safety. The DfT guidance, published in February this 
year and concerning the safe purchasing, use, charging and storage of 
batteries can be viewed on the following link: 
www.gov.uk/government/news/new-guidance-to-enhance-e-bike-and-e-
scooter-safety  

 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 The Home Office-maintained “Fire England” website, containing advice on 
safe charging of e-cycle and e-scooter batteries, can be viewed on the 
following link: www.fireengland.uk/news/how-keep-your-home-safe-when-
charging-your-e-bike-or-e-scooter    

Consumer safety information on e-cycle and e-scooter batteries, published by 
the Office for Product Safety and Standards, can be viewed on the following 
link: www.gov.uk/government/news/opss-publishes-consumer-information-on-
e-bike-and-e-scooter-battery-safety  

In addition to these published materials, Fire and Rescue Services have 
sought to actively promote fire safety messaging on e-cycle and e-scooter 
batteries. The London Fire Brigade’s “Charge Safe” campaign is an example 
of this, and can be viewed on the following link: www.london-
fire.gov.uk/chargesafe. Avon Fire and Rescue have also published safety 
information, and this can be viewed on the following link: 
www.avonfire.gov.uk/safety/home/electrical-items/e-scooters-bikes  

The Office for Product Safety and Standards has commissioned research 
from Warwick Manufacturing Group to better understand the safety issues 
associated with the lithium-ion batteries. The outcome of this research, 
coupled with research from the Department for Transport on how future 
regulations on e-scooters could be developed (and which contains a section 
on battery safety) will inform any further action from government. Both pieces 
of research are scheduled to be published later this year.  

I am aware you have also written to the Office for Product Safety and 
Standards. The safety and enforcement of consumer products, and the role of 
standards, is part of their remit, and I anticipate they will be best placed to 
respond to you on this point. 

Pending the outcome and publication of the research referred to above, we 
have concluded that there is no additional action that would be appropriate for 
the Department for Transport to take at this stage. 

Yours sincerely, 

MINISTER FOR LOCAL TRANSPORT
Response from Opss (PDF)
Office for Product Safety and 
Standards 
Cannon House 
18 The Priory Queensway 
Birmingham 
B4 6BS 

General enquiries: +44 (0)121 345 1201 

12 September 2024 

M. E. Voisin 
HM Senior Coroner for Avon 
The Coroner's Court 
Old Weston Road 
Flax Bourton 
BS48 1UL 

Sent by email to:  
AvonCoronersTeam@bristol.gov.uk 
Dear Mrs Voisin, 

Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 25 June 
2024, following your investigation and inquest into the death of Abdul Jabar Oryakhel, 
who  died  on  25  September  2022  whilst  escaping  a  fire  caused  by  an  overheating 
lithium-ion e-bike battery pack. 

I was very sorry to hear of Mr Oryakhel’s death. If you have the opportunity, please do 
pass on my deepest sympathies to his family and friends.  

The  Office  for  Product  Safety  and  Standards  (OPSS),  within  the  Department  for 
Business and Trade, is the UK’s national product regulator, and the safety of e-bikes, 
e-scooters, their batteries and associated products is a top priority for us. In early 2023, 
OPSS  began  a  dedicated  programme  of  work  to  better  understand  and  tackle  the 
causes of product safety issues in these products in response to the growing number 
of incidents being reported.  

This  programme  is  aimed  at  protecting  consumers  through  better  understanding  of 
risks  from  lithium-ion  batteries  and  how  product  components  interact;  increasing 
business compliance through regulatory advice and action; and issuing clear safety 
messages  to  consumers  to  raise  awareness  of  risks.  In  addition,  OPSS  has  a 
programme  of  work  addressing  the  sale  of  non-compliant  products  made  available 
through online marketplaces, often by third parties based overseas.   

Lithium-ion batteries and chargers are subject to UK product safety laws. Lithium-ion 
batteries  must  comply  with  the  requirements  of  the  General  Product  Safety 
Regulations  2005,  while  battery  chargers  are  subject  to  the  requirements  of  the 
Electrical Equipment (Safety) Regulations 2016. These regulations place obligations 
on  manufacturers  and  importers  to  only  place  safe  products  on  the  UK  market.  In 
addition, distributors, including online marketplaces when they undertake the activities 
of  distributors,  must  not  make  available  products  they  know,  or  should  know,  are 
unsafe.  OPSS  and  Local  Authority  Trading  Standards  have  powers  to  take  action 
where these requirements are not met. 

Over the last two years we have undertaken regulatory interventions in this area, such 
as  serving  withdrawal  notices  to  require  the  removal  of  dangerous  models  of  UPP-
manufactured e-bike batteries from the market. We are using data and intelligence to 

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 

 
 
 
 
 
 
 target unsafe and non-compliant goods, including coordinating product removals with 
Local  Authority  Trading  Standards teams working at the  border. Since 2022, OPSS 
has  published  information  regarding  18  product  recalls,  and  20  other  regulatory 
actions, relating to e-bikes, e-scooters and associated products. We have carried out 
inspections of technical product documentation and quality assurance processes for 
more than 90 UK-based businesses involved in the manufacture or supply of these 
products, to check their compliance.  

Working with local authorities, we launched a new programme this year to reach small 
UK businesses that repair or modify e-bikes, e-scooters or their batteries, to ensure 
these businesses are aware of and comply with the regulations that apply to them. We 
also work closely with fire and rescue services and have established a system for them 
to  report  any  fire  incidents  that  involve  products  in  real  time,  so  we  can  gather 
intelligence and  when necessary, take  appropriate action in relation to the products 
involved. 

In your report, you have raised a concern over a lack of understanding of risks in this 
area and the lack of a specific British Standard for e-bike batteries and chargers. Our 
research  and  evidence  points  to  complexity  with  the  products  and  associated 
components, which may be safe when placed on the market but may become unsafe 
if modified or if non-compatible replacement batteries or chargers are used. As part of 
our  e-bike  programme,  OPSS  commissioned  a  research  study  from  Warwick 
Manufacturing  Group  (WMG)  into  potential  hazards  and  risks  from  e-bikes  and  e-
scooters,  including  their  batteries.  This  includes  compatibility  issues  as  well  as  an 
assessment of all relevant standards, to identify any areas where changes to voluntary 
standards could assist businesses to comply with the law. We expect the research to 
be published soon, once it has completed independent peer reviews.  

While  the  creation  of  new  voluntary  standards  is  a  matter  for  the  British  Standards 
Institution  (BSI),  we  will  carefully  consider  any  relevant  recommendations  made  by 
WMG.  OPSS  has  already  commissioned  BSI  to  develop  a  Publicly  Available 
Specification  for  e-bikes,  e-scooters,  their  batteries,  conversion  kits  and  related 
products, which we hope to be in place in the next 18 months. OPSS has previously 
designated,  with  restrictions,  the  standard  BS  EN  15194  for  e-bikes,  which  gives 
products that meet the standard a presumption of conformity with the law (except in 
regard to the clauses restricted under the designation). However, whether businesses 
choose  to  follow  a  standard  remains  voluntary,  and  they  must  still  meet  all  their 
obligations in law.  

OPSS has also been actively raising awareness of the risks that these products can 
pose. In December 2023, OPSS published a Government safety message on e-bikes 
and e-scooters with recommendations on the steps consumers can take to reduce fire 
risks if they purchase, use or charge an e-bike or e-scooter. The steps include 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. We are planning a new safety campaign with consumer 
messaging on purchasing e-bikes and e-scooters, which we expect to be launched in 
the autumn. 

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 

 
 OPSS has also joined up with other Government Departments to support consumer 
safety messaging for e-bikes, including Department for Transport guidance, published 
in  February  this  year:  www.gov.uk/government/news/new-guidance-to-enhance-e-
bike-and-e-scooter-safety and ‘Fire England’ guidance published by the Home Office 
last  year:  www.fireengland.uk/news/how-keep-your-home-safe-when-charging-your-
e-bike-or-e-scooter.  

OPSS  is  engaging  with  major  gig  economy  delivery  firms,  such  as  Uber  Eats  and 
Deliveroo, to encourage wider dissemination of safety information about e-bikes and 
batteries to delivery riders and couriers, who are key users of these products.   

Regulating new and emerging markets, as well as new models of supply, does present 
challenges.  The  Government  has  recently  introduced  the  Product  Regulation  and 
Metrology Bill into Parliament with a view to allowing the UK to better respond to new 
product  risks.  The  Bill  is  designed  to  give  Government  access  to  new  regulation-
making  powers  to  regulate  new  or  innovative  products,  to  regulate  products  being 
made available via new and emerging business models including online marketplaces, 
and to ensure that online marketplaces have clear responsibilities for supplying safe 
products.  

The safety of e-bikes and lithium-ion batteries remains a high priority for OPSS and we 
believe the actions outlined above will make a material difference to consumer safety 
in this area.  

Thank you  again  for raising these important issues. I would be grateful if you could 
share a copy of this letter with colleagues who may find it useful. 

Kind regards, 

Chief Executive 

OPSS 

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
Response from West of England Combined Authority (PDF)
12th September 2024 

This information has been prepared by the West of England Combined Authority’s Transport Team in 
response to the Regulation 28 Report to prevent future deaths issued on 25th June 2024 by M. E. Voisin, 
HM Senior Coroner for Avon. 

A Regulation 28 Report to Prevent Future Deaths was sent to the West of England Combined Authority, 
requesting a response. In particular, to provide details of action taken or proposed to be taken, setting 
out the timetable for action, or otherwise explain why no action is proposed. 

The report concerned the investigation into the death of Abdul Jabar Oryakhel. The deceased died trying 
to escape from a fire in his flat caused by the overheating and ignition of a lithium-ion battery pack used 
for an e-Bike that was stored in the property. The e-Bike in question was not connected with the eBikes 
available for rental through the West of England’s contracted supplier. 

Coroner’s concerns: 

•  Apparent lack of understanding of the dangers with Lithium-ion batteries used for e-bikes and e-

scooters. 

•  That there is currently 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. 

•  That there is an increase in the number of people buying and using e-bikes and e-scooters. 

Response of the West of England Combined Authority 

Specific actions to address the concerns raised by the Coroner do not lie within the strategic functions of 
the West of England Combined Authority. The areas of concern require national government action in the 
first instance, through legislation and regulation. 

Further information 

In July  2020,  the  Government  passed legislation  allowing trials of electric scooters  (e-scooters) on the 
public  highway.    Prior  to  the  legislation,  the  use  of  both  privately  owned  and  rental  e-scooters  was 
prohibited on the public highway, and only permissible on private land with the landowner’s permission. 

To  run  an  e-scooter  trial,  local/regional  authorities  needed  to  make  a  successful  application  to  the 
Department for Transport.  The West of England Combined Authority applied and was successful.  

Following  the  successful  application,  the  West  of  England  Combined  Authority  procured  a  concession 
contract for e-scooter rental services.  The concession contract was awarded and operations commenced 
from October 2020. 

1 

 
 
 
 
 
 In January 2023 the West of England Combined Authority re-tendered the concession contract, with the 
additional scope of e-bike and e-cargo bike rental services (in addition to e-scooters).  Following an open 
procurement, the Combined Authority awarded the new contract.  By November 2023 the new contract 
was fully operational and is still running.  

The contract defines two types of vehicle rental and associated battery charging: 

1.  On-street rental: Customers rent a vehicle “on-street” using a smartphone which remotely unlocks 
the vehicle and enables it to be ridden.  Vehicles can only be ridden and returned within a designated 
area within the West of England region, restricted to the public highway.  When a rental is finished, 
the vehicle is de-activated and can only be used again by a customer using their smartphone.  It is 
considered theft if members of the public remove a vehicle from the public highway.  Vehicle batteries 
are  charged  by  the  operator  (i.e.  Voi  or  Tier)  using  a  “battery  swap”  method.    The  battery  swap 
method involves the operator replacing depleted batteries with newly charged batteries.  Batteries 
are charged by the operator at a warehouse.  

2.  Long term rental (e-scooter only): Customers apply to the operator to rent an e-scooter on a long-
term rental (LTR) basis.  The operator delivers the e-scooter to the residence of the applicant and 
provides them with the vehicle, charger, and an information pack.  The customer is charged a monthly 
fixed  fee  for  the  rental  of  the  e-scooter,  and  the  customer  is  responsible  for  vehicle  storage  and 
battery charging. 

       However,  as of  6am  Tuesday  3rd  September  2024  the  Long-Term  Rental  service  for e-scooters  has 
been paused. Users have been asked to leave their vehicles outside for collection. At 6am Wednesday 
4th September 2024 the e-scooters were remotely switched to maintenance mode to prevent use. The 
contractor then began the process of recovering the e-scooters. 

       No event has occurred that led to the pause in service. Rather, the contractor’s Health & Safety and 
Vehicle  Product  teams  have  reassessed  the  risks  associated  with  users  charging  the  e-scooters  at 
home. Given the potential impact of the risk, the decision was taken to pause the service and explore 
mitigations before potentially reintroducing. Being permitted as part of the national e-scooter trial, 
the Department for Transport have said that the resumption of the service could only take place if 
both they and the Combined Authority are comfortable with the risk assessment and any mitigations 
in place. 

What actions the Combined Authority has taken in the past to mitigate the risks of  home-based 
lithium-ion battery fires 

The  West  of  England  Combined  Authority  believes  the  provision  of  the  on-street  rental  e-scooter 
service (and now with e-bikes and e-cargo bikes), is providing a legal, convenient and affordable  

2 

 
 
 
 
 
 
 
 alternative to private ownership of similar vehicles.  For some people this will have reduced the need 
(and therefore the actual number), of privately owned vehicles kept at home, and therefore reduced 
the chance of home-based lithium-ion battery fires. 

What actions the Combined Authority will take in the future to mitigate the risks of  lithium-ion 
battery fires in homes 

The Combined Authority is continuing to participate in the national e-scooter trial. Through this, the 
Combined Authority can contribute evidence of e-scooter (and now e-Bike) usage, making the case 
for  legislation  and  regulation  that  safely  incorporates  e-scooters  into  the  transport  system.  The 
Combined Authority is also able to work with Tier to communicate best practice in terms of safe e-
scooter use (including charging) and demonstrate the benefits of high product safety standards. 

------------------------------------------------------------------------------------------------------------------------------------------ 

3

Related reports

Other reports by Maria Voisin

See all →

More reports categorised “Other related deaths”

See all →

Track Product related deaths

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.