Prevention of Future Deaths reports · 2024
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 report | 25 Jun 2024 |
|---|---|
| Reference | 2024-0343 |
| Deceased | Abdul Oryakhel |
| Coroner | Maria Voisin |
| Coroner area | Avon |
| Category | Other related deaths · Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 3 |
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.
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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
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.
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
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
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.
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