Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0533, written 7 Oct 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Oct 2024 |
|---|---|
| Reference | 2024-0533 |
| Deceased | Helen Davey |
| Coroner | Jeremy Chipperfield |
| Coroner area | Durham and Darlington |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (After Inquest) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Trade and Business Office for Product Safety and Standards Department for Business and Trade 1 CORONER I am Jeremy Chipperfield, senior coroner for the coroner area of Durham and Darlington 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 10-Jun-24, I commenced an investigation into the death of Helen DAVEY, 39. The investigation concluded at the end of the inquest on 04-Oct-24. The conclusion of the inquest was that the death was accidental. 4 CIRCUMSTANCES OF THE DEATH The deceased was leaning over the storage area of an Ottoman-styled “gas-lift bed” when the mattress platform descended unexpectedly, trapping her neck against the upper surface of the side panel of the bed’s base. Unable to free herself, she died of positional asphyxia. One of the two gas-lift pistons was defective. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows The existence and use of gas piston bed mechanisms whose failure presents risk to life. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 02-Dec-24. 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 family. 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 07-Oct-24
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Office for Product Safety and Standards Cannon House 18 The Priory Queensway Birmingham B4 6BS General enquiries: Jeremy Chipperfield HM Senior Coroner County Durham and Darlington Coroners Service North Terrace, Civic Centre Crook DL15 9ES Sent via email 2 December 2024 Dear Mr Chipperfield, Regulation 28: Report to Prevent Future Deaths – Helen Davey Thank you for writing to the Secretary of State for Business and Trade Jonathan Reynolds MP, and the Office for Product Safety and Standards (OPSS), regarding your Regulation 28 Report to Prevent Future Deaths dated 7 October 2024. This followed your investigation and inquest into the death of Helen Davey, who died on 7 June 2024 as a result of positional asphyxia caused by an ‘Ottoman’ style bed believed to have closed unexpectedly on her. The Secretary of State has asked me, in my role as Chief Executive of OPSS, to respond to your report on behalf of the Department. May I say how sorry I was to hear of Helen Davey's death. If you have the opportunity, please convey my condolences and those of the Secretary of State and Ministers, to her family and friends. As you may know, OPSS, within the Department for Business and Trade, is the UK’s national product regulator, covering all consumer products except food, vehicles and medicines. OPSS’ primary purpose is to protect people and places from product-related harm. We take the safety of consumers seriously and, alongside Local Authority Trading Standards, we have access to powers to take action where manufacturers, importers or distributers do not meet their responsibilities for product safety set out in UK law. The safety (other than fire safety) of Ottoman-style beds is regulated by the General Product Safety Regulations 2005 (GPSR). These Regulations place obligations on manufacturers and importers to make sure products they supply are safe. Manufacturers and importers must also 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 consider any risks that may arise from the product in normal or foreseeable use and take action to avoid them or to mitigate against them. There are also requirements for businesses to provide appropriate warnings relating to any risks the product may pose and instructions so that consumers can use the product safely. Following media reports of this incident, OPSS contacted Durham Constabulary to request further details including any information that would help to identify the specific product involved. In response, we received photos of the bed and brief details of the scene. However, from the limited information available we have been unable to identify the specific product model or manufacturer to investigate whether the product was non-compliant with GPSR. If you hold any further information about the product, or should more information come to light, we will of course review it with a view to further action. OPSS has also contacted the British Standards Institution (BSI), the UK’s national standards body, about this incident. BSI are responsible for independently producing national and international technical standards, and I know they have already raised awareness of it with their counterparts in the international and European standards bodies. OPSS has written to request that BSI reviews relevant UK furniture standards, including standards for furniture testing methods, to ensure they adequately address the safety of Ottoman-style beds, including how they prevent beds from descending unexpectedly should a lifting mechanism fail. While product standards are voluntary, they can assist businesses in complying with their legal safety obligations. OPSS is writing to relevant trade bodies, including the National Bed Federation, the British Furniture Manufactures Association and British Furniture Confederation, to ask that they make their members aware of the incident and the potential risk should a lifting mechanism fail, so that they can ensure that risk has been considered and addressed in any similar products. Thank you for bringing this matter to our attention. 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
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