Prevention of Future Deaths reports · 2024

Luke Albiston O’Donnell

Regulation 28 report to prevent future deaths, reference 2024-0678, written 9 Dec 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report9 Dec 2024
Reference2024-0678
DeceasedLuke Albiston O’Donnell
CoronerAnita Bhardwaj
Coroner areaLiverpool and Wirral
CategoryProduct related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

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

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Office of Product Safety and Standards (OPSS)
2 National Fire Chief’s Council
3 The Chief Coroner

1

CORONER

I am Anita BHARDWAJ, Area Coroner for the coroner area of Liverpool and Wirral

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 14 August 2024 I commenced an investigation into the death of Luke Marshall
ALBISTON O'DONNELL aged 8. The investigation concluded at the end of the inquest on 05
December 2024. The conclusion of the inquest was that:

Official

Cause of death:

1a Hypoxia and Carbon Monoxide Poisoning

Conclusion:

Accident

4

CIRCUMSTANCES OF THE DEATH

Luke Marshall Albiston O'Donnell was an 8-year-old boy who died in hospital following a fire
at his home address. A full investigation was carried out by Merseyside Fire and Rescue
Service which found an e-bike was on charge in the front room of the house. The fire
commenced as a result of the ignition of a lithium battery, from the e-bike, which has come
into contact with combustible materials. The failure of the battery cells has enabled the fire
to develop rapidly.

5

CORONER’S CONCERNS

During the course of the investigation my inquiries 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:
(brief summary of matters of concern)

The general public do not appreciate the life-threatening risks involved with having lithium
iron batteries, from electronic bikes in this case, stored in domestic properties. There
appears to be a lack of communication/media coverage about the dangers involved with

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

 storing appliances such as electronic bikes/scooters in domestic properties. There have
already been 3 deaths associated with lithium batteries in the home in Merseyside and we
have been informed there a number of similar fatalities across England.

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you (and/or
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 3 February 2025. 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.
COPIES and PUBLICATION

8

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

The family of Luke O’Donnell

I have also sent it to

i.
ii.

Merseyside Fire and Rescue Service
The National Fire and Rescue Service

Official

who may find it useful or of interest.

I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or
of interest.

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

Dated: 09/12/2024

Anita BHARDWAJ
Area Coroner for
Liverpool and Wirral

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Nfcc (PDF)
Anita Bhardwaj 

Area Coroner for the coroner area of Liverpool and Wirral 

Sent by email to: 

03 February 2025 

Dear Ms Bhardwaj, 

c/o 71-75 Shelton Street 
Covent Garden 
London 
WC2H 9JQ 
www.nfcc.org.uk 

Thank you for raising the concern in relation to the death of Luke Albiston O’Donnell on 4th 
August 2024. It is with great sadness that I read about the circumstances of his death. The 
National Fire Chiefs Council (NFCC) is committed to a culture of learning and improvement 
and seeks to support fire and rescue services 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 the NFCC as being an organisation that has the power to 
take action to prevent future fire deaths associated with the charging of electric scooters 
that are powered by lithium-ion batteries. 

We recognise the seriousness and devasting impact that fires caused by lithium-ion 
batteries in electric scooters can cause to families across the UK and note the increasing 
occurrences of these types of incidents. We are committed to supporting the sector in 
delivering impactful prevention campaigns and initiatives. This includes our Charge Safe - 
NFCC campaign which sets out public advice for charging e-bikes and e-scooters as well 
as providing warning signs that a battery could be a fire hazard. 

In addition to this, we support and signpost fire and rescue services to the Office for 
Product Safety and Standards guidance on Buy Safe, Be Safe: avoid e-bike and e-scooter 
fires - GOV.UK. This campaign provides resources that gives consumers advice about 
what to look for when purchasing an e-bike or e-scooter as well as advice about 
maintenance across the equipment’s life cycle.   

We also have campaign resources available for fire and rescue services on Recycle your 
electricals - NFCC. This includes links to Electrical recycling - Where to recycle & donate.  

As with all prevention activity, we recognise the significant challenge that fire and rescue 
services have in identifying and delivering behaviour changing interventions to individuals 
at risk. The growing market for e-bikes and e-scooters means that fire and rescue services 
are having to focus more resources to understand the demographics and behaviours of 
individuals that may be prone to these types of fires. To help fire and rescue services with 
this, we are looking to gain further understanding of the issues through more research. This 
includes working with our Academic Collaboration, Evaluation and Research (ACER) 

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 

 
 
 
 
 
 
 
 
 Group - NFCC and our international partners to see what research already exists and 
identify potential gaps in our knowledge. We can then use this new understanding to tailor 
and update our campaign materials for fire and rescue services to use. 

Product development and innovation is outpacing safety standards, however NFCC is 
aware of the current Product Regulation and Metrology Bill that was introduced in the 
House of Lords on the 4 September 2024 which aims to improve the Government’s ability 
to be responsive to new product risks. Previously NFCC gave its backing to Electrical 
Safety First’s Private Members Bill, ‘The Safety of Electric-Powered Micromobility Vehicles 
and Lithium Batteries Bill’ which made provisions for improved safety standards of e-bike 
and e-scooter batteries.  

As the Product Regulation and Metrology Bill progresses through Parliament, NFCC will 
continue to advocate for stronger product safety rules to ensure that there are robust 
product standards and third-party certification testing requirements in place or e-bikes, e-
scooters, chargers and batteries and e-bike conversion kits. Additionally, NFCC will 
advocate for the introduction of enforceable, mandatory online marketplace regulations to 
ensure that all e-bikes, e-scooters and related batteries, chargers and conversion kits sold 
in the UK, whether sold physically or via online platforms, meet UK designated standards.  

In early 2024, I attended a Ministerial meeting at the Home Office, hosted by the then Fire 
Minister. This meeting brought together representatives from various Government 
departments to ensure a shared understanding of the fire safety risks posed by Personal 
Light Electric Vehicles (PLEVs) and to discuss current and planned mitigations to manage 
these risks. I provided the NFCC perspective on PLEV fires. The meeting also focused on 
data and intelligence, product construction standards and building design, consumer 
awareness and guidance, online marketplaces and enforcement, and disposal and 
recycling. 

Following the tragic death of Luke, we have been in liaison with Merseyside Fire and 
Rescue Service to ensure that all learning captured from the incident is processed through 
our NFCC Organisational Learning arrangements. 

In doing this, we will not only be able to share key learning points with UK fire and rescue 
services, but we will also be able to reflect on national Home Safety Fire Prevention 
guidance and develop our campaign resources. This will ensure that those who own or 
operate e-bikes or e-scooters are enabled to understand the risks and prevent similar 
incidents from occurring in their homes.  

Finally, I have taken the immediate step of writing to all Chief Fire Officers specifically to 
inform them of this and other incidents of this type, providing details of existing resources 
and the intentions of NFCC to explore further learning and resources. I have also 
requested their support to raise awareness.   

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 

 
 
 
 
 
 
 
 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
Response from Opss (PDF)
OFFICIAL-SENSITIVE 

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

3 February 2025 

Mrs Anita Bhardwaj 
Area Coroner, H.M. Coroner's Court,  
Gerard Majella Courthouse 
Boundary Street, 
Liverpool L5 2QD 

Dear Mrs Bhardwaj, 

Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 9 
December 2024, following your investigation and inquest into the death of Luke 
Marshall Albiston O’Donnell, who died in hospital following a house fire on 4 August 
2024, caused by a lithium-ion e-bike battery. 

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

The Office for Product Safety and Standards (OPSS), within the Department for 
Business and Trade, is the UK’s national product regulator. We are aware that as the 
use of e-bikes has become more widespread, there has been an increasing number 
of fire incidents associated with them, some of which have tragically resulted in 
fatalities such as the one which sadly took Luke’s life. The safety of these products is 
a priority across Government and OPSS has a programme of work to understand 
and act on the issues that have been causing these fires.  

In your report, you raise a key concern over a lack of communication and media 
coverage regarding the dangers that can be associated with these products. To raise 
awareness, the Government launched the Buy Safe, Be Safe campaign in October 
2024, that aims to highlight the serious risks associated with buying and using 
unsafe e-bikes and their batteries. The campaign focuses on encouraging 
consumers to only buy safe products from reputable sellers, only replace items with 
products recommended by the manufacturer and to use professionals if converting 
or repairing e-bikes and e-scooters.   

OPSS is currently working with other Government departments, as well as external 
stakeholders including Electrical Safety First, the Royal Society for the Prevention of 
Accidents, local authorities, fire and rescue services and retailers to amplify these 
important safety messages through their networks and communication channels. 

OFFICIAL-SENSITIVE 

 
 
 
 
 
 
 OFFICIAL-SENSITIVE 

The Buy Safe, Be Safe campaign builds on previous activity, including an ‘important 
safety message’ published in December 2023, which contained advice for 
consumers who own, or are thinking of purchasing, e-bikes or e-scooters. This can 
be read here: Government Safety Message on e-bikes and e-scooters - GOV.UK 

OPSS has also supported other Government departments’ safety messaging for e-
bikes, e-scooters and lithium-ion batteries, including Department for Transport 
guidance for product owners and public transport operators, and guidance 
concerning fire safety in the home, published by Fire England. We are determined to 
continue raising awareness of the risks posed by unsafe products, working with 
industry, other stakeholders and across Government.  

Alongside this, our programme of work focuses on understanding, identifying and 
acting to remove unsafe e-bikes, e-scooters or lithium-ion batteries from the market.  
In January, OPSS published independent research commissioned from Warwick 
Manufacturing Group (WMG) into the safety of lithium-ion batteries commonly used 
in e-bikes and e-scooters. The research includes technical analysis of battery safety, 
product inspections and laboratory testing. It takes forward our understanding of how 
battery failures occur during real-world use and environments, and the types of 
processes and materials used in product manufacture that achieve safer design and 
safer use of lithium-ion batteries. We are carefully considering its findings and a 
summary of our recent regulatory activity on this subject is set out on gov.uk.  

OPSS has already commissioned the British Standards Institution (BSI) to develop a 
Publicly Available Specification (PAS) for lithium-ion battery systems for e-bikes, 
conversion kits and other similar products. Businesses can use a PAS, which is a 
type of voluntary product standard, to demonstrate their compliance with product 
safety regulations. The development of the PAS will be led by a technical expert 
steering group, including representatives from industry and academia as well as 
OPSS and BSI.  

Many of the serious fires that have occurred in e-bikes have involved a process 
known as thermal runaway, in which the temperature of individual battery cells 
contained within a battery reaches a critical point at which exothermic reactions 
occur, resulting in the release of flammable and potentially toxic gases that ignite, 
causing a fire and/or explosion. In December 2024, the Secretary of State introduced 
new statutory guidelines for lithium-ion batteries supplied for use with e-bikes or e-
bike conversion kits. The guidelines clarify that lithium-ion batteries for e-bikes must 
have mechanisms to address the risk of thermal runaway to be considered a safe 
product and meet product safety regulations. The new statutory guidelines apply in 
Great Britain and cover all lithium-ion batteries for e-bikes, including those sold 
online or sold for use with a conversion kit. Businesses must take account of the 
guidelines when assessing whether the battery is a safe product under the General 
Product Safety Regulations 2005.   

It is an offence to place a lithium-ion battery on the market if it is not a safe product, 
and OPSS and Local Authority Trading Standards have powers to take enforcement 

OFFICIAL-SENSITIVE 

 
 
 OFFICIAL-SENSITIVE 

action, including removing these products from the market or prosecution for the 
most serious cases.  

OPSS is actively enforcing these requirements and last year took enforcement action 
to remove from sale unsafe models of Unit Power Pack (UPP)-branded e-bike 
batteries, that have been linked to several serious fires in the UK. We have also 
published a further 21 product recalls and 29 other product notifications about unsafe 
or non-compliant e-bikes, e-scooters or their batteries which contain advice for 
consumers, retailers and local authorities on actions they should take to protect 
people from harm. 

The Government has recently introduced the Product Regulation and Metrology Bill 
into Parliament with a view to future proofing the UK’s product safety framework. 
Once enacted, it will enable Ministers to make regulations to capture new and 
innovative products, and to clarify the responsibilities that online platforms have with 
regard to product safety. 

OPSS is continuing to prioritise work to raise public awareness and improve the 
safety of e-bikes, e-scooters and lithium-ion batteries. I believe the actions we have 
already taken through the Buy Safe Be Safe campaign, the new statutory guidelines 
and enforcement action are making a material difference to consumer safety in this 
area that can help to prevent tragic fatalities like Luke’s in the future.  We are 
currently assessing what additional steps we can take to build on the WMG findings 
to improve safety even further.   

Thank you for writing to OPSS on this matter. I would be grateful if you could share a 
copy of this letter, and the links enclosed, with any of your colleagues who may find it 
useful. 

Kind regards, 

Chief Executive 
OPSS 

OFFICIAL-SENSITIVE 

 
 
 
 
 
 
 
 
 
 
 OFFICIAL-SENSITIVE 

Full web addresses referred to in this letter 

Buy Safe, Be Safe 
https://www.gov.uk/guidance/buy-safe-be-safe-avoid-e-bike-and-e-scooter-fires 

Government Safety Message on e-bikes and e-scooters (December 2023) 
https://www.gov.uk/guidance/government-safety-message-on-e-bikes-and-e-scooters 

Department for Transport guidance  
https://www.gov.uk/government/news/new-guidance-to-enhance-e-bike-and-e-
scooter-safety 

Fire England guidance 
https://fireengland.uk/fire-safety/charging-your-e-bike-or-e-scooter 

Warwick Manufacturing Group research  
https://www.gov.uk/government/news/government-publishes-research-report-into-e-
bike-battery-safety 

OPSS regulatory activity update  
https://www.gov.uk/government/publications/personal-light-electric-vehicle-plev-
battery-safety-research/opss-regulatory-activity-update-e-bikes-e-scooters-and-
lithium-ion-batteries 

OFFICIAL-SENSITIVE

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