Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0677, written 6 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 6 Dec 2024 |
|---|---|
| Reference | 2024-0677 |
| Deceased | Champagauri and Dipak Bhatt |
| Coroner | Peter Straker |
| Coroner area | London (North) |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 8 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
North London Coroner’s Service, Barnet, Brent, Enfield, Haringey and Harrow, Barnet Coroner’s Court, 29 Wood Street, London, EN5 4BE E-mail: The Coroner’s Service REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: , Chief Executive Office of Product Safety Standards 4th Floor Cannon House 18 The Priory Queensway Birmingham B4 6BS C/O: , Chief Executive & & British Standards Institute 389 Chiswick High Road London W4 4AL C/O: The Home Office Fire Policy Team Direct Communications Unit 2 Marsham Street London SW1P 4DF C/O: National Fire Chief’s Council 71-75 Shelton Street Covent Garden London WC2H 9JQ C/O: , Chief Executive Association of Manufacturers of Domestic Electrical Appliances Vintage House 36-37 Albert Embankment London SE1 7TL Email: C/O: , Chief Executive Chartered Trading Standards Institute 1 Sylvan Court Sylvan Way Southfields Business Park Basildon Essex SS15 6TH C/O: & , Managing Director Hotpoint UK Appliances Limited Morley Way Peterborough PE2 9JB C/O: , Chief Executive North Yorkshire Council County Hall Northallerton DL7 8AD C/O: & 1 CORONER I am Mr P. Straker, Assistant Coroner for the coroner area of the Northern District of Greater 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 the 17th of May 2023 I commenced investigations into the deaths of Champagauri and Dipak Bhatt. The investigations concluded on the 15th of November 2024 after inquests held over the 6th, 7th and 8th of November 2024. The inquests had the following short narrative conclusions: (a) Following a fire caused by an electrical fault in the tumble dryer, Champagauri Bhatt died from the resulting inhalation injury. (b) Following a fire caused by an electrical fault in the tumble dryer, Dipak Bhatt died from the resulting inhalation injury. 4 CIRCUMSTANCES OF THE DEATH On the evening of 29th of March 2023 a fire caused by an electrical fault in the tumble dryer at Edgware caused Champagauri and Dipak Bhatt to die from inhalation injuries. There was a 10% chance the EMI filter caused the fire and a 90% chance the condensate pump caused the fire. 5 CORONER’S CONCERNS During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire. (2) That changes in information management would result in better analysis of, and learning from, white goods fires. (3) Manufacturers to give the and Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warrantyee for condensate pumps and RFI filters. (4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards. (5) Manufacturers to share data on decisions and rationale behind recall / replacement of condense pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work. (6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations. (7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates. (8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and your organisation 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 Friday 31 January 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; - 1. The family of Ms Champaguri and Mr Dipak Bhatt 2. London Fire Brigade 3. Hotpoint 9 Date: 06/12/2024
8 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.
28 January 2025 To Mr P. Straker, Assistant Coroner, North London Coroner’s Service Barnet Coroner’s Court 29 Wood Street. London. EN5 4BE Re: AMDEA Response to Coroner's Report Dear Mr Straker, Thank you for your regula(cid:415)on 28 report to prevent future deaths, dated 6 December 2024, concerning the fire incident involving a domes(cid:415)c appliance and resul(cid:415)ng in the tragic deaths of Messrs and Mses Champagauri and Dipak Bha(cid:425). We appreciate the thorough inves(cid:415)ga(cid:415)on, and the concerns raised in your report. We have carefully reviewed the content of the findings and address below each point of concern in turn. AMDEA remains commi(cid:425)ed to collabora(cid:415)ng with industry stakeholders to enhance product safety and will con(cid:415)nue to share insights at na(cid:415)onal and interna(cid:415)onal standards development commi(cid:425)ee mee(cid:415)ngs. These ongoing efforts aim to drive con(cid:415)nuous improvement, enhancing informa(cid:415)on management, sharing best prac(cid:415)ces, and upholding the highest safety standards across our sector. We value the opportunity to contribute to the preven(cid:415)on of future deaths and are commi(cid:425)ed to working closely with the Office of Product Safety Standards (OPSS), the London Fire Brigade (LFB), and other relevant bodies to implement effec(cid:415)ve solu(cid:415)ons. Please do not hesitate to reach out if further clarifica(cid:415)on is required. Yours sincerely, CEO, AMDEA AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823 (1) That ingress of moisture into condensate pumps may result in tracking faults causing resis(cid:415)ve hea(cid:415)ng and fire. AMDEA and its membership are commi(cid:425)ed to promo(cid:415)ng product safety and addressing poten(cid:415)al hazards such as moisture ingress into condensate pumps, which may lead to tracking faults, resis(cid:415)ve hea(cid:415)ng, and fires. AMDEA and its members are also commi(cid:425)ed to promo(cid:415)ng product safety and sharing of hazard- related informa(cid:415)on through our Safety Liaison Panel (SLP) func(cid:415)on. Our membership ac(cid:415)vely inves(cid:415)gates public usage data, service feedback and field findings to con(cid:415)nuously improve product designs. These efforts include considera(cid:415)ons for all components within a product. The condensate pump is called out specifically within the coroner’s report. However, members design teams consider all component posi(cid:415)oning and seal and enhance moisture protec(cid:415)on for all components and therefore mi(cid:415)gate water ingress risks. Manufacturers rigorously test products to ensure compliance with safety standards outlined in legisla(cid:415)on such as the ‘Electrical Equipment (Safety) Regula(cid:415)ons 2016’ under Schedule 2, where the technical documenta(cid:415)on held by the manufacturer “must make it possible to assess the electrical equipment's conformity to the relevant requirements and must include an adequate analysis and assessment of the risk(s).” In prac(cid:415)ce, our members are working itera(cid:415)vely and con(cid:415)nuously risk assessing, then revisi(cid:415)ng design based on ongoing life tes(cid:415)ng, user findings and field feedback allowing manufacturers to enhance the sealing and protec(cid:415)on of said components. Furthermore, they are conduc(cid:415)ng rigorous tes(cid:415)ng to ensure that products con(cid:415)nue to meet and even exceed the safety standards they are aligned too and ensuring any tracking faults are reduced and handled in the risk assessments therefore reducing likelihood of any resis(cid:415)ve hea(cid:415)ng and fire. It is worth no(cid:415)ng that manufacturers recommend that large appliances be repaired by qualified professionals, unless otherwise stated. Adherence to manufacturer specifica(cid:415)on spares is important for maintaining the safety and performance of appliances, as improper servicing or the use of non-approved parts can compromise product integrity and increase safety related risks. We would be interested in learning more about this specific issue to ensure our efforts remain aligned with emerging safety concerns and will be adding this as a topic of discussion at our Safety Liaison Panel mee(cid:415)ngs. AMDEA’s members incorporate comprehensive design procedures, including DFMEA (Design Failure Modes Effects and Analysis) and adap(cid:415)ve risk assessment processes, which are con(cid:415)nuously re-evaluated as new findings emerge. Our members adhere to the latest versions of the EN IEC and BSI standards, including 60335-1 for general appliance safety and IEC 60335-2-11 specific to tumble dryers. These standards include clause 15, which focuses on moisture resistance with tests simula(cid:415)ng real world condi(cid:415)ons to prevent electrical hazards related to moisture ingress. Addi(cid:415)onally, IEC 60529, which defines the interna(cid:415)onally recognised IP (Ingress Protec(cid:415)on) code and used across mul(cid:415)ple industries, guides manufacturers in designing enclosures that withstand environmental factors, such as water exposure. AMDEA and its membership remain commi(cid:425)ed to collabora(cid:415)ng with industry stakeholders to enhance product safety and share insights at na(cid:415)onal and interna(cid:415)onal standards development commi(cid:425)ee mee(cid:415)ngs. These efforts aim to drive con(cid:415)nuous improvement, share best prac(cid:415)ces, and uphold the highest safety standards across the sector. AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823 (2) That changes in informa(cid:415)on management would result in be(cid:425)er analysis of, and learning from, white goods fires. AMDEA is strongly in favour of effec(cid:415)ve informa(cid:415)on management, which allows for detailed analysis and con(cid:415)nuous improvements in mi(cid:415)ga(cid:415)ng white goods fires. Members rely on a variety of data sources including reports from consumers, Fire Services, and regulatory agencies to inform their own risk assessments and design processes. As appliances become increasingly connected, this data is also shared directly with the manufacturer to further feed into these processes. AMDEA holds monthly mee(cid:415)ngs with LFB and OPSS to discuss areas of concern and emerging trends. Addi(cid:415)onally, through our bi-annual Safety Liaison Panel mee(cid:415)ngs, we collaborate closely with our members, Fire Services, Trading Standards and OPSS’s data team. These mee(cid:415)ngs focus on iden(cid:415)fying trends and staying informed about changes in product and fire safety. To further strengthen our efforts, we have recently implemented an annual comprehensive data management colla(cid:415)on system. This system collates data from a variety of sources including OPSS and anonymised data from our membership. This collected data enables us to further analyse and disseminate safety related informa(cid:415)on related to specific appliances. This exercise has already proven instrumental in iden(cid:415)fying trends, suppor(cid:415)ng targeted incident analysis, and driving safety enhancements at Interna(cid:415)onal IEC standards level. AMDEA remains commi(cid:425)ed to refining the system annually to ensure it con(cid:415)nues to serve as a valuable tool in improving safety outcomes and reducing the risk of white goods fires. AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823 (3) Manufacturers to give the Office of Product Safety Standards (OPSS), as the regulator, and London Fire Brigade (LFB), informa(cid:415)on to support their fire preven(cid:415)on work data on parts replaced on warranty for condensate pumps and RFI filters. We fully support the efforts of the Office of Product Safety Standards (OPSS) and the London Fire Brigade (LFB) in enhancing fire preven(cid:415)on and recognise the importance of sharing relevant data to enhance safety outcomes. One of our key ini(cid:415)a(cid:415)ves, AMDEA’s “Register my Appliance” campaign and website Home - Register My Appliance supported by Fire Services and other stakeholders enables homeowners to register their appliances, suppor(cid:415)ng manufacturers to maintain customer records for warranty purposes, manufacturer record support for communica(cid:415)ons on vital communica(cid:415)ons for recalls and safety enhancements through improvements, traceability, and accountability for poten(cid:415)al issues. Addi(cid:415)onally, the website includes a detailed sec(cid:415)on that lists all relevant recalls across AMDEA’s membership for simple consumer reference. When manufacturers iden(cid:415)fy issues related to defec(cid:415)ve parts that pose risks under the ‘Electrical Equipment (Safety) Regula(cid:415)ons 2016’. Regula(cid:415)on 12 (2) requires that they “must immediately inform the market surveillance authority”. Similarly, the UK ‘General Product Safety Regula(cid:415)ons’ (GPSR) 2005, clause 9.(1) mandates obliga(cid:415)ons of producers and distributers to “no(cid:415)fy an enforcement authority in wri(cid:415)ng” if a product on the market poses risks incompa(cid:415)ble with the general safety requirements. This obliga(cid:415)on is reinforced through the OPSS ‘Product Safety and Noncompliance No(cid:415)fica(cid:415)on Guidance’ and the PAS7100:2022 code of prac(cid:415)ce for Product Recalls and other correc(cid:415)ve ac(cid:415)ons for businesses and regulators. Through our Safety Liaison Panel, we facilitate discussions within our membership and other stakeholders on topics relevant to safety issues. These ongoing collabora(cid:415)ons reflect the industries commitment to suppor(cid:415)ng consumer safety, promo(cid:415)ng sustainability and collabora(cid:415)on between AMDEA, our members, OPSS and LFB to improve product and user safety. AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823 (4) Working group CPL / 61 to look at standards of manufacture of mains and sub-mains- operated condensate pumps and RFI filters. AMDEA, as an industry representa(cid:415)ve, along with many of its members, ac(cid:415)vely par(cid:415)cipates in the CPL/61 working group. This group is dedicated to reviewing and establishing robust standards for products and their associated componentry, addressing specific areas when trends or issues are iden(cid:415)fied. AMDEA and its membership have not been involved in discussions specifically on condensate pumps and it would be helpful to receive more background informa(cid:415)on and insights into the findings that led to the inclusion of these points in the report. Despite condensate pumps and RFI filters being called out specifically here, their considera(cid:415)on may fall within the scope of risk assessments rather than directly within standards. The standards developed through CPL/61 set a method to support mee(cid:415)ng the requirements within the appropriate legisla(cid:415)on. The working group’s ini(cid:415)a(cid:415)ve sets the required safety standards, helping to reduce the risk of safety incidents and promo(cid:415)ng con(cid:415)nuous improvement within industry specific standards. AMDEA remains commi(cid:425)ed to suppor(cid:415)ng this working group and its vital func(cid:415)ons. AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823 (5) Manufacturers to share data on decisions and ra(cid:415)onale behind recall / replacement of condensate pumps and RFI filters with the Office of Product Safety Standards (OPSS) as the regulator, and London Fire Brigade, to support fire preven(cid:415)on work. Transparency is a core principle within AMDEA’s membership, ensuring that safety prac(cid:415)ces are upheld across the industry. Through AMDEA’s Panels, we promote best prac(cid:415)ces in recalls, servicing and parts replacement facilita(cid:415)ng shared learning and collabora(cid:415)on amongst manufacturers. AMDEA and its members not only support but also took part in the development of the OPSS and BSI document PAS7100:2022, which is a code of prac(cid:415)ce for Product Recalls and other correc(cid:415)ve ac(cid:415)ons for businesses and regulators. The “Register my Appliance” ini(cid:415)a(cid:415)ve, also promoted by London Fire Brigade and other fire services around the UK, ensures that homeowners are aware of any recalls available for their appliance and as a record of iden(cid:415)fica(cid:415)on of appliances within homes. This data is held by the manufacturers so that in the event of a safety recall or enhancement the appliance owners can be contacted should there be product safety changes to be conducted. Our members are commi(cid:425)ed to working closely with regulators, including the OPSS and will provide data on decisions and the ra(cid:415)onale behind product recalls or replacements when required. It is also important to know that OPSS holds the relevant informa(cid:415)on regarding decisions and the ra(cid:415)onale for recalls or replacements of condensate pumps and RFI filters. AMDEA will con(cid:415)nue to support this func(cid:415)on as needed and facilitate any addi(cid:415)onal data sharing to enhance fire preven(cid:415)on. Manufacturers have a legal obliga(cid:415)on to report safety incidents to OPSS, Trading Standards, and their Primary Authori(cid:415)es, in accordance with the ‘General Product Safety Regula(cid:415)on’ and associated OPSS guidance. This includes documents such as ‘Product-Related Fire Incident No(cid:415)fica(cid:415)ons’ and ‘Product Safety and Noncompliance No(cid:415)fica(cid:415)on Guidance’. These regula(cid:415)ons and guidelines highlight the cri(cid:415)cal need to iden(cid:415)fy and report fire incidents linked to consumer products to the appropriate businesses and regulatory bodies. Should significant trends emerge, we recognise the importance of collabora(cid:415)on between the manufacturer and OPSS. Such partnerships aid in the iden(cid:415)fica(cid:415)on of poten(cid:415)ally hazardous products, support fire preven(cid:415)on efforts and contribute to safer environments for the consumer. AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823 (6) Companies inves(cid:415)ga(cid:415)ng fires to no(cid:415)fy Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those inves(cid:415)ga(cid:415)ons. Manufacturers are required to proac(cid:415)vely report safety incidents to OPSS, Trading Standards, and their Primary Authori(cid:415)es, as outlined in the ‘General Product Safety Regula(cid:415)ons’ and the relevant OPSS guidance including ‘Product-Related Fire Incident No(cid:415)fica(cid:415)ons’, and also market surveillance and enforcement authori(cid:415)es ‘Product Safety and Noncompliance No(cid:415)fica(cid:415)on Guidance’. These guidelines emphasise the importance of iden(cid:415)fying and repor(cid:415)ng fire incidents origina(cid:415)ng from consumer products to relevant businesses and regulators. AMDEA supports this process through its product iden(cid:415)fica(cid:415)on service, as part of the Safety Liaison Panel remit. This includes providing a ‘code of prac(cid:415)ce’ and guidelines for obtaining appliance photos to aid in iden(cid:415)fica(cid:415)on. When remote iden(cid:415)fica(cid:415)on cannot be confirmed, AMDEA members may a(cid:425)end the site, providing the appliance is preserved. However, this is not always possible due to the site clearance prac(cid:415)ces, limi(cid:415)ng the ability to confirm appliance iden(cid:415)ty. To improve the effec(cid:415)veness of fire inves(cid:415)ga(cid:415)ons, cross-sector data sharing is essen(cid:415)al. Despite ongoing rela(cid:415)onships, certain sectors, such as insurers, have historically not shared data with AMDEA or its members, which hinders the effec(cid:415)veness of data colla(cid:415)on. An enhanced collabora(cid:415)on across sectors would improve data colla(cid:415)on sta(cid:415)s(cid:415)cs. Current UK governmental guidance suggests logging the following at the scene of a fire concerning a consumer product: The product involved, including model and serial numbers. The age and place of purchase. The degree of severity of the fire. If changes are proposed to the guidance, it will be crucial to establish clear repor(cid:415)ng standards to ensure na(cid:415)onwide consistency and understanding. While this would increase administra(cid:415)ve burden across the chain and at (cid:415)mes there would be no guarantees that data was conclusive it would strengthen the overall amount of data collected and therefore, the response to fire incidents. AMDEA members remain commi(cid:425)ed to no(cid:415)fying Trading Standards and OPSS of the outcomes of fire inves(cid:415)ga(cid:415)ons. This prac(cid:415)ce ensures all relevant authori(cid:415)es are informed of poten(cid:415)al hazards and enables them to take appropriate ac(cid:415)on to mi(cid:415)gate risks effec(cid:415)vely. AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823 (7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conduc(cid:415)ng risk assessments to account for persons in a property and their ac(cid:415)ons, i.e., sleeping whilst a product is taking advantage of lower electricity rates. As a manufacturing trade body, we fully support the importance of robust risk assessments within the industry, and we acknowledge that this prac(cid:415)ce is already mandated under the ‘Electrical Equipment (Safety) Regula(cid:415)ons 2016’. While the use of the PRISM methodology remains op(cid:415)onal, AMDEA is suppor(cid:415)ve of the framework, value, and relevance, par(cid:415)cularly as it is employed by regulators. To promote PRISM’s adop(cid:415)on and understanding, AMDEA regularly discusses PRISM within our panels and host training events in collabora(cid:415)on with OPSS. These events ensure our membership is fully informed and equipped to apply its key principles effec(cid:415)vely. Risk assessment methodologies must integrate with mechanisms for product safety monitoring and no(cid:415)fica(cid:415)on. Manufacturers within the EU use the Safety Gate (formerly RAPEX) system for rapid alerts about hazardous products. Post-Brexit, OPSS has introduced the ‘Product Safety Database’ (PSD). The PSD facilitates no(cid:415)fica(cid:415)ons from local authori(cid:415)es, market surveillance authori(cid:415)es and manufacturers about poten(cid:415)ally hazardous products and allows the UK to act independently to safeguard consumers. However, the PSD lacks the integrated EU-wide coordina(cid:415)on offered by safety gate, therefore there are poten(cid:415)al for gaps in iden(cid:415)fying and addressing risks across UK/NI/EU borders. Risk assessment processes must con(cid:415)nuously evolve to reflect shi(cid:332)s in market dynamics, technological advancements, and consumer behaviours. Adaptable frameworks, such as PRISM are well-suited to address these challenges including scenarios such as accoun(cid:415)ng for individuals sleeping while appliances operate during discounted (or even free) off-peak energy opera(cid:415)on periods. In addi(cid:415)on, PRISM expands on the tradi(cid:415)onal scope of risk assessments by addressing a broader range of safety factors, including mental health considera(cid:415)ons. While AMDEA remains commi(cid:425)ed to suppor(cid:415)ng the implementa(cid:415)on of adaptable and comprehensive risk assessments aligned with evolving safety and consumer needs, we note that our members already employ their own robust systems that effec(cid:415)vely cover these points without being part of the PRISM framework. We will con(cid:415)nue to recommend PRISM as a complementary tool to help adapt and enhance their exis(cid:415)ng risk assessment processes, rather than as a replacement. Manda(cid:415)ng the use of PRISM as a standalone requirement risks crea(cid:415)ng a UK-specific divergence, poten(cid:415)ally leading to inconsistencies and addi(cid:415)onal documenta(cid:415)on to manage within the broader market. Encouraging manufacturers to adopt flexible systems allows for op(cid:415)mum alignment and interoperability between EU safety gate (RAPEX) and the Product Safety Database (PSD). This approach ensures consistency, the highest safety standards across markets and alignment with interna(cid:415)onal best prac(cid:415)ces while minimising addi(cid:415)onal administra(cid:415)ve complexity. AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823 (8) Iden(cid:415)fica(cid:415)on plates on appliances that will not be destroyed by fire akin to those on vehicles. It is important here to note that the specific case in ques(cid:415)on was not brought to AMDEA’s a(cid:425)en(cid:415)on, and as such, we are unaware of the relevance or connec(cid:415)on of the iden(cid:415)fica(cid:415)on plate to our current prac(cid:415)ces. In this instance, the appliance was clearly iden(cid:415)fied, and the manufacturer was no(cid:415)fied well before AMDEA received any details. Iden(cid:415)fica(cid:415)on is increasingly achieved through digital means, such as online appliance registra(cid:415)on or digital receipts. Over the past 18 months, AMDEA has collated and analysed data for fire incidents involving uniden(cid:415)fiable appliances. The data con(cid:415)nues to show that the number of such cases remain low, which does not jus(cid:415)fy the widespread implementa(cid:415)on of fire-resistant iden(cid:415)fica(cid:415)on plates. However, AMDEA remains commi(cid:425)ed to enhancing the exis(cid:415)ng processes, which effec(cid:415)vely support manufacturers in conduc(cid:415)ng post-fire incident inves(cid:415)ga(cid:415)ons and where necessary ini(cid:415)a(cid:415)ng product recalls. The proposal for iden(cid:415)fica(cid:415)on plates on appliances which are resilient to fire has been thoroughly inves(cid:415)gated and researched as part of the Safety Liaison Panel’s remit. By bringing together fire brigades and manufacturers, a process and ‘code of prac(cid:415)ce’ for addressing uniden(cid:415)fiable appliances was established. It is worth no(cid:415)ng that that within the automo(cid:415)ve industry, metal iden(cid:415)fica(cid:415)on plates, such as VIN (Vehicle Iden(cid:415)fica(cid:415)on Number) plates, are designed to withstand various environmental condi(cid:415)ons, including heat. However, in severe fire incidents, these plates can also become damaged or destroyed, complica(cid:415)ng the iden(cid:415)fica(cid:415)on process. AMDEA’s current system developed as part of the ‘code of prac(cid:415)ce’ includes a process where uniden(cid:415)fiable cases are reported to AMDEA via specific email channels and then disseminated within our membership. AMDEA’s members are then given an opportunity to rule themselves out or indicate whether they believe its theirs and wish to a(cid:425)end the scene for further inves(cid:415)ga(cid:415)on. While this process has successfully facilitated feedback, in a limited number of cases the appliance is too severely damaged or not been held as part of the scene, making onsite confirma(cid:415)on of the appliance impossible. Fire incident data for key appliances is collated annually in line with interna(cid:415)onal IEC focuses, helping to iden(cid:415)fy trends and inform on safety improvements. AMDEA will con(cid:415)nue to monitor the situa(cid:415)on and collaborate with Fire Services and manufacturers to explore prac(cid:415)cal, data-driven measures that enhance appliance safety. AMDEA Vintage House 36 – 37 Albert Embankment London SE1 7TL Tel.: +44(0)20 7405 0666 info@amdea.org.uk Registered in England No. 1465823
Mr P Straker Assistant Coroner for the coroner area of the Northern District of Greater London BY EMAIL 28 January 2025 Dear Sir, Champaguri and Dipak Bhatt : Prevention of future deaths report Introduction 1. We write in response to your Regulation 28 report of 06 December 2024 concerning the deaths of Champaguri and Dipak Bhatt (“the Report”). 2. BSI would like at the outset to express its deepest sympathy and condolences for the family of the victims. 3. We are responding in particular to No.5 (Coroner’s Concerns) Item 4 in the Report: “Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.” ______________________________________________________________________________________________________________________________________________ BSI Group The Netherlands B.V. Say Building John M. Keynesplein 1-27 Amsterdam Bergen 1066 EP Netherlands bsigroup.nl +31 20 346 0780 BSIMedDev.NB2797@bsigroup.com BSI. All rights reserved. © 2024 BSI’s role 4. BSI’s role as the NSB is established by Royal Charter. BSI has several governing documents (available online): a. BSI’s Royal Charter and Bye-laws 1981; b. A Memorandum of Understanding (MoU) of 16 September 2024 between HM Government and BSI in respect of BSI’s activities as the United Kingdom’s NSB; c. BS 0: 2021 ‘A standard for standards – Principles of standardization’ (BS 0) 5. Article 1.2 of the MoU provides that BSI’s role as the NSB includes: a) the management, co-ordination and understanding of British Standards and BSI standardisation products; b) participation by BSI in European and international standards bodies, and other international activity undertaken in the interests of BSI as the United Kingdom’s NSB; c) publication, promotion, marketing, distribution and information activities concerned with British Standards, BSI’s other standardisation products, and standardisation generally; d) support any corporate infrastructure activities intended, wholly or in part, to enable paragraph 12(a) to (c) above. The Director of Standards has the primary responsibility for the activities set out above. BSI’s present Director of Standards is Dr Scott Steedman (the role is incorporated within his responsibilities as Director-General, Standards). 6. BSI develops and distributes standards in response to the needs of UK stakeholders, which include HM Government and business. Standards are technical documents representing good industry practice. They are voluntary documents drafted by independent experts, as distinct from legislation or regulation from government. 2 © 2024 BSI. All rights reserved. 7. BSI’s role as the National Standards Body is to facilitate expert committees to achieve consensus on industry standards and best practice and to act as the publisher of standards. BSI does not retain in-house expertise on the subject matter of standards. Further, BSI is not a regulatory body and is therefore unable to advise on regulatory matters, which are a matter for HM Government. 8. Each individual standard is the responsibility of one committee. It is the committee who is responsible for the technical content of the standard, not BSI. The committees are composed of: a. An independent chair, b. External experts, who are responsible for the technical content of national standards, and for contributing the UK’s technical input into European and international standards, and c. BSI staff, who are responsible for the management of the committee, editorial input and ensuring the committee follows BSI’s processes. 9. Each committee has a defined scope, and develops standards within that scope. For European and international standards the committee acts as a local (British) ‘mirror committee’. 10. The responsible UK committee in this instance is entitled CPL/61: Safety of household and similar electrical appliances. Its scope is: “Under the direction of the Standards Policy and Strategy Committee, is responsible for providing UK input into IEC TC 61, SC 61C and CENELEC TC 61 on matters relating to IEC/EN 60335-1 and Part 2s in the following areas: safety of home laundry and dishwashing machines together with IEC/EN 61770 for electrical appliances connected to the water mains, avoidance of backsiphonage and failure of hose-sets, (formerly within the scope of CPL/61/14, now disbanded), safety standards for motor 3 © 2024 BSI. All rights reserved. compressors, refrigerating appliances and similar appliances for household and commercial use (formerly within the scope of CPL/61/3, now disbanded), safety standards for electrical commercial catering equipment (formerly within the scope of CPL/61/5, now disbanded) and requirements for gas, oil and solid-fuel burning appliances having electrical connections (formerly within the scope of CPL/61/35, now disbanded”). (see https://standardsdevelopment.bsigroup.com/committees/50001507). Committee’s Response 11. BSI convened a meeting of CPL/61 on 21 January 2025 to discuss the Report. 12. The members present represented the following organizations: • Agricultural Engineers Association (AEA) • Association of Manufacturers of Domestic Appliances (AMDEA) • Vending and Automated Retail Association (AVA) • BEAMA Installation Ltd • British and Irish Spa and Hot Tub Association (BISHTA) • British Home Enhancement Trade Association • BSI Consumer and Public Interest Network • Department for Business and Trade • Electrical Safety First • Hot Water Association • London Fire Brigade (LFB) • Portable Electric Tool Manufacturers Association 4 © 2024 BSI. All rights reserved. • Vending and Automated Retail Association (AVA) • Which? 13. The responsible BSI committee manager, Mrs Geraldine Salt, recorded the following note of the meeting: a. The Coroner’s report stated that the fire had been caused by an electrical fault in the tumble dryer and that there was a 10% chance the EMI filter had caused the fire and a 90% chance the condensate pump had caused the fire. b. The Coroner asked CPL/61 to look at standards of manufacture of mains and sub mains operated condensate pumps and filters, to consider if the. c. The Committee considered this request and decided that in order to be able to reach an informed engineering decision regarding making an appropriate amendment to the standard, more specific information regarding the fire investigation and its conclusions was needed. In particular: a) The LFB representative reported at the CPL/61 meeting that its experts had considered that the fire had been caused by a fault within the door switch mechanism and CPL/61 would like to understand the reasoning as to why this consideration has been discounted. b) The committee asks whether it is possible for the expert reporting which took place during this Court case to be made available to the committee. c) The committee also asks if it could be provided with details of the appliance itself, including its age and whether it had ever been subject to a recall. 5 © 2024 BSI. All rights reserved. d. CPL/61 considers that without the above information, it is not in a position to make a decision on how best the standard can be amended to address the cause of the fire. e. CPL/61 is therefore unable to respond in full to the Coroner’s letter at present but it will be holding a further meeting on 6 February 2025. Should the above information be available to the committee at that point, then it will be able to look further into the matter with a view to deciding how the cause of the fire can be best addressed in the relevant standards. Yours sincerely, Head of Governance & Risk, Knowledge Solutions BSI, 389 Chiswick High Road, London, W4 4AL, UK bsigroup.com | LinkedIn| We support the UN Sustainable Development Goals, so please consider the environment before printing this email The British Standards Institution is a member of BSI Group and is incorporated in England under Royal Charter. Its principal address is 389 Chiswick High Road, London, W4 4AL, United Kingdom. 6 © 2024 BSI. All rights reserved.
Chartered Trading Standards Institute’s response to the Coroners Service Regulation 28 report to prevent future deaths CTSI was deeply saddened to hear of the deaths of Champagauri and Dipak Bhatt. We welcome the opportunity to respond to the findings in the coroner’s report, and we fully support the call for further action to be taken to prevent future deaths. CTSI has long campaigned about the safety of appliances in consumers homes and that there must be mechanisms in place to ensure that when issues are identified with certain makes and models that these are addressed as urgently, e(cid:431)ectively and e(cid:431)iciently as possible. When dealing with a recall of possibly thousands of appliances, across di(cid:431)ering makes and models, supplied at di(cid:431)ering times by multiple retailers, this is not something that one local authority Trading Standards has the resources or mechanisms to deal with. CTSI called for the creation of a Government body to be responsible for national product safety issues and the O(cid:431)ice for Product Safety and Standards (OPSS) was set up in 2018 with a specific remit to deal with national product safety issues and recalls. About CTSI The Chartered Trading Standards Institute (CTSI) is one of the world’s longest- established organisations dedicated to the field of Trading Standards and Consumer Protection. At CTSI, and through the Trading Standards profession, we aim to promote good trading practices and to protect consumers. We strive to foster a strong vibrant economy by safeguarding the health, safety and wellbeing of citizens through empowering consumers, encouraging honest business, and targeting rogue practices. We provide information, guidance and develop evidence-based policies and campaigns to support local and national stakeholders including central and devolved governments. CTSI also provides the secretariat to the All-Party Parliamentary Group on Consumer Protection and campaigns on range of topics including product safety issues. CTSI is responsible for business advice and education in the area of Trading Standards and consumer protection legislation, including running the Business Companion service to provide clear guidance to businesses on how to meet their legal and regulatory obligations. Response to findings We note that the coroner’s report in this case has ruled that there was a 10% chance the EMI filter in the appliance caused the fire and a 90% chance the condensate pump caused the fire. OFFICIAL - SENSITIVE CTSI understands that Hotpoint UK Appliances Ltd has a Primary Authority agreement with North Yorkshire Council Trading Standards, and in regard to this incident the Trading Standards team are leading the activity with Hotpoint UK Appliances Ltd directly. CTSI believes the correct action in this case is for Hotpoint UK Appliances Ltd to work closely with North Yorkshire Council Trading Standards to further investigate the safety of the product, and if an issue is identified to take appropriate steps, including to instigate a product recall if necessary. CTSI recognises that OPSS as the National Regulator for product safety continues to support North Yorkshire Council Trading Standards to understand the true scale and risk of the problem, agree the actions needed to prevent any further harm or injury occurring, and the timescales in which this should happen. This must be done to ensure that consumers are being protected from any unsafe appliances in their homes. If OPSS find that appropriate action is not being taken by Hotpoint UK Appliances Ltd, or have concerns that the actions are not being taken with enough speed to protect consumers, they can use their powers to start corrective action. CTSI, along with local authority Trading Standards O(cid:431)icers, can work with OPSS to ensure the message around any such safety issue and recalls are implemented e(cid:431)ectively and have the greatest impact. CTSI would also like to see OPSS look at the wider recommendations made in the report as we believe these require a national approach to address national issues. In the EU and Northern Ireland, it is now mandatory for manufacturers to report dangerous products on the safety business gateway and there is a consumer gateway where consumers can report dangerous products. To ensure that all consumers are protected this should be an option available to GB consumers. In conclusion, CTSI remains committed to ensuring that electrical products are safe, and that processes for keeping consumers informed of risks and dangers are robust to ensure that preventable deaths or deaths injuries are avoided. OFFICIAL - SENSITIVE
Hotpoint UK Appliances Ltd. Morley Way Peterborough PE2 9JB Registered in London 106725 VAT No 513936740 HOTPOINT UK APPLIANCES LIMITED’S RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS DATED 6 DECEMBER 2024 This is the response of Hotpoint UK Appliances Limited ( Hotpoint ) to the Regulation 28 Report to Prevent Future Deaths arising out of the Inquest into the deaths of Champaguri Bhatt and Dipak Bhatt. Before we address the Assistant Coroner’s report we would like to express our deepest condolences to the Bhatt family and anyone affected by this tragedy. The matters of concern raised by the Assistant Coroner relate to industry-wide challenges. The response to those concerns should be considered in light of the broader regulatory framework that underpins product safety in the UK together with an ongoing revision by the Government. Current Product Safety Legal Framework The UK has a comprehensive framework of laws covering product safety, derived primarily from EU law. The overarching legislation is the General Product Safety Regulation 2005 (“ GPSR ”), which sets out general safety rules that apply to all products unless those products are subject to sector specific legislation. In the case of electrical appliances, the applicable sector-specific legislation is the Electrical Equipment (Safety) Regulation 2016 (“ EESR ”). These product safety laws set out objectives and rules governing the safety of products. The underlying technical rules that ensure these objectives are met are contained in technical standards. Designated Standards 1 are technical standards, often based on international standards, that are officially recognised by the Government. The standards set out a series of technical requirements that must be met in order for the product to be declared compliant. The safety of a product that complies with a technical standard is presumed. Designated Standards are written by a committee of technical experts including manufacturers, independent accredited test houses, enforcement authorities and others and, in the UK, published by the British Standards Institute. They are often subject to revision as new risks are discovered over time. That process ensures that thorough testing can be conducted by independent technical experts to determine whether any risk exists, and if so, whether it is appropriate in all the circumstances to revise the technical standards to address that risk. Additionally, the Government is able to develop additional standards where they feel appropriate and there are examples in recent times where OPSS has done exactly that. We view meeting the standards as the minimum level of safety. In addition to meeting the standards, we do additional testing to ensure, as much as is possible, that a product is safe. That includes This is known as Failure Mode and putting faults on products and assessing the consequences. Effect Analysis (FMEA). The product safety framework contains checks and balances to ensure that new and emerging safety risks are discovered and addressed. In particular, there are specific obligations placed on industry to: 1 Called Harmonised Standards in the European Union. ● ● ● monitor and investigate safety risks; take corrective action (e.g. recalls) to address non-conformities; and report safety risks to Trading Standards If the UK authorities are investigating a safety issue, they can make an initial request for relevant information to be shared willingly. In the event of a refusal, they have tools, including Regulation 28 of the GPSR, to require companies to provide information in relation to product safety issues. A failure to comply is a criminal offence. Upcoming Changes to Product Safety Legal Framework The legal framework in the UK is likely to be updated this year. The Product Regulation and Metrology Bill (the “Bill”) is currently being debated in the House of Lords. The Bill is intended to be an enabling Act with detailed regulations passed after it has been enacted, so the precise scope is not known. However, following a consultation by the Office for Product Safety and Standards (“ OPSS ”) in October 2023, 2 it is clear that the Government is considering issues relevant to a number of the matters raised by the Assistant Coroner. In particular: ● ● Proposal 8: Facilitate a rich source of data, by creating a new legal data gateway – this would enable the Government to request that product safety data is shared by industry with the authorities, including the OPSS and Trading Standards. Proposal 9: All notification of recalls and serious product safety incidents and other corrective action by a manufacturer or distributor is sent to OPSS, rather than the local authority, as soon as the economic operator has knowledge of an unsafe product – this would streamline the report of product safety incidents to the OPSS. These proposals have been subject to feedback from multiple stakeholders. In its response to the Consultation, 3 OPSS noted that: ● e. Better use of data: capturing high-quality product safety data in a central repository to identify product safety risks and allow targeted intervention and establishing a legal data gateway that integrates existing systems and allows sharing of intelligence e.g. between market surveillance authorities, to aid compliance and enforcement – over two thirds of responses were supportive, however, businesses suggested caution around how the data would be shared given the need to consider confidentiality. Matters of Concern (1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire 2 https://assets.publishing.service.gov.uk/media/64ca51246ae44e001311b3e7/uk-product-safety-review -consultation-august-2023.pdf 3 https://www.gov.uk/government/consultations/smarter-regulation-uk-product-safety-review/outcome/go vernment-response-to-the-product-safety-review-and-next-steps#appendix-b-summary-of-responses-t o-the-product-safety-review 2 Manufacturers have an obligation to only place products on the market that are safe. They must ensure the products have been designed and manufactured in line with established safety objectives. Many manufacturers (including Hotpoint), demonstrate those safety objectives have been met by testing their products against relevant safety standards as described above. In addition to testing all our products to the appropriate industry safety standards, all the results of those tests are checked and approved by an independent accredited test facility. Once a product is placed on the market, we are required to monitor the field to identify any safety related incidents that will subsequently feed into risk assessments. We have a robust process in place for doing this. Having interrogated our data following the tragic deaths of Champaguri Bhatt and Dipak Bhatt, we cannot find any evidence of safety issues with the ingress of water into condensate pumps in our products. However, that does not exclude the possibility of there being a wider industry issue, and, if stakeholders involved in setting standards agree that there is a requirement to focus on potential risk with condensate pumps, we will of course actively participate in that process. (2) That changes in information management would result in better analysis of, and learning from, white goods fires As outlined below, we regularly engage with other stakeholders to discuss how systems and processes can be changed to improve consumer safety. (3) Manufacturers to give the OPSS as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters (5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters OPSS as the regulator and LFB to support their fire prevention work (6) Companies investigating fires to notify Trading Standards and the OPSS of the outcome of those investigations These matters of concern all relate to the collection and sharing of information around product safety risks and incidents. As noted above, the product safety legal framework places responsibility on manufacturers and other actors in the supply chain to monitor and investigate safety issues and report safety risks. The UK authorities have investigatory tools, including Regulation 28 of the GPSR, to require companies to provide information in relation to product safety issues where the information is not given willingly. A failure to comply is a criminal offence. That is the proper route for authorities that are minded to require manufacturers to disclose sensitive company information. We note that data sharing is within the scope of the Government’s ongoing product safety review, although the scope is not as broad as the matters recommended to the Assistant Coroner by the LFB. Hotpoint is a member of AMDEA, the white goods trade association, and actively participates in industry meetings, including on safety and standards. We regularly engage with the LFB, OPSS and NGOs such as Electrical Safety First, both through industry meetings and directly, to explore how all 3 stakeholders can work together with the aim of improving safety. We are also actively involved with BSI and European International Standards bodies in the development of safety and performance standards. We fully support the development of systems to improve product safety, including data sharing and information management that can be adopted cross industry and supported by all stakeholders. (4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters Hotpoint welcomes the role of standards bodies such as the British Standards Institute in the continuing improvement of safety standards. Hotpoint is an active participant in standards development, with its representatives sitting on technical committees on a range of standards, and is very supportive of all efforts to improve product safety where new and emerging risks have been discovered. (7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. while sleeping whilst a product is taking advantage of lower electricity rates Manufacturers are already required to demonstrate that their appliances are safe, and, if it is subsequently found they are not safe, to risk assess to determine the level of risk. PRISM was not developed with the intention that it would be used to assess the safety of the design of a product prior to manufacture. It is a methodology developed from the EU’s RAPEX methodology for the assessment of unexpected risks that may occur in products that are already on the market. In the OPSS’ guidance on PRISM, it states: “As noted above, this guidance is intended for use by market surveillance officers. It is not intended to be used by businesses when undertaking pre-market risk assessment as part of the process of assessing the conformity of their products to relevant essential requirements or when considering the general safety requirement contained within the General Product Safety Regulations 2005 (GPSR).” 4 That being said, there are elements of PRISM that can be applied usefully to a pre-market risk assessment process. For example, it is already common for foreseeable risks associated with sleeping to be taken into account when assessing the risks of electrical products that operate at night. (8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles We know that indelible marking is under consideration by the CPL / 61 Standards committee 5 . The committee has formed a working group to look at this issue, and as a company, we are members and actively involved in that working group. On 8 January 2024, the LFB wrote to the Senior Coroner. At point 6, the LFB refers to working with AMDEA on a means of identifying fire damaged white goods via the sharing of digital images between 4 Section 1.2 of Guide for GB Market Surveillance Authorities and Enforcing Authorities Responsible for Regulating Consumer Product Safety, version 2.0, October 2024 (https://assets.publishing.service.gov.uk/media/66fd385ae84ae1fd8592ec93/prism-guidance-v02.pdf) 5 The CPL / 61 Standards Committee is a committee headed by BSI, which considers UK input to the international standard on household and similar electrical appliances, including tumble dryers. 4 appliance manufacturers and FRS. The LFB notes that if it does not show clear evidence of sustainable success, then the LFB would recommend an indelible marking scheme . Our understanding from AMDEA is that the trial is working well and is being rolled out to other Fire Services (outside the LFB). Additionally, indelible marking is only a benefit from the day it’s implemented, it does not help with the identification of any products produced before that date and already in the market. The AMDEA trial does address this challenge. As this issue is an industry-wide issue with national ramifications, any change would need to be implemented through updates to standards or regulation. We will obviously continue to support theLFB/AMDEA initiative of digital identification and comply with any future industry wide regulatory requirements. Hotpoint will work with government policy makers, regulators, fire services, manufacturers and other stakeholders to ensure that we continue to raise the bar for appliance product safety in the UK. We are always available to discuss relevant topics at your disposal. Your Sincerely, Managing Director 5
Assistant Coroner for the coroner area of the Northern District of Greater London c/o 71-75 Shelton Street Covent Garden London WC2H 9JQ www.nfcc.org.uk Sent by email to: 31 January 2025 Dear Mr Straker, Thank you for raising the concern in relation to the deaths of Champagauri and Dipak Bhatt on 29 March 2023. It is with great sadness that I read about the circumstances of their deaths. The National Fire Chiefs Council (NFCC) is committed to a culture of learning and improvement and seeks to support fire and rescue services (FRSs) to embed a learning culture. We actively track Prevention of Future Deaths Reports and share them with our members to ensure all opportunities to improve are taken. In your report you have identified NFCC as an organisation that has the power to take action to prevent future fire deaths by receiving information from manufacturers on condensate pumps and RFI filters that are replaced on warranty, or that have been recalled. The purpose for this is so NFCC has a better understanding of where such parts are having problems. Unfortunately, this is not currently within the remit of NFCC. However, we do support the single recall register, which was a key output of the Total Recalls campaign initiated by London Fire Brigade and rolled out nationally. This was created as a consumer-facing initiative and focused on products rather than parts that could be causing issues across multiple appliances. This is recorded on a national register which can be found here: Product Safety Alerts, Reports and Recalls - GOV.UK In our shared experience, it can be extremely challenging to persuade manufacturers to recall products with known risks and there is a reluctance to share information on potential issues. In the past we have seen manufacturers only issue recalls after significant events and following public and political pressure, and in some cases the threat of legal action from Trading Standards (as part of the Primary Authority arrangement). FRSs play a critical role in reporting products that lead to fires. However, determining the make and model of appliances involved in fires can be extremely difficult for Fire Investigators, let alone the component parts that may have been at fault. This is because the products are often so badly damaged, and owners do not always have this information. A key ask of London Fire Brigade’s campaign was for manufacturers to have the make and model on each appliance in a material that couldn’t be destroyed by fire (e.g. a metal plate) Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 1954 46 but not all manufacturers are doing this. See more here: Model and serial number identification | London Fire Brigade. There is currently no obligation on manufacturers to share information when a fault is found in components in appliances with FRSs, and we would welcome support for manufacturers to share their risk assessments, or at least key elements of the risk assessment on request (including details of components), when patterns of faults are found that may present a risk to the public. In response to the recommendations made, NFCC notes that there is currently a Product Safety and Metrology Bill, which is at the Report Stage in the Lords – following feedback from FRSs. There are powers outlined in section 7 of the Bill, which should enable sharing of information with emergency services (including FRSs). We believe it is important that this part of the bill clearly sets out a duty for manufacturers or commercial enterprises to share information on product/component safety faults (on request) that present a safety risk (of fire), to help prevent loss of life, safeguard our communities and homes. The OPSS currently gather data regarding product safety issues and seek to share information on product safety risks with FRSs and with NFCC Fire Investigation Strategic Steering Group. However, NFCC believe that it is important that the Product Safety and Metrology Bill does not lose this particular clause during its passage through parliament. Yours sincerely Chair National Fire Chiefs Council Registered office: National Fire Chiefs Council Limited, 71-75 Shelton Street, Covent Garden, London, United Kingdom, WC2H 9JQ. Registered in England as Limited Company No. 03677186. Registered in England as Charity No. 1074071. VAT Registration No. 902 1954 46
Mr P Straker Assistant Coroner (Northern District of Greater London) North London Coroner’s Service Barnet, Brent, Enfield, Haringey and Harrow Barnet Coroner’s Court 29 Wood Street London EN5 4BE Chief Executive North Yorkshire Council County Hall Northallerton North Yorkshire DL7 8AD Tel: 01609 532444 Email: 30 January 2025 Dear Sir, Regulation 28 Report to Prevent Future Deaths Thank you for providing a copy of your report to North Yorkshire Council as the primary authority for Hotpoint UK Appliances Ltd. The primary authority agreement that the council’s trading standards service has with Hotpoint UK Appliances Ltd is a limited one involving a monthly review of the complaints received by the Citizens Advice Consumer Service and trading standards services around the country. Neither this service nor Hotpoint UK Appliances Ltd has received any other complaint about the identified parts overheating or causing a fire. Since the receipt of the Prevention of Future Deaths report, the company has conducted forced failure testing going beyond that required by the Standard. The testing was conducted at an in-house facility in Italy so could not be observed by a trading standards officer, however, it was overseen by is a member of the IEC TC89 Committee reviewing safety standards for Fire Hazard, and it has been confirmed that she was fully aware of the Bhatt case and the verdict. The filters and pumps passed all the tests. , of the Beko Europe Safety team. The company has conducted a risk assessment taking into account the absence of other complaints and the test outcomes. This indicates that a recall is not necessary and does not identify any improvements to the components. There is a model of the tumble dryer containing the condensate pump referred to in your report which is no longer manufactured but is still available on the market. I have asked the trading standards service to arrange for testing against the Standard of a test purchase of the model as an additional check on the company’s findings. OFFICIAL Hotpoint UK Appliances Ltd has confirmed that it will comply with any changes in the law introduced as a result of your recommendations, and officers will review such compliance as part of future primary authority meetings. Chief Executive OFFICIAL
Office for Product Safety and Standards Cannon House 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 31 January 2025 Peter H Straker Assistant Coroner North London Coroner’s Service Barnet Coroner’s Court 29 Wood Street London EN5 4BE By email: Dear Mr Straker, Thank you for sharing your Regulation 28 Report to Prevent Future Deaths, dated 6 December 2024, following your investigation and inquest into the deaths of Ms Champagauri Bhatt and Mr Dipak Bhatt, from inhalation injuries sustained due to a fire caused by an electrical fault in a tumble dryer. I was very sorry to hear of Champagauri and Dipak’s deaths. If you have the opportunity, please do pass on my deepest sympathies to their 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, responsible for the regulation of most consumer goods, including electrical appliances. OPSS was made aware of this incident by London Fire Brigade on 31 March 2023, and took the following steps - we made contact with the manufacturer of the tumble dryer, Hotpoint UK Appliances Ltd, and with the relevant local authority that leads the regulation of the business through Primary Authority, North Yorkshire County Council. Following OPSS’ evaluation of the early information in this incident, it was agreed with North Yorkshire County Council that they would lead the investigation in this case. OPSS remains in regular contact with the Council and continues to offer them any necessary support. I understand that they also received a copy of your report and will be responding to you directly. You may be aware that in 2018-2019, OPSS was the lead regulator overseeing a national recall affecting up to 5 million tumble dryers, sold under the Hotpoint, Indesit, Swan, Creda and ProLine brands. That recall was instigated to address a risk of fire caused by fluff coming into contact with heating elements within the dryers. We have no evidence to suggest that the model in this incident was involved in the earlier recall. 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 Office for Product Safety and Standards Cannon House 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 I would like to address the matters of concern in your report which OPSS is best placed to consider. You have raised the issue of data and information sharing between manufacturers and regulators, particularly when manufacturers are investigating potential safety issues with their products. Under the Electrical Equipment (Safety) Regulations 2016, manufacturers of electrical goods are already required to notify regulators when they become aware of a safety issue with a product they have placed on the market. The Regulations also provide regulators with powers to require information from manufacturers or other persons in the supply chain regarding product safety issues, and to require corrective actions to ensure they are addressed. OPSS has also established a process of information sharing with London Fire Brigade (LFB) and other Fire and Rescue Services (FRS) to collect information about product- related fires, known as Product-related Fire Notifications (PFNs). In more serious cases, including those involving serious injuries or fatalities, fire investigators can undertake detailed investigations to determine the cause, defect or failure that led to a product- related fire breaking out. OPSS has been gathering this information in partnership with LFB since 2020, and other FRS since February 2023, when OPSS published guidance Product-Related Fire Incident Notifications - GOV.UK to assist and support FRS to report product-related fires. This approach helps OPSS in identifying products that may be putting people at risk, so we can consider and take any action necessary. As an example, OPSS were notified of reports from several FRS of fires in the UK caused by the same UPP brand of e-bike battery. OPSS was able to carry out enforcement action to prohibit online marketplaces, online sellers and the manufacturer from supplying the battery in the UK. OPSS continues to actively promote the value of reporting product-related fires to individual FRS and fire investigation teams, and the role it can play in dealing with unsafe products. The Government has introduced a new Product Regulation and Metrology Bill, which is currently going through Parliament. The Bill includes provisions that will facilitate, among other things, information exchange on product safety issues and includes powers to make regulations for information sharing and co-operation with, for example, emergency services in future. It also includes powers to amend our existing product regulations to strengthen notification requirements, should that be necessary in future. 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 Office for Product Safety and Standards Cannon House 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 You have raised the issue of manufacturer risk assessments. Those supplying electrical equipment such as tumble dryers are already required to carry out pre-market risk assessments when assessing the overall conformity of their products to the requirements in the regulations, and document these actions. This includes risks that might arise from the product’s use in instances of predictable human behaviour, such as when people are asleep. OPSS’ PRISM tool is a post-market risk assessment methodology for product regulators to use across the broad spectrum of consumer products. While businesses can consider the use of PRISM, it is their responsibility to determine how to fully identify and mitigate risks that might arise in their specific products before they are placed on the market, and fulfil their safety obligations in the regulations. I know that you have also addressed your report to the British Standards Institution (BSI) regarding your recommendation that BSI Committee CPL/61 should review the voluntary standards concerning the manufacture of mains and sub mains operated condensate pumps and RFI filters, to consider whether they should be improved. I would like to reassure you that OPSS is committed to supporting any changes to product standards that could help raise safety levels further. Representatives from OPSS attend this Committee, and we will work with BSI to update and improve the standard wherever necessary. You also raised the issue of product identification plates. The Electrical Equipment (Safety) Regulations 2016 require that before placing electrical equipment on the market, a manufacturer must ensure that it bears a type, batch or serial number or other element allowing its identification, and is marked with the contact details at which the manufacturer can be contacted. BSI have previously been asked by Ministers to consider the feasibility for fire resistant identification marking for large electrical appliances to be included in international standards. In response, BSI commissioned a working group to explore how a requirement for fire-resistant marking could work in practice. This working group is currently trialing a pilot approach to enabling the identification of fire-damaged appliances and supporting their traceability. We are seeking an update from BSI on the progress of this pilot project. I hope that Champagauri and Dipak’s family are reassured that this tragic incident is already being considered by product regulators. While North Yorkshire County Council is taking the lead in investigating this case, OPSS will continue to engage with them and other stakeholders, so that we can provide any support needed and can learn from any 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 Office for Product Safety and Standards Cannon House 18 The Priory Queensway Birmingham B4 6BS General enquiries: +44 (0)121 345 1201 lessons that may have wider implications for the safety of this or other similar products in future. Thank you again for writing to OPSS on this matter. 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
Mr P. Straker Assistant Coroner North London Coroner’s Service DECS Reference: Dear Mr Staker, Minister of State for Policing, Fire and Crime Prevention 2 Marsham Street London SW1P 4DF www.gov.uk/home-office 3 February 2025 I refer to your report dated 18 December 2024 provided in accordance with your duty under paragraph 7, Schedule 5 of the Coroners and Justice Act 2009, and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. Please accept my sincere apologies for not getting this to you by the deadline of 31 January 2025. I offer my sincerest condolences to the family and friends of Champagauri and Dipak Bhatt. I understand from your report that the inquest concluded that Champagauri and Dipak Bhatt died from inhalation injuries following a fire caused by an electrical fault in a tumble dryer. You have suggested that changes in information management would result in better analysis of, and learning from, white goods fires, but there is no explanation in your report as to which aspects of information management need to change. In the absence of more information, it is not possible to provide a specific response to your recommendation. However, it may be helpful to note that as soon as a fatal fire is confirmed a suitably qualified Fire Investigation Officer is asked to attend and a Tier 2 Fire Investigation is undertaken. These investigations are led by the police who produce a forensic investigation plan. The Fire Investigation Officer undertakes their own inspection as part of this process and produces a report of their findings which they submit to the Police. In addition, Fire and Rescue Services undertake their own fatal fire reviews, usually chaired by the Director or Assistant Director with responsibility for fire prevention. A fatal fire review report is then produced which includes any learning that can be taken from the incident. Where appropriate, this will be shared with other Fire and Rescue Services and relevant information may also be shared with external stakeholders (e.g. Safeguarding Boards, the Health and Safety Executive and Trading Standards) as part of the fire investigation process. Yours sincerely, Minister of State for Policing, Fire and Crime Prevention
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