Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0387, written 29 Jul 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jul 2025 |
|---|---|
| Reference | 2025-0387 |
| Deceased | Thomas Hill |
| Coroner | Jason Pegg |
| Coroner area | Hampshire, Portsmouth and Southampton |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHSNOTE: This form is to be used after an inquest.REGULATION 28 REPORT TO PREVENT DEATHSTHIS REPORT IS BEING SENT TO:1 Chief Executive Officer, Office for Product Safety and Standards1CORONERI am Jason PEGG, HM Acting Senior Coroner for the coroner area of Hampshire, Portsmouth and Southampton2CORONER’S LEGAL POWERSI 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 2013.3INVESTIGATION and INQUESTOn 11th November 2015 I commenced an investigation into the death of Thomas Oliver HILL aged 18. The investigation concluded at the end of the inquest on 2nd June 2025.4CIRCUMSTANCES OF THE DEATHThe deceased died on 28th October 2015 in the rear of an ambulance on a road between Brechin and Dundee, Scotland. The deceased inhaled a fatal quantity of carbon monoxide whilst in the bathroom of , Glenesk, Angus, Scotland whilst preparing for a bath. The carbon monoxide had been expelled from a lit liquified petroleum gas cabinet heater. The bathroom was of insufficient size for the flue-less liquified petroleum gas cabinet heater to be safely used without causing a build-up of carbon monoxide. The liquified petroleum gas cabinet heater burner plaques were cracked which contributed to the death by exacerbating the build-up of carbon monoxide.5CORONER’S CONCERNSDuring 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:The flue-less liquified petroleum gas cabinet heater was operated in a room which was too small dimension so to safely use the heater without causing a build-up of carbon monoxide. A warning label was affixed inside the cabinet heater in the space occupied by the liquified petroleum gas bottle.There was an absence of a visible warning label on the outside of the heater.It was not obvious to all potential users of the heater that the heater could only be used safely in a room of sufficient dimension.The risk applies particularly so in the case of rented cottages and similar premises such as .6ACTION SHOULD BE TAKENIn 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.Regulation 28 – After InquestDocument Template Updated 30/07/2021 7YOUR RESPONSEYou are under a duty to respond to this report within 56 days of the date of this report, namely by September 23, 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.8COPIES and PUBLICATIONI have sent a copy of my report to the Chief Coroner and to the following Interested PersonsI have also sent it to National Residential Landlords Association 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.9Dated: 29/07/2025Jason PEGGHM Acting Senior Coroner forHampshire, Portsmouth and SouthamptonRegulation 28 – After InquestDocument Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham B4 6BS Jason Pegg HM Acting Senior Coroner, Hampshire, Portsmouth and Southampton Coroner's Office Castle Hill Winchester Hampshire SO23 8UL Regulation 28: Prevention of Future Deaths Report Thomas Oliver Hill 26 September 2025 Dear Mr Pegg, Thank you for sharing your Regulation 28 Report to Prevent Future Deaths, dated 29 July 2025, following your investigation into the death of Mr Thomas Hill on 28 October 2015, caused by inhalation of a fatal quantity of carbon monoxide from a portable liquified petroleum gas (LPG) cabinet heater. I am responding in my role as Chief Executive of the Office for Product Safety and Standards (OPSS), which is part of the Department for Business and Trade. Thank you for granting a short extension to OPSS as we carefully considered this tragic case, and our response. OPSS is the UK’s product regulator, responsible for the product safety framework covering most consumer products, except food, vehicles and medicines. This framework requires that all consumer products, including gas appliances, are safe when they are placed on the market, when used as intended and in foreseeable conditions of use. At the time the product in this case was manufactured, the legislation in force was the Gas Appliances (Safety) Regulations 1995 (the 1995 Regulations). The manufacturer was required, through the design and construction of the appliance, as well as provision of instructions and warnings placed on the product and its packaging, to eliminate, reduce or guard against potential risks. The essential requirements in the current legislation (Regulation 2016/426 on appliances burning 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 Multistory 18 The Priory Queensway Birmingham B4 6BS gaseous fuels) require there to be instructions for use (intended for the user) and appropriate warning notices, which must also appear on the packaging, when products are placed on the market. You raise concerns that the placement of warning labels on the product may have contributed to Mr Hill’s death, as safe use of the portable LPG heater may not be obvious to all potential users such as those in temporary residential settings like a holiday property. The 1995 Regulations and the voluntary standard for dedicated liquefied petroleum gas appliances (BS EN 449:2002) are not prescriptive about the location of warnings. There is no evidence to suggest that the warning on this specific product regarding sufficient ventilation did not meet the requirements of the regulations and the voluntary standard at the time. I understand the warning directed users to the product’s instructions, but these were not available to the tenants of the property. Manufacturers have a legal duty to monitor the safety of their products on the market and to take action if they become aware of any safety issues. OPSS has written to BSH Home Appliances Ltd in the UK to ensure the business is aware of this incident, and to ask how they monitor for any safety issues with this or similar models of LPG heaters that may occur in reasonably foreseeable conditions of use, including use in rental accommodation. In addition, in light of the risks identified in this case, OPSS has written to the British Standards Institution, the UK’s standards-making body, to request the relevant committee(s) for BS EN 449:2002 +A1:2007 review the standard in relation to the placement and content of warnings on portable gas appliances, when considering all conditions of reasonably foreseeable use. Alongside the product safety regime for gas appliances, there is a separate regime led by the Health and Safety Executive (HSE) – the Gas Safety (Installation and Use) Regulations 1998 – that provides protections for users of leased or rented accommodation, in relation to gas safety, including safe gas appliances. This regime places responsibilities on landlords which we understand were not properly carried out for the property in which Mr Hill died. The HSL report, and subsequent criminal investigation, makes clear that the product that caused Mr Hill’s death should not have been available for tenants’ use. You have sent a copy of this Prevention of Future Deaths report to the National Residential Landlords Association. I will be contacting them to understand their views and the information they share with their members, and I am copying this letter to the HSE, so that we can consider their position on landlords’ responsibilities for gas safety in all cases of reasonably foreseeable use, alongside the product safety regulations that apply to appliances, to ensure the regimes work properly in tandem to protect people from harm. 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 Multistory 18 The Priory Queensway Birmingham B4 6BS Thank you for writing to OPSS and bringing Mr Hill’s very sad death to my attention. Yours sincerely, Chief Executive OPSS The Office for Product Safety and Standards (OPSS) delivers consumer protection and supports business confidence, productivity and growth. It is part of the Department for Business and Trade. gov.uk/opss
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