Elizabeth Van Der Drift

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS 

Elizabeth Van Der Drift (date of death 19 March 2024) 

THIS REPORT IS BEING SENT TO: 

1. 

Chief Executive 
Sainsbury’s 
33 Holborn 
London 
EC1N 2HT 

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 21 March 2024, an investigation was commenced into the death of 
ELIZABETH VAN DER-DRIFT, then aged 93 years. The investigation  
concluded at the end of inquest heard by me on 1 August 2024.  

The inquest concluded with a short-form conclusion of accidental death. The 
medical cause of death was:  

1a aspiration pneumonia  
1b ingestion of toxic substance (laundry detergent) 
1c dementia 

4 

CIRCUMSTANCES OF DEATH 

Ms Van Der-Drift had lived with dementia for a number of years. Her  
condition was such that she often could not recall when she last consumed 
food and she would often go in search of something to eat.   

Sometime on the night of 13/14 March 2024, she gained access to laundry  
detergent tablets/pods that were brightly coloured. Given the nature of the  
packaging and the tablets/pods, I determined that, given her cognitive  
impairment as a result of the dementia, Ms Van Der-Drift likely believed that  
they were some form of sweet or confectionary. Having gained access to the  
tablets/pods, she bit into at least one of them. Shortly thereafter, Ms Van Der- 
Drift was found complaining of stomach pain and shortness of breath.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 An ambulance conveyed Ms Van Der-Drift to hospital where, despite  
treatment, her condition deteriorated, and she died in hospital on 19 March 
2024. 

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.  

I have previously issued a Prevention of Future Deaths Report about 
industry-wide concerns, and I have attached a copy of that report for your 
information. However, on further reflection I am also reporting to you as the 
retailer of the product, which was labelled under Sainsbury’s brand. 

The MATTERS OF CONCERN are as follows: 

(1) The product in question, Sainsbury’s Tropical Escape Bio Laundry 

Capsules, due to its eye-catching colours, appearance, and 
packaging, is being confused with food and risks being accidently 
ingested by those with dementia or other cognitive impairment (as well 
as children). 

(2)  There was no safety feature observed on the packaging that made 

accessing the content particularly difficult, which increases the risk of 
accidental or inadvertent ingestion. 

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 

You are under a duty to respond to this report within 56 days of the date of  
the report, namely by 10 October 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: 

•  The daughter of Elizabeth Van Der-Drift; and 

•  The recipients of my original report (The Secretary of State for Health 
and Social Care, CEO of the Office for Product Safety and Standards, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 and Director General of the UK Cleaning Product Industry 
Association). 

The Chief Coroner may publish either or both in a complete or redacted or 
summary form. She may send a copy of this report to any person she 
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 
publication of your response by the Chief Coroner. 

9 

Ian Potter 
Assistant Coroner 
Inner North London 

15 August 2024

Mr Ian Potter 

HM Assistant Coroner 
Inner North London 

Tuesday, October 8th 2024 

Your Reference: 

Dear Mr Ian Potter, 

Engagement and Policy 
Division 

Health & Safety Executive 
Mallard House  
3 Peasholme Green 
York YO1 7PX 

Tel: +

Thank you for your Regulation 28 report in relation to the death of Elizabeth Van 
Der-Drift, dated August 13th 2024. Your report was addressed to the Secretary of 
State for Health and Social Care and to the Office for Product Safety and Standards, 
but the report was transferred to the Health and Safety Executive (HSE) from the 
Department of Health and Social Care. This was because your concerns touch on 
areas for which we have policy responsibility in respect of the classification, labelling 
and packaging of hazardous substances and mixtures (chemicals). I am aware that 
the Office of Product Safety and Standards (OPSS) will provide a separate 
response. 

In considering this matter HSE has engaged with the relevant industry association 
(the UK Cleaning Products Industry Association, UKCPI) and officials from the 
Department for Environment, Food and Rural Affairs (Defra), who have policy 
responsibility for the Detergents Regulations.  

Before I address your concerns, may I take this opportunity to express my 
condolences to the family and friends of Ms Van Der-Drift regarding the tragic 
circumstances that gave rise to the report. 

Your report highlights the following areas of concern for which HSE has 
responsibility: 

(i) 

(ii) 

laundry tablets/pods and their packaging are being produced in a way 
that, by virtue of their bright colouring, appearance, and packaging, they 
are being confused with food by people living with dementia or other 
cognitive impairment; and  

there is no obvious design feature, in terms of the packaging, that makes 
accessing the content particularly difficult for someone with even the 
most basic of manual dexterity. 

This response identifies the relevant regulatory provisions in the assimilated 
Regulation (EC) No.1272/2008 on the classification, labelling and packaging of 
substances and mixtures (‘the GB CLP Regulation’), with respect to the packaging of 
laundry tablets/pods for consumers (liquid consumer laundry detergents in soluble 
packaging for single use). The specific provisions, including guidance, are also set 
out in an Annex in this document. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 I hope this information addresses your concerns and reassures you as to the 
existing regulatory provisions that are in place on the design and safety features of 
the packaging of laundry tablets/pods for consumers. 

Laundry tablets/pods and their packaging 

In 2015, a change was made to legislation to address concerns that laundry 
tablets/pods, and their packaging, were being produced in a way that makes them 
attractive by virtue of their bright colouring, appearance, and packaging. Additional 
safety measures were implemented for liquid consumer laundry detergents in 
soluble packaging to ensure better protection of the general public, especially  
children but also to protect other vulnerable groups, for example, those with learning 
disabilities or those living with dementia or other cognitive impairment. 

This regulatory response was initiated to take action in resonse to a number of 
severe incidents of poisoning and eye damage involving children and other 
vulnerable groups, caused by liquid consumer laundry detergents in soluble 
packaging for single use.  

According to Article 35(2) of the GB CLP Regulation, the supplier is responsible for 
taking all necessary steps to make sure that the design of the packaging is not 
attractive to children arouse their curiosity or to mislead consumers; the presentation 
of the packaging must not be a design used for foodstuff.  

Design features of consumer laundry detergent packaging 

Article 35(2) and section 3.3 of Annex II to the GB CLP Regulation set out the  
detailed legal requirements on the design of the packaging and the labelling of liquid 
consumer laundry detergents in dosages for single use contained in a soluble 
packaging. 

Design features to ensure packing does not arouse the activty curiosity of children or 
other vulnerable groups to protect them include: 

•  making this type of product less visible by using opaque outer packaging;  
• 
including an aversive agent (such as a bittering agent) in the soluble 
packaging to cause an immediate repulsive effect when in contact with the 
mouth; and 
rendering access to this type of product more difficult by making the soluble 
packaging more physically resistant (mechanical resistance and water 
dissolution).   

• 

Supplemental information is also highlighted on the label of the outer packaging of 
liquid consumer laundry detergents in soluble packaging for single use. 

Matters of concern and details of action taken or proposed to be taken by HSE 

Without knowledge of the full circumstances of the death or the identity of the 
specific laundry tablets/pods that Ms Van Der-Drift consumed, we are unable to 
comment on the extent to which the product in question may have been compliance 
with the packaging and labelling requirements for liquid consumer laundry 
detergents in soluble packaging in the GB CLP Regulation.  

There are requirements related to design features in terms of the packaging of 
laundry tablets/pods to make accessing the contents more difficult. Even though the 
GB CLP Regulation does not specifically set out protective measures for those with 
dementia or cognitive disabilities as an explicit legal requirement, the secure 

 
 
 
 
 
 
 
 
 
 
 
 packaging and labelling requirements provide some mitigation in accessing the 
laundry tablets/pods.  

Where an individual is unable to identify hazard communicated through the label, 
parents, support staff or carers for vulnerable persons should make that identification 
on their behalf and implement safeguarding measures for that individual, including 
restricting access through safe storage, whether in the home, residential care or care 
home. 

HSE is not proposing additional provisions to the GB CLP Regulation but will 
continue to keep the position under review, including whether further regulatory 
measures might be needed. HSE will continue to work with bodies that enforce CLP, 
including trading standards and local authorities to address breaches of the 
regulation. 

I hope this response helps to address the concerns set out in your report and 
explains our position. 

Yours sincerely, 

Classification, Labelling and Packaging Team Leader 

 
 
 
 
 
 
 
 
 
 
 ANNEX 

RELEVANT REGULATORY PROVISIONS AND GUIDANCE WITH RESPECT TO 
THE PACKAGING OF LAUNDRY TABLETS/PODS (LIQUID CONSUMER 
LAUNDRY DETERGENTS IN SOLUBLE PACKAGING FOR SINGLE USE) 

The assimilated Regulation (EC) No.1272/2008 on the classification, labelling and 
packaging of substances and mixtures (‘the GB CLP Regulation’), for which HSE, as 
the GB CLP Agency, has policy responsibility, sets out a number of measures that 
must be taken by suppliers to ensure hazardous substances and mixtures such as 
liquid consumer laundry detergents in soluble packaging for single use (laundry 
tablets/pods) are compliant.  

General requirements for packaging 

Article 35 of the GB CLP Regulation includes general requirements for packaging 
containing hazardous substances or mixtures to ensure that: 

• 

• 

• 

the packaging is designed, constructed and fastened so that the contents 
cannot escape; 
the materials of the packaging and fastening are not damaged by the 
contents and are not liable to form hazardous compounds with the contents;  
the packaging and fastenings are strong and solid throughout to ensure that 
they will not loosen; 

•  packaging fitted with replaceable fastening devices is properly designed to 

• 

• 

allow repeated refastening without the contents escaping;  
the packaging does not attract or arouse the curiosity of children or mislead 
the consumer when supplied to the general public;  
the packaging does not have a similar presentation or a design used for 
foodstuff or animal feed stuff or medicinal or cosmetic products which would 
mislead the consumers 

Additional rules for pacakaging of substances and mixtures to be supplied to 
the general public 

The GB CLP Regulation also sets out additional rules for substances and mixtures to 
be supplied to the general public: 

• 

• 
• 

the use of child-resistant fastenings, also referred to as child-resistant 
closures;  
the use of tactile warnings of danger; and  
specific safety measures for liquid consumer laundry detergents in soluble 
packaging for single use. 

A consumer laundry detergent is a detergent used for laundry, placed on the market 
for use by the general public and non-professionals, including public launderettes 

Other Regulations  

In addition to the GB CLP Regulation, the assimilated Detergents Regulation – 
Regulation (EC) No.648/2006 - establishes technical standards and requirements in 
relation to detergents and surfactants for detergents including labelling requirements 
to ensure a high degree of protection for human health and the environment. 

Other general consumer product safety legislation, such as the General Product 
Safety Regulation 2005, will also apply. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Design features of consumer laundry detergent packaging 

Article 35(2) and section 3.3 of Annex II to CLP set out the following legal 
requirements on the design of packaging and the labelling of liquid laundry 
detergents in dosages for single use contained in a soluble packaging.  

Guidance on the design features below is taken from the European Chemicals 
Agency (ECHA) Guidance on Labelling and Packaging – Version 4.0 of March 2019.   

Obligation to market liquid consumer laundry detergents in an outer 
packaging  

Liquid consumer laundry detergents contained in soluble packaging for single use 
(for example, liquid capsules or liquitabs for use in washing machines) must be 
contained in an outer packaging. Failure to do so is considered as non-compliant 
with Article 35(1) and section 3.3.1 of Annex II to the GB CLP Regulation.  

Provisions on the outer packaging  

In order to reduce the attractiveness to children and other vulnerable groups of liquid 
consumer laundry detergents contained in soluble packaging for single use, the 
outer packaging must be opaque or obscure (for example non-see through container 
of a block colour(s)) to prevent visibility of the contents, i.e. the product or individual 
doses. The outer packaging must also bear a precautionary statement P102 (“Keep 
out of reach of children”) at a visible place and in a format that attracts attention.  

Furthermore, the outer packaging must be a self-standing container that is easily re-
closable, i.e. the pack closure must be easily re-closable in one single movement 
(for example with one finger pressure for a tub packaging). This measure aims to 
avoid the risk that the container will simply be left open if closing is too difficult.  

As the main cause of incidents seems to be the easy access to the laundry 
tablest/pods, the outer packaging must be fitted with a closure that impedes the 
ability of young children and other vulnerable groups to open the packaging. Such a 
closure should require a coordinated action of both hands with a certain strength that 
makes it difficult to open it.  

This requirement does not necessarily correspond with the closure requirement for 
child resistant fastenings. In addition, the pack closure must be designed for 
repeated use to maintain its functionality under conditions of repeated opening and 
closing for the entire life span of the outer packaging.  

Provisions on the soluble (inner) packaging  

Additional technical requirements (mechanical resistance and water dissolution) 
were introduced to make the soluble packaging more resistant. In addition to the 
requirements for the outer packaging, the soluble packaging must contain an 
aversive (e.g. bittering or other repulsive) agent against oral exposure. The aversive 
agent must be added in a concentration that is safe and that causes oral repulsive 
behaviour within a maximum time of six seconds.  

The soluble film must meet minimum mechanical and dissolution resistance criteria. 
It must retain the liquid content for at least 30 seconds when placed in water at 20°C. 
It must also resist mechanical compression of at least 300 N under standard test 
conditions.

Office for Product Safety and Standards 
Cannon House 
18 The Priory Queensway 
Birmingham 
B4 6BS 

General enquiries: +44 (0)121 345 1201 

08 October 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 

Elizabeth Van Der-Drift  

Thank you for sending me your Regulation 28 Prevention of Future Deaths Report, dated 13 
August 2024, following your investigation and inquest into the death of Elizabeth Van Der-Drift 
who died on 19th March 2024. 

I was very sorry to hear of Ms Van Der-Drift’s death. If you have the opportunity, please  do 
pass on my deepest sympathies to her family and friends.  

I  know  that  you  have  also  written  to  the  Department  for  Health  and  Social  Care,  which  I 
understand  has asked the Health and Safety Executive to respond on the issues that fall within 
their purview, and the UK Cleaning Products Industry Association (UKCPI).  I have therefore, 
focussed my response on the areas within OPSS’ area of responsibility.    

As you will know, the UK’s product safety laws require that only safe consumer products be 
placed on the market. Manufacturers or importers  have obligations to ensure their products 
are  safe.  In  addition,  distributors  must  not  supply  products  they  know,  or  should  know,  are 
unsafe. OPSS has not been made aware of any evidence to suggest that the pods were non-
compliant with relevant product safety rules, or did not meet the requirements in relation to the 
chemical substances the laundry pods contained. 

In considering the issues raised in your report we, like you, have considered the requirements 
of  the  Food  Imitations  (Safety)  Regulations  1989.  The  requirements  extend  to  products  in 
scope that any person, including but not restricted to children, could ingest, causing harm. The 
exact details of how Ms Van Der-Drift came to access the laundry pods, leading to this tragic 
incident,  are  unclear.    OPSS  is  only  aware  of  one  other  case  on  record  where  a  person 
suffering from dementia has ingested a similar type of product leading to a similar outcome. I 
therefore do not think  that an amendment to the Food Imitations (Safety) Regulations  or its 
supporting  guidance,  to  include  laundry  pods  within  their  scope,  would  be  a  proportionate 
response to this incident.   

However,  other  legislation,  such  as  the  Chemicals  Classification  Labelling  and  Packaging 
(CLP)  Regulations  (2008),  is  in  place to help  protect  vulnerable  individuals  from mistakenly 

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 

 
 
 
 
 
 
 
  
 
 
 
 
 ingesting the products such as laundry pods, by requiring manufacturers to take reasonable 
steps  to  provide  that  protection.  I  know  that  the  Health  and  Safety  Executive,  who  have 
ownership of CLP, will be responding to you separately on the consideration of whether the 
CLP requirements have been met.   

I can assure you that where appropriate we will continue work with and through other agencies 
to address safety issues where we identify breaches of existing legislation or where there are 
concerns around packaging that leads to an unacceptable risk to consumers and vulnerable 
groups.   

As part of this the OPSS has spoken to the UKCPI to obtain further insight into industry views 
and  actions  they  might  be  able  to  take.  I  understand  that  the  UKCPI  is  exploring  a  new 
awareness campaign dedicated to providing information for those with caring or safeguarding 
responsibilities.  

OPSS will ensure that this campaign is promoted to local regulators across the UK, through 
our relationships with Trading Standards in Great Britain and Environmental Health in Northern 
Ireland. 

Yours sincerely, 

Chief Executive

Ian Potter 
Assistant Coroner 
Inner North London 
By email only 

Dear Sir, 

Regulation 28 Report 

33 Holborn 
London 
EC1N 2HT 

sainsburys.co.uk 

07 November 2024 

We refer to your Regulation 28 Report and respond to the matters of concern in your report in 
that: 

1.  The product in question, Sainsbury’s Tropical Escape Bio Laundry Capsules, due to its eye-
catching colours, appearance, and packaging, is being confused with food and risks being 
accidently  ingested  by  those  with  dementia  or  other  cognitive  impairment  (as  well  as 
children). 

Sainsbury’s  and  their  suppliers  adhere  to  the  A.I.S.E.  Liquid  Detergent  Capsule  Product 
Stewardship Programme (LDC PSP) guidance in this area. For over 30 years, A.I.S.E. have made 
continual  commitments  on  product  safety  that  go  beyond  legislation  and  have  launched  a 
range of voluntary initiatives to engage with consumers and professional users on safe and 
sustainable habits, use and disposal of products and packaging. This voluntary product safety 
initiative includes guidance for retailers and producers of detergent capsules, which aims to 
support safe use and storage of LDCs by consumers to significantly reduce the incidence of 
accidental exposure to these products, in particular involving young children.  

Brands and own brand retailers participating in the LDC PSP commit to: 

1.  applying a prominent and readily visible safe use patch (also referred to as the “Yellow 
Patch”) on all LDC packaging as well as the industry’s safe use icons keep out of reach 
of children”, accompanied by the sentence: ‘Keep away from children’ (recommended) 
or the P102 sentence ‘Keep out of reach of children’, 2) the appropriate A.I.S.E. icon 
“close the pack”, accompanied by the sentence: ‘Close the lid properly’ (for tubs) or 
‘Close  the  bag  properly’  (for  stand-up  pouches),  3)  the  title  “HANDLE  AND  STORE 
SAFELY” (preferably in capital letters), 4) The statement: “©A.I.S.E.” statement, 5) The 
URL: www.keepcapsfromkids.eu. 

2.  a closure of superior child-impeding efficacy. 

3.  measures  to  reduce  the  visibility  of  LDC  through  the  product  packaging:  opaque 

packaging; obscure packaging; or any equivalent. 

In addition, the capsules have Bitrex (a bittering agent that is activated on contact with the 
tongue) included in the capsule film to deter ingestion.  The labelling below was included on 
our packaging in line with the AISE: 

Registered in England & Wales. Company registration number: 3261722 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 As a responsible retailer, we take the safety of consumers seriously and are sorry to learn of 
this incident.  

2.  There was no safety feature observed on the packaging that made accessing the content 

particularly difficult, which increases the risk of accidental or inadvertent ingestion. 

We do not accept that there was no safety feature on the packaging.  The product in question 
was contained in a Doypack with a child-impeding closure.  However, the Doypack or carton 
closures are only a deterrent if they are properly closed and in line with the AISE protocol the 
first advice is always close properly and keep out of reach, both of which statements are on 
our products in picture and word formats. 

We have since changed our packaging to remove plastic packaging to a cardboard box with a 
child impeding closure. The new cardboard box has undergone testing in line with the AISE 
Test Protocol for Child-Impeding Closures (CIC) and the product continues to meet the LDC 
PSP guidance. 

We  trust  the  above  satisfies  you  that  our  packaging  does  meets  the  appropriate  safety 
standards and demonstrates that no further action is required beyond that already detailed. 

Yours faithfully 

Sainsbury’s Group Legal Services 

Registered in England & Wales. Company registration number: 3261722

2 October 2024 

UKCPI response to the Coroner’s Prevention of Future Deaths report – 
Elizabeth Van Der Drift 

The UK Cleaning Products Industry Association (UKCPI) is the leading trade 
association representing UK producers of cleaning and hygiene products used in the 
home as well as in industrial and institutional workplaces.  

Our UK members manufacture soaps, detergents, dish wash, laundry, air care 
products, surface cleaners, polishes and disinfectants including sanitisers. Products 
that – perhaps uniquely – are used in every home, in every workplace, every day, by 
everyone to provide the clean, safe and hygienic environment we take for granted.  

As a trade association we work in partnership with our stakeholders including policy 
makers, the public and the media, to inform discussions about cleanliness, hygiene 
and sustainable cleaning and to ensure that our products are used safely and as 
intended. 

We were saddened to hear of Elizabeth Van Der Drift’s accidental death and the 
circumstances in which this happened. This is especially so given the purpose of our 
products is to enhance and provide a safe home or workplace for families and 
individuals. 

This tragic accident is extremely rare. The National Poisons Information Service or 
NPIS receive approximately 40,000 telephone enquiries per year. Typically 8% of 
enquiries per year involve adults aged > 74 years.  

The majority of these exposures (>80%) involve medicines, with household products 
accounting for <10% of exposures. Of these 300 exposures per year 78% involve 
washing up liquid, anti-bacterial or disinfectant products, 10% kettle descalers, 6.5% 
laundry powders and liquids and 5% (or 15 exposures) are attributable to laundry 
capsules and dishwash tablets.  

In approximately 2% of enquiries regarding patients in this age group (>74 years), a 
diagnosis of Alzheimer’s was documented, and dementia recorded in around 10%.   
Most exposures (85%) occur in the home and 12% in nursing/residential homes.  
NPIS has a classification (the PSS or Poisoning Severity Score) for assessing the 
severity of poisoning at the time of the enquiry. ‘Moderate’ toxicity is observed in 3% 
and ‘severe’ toxicity in a similar number of cases. The majority of exposures reported 
to the NPIS (>90%) result in no or minor clinical features only. 

The circumstances in which this accident happened was described (media reports) 
as ‘assisted living’ and could provide laundering through a shared or communal 
laundry room. If this was the case it would likely have been unsupervised, where the 
product might have been easily available especially if the packaging was not secured 
properly after use or stored safely. 

What this data highlights is that accidental exposures occur from a range of 
household products and reinforces our approach to raise awareness of the need for 
safe storage of all cleaning and hygiene products. 

c/o Allen Accountancy, 13 Gwenfro Units, Wrexham, LL13 7YP 
07843 199397 ukcpi@ukcpi.org  www.ukcpi.org 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 What follows is a short background and review on liquid capsules safe use and then 
our proposed action addressing the concern of safe storage of household cleaning 
products including laundry capsules in the elderly / dementia sufferer environment. 

Liquid laundry detergent capsules (LLDC) - background 

a.  LLDC are a single or unit dose of detergent contained in a water-soluble film. 

They most commonly contain a mix of anionic and non-ionic surfactants together 
with solvents, colourants, fragrance and other ingredients such as enzymes in 
biological products.  

b.  LLDC enable the user to accurately dose for a laundry wash (one capsule per 

load) to avoid overdosing and are in a soluble format for use at low temperature 
to reduce energy use.   

c.  They are therefore seen as a convenient and sustainable laundry washing 

product with over a billion capsules sold annually in the UK alone. They have 
been on the UK market since 2000. 

d.  However, as their popularity increased there were a small number of accidental 

exposures, mostly involving young children. 
Although the majority of those exposed to liquid laundry detergent capsules were 
asymptomatic or suffered only minor clinical features after exposure, a small 
proportion required a hospital visiti. Reference: NPIS Clinical Tox 2017 paper 

e.  There have been no known UK infant fatalities due to these exposures and 

almost all were the result of unintended access to the product in the home, i.e. 
either the capsule container was left open and / or stored in an easily accessible 
location for an unsupervised infant. 

Ensuring safe use and preventing infant accidents 

a.  Due to growing concern by the industry over the accidental exposures, in 2012 
AISE, the European trade association for detergent manufacturers, established 
its own voluntary set of safety measures. This is named the Product Stewardship 
Programme (PSP) for Liquid Detergent Capsulesii.  

b.  These safety measures were quickly adopted by all EU capsule manufacturers, 

including in the UK, and require manufacturers to:  

i.  ensure the outer packaging is obscure or opaque  
ii.  modify the closures to an industry standard to impede the access 

by infants 

iii.  provide icons and safe use messages prominently on the outer 

packaging by use of a visible industry-wide safety icon and panel – 
examples below for both pouches and box packaging: 

c/o Allen Accountancy, 13 Gwenfro Units, Wrexham, LL13 7YP 
07843 199397 ukcpi@ukcpi.org  www.ukcpi.org 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 iv.  adopt an advertising code of conduct and industry-wide safety 

message in brand communication including broadcast 

v.  Maintain a dedicated web-based campaign namely 

www.keepcapsfromkids.eu  

c. 

In 2014, this then became the template for adoption into EU legislation; the 
Classification, Labelling and Packaging Regulation or CLP.iii  
This added further protective measures such as imposing a minimum resistance 
of the soluble film membrane, retaining its liquid content for at least 30 seconds 
when the soluble packaging is placed in water at 20°C and adding an aversive 
bittering agent ‘which elicits oral repulsive behaviour within a maximum of 6 
seconds’.  

The industry’s own PSP programme was retained as it goes beyond the 
regulatory requirement in areas of on pack communication and advertising. 

d.  In 2014, AISE carried out a large-scale prospective research study in 

collaboration with five Poison Centres, to help better understand accident 
circumstances and thus to confirm that the most appropriate measures are taken 
to address any safety concerns. It found that since the introduction of the 
industry’s PSP, the number of incidents reported to the Poison Centres have 
decreased on average by 32% and that the preliminary findings of the data 
indicate that unsafe storage was the main cause of accidents involving children.  

e.  In 2017, the European Commission produced a final report on Detergent Mixtures 
in Soluble Packaging (the ‘LiquiCaps’ study’)iv to study i) LLDC safety, ii) the 
impact of measures on LLDC safety and iii) appraise possible additional safety 
measures. The report in full can be found here, but in summary it also concluded 
that the majority of accidental exposures occurred when the products were easily 
accessible by children in the home.  

f. 

In the UK, and in addition to the above voluntary and regulatory requirements, we 
established a home safety campaign with RoSPA (The Royal Society for the 
Prevention of Accidents), to promote safe storage in the home. 

‘Take Action Today’v is a communications and awareness programme delivered 
through existing home visit programmes aimed at families with new babies and / 
or families in areas of deprivation known to have high rates of infant accidents.  

c/o Allen Accountancy, 13 Gwenfro Units, Wrexham, LL13 7YP 
07843 199397 ukcpi@ukcpi.org  www.ukcpi.org 

 
 
 
 
 
 
 
 
 It is now in its 11th year with over 50 regional launches taking the safe storage 
message directly into over 700,000 families to help prevent poisoning accidents 
in the home. The professional home visitor has a simple checklist to go through 
with the parent and there is a kitchen ‘magnetic’ leave behind with safe storage 
messages. The campaign has been hugely successful in reducing hospital 
admissions due to accidental exposures amongst infants by 45% for period 
2022/23 and 50% for 2023/24 (NHS data provided by RoSPA). Detailed 
campaign presentation can be found here.vi 

Extrapolation of measures to reduce infant accidents to the elderly/dementia 
sufferer 

There is a significant overlap in the cognitive state of young children and that of 
elderly dementia sufferers which is best described as an “absence of inhibition”, or 
said differently, an absence of risk awareness around the house. (Covey, H. C. 
(1993). A return to infancy: Old age and the second childhood in history. The 
International Journal of Aging and Human Development, 36, 81–90)vii 

This similarity could allow us to extrapolate the conclusions of the research and 
campaigning with parents of infants to carers / care managers of cognitively impaired 
persons/dementia sufferers.  

We know that infants build up their inhibitions about what to put into their mouth and 
what not to put in their mouth by experience, hence initially many items are explored 
by mouth. 
For dementia sufferers, as the disease progresses they often lose these learned 
inhibitions and / or the ability to distinguish hazardous materials from non-hazardous 
such as foodstuffs.  

This loss of inhibition can be gradual, intermittent i.e. extremely difficult to predict and 
as manufacturers have no control over the product use in the user environment, so 
the role of the care giver becomes critical in ensuring that the user environment is 
safe. 

The measures industry currently takes, both regulatory and voluntary, mean that the 
product itself and the packaging it is in is inherently safe and the likelihood of 
accidental ingestion should be extremely low for all age groups.  

Our ‘Take Action Today’ campaign aims to make the home environment safe for 
infants which means ensuring that the parent is suitably informed about safe use and 
safe storage.  

This approach could be applied to the care environment and has the added benefit 
that it also helps remind and therefore prevent accidental exposure to other cleaning 
product types (acid and bleach based corrosive cleaners) as well as other 
substances such as medicines. 

c/o Allen Accountancy, 13 Gwenfro Units, Wrexham, LL13 7YP 
07843 199397 ukcpi@ukcpi.org  www.ukcpi.org 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Proposed action 

The industry has demonstrated that it is prepared to take appropriate and 
proportionate action to ensure the safe use of its products. 

As described above, we have had and continue to have a leading role in addressing 
infant accidental exposure in the home and believe this experience can be applied 
with similar success in the elderly / dementia care environment.   

Our actions laid out below are quick to deliver, reliable in terms of ongoing impact, 
applicable to the safe storage of all cleaning products (such as bleaches and 
disinfectants etc), reinforce the message for the safe storage of other products such 
as medicines and are proportionate to the level of accidental exposure currently 
being recorded. 

Speaking to the CQC and charities including RoSPA, Age UK, Dementia UK and The 
Alzheimer's Society, there does not seem to be any clear guidance on the safe use 
or storage of cleaning chemicals in a care environment - be that in the home of a 
sufferer or in a care home setting (unlike for medicines). 

There is The fundamental standards - Care Quality Commission (cqc.org.uk)viii which 
apply to all registered care facilities regulated by the CQC in England. Included in the 
standards is ‘premises and equipment’ and this includes ensuring that premises are 
safe, and so can include care homes responsibilities on safety around the home on 
chemical storage etc. 

It is relevant to note that responses to our Keep Caps From Kids website include 
emails from elderly consumers (often with reduced hand strength or arthritis) 
complaining about the difficulty in opening laundry containers (and having to resort to 
knives and scissors) and they admit that they do not reclose the hard to open 
containers.  

We know that the majority of large care and residential homes will have professional 
laundering and cleaning services on or off site and the likelihood of patients 
accessing hazardous products is minimal.  

However, in the smaller establishments, assisted living, independent living and 
ultimately in the home of say an early-stage dementia sufferer we believe that risks of 
accidental exposure can be best managed and minimised by ensuring that the care 
giver has greater awareness of safe use and storage of household chemicals. NPIS 
data shows that 80% of accidental exposures occur in the homes of the elderly 
<74yrs. 

There is already an established requirement for the safe use and storage of 
medicines with regulation (Medicines Act 1968) and guidance (NICEix and CQCx) 
existing to ensure effective storage in a lockable cupboard for example.  

c/o Allen Accountancy, 13 Gwenfro Units, Wrexham, LL13 7YP 
07843 199397 ukcpi@ukcpi.org  www.ukcpi.org 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 However, guidance on providing a safe environment tends to be general in nature 
and not specific to avoid accidental exposure to household cleaning products, 
including LLDC. For example: 
https://www.alzheimers.org.uk/sites/default/files/migrate/downloads/making_your_ho
me_dementia_friendly.pdf  

As previously described, UKCPI has a longstanding and successful national 
campaign delivered by RoSPA targeting families with infants.  

‘Take Action Today’ aims to reduce accidents amongst children under 5 by ensuring 
parents understand how to use and store safely all household cleaning products 
(including laundry capsules), to prevent infant access, i.e. the campaign builds on the 
safety measures already built into the product and product packaging and addresses 
the home environment where the cleaning products are used. 

We believe that in partnership with the appropriate agencies or charities we could 
research, develop and tailor such a campaign to target care givers in assisted living, 
independent living, care homes, residential care and in the home of the sufferer to 
ensure that they are fully aware of the need to ensure safe and secure storage of 
household cleaning products including LLDC. 

Our action would be to explore how such a campaign could be executed with 
industry support and delivered through organisations such as the CQC and charities 
such as RoSPA, Age UK, Dementia UK and The Alzheimer’s Society, all of whom we 
have already had preliminary discussions. 

Such a campaign would deliver a broad range of reduced risk not just of accidental 
ingestion but also skin and eye damage from all household products as well as other 
products categories such as medicines and garden chemicals.  

We would expect to be able to report back within 12 months on campaign messages, 
delivery partners and how to measure impact. 

c/o Allen Accountancy, 13 Gwenfro Units, Wrexham, LL13 7YP 
07843 199397 ukcpi@ukcpi.org  www.ukcpi.org 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Annex 
The Coroner’s concerns  

a.  The Coroner specifically references LLDC ‘as being colourful and potentially 

sweet-like in their appearance’.  
The bright colour of capsules was also claimed to be a factor in infant poisonings 
and led to a body of research workxi and an EU Commission reportxii concluding 
that there was no discernible colour preference when infants were exposed to a 
range of coloured household laundry products. 

Also, an inquest only recently reported that a male dementia sufferer died after 
pouring a liquid laundry product on his breakfast cereal. The detergent was 
purple so unlikely to be confused with milk/foodstuff. This would support the view 
that it is not colour but simply a dementia sufferer’s inability, at some point in their 
disease progression, to distinguish between hazardous and non-hazardous 
materials. 

UK legislation specifically requires manufacturers to avoid any confusion over 
their product use, for example: 
Under CLP there is a provision that “Packaging containing a hazardous 
substance or a mixture supplied to the general public shall not have either a 
shape or design likely to attract or arouse the active curiosity of children or to 
mislead consumers, or have a similar presentation or a design used for foodstuff 
or animal feeding stuff or medicinal or cosmetic products, which would mislead 
consumers.”xiii 
Under the Biocidal Products Regulation; “In addition, products which may be 
mistaken for food, including drink, or feed shall be packaged to minimise the 
likelihood of such a mistake being made. If they are available to the general 
public, they shall contain components to discourage their consumption and, in 
particular, shall not be attractive to children.”xiv 
Finally, it should be noted that as far as the industry is aware there have been no 
successful cases brought against any cleaning product including laundry under 
the criteria of The Food Imitations (Safety) Regulations 1989. The regulation 
looks at the form, odour, colour, appearance, packaging, labelling, volume or size 
when determining if it is imitating a food. 

b.  The Coroner specifically mentions ‘no obvious design feature, in terms of the 
packaging, that makes accessing the content particularly difficult’. This is 
confusing given the various measure previously described required under CLP. 

I have requested and received samples of the pouch packaging for this SKU and 
can confirm that it is fully compliant with the requirements of GB CLP Regulation 
and industry PSP.   

Whilst unable to verify the situation at the time of the accidental ingestion, as 
previously mentioned, it is possible that the packaging was left open or damaged 
because the container was difficult to open.  

c/o Allen Accountancy, 13 Gwenfro Units, Wrexham, LL13 7YP 
07843 199397 ukcpi@ukcpi.org  www.ukcpi.org 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 References 

i A review of 4652 exposures to liquid laundry detergent capsules reported to the United 
Kingdom National Poisons Information Service 2008–2018  

ii Product Stewardship Programme (PSP) for Liquid Detergent Capsules.  

iii Retained EU legislation Commission Regulation (EU) No 1297/2014 amending Part 3 of 
Annex II to Regulation (EC) No 1272/2008 
https://www.legislation.gov.uk/eur/2014/1297/annex 

iv Study on hazardous detergents mixtures contained in soluble packaging for single use 
('LiquiCaps Study') 

v Take Action Today, Put Them Away campaign 

vi RoSPA Take Action Campaign presentation 

vii (Covey, H. C. (1993). A return to infancy: Old age and the second childhood in history. The 
International Journal of Aging and Human Development, 36, 81–90) 

viii The fundamental standards - Care Quality Commission (cqc.org.uk)  

ix https://www.nice.org.uk/guidance/ng46 

x https://www.cqc.org.uk/guidance-providers/adult-social-care/storing-medicines-care-homes 

xi https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199976 

xii https://ec.europa.eu/health/scientific_committees/consumer_safety/docs/sccs_o_056.pdf  
xiii Retained EU legislation Regulation (EC) 1272/2008 Article 35 Para 2 
https://www.legislation.gov.uk/eur/2008/1272/pdfs/eur_20081272_2008-12-16_en.pdf 

xiv Retained EU legislation Regulation (EU) No 528/2012 Article 69 Para 1 
https://www.legislation.gov.uk/eur/2012/528/article/69 

c/o Allen Accountancy, 13 Gwenfro Units, Wrexham, LL13 7YP 
07843 199397 ukcpi@ukcpi.org  www.ukcpi.org