Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0407, written 5 Aug 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Aug 2025 |
|---|---|
| Reference | 2025-0407 |
| Deceased | Mohsin Janjua |
| Coroner | Martin Fleming |
| Coroner area | West Yorkshire Western |
| Category | Product related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 Office for Product Safety & Standards 1 CORONER I am M D FLEMING, HM Senior Coroner for the coroner area of West Yorkshire Western Coroner Area 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 13/12/2023 I opened an inquest into the death of Mohsin Janjua who, at the date of his death was aged 28 years old. The inquest was resumed and concluded on 30/07/2025. I found that the cause of death to be: - 1a The Effects of Fire I concluded with a narrative conclusion: On 02/12/2023, Mohsin Janjua died from the inhalation of products of combustion in a house fire at his home address at , Bradford. Unknown to him, he had previously purchased an unsafe lithium battery on the internet in order to convert his bicycle with other modifiable parts to an E-bike, which he left on charge overnight in his living room. It is found more likely than not that the fire was caused by a catastrophic failure of the ion lithium battery. 4 CIRCUMSTANCES OF THE DEATH During the early hours of 02/12/2023, whilst the family were asleep at their home address of , Bradford a pedal cycle converted by Mohsin to an e-bike suddenly caught fire after he had plugged its battery into the mains in the living room where he was sleeping on the sofa. When Mohsin became aware he immediately alerted his mother and son in the upstairs bedroom and they were all able to exit by way of the front door. However since Mohsin’s brother was thought to be trapped inside the house, Mohsin re entered the burning property in a bid to locate him, albeit in doing so he was unaware that his brother had previously jumped to safety from his upstairs bedroom window, sustain injuries in the process. Notwithstanding his injuries, Mohsins brother made his own desperate attempt to re enter the property, risking his own life, but despite his best efforts, was forced back by the density of the toxic smoke and fire intensity to escape down the stairs. Upon the arrival of fire service and upon entering the property, Mohsin was found unresponsive in the rear upstairs bedroom, but was subsequently found to have died. The inquest heard that Mohsin had converted his Carrera bike with an electric motor 18 Regulation 28 – After Inquest Document Template Updated 30/07/2021 months previously and that he had replaced the motor a week before he died with a 20am/hour 52-volt battery. Test purchases were conducted after it was established that he had purchased the battery from a site on eBay and a forensic examination of this along with the recovered remains of the lithium battery from the fire. The test purchase battery and charger, thought to have emanated from China, were found not to confirm with UK safety standards and regulations. Although the battery recovered from the fire showed some similarities with the test purchase, the extent of its fire damage prevented further identifications. The fire investigation officer confirmed in his evidence that the ion-lithium battery purchased by Mohsin was the source of the fire. 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) • To review and reconsider the adequacy of the of the current unregulated sale of lithium- ion batteries, especially those intended for e-bike conversions through online market places, since they pose a significant and growing risk to public safety. • Fires caused by substandard or non-compliant batteries have increased and many originate from online marketplaces. • At the moment it is my understanding that online market places disclaim responsibility for the safety of 3rd party goods, so I ask that you give consideration to the appropriateness of regulations to make online marketplaces jointly responsible for ensuring the safety and legal compliances of products sold on their sites. • Consider further steps to increase the general publics awareness with regard to the life threatening risks involved with lithium ion batteries from e-bikes in this case stored in domestic properties. 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 September 25, 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 I have also sent it to Regulation 28 – After Inquest Document Template Updated 30/07/2021 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: 05/08/2025 M D FLEMING HM Senior Coroner for West Yorkshire Western Coroner Area Regulation 28 – After Inquest Document 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 Mr M D Fleming HM Senior Coroner for West Yorkshire Western Coroner Area HM Coroners Court, Cater Building 1 Cater Street Bradford BD1 5AS 25 September 2025 Dear Mr Fleming, Thank you for sharing your Regulation 28 Report to Prevent Future Deaths, dated 5 August 2025, concerning the death of Mohsin Janjua following a house fire started by an e-bike battery. 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. I was sorry to hear of Mr Janjua’s death. In my letter to you of 31 May 2024 I set out some of the actions OPSS were taking at that time. I am grateful for the opportunity to outline the further actions we have been taking since. Regulatory framework The safety of e-bikes and their batteries is a high priority for Ministers and for OPSS. Lithium-ion batteries for e-bikes and conversion kits are regulated under the General Product Safety Regulations 2005 (GPSR). This places obligations on those producing or importing consumer products, including lithium-ion batteries, to ensure their products are safe before being placed on the market, whether sold online or in physical retailers. Distributors also have duties regarding product safety under GPSR. OPSS and Local Authority Trading Standards departments have powers to take action when non-compliant or unsafe products are identified, including removing them from sale. While product safety regulations do already apply to online marketplaces when they are carrying out the activities of a distributor, we recognise that the growth of e- commerce has created challenges for the product safety framework. The Government recently introduced the Product Regulation and Metrology Act 2025, which received Royal Assent in July 2025. The Act enables Government to introduce new duties on online marketplaces with regards to product safety. TGovernment has committed to consult on these responsibilities at the earliest opportunity, to create a proportionate regulatory framework where online marketplaces prevent non- compliant and unsafe products being made available on their platforms. 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 In December 2024 the Department introduced statutory guidelines for the safety of lithium-ion batteries supplied for use with e-bikes. These guidelines apply to all lithium-ion batteries for e-bikes, including those sold online or sold for use with a conversion kit. They set out what is required for these batteries to be considered a safe product under GPSR, including that they must have a mechanism, or mechanisms, to protect against the risk of thermal runaway, which is a major cause of battery fires. We expect product distributors, including online marketplaces acting as distributors, to take account of the guidelines in assuring themselves that the product is compliant and meets the requirements of GPSR before making a lithium- ion battery available on the market. OPSS senior leaders regularly meet with the major online marketplaces operating in the UK market to hold them to account for their product safety responsibilities, including implementing these guidelines. We are also working with businesses and other stakeholders to improve technical understanding of producing safer e-bike batteries. We have commissioned the British Standards Institution (BSI) to produce a fast-track standard – known as a publicly available specification (PAS) – on technical requirements for battery systems used in e-bikes, e-scooters and conversion kits. The PAS will be informed by a significant research project we commissioned from Warwick Manufacturing Group on lithium-ion battery safety, which was published in January 2025 on gov.uk. Businesses will be able to follow the recommendations in this PAS to help demonstrate their products comply with product safety regulations. The development of the PAS is being led by a technical expert steering group, including representatives from industry and academia. We anticipate it will be published by BSI in 2026. Enforcement Action OPSS’ investigation into the safety of the lithium-ion battery involved in the fire which led to Mr Janjua’s death, and another serious fire in the West Midlands, identified the specific models of UPP battery involved. The evidence enabled OPSS to take enforcement action in January 2024 to prohibit the sale of these battery models in the UK, which included their supply by online marketplaces. 26 Withdrawal Notices were served on eight online marketplaces, two manufacturers and 16 other sellers, requiring them to immediately stop the supply of two dangerous models of UPP battery. OPSS also published public safety messages advising consumers not to use the models and how to dispose of them safely. 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 The prohibition on supply of these dangerous batteries remains in place. Should regulators become aware the models are available in the UK, action will be taken to remove them from the market. Public awareness In 2024 the Government’s safety campaign ‘Buy Safe, Be Safe’ was launched, aimed at raising public awareness of the risks from dangerous e-bikes, e-scooters and their components with advice on safer purchasing and charging practices. OPSS is working closely with other Government departments, as well as safety charities Electrical Safety First and 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. OPSS has also produced Buy Safe, Be Safe videos with five key safety steps that users should take if they own or use e-bikes. These videos have been translated into several languages. They are aimed particularly at food delivery riders, based on insights from gig economy companies. OPSS has shared the videos with those companies and encouraged them to raise awareness with riders and couriers. While I believe that the actions outlined above will make a material difference to consumer safety in this area, e-bike safety, and the sale of unsafe products via online marketplaces, remains a priority area for OPSS. Thank you again for raising these important issues. I would be grateful if you could share a copy of this letter with colleagues who may find it useful. Kind regards, Chief Executive Office for Product Safety and Standards 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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