Jacqueline Langworthy

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

HM Assistant Coroner Linda Lee 
Coroner’s Service,  
Cheylesmore Manor House, 
Manor House Drive,  
Coventry,  
CV1 2ND 

18th December 2025 

Dear Ms Lee,  

Thank you for the Regulation 28 report sent to the Secretary of State / the Department of 

Health and Social Care about the death of Jacqueline Mary Langworthy. I am replying as 

the Minister with responsibility for Adult Social Care.       

Firstly,  I  would  like  to  say  how  saddened  I  was  to  read  of  the  circumstances  of  Miss 

Langworthy’s death, and I offer my sincere condolences to her family and loved ones. The 

circumstances your report describes are concerning and I am grateful to you for bringing 

these  matters  to  my  attention.  Please  accept  my  sincere  apologies  for  the  delay  in 

responding to this matter. 

The  report  raises  concerns  over  the  fact  that  many  platform  lifts  are  still  in  use  in  care 

settings  without  hold-to-run  controls,  which  you  note  can  be  retrofitted  at  a  relatively  low 

cost, and that there is limited awareness of the risk posed by the  absence of hold-to-run 

devices.  

Officials  within  the  Department  of  Health  and  Social  Care  have  considered  your  report 

carefully  and  concluded  that  the  responsibility  for  these  concerns  sits  within  another 

  
  
 
 
 
 
 
 
 
 
   
 
 
 
 
 
  
   
 organisation. I understand that this report was also sent to the Health and Safety Executive, 

which has provided a comprehensive response, including the steps taken to increase the 

awareness of local authorities and the wider healthcare industry to the risks associated with 

this  unfortunate  incident.  I  have  also  written  to  the  HSE  to  ask  that  they  monitor  for any 

similar incidents, and to keep under review whether any further action is necessary.   

Thank you for bringing these concerns to my attention. 

Yours sincerely, 

MINISTER OF STATE FOR CARE

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

5th January 2026 

Sarah Albon 
Chief Executive, Health & Safety Executive 
Redgrave Court 
Merton Road 
Bootle 
Merseyside L20 7HS 

Dear Ms Albon,  

I  am  writing  to  you  in  relation  to  the  Prevention  of  Future  Deaths  report  issued  by  HM 
Assistant Coroner for Coventry and Warwickshire, Linda Lee, about the death of Jacqueline 
Mary Langworthy.  

The  incident  that  led  to  Ms  Langworthy’s death  is most  concerning.  While  the  matters of 
concern  raised  by  the Coroner do not  fall  within  the  responsibilities  of  the  Department  of 
Health  and  Social  Care,  I  nonetheless  share  the  Coroner’s  concern  that  future deaths  in 
similar tragic circumstances are prevented.  

I  have  seen  the  HSE’s  comprehensive  response  to  the  Coroner  and  appreciate  the 
responsibilities of employers to ensure there is robust assessment and mitigation of risks, 
as well as suitable instruction, training and supervision of staff operating work equipment. I 
also welcome the steps taken to raise awareness within local authorities and the healthcare 
sector of the risks associated with this case.  

I  am  writing  to  both  share  my  concern  and  to  ask  that  the  HSE  monitor  for  any  similar 
incidents and keep under review whether any further action may be necessary.   

I  am  copying  this  letter  to  HM  Assistant  Coroner,  Linda  Lee,  and  the  Minister  for  Social 
Security and Disability, Stephen Timms MP. 

Yours sincerely, 

MINISTER OF STATE FOR CARE

Health and Safety 
Executive 

HSE Engagement and 
Policy Division 

Date: 3 September 2025 

Assistant Coroner Coventry and Warwickshire 

Dear Madam, 

REGULATION 28 PREVENTION OF FUTURE DEATHS – the death of Jacqueline 
Mary LANGWORTHY 

Thank you for your Regulation 28 report to 
relation to the tragic death of Jacqueline Mary Langworthy whilst using a platform lift in 
her role as a care assistant. I am responding as the Head of the Local Authority and 
Entertainments Team at the Health and Safety Executive (HSE) which holds the 
operational policy lead for health and safety regulation of several of the local authority 
enforced sectors. 

, HSE Chief Executive, in 

Your report raises as matters of concern, that: 

-  many platform lifts still in use in care settings and other premises do not have 

hold-to-run controls; 

-  evidence was received indicating that such controls can be retrofitted at 

- 

relatively low cost; and 
there is limited awareness of both the risks posed by the absence of hold-to-run 
devices  and the feasibility of fitting such devices to existing platform lifts. 

I will address each of these points in turn. 

Lifts in other care homes do not have hold to run controls 

There is currently no legal requirement to retrofit hold-to-run controls. As employers 
those managing/running care homes have responsibilities under health and safety law 
to ensure, so far as is reasonably practicable, the health and safety of their staff and 
others who might be affected, such as residents and visitors. They are required to 
carry out risk assessments. As a minimum the employer is expected to: 

identify what could cause injury or illness in the business (hazards); 

- 
-  decide how likely it is that someone could be harmed and how seriously (the 

risk); 
take action to eliminate the hazard, or if this isn't possible, control the risk. 

- 

Assessing risk is just one part of the overall process used to control risks in the 
workplace, employers must share the findings of the risk assessment with their staff, 
instruct, train and supervise them.  

HSEHR00799 

 
 
 
 
 
 
 
 
 
 
 
 Regarding the lift, Approved Code of Practice (ACoP) and Guidance L22, Safe use of 
work equipment. Provision and Use of Work Equipment Regulations 1998. Approved 
Code of Practice and guidance L22 describes measures which should be taken by a 
duty holder to prevent access to dangerous parts of work equipment, eg the trapping 
point between the lift platform and fixed parts of the lift shaft. 

The hierarchy of control for preventing access to dangerous parts is described in 
paragraph 145 of L22: Regulation 11(2) specifies the measures that must be taken to 
prevent access to the dangerous parts of the machinery and achieve compliance with 
regulation 11(1). The measures are ranked in the order they should be implemented, 
where practicable, to achieve an adequate level of protection. The levels of protection 
are:  

a)  fixed enclosing guards;  
b)  other guards or protection devices such as interlocked guards and pressure 

mats;  

c)  protection appliances such as jigs, holders and push-sticks etc.  

Information, instruction, training and supervision will be needed regardless of the level 
of protection chosen. 

The risks relevant to this incident, of entrapment, shearing, crushing and trapping are 
readily foreseeable. They are referenced in BS 6440:1999, BS EN 81-41:2010, and 
reference is made in the lift user manual to “trapped between a fixed and moving part 
of the lift.” In this situation there was a pressure sensitive edge to the platform to 
prevent crushing and shearing and a slow travel speed so, in engineering terms, this 
is not the lowest level in the hierarchy, nevertheless, the dutyholder must still place a 
high reliance on robust non-engineering safeguards such as information, instruction, 
training and supervision. 

This will be the case for any lift of this type in any business setting, including in the 
care sector, and the resultant risks must be addressed in the assessment and the 
controls in place with systems of work and engineering controls working in tandem. 

Controls can be retrofitted at relatively low cost 

The purpose of the legislation is to control the risk and this may be achieved in several 
ways. The law does not require retrofit of hold-to-run controls, but these may be one 
way of reducing risk and HSE supports the adoption of reasonably practicable 
measures that do this, particularly where it enhances safety and is feasible in the 
context of the specific lift installation, along with the necessary instruction in how they 
should be used, especially where this is reasonably practicable to do so.   

Dutyholders will need to consider this option as part of their risk assessment process, 
taking into account the design and operational characteristics of the lift, and ensuring 
that any modifications are accompanied by appropriate training and supervision. 
However, it may be that safe operation can also be achieved without installation of 
hold-to-run controls if part of an appropriate robust safe system of work. 

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 Limited awareness of the feasibility of fitting hold-to-run controls to existing 
platform lifts 

Enforcement of the health and safety legislation is split between HSE and the local 
authorities, who are independent regulators in their own right. HSE and LAs work 
closely to ensure consistent enforcement of health and safety legislation. As noted 
above, this type of lift will be used in other settings and so the risks may not be 
specific to care homes. 

To increase awareness among local authority enforcement officers I have asked that 
this matter is raised at the national Local Authority Health and Safety Practitioner 
Forum (https://www.hse.gov.uk/lau/national-committees.htm) and in a technical LA 
bulletin. I have also asked that the circumstances be shared with CQC, from a patient 
safety perspective, in a healthcare bulletin, to the wider healthcare industry and widely 
within the industry. 

I am aware, through HSE’s contact with the Lift and Escalator Industry Association 
(LEIA), that they have raised your concerns with their relevant committees and that 
they have previously published a home-lift guide to help in selection of lift solutions 
(https://www.leia.co.uk/wp-content/uploads/2019/05/LEIA-home-lifts-guide-fnl.pdf). 

I hope that the above information addresses the matters raised. 

Yours faithfully 

Head of Local Authority and Entertainments Team 
Technical Support and Engagement Group 
Engagement and Policy Division 

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18 November 2025 

Mrs Linda Lee 
Assistant Coroner, Coventry and Warwickshire 
Coventry Coroner’s Office 
Coventry City Council 
PO Box 7097 
Coventry 
CV6 9SL 

Dear Mrs Lee, 

Regulation 28 letter – Coventry Coroner 

Many thanks for your letter of 18 July to which we sent an interim response dated 26 August. 

We take such matters very seriously and took immediate action as we reported to you in our letter of 
26 August.  As agreed are now writing with the further actions we have taken.   

We publish safety notices on our website at  https://www.leia.co.uk/technical/product-information/ 
which is a resource to which those in our sector make reference. 

Following discussions with Phoenix Lifting Systems, we published a safety notice on our website on 19 
August  on 
is  at: 
  This  notice 
https://www.leia.co.uk/wp-content/uploads/2025/08/00162-18-August-2025-Phoenix-Lifting-
Systems-Safety-Information-Lifting-platforms-with-one-touch-platform-controls.pdf . 

their  behalf  which  was  emailed 

to  our  members. 

In our earlier email exchange, you agreed that we could make a limited response before 15 September 
and the details above formed our limited response.  The remainder of this letter reports on the further 
measures we have taken.   

Our comments are made in relation to the three matters of concern you raised.  

(1) “Many platform lifts still in use in care settings and other premises do not have hold-to-run 

controls”. 

Since our earlier letter and publication of the safety notice on behalf of Phoenix Lifting Systems, 
we  have  worked  with  our  specialist  committees  and  understand  that  there  might  be  lifting 
platforms installed from other manufacturers with latching/automatic platform controls.  We 
published a further safety notice on 12 November  which we circulated to our members and 
which  is  on  our  website  at:  https://www.leia.co.uk/wp-content/uploads/2025/11/00163-12-
November-2025-lifting-platforms-with-one-touch-platform-controls.pdf  

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 (2) “Evidence was received indicating that such controls can be retrofitted at relatively low cost”. 

Please see our safety notice of 12 November which provides advice to lifting platform owners 
to seek the assistance of their lifting platform maintenance contractors to establish feasibility 
of making such changes.  While we understand that in the case of unmodified lifting platforms 
manufactured by Phoenix Lifting Systems the modification might be straight forward, this might 
not be case for other manufacturers hence our advice. 

(3)  “There is limited awareness of both the risks posed by the absence of hold-to-run devices”. 

Our safety notice of 12 November seeks to address this. 

We remain of the view that a warning issued by the HSE on such risks would be very valuable. 

This addresses the issues raised in your letter in relation to lifting platforms.  More broadly, we have 
recognized that prior to 1979 lifts might been installed without car doors and with latching/automatic 
controls.    Most  such  lifts  would  have  been  entirely  replaced  or  improved  with  safety  measures  to 
address these hazards; unmodified lifts might have similar hazards to the lifting platform addressed 
above.  In case there are such lifts left unimproved, we have made proposals to address these hazards 
for the revision of BS 5655-11 (a standard for the modernization of existing lifts).  This revision work at 
the  British  Standards  Institution  (BSI)  and  is  subject  to  BSI’s  revision,  commenting  and  approval 
process: https://standardsdevelopment.bsigroup.com/projects/2024-00910. 

In summary, we have: 

•  published a safety notice on behalf of Phoenix Lifting Systems as an initial response; 

•  published  a  further  safety  notice  to  address  similar  hazards  in  other  lifting  platforms  from 

other manufacturers; 

•  made  proposals  for  inclusion  of  recommendations  for  the  revision  of  BS  5655-11  to  cover 

legacy lifts with similar hazards to the those identified by this case. 

I trust that this addresses the matters of concern in your letter.  Please let us know if we can assist 
further. 

Yours sincerely  

LEIA Managing Director  

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26 August 2025 

Mrs Linda Lee 
Assistant Coroner, Coventry and Warwickshire 
Coventry Coroner’s Office 
Coventry City Council 
PO Box 7097 
Coventry 
CV6 9SL 

Your Ref: 9950756 

Dear Mrs Lee, 

Regulation 28 letter – Coventry Coroner 

Many thanks for your letter of 18 July. 

We take such matters very seriously and have been in email correspondence to clarify your expectation 
of what action we can take, and to understand more of the circumstances of the accident leading to 
Jacqueline Langworthy’s death.  Many thanks for engaging with us and providing further details. 

The  further  details  you  provided  indicated  that  the  accident  occurred  on  a  lifting  platform 
manufactured by Phoenix Lifting Systems.  Phoenix Lifting Systems is not a member of our Association 
and so we have limited influence (our role as a trade association is advisory).  Nevertheless, we have 
held a meeting with Phoenix Lifting Systems in our offices and have agreed a safety notice which we 
published  on  our  website  at:  https://www.leia.co.uk/technical/product-information/  on  19  August 
when we also emailed it to all our members.  

In the email exchange, you agreed that we could make a limited response before 15 September and 
the details above form our limited response.   

The remainder of the letter looks at issues which we believe are needed for a fuller response to your 
letter.  Owing to holidays and the frequency of our meetings, this would take us beyond 15 September 
so we would provide a fuller response on this point in due course. 

Our comments are made in relation to the three matters of concern you raised.  

(1) “Many platform lifts still in use in care settings and other premises do not have hold-to-run 

controls”. 

We understand that Phoenix Lifting Systems did supply some lifting platforms which did not 
have hold to run controls in the period indicated on their notice.   

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We are working with our specialist committees to understand whether there might be other 
lifting platforms from other manufacturers which might not have hold to run controls – and if 
so what action we could take. 

(2) “Evidence was received indicating that such controls can be retrofitted at relatively low cost”. 

We  understand  that  this  evidence  came  from  the  care  home  owner  (presumably  after  the 
accident).  Our discussion with Phoenix Lifting Systems  supports this for the lifting platforms 
that they manufactured and which still retain their original control systems. 

As  above,  if  a  similar  issue  applies  to  other  manufacturers,  we  would  need  to  understand 
whether they are readily retrofitted and then to consider action we could take.  

(3)  “There is limited awareness of both the risks posed by the absence of hold-to-run devices”. 

LEIA  previously  published  a  homelift  guide  which  included  the  use  of  constant  pressure 
platform 
controls:  https://www.leia.co.uk/wp-content/uploads/2019/05/LEIA-home-lifts-
guide-fnl.pdf  This guide was published after the introduction of BS EN 81-41 requiring platform 
control to be hold to run so would not have raised such risks. 

We are aware of HSE safety warnings for lifting platforms published in 2012 and 2019 but which 
did not deal with these risks.  We note that your letter was sent also to the HSE and believe 
that a warning issued by the HSE on such risks would be very valuable.  We have suggested this 
to the HSE and will have a meeting with HSE later in September when we will raise this. 

In  summary,  we  have  published  a  warning  notice  on  behalf  of  Phoenix  Lifting  Systems  as  an  initial 
response  and  will  continue  to  look  into  these  three  matters.    We  would  most  likely  make  a  fuller 
response in October. 

Many thanks again for your flexibility in this. 

Yours sincerely  

LEIA Managing Director  

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