18 Jul 2025 David Joseph HAYES · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3
Failure of washing detergent containers to restrict access by vulnerable adults or children View source Insufficient labelling warnings about risks to vulnerable adults and children View source Lack of public awareness of the need to safeguard detergents from vulnerable adults View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Dementia UK Department for Environment, Food & Rural Affairs The Royal Society For The Prevention Of Accidents
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Department for Environment, Food & Rural Affairs
Review detergents regulations with industry, considering legislative amendments and alternative measures to improve consumer safety.
View source
The Royal Society For The Prevention Of Accidents
Develop practical guidance for carers on safely storing and handling hazardous household substances.
View source
The Royal Society For The Prevention Of Accidents
Promote safe household chemical storage through guidance and public messaging, including original containers, separation from food and medicines, and marked cupboards.
View source
The Royal Society For The Prevention Of Accidents
Engage manufacturers and regulators to encourage packaging that avoids food or drink resemblance and clearer warnings addressing risks to vulnerable adults.
View source
Dementia UK
Provide home-safety information on laundry products through the “Keeping safe at home” leaflet.
View source
Dementia UK
Engage with UKCPI to support development of a national laundry-product safety awareness campaign for the public and professionals.
View source
Dementia UK
Have Dementia UK’s lived-experience panel review the campaign’s safety products and collateral for relevance to people with dementia, families and professionals.
View source
The Royal Society For The Prevention Of Accidents
Deliver a national social media campaign raising awareness of household chemical risks for people with dementia.
View source See 5 more actions
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AI-generated summary
David Joseph HAYES · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Joseph HAYES, who had dementia, accidentally ingested washing detergent after confusing its packaging with a milk carton. He subsequently suffered vomiting, aspiration and pneumonitis, and died on 21 April 2025. The principal concerns were the detergent’s packaging and colouring, its accessible screw-top lid, and whether labelling and public awareness adequately addressed risks to vulnerable adults.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of washing detergent containers to restrict access by vulnerable adults or children
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” Source location David Joseph HAYES · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient labelling warnings about risks to vulnerable adults and children
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children .
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” Source location David Joseph HAYES · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of public awareness of the need to safeguard detergents from vulnerable adults
Wider context from the report “1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease.
3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible.
” Source location David Joseph HAYES · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review detergents regulations with industry, considering legislative amendments and alternative measures to improve consumer safety.
Verbatim wording from the response “Whilst both regulatory and non-regulatory measures already exist to provide consumer protections, including for vulnerable people, Defra, working with colleagues across government as needed, will consider whether there are opportunities for improvements to these measures. In line with the UK government’s ‘new approach to ensure regulators and regulation support growth’, Defra aims to review our detergents regulations to consider whether any amendments are needed to improve our detergents regime. We will engage with the detergents industry to inform this work. In line with the Better Regulation Framework, whilst our policy review aims primarily to consider legislative changes, we will also consider alternative measures to regulation such as industry codes of conduct or standards that may be applicable.” Source location Response from Department for Environment, Food & Rural Affairs
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop practical guidance for carers on safely storing and handling hazardous household substances.
Verbatim wording from the response “• The development of practical guidance for carers on safer storage of these products within the home.” Source location Response from RoSPA
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote safe household chemical storage through guidance and public messaging, including original containers, separation from food and medicines, and marked cupboards.
Verbatim wording from the response “Our guidance promotes safe storage practices, such as keeping chemicals in their original containers, storing them separately from food and medicines, and using clearly marked cupboards with written or visual signage to indicate their contents. We also encourage manufacturers and regulators to review packaging and labelling practices——avoiding designs that resemble food or drink containers in particular - and to expand existing warnings and plain-language instructions to include the risk posed to vulnerable adults.” Source location Response from RoSPA
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage manufacturers and regulators to encourage packaging that avoids food or drink resemblance and clearer warnings addressing risks to vulnerable adults.
Verbatim wording from the response “Our guidance promotes safe storage practices, such as keeping chemicals in their original containers, storing them separately from food and medicines, and using clearly marked cupboards with written or visual signage to indicate their contents. We also encourage manufacturers and regulators to review packaging and labelling practices——avoiding designs that resemble food or drink containers in particular - and to expand existing warnings and plain-language instructions to include the risk posed to vulnerable adults.” Source location Response from RoSPA
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide home-safety information on laundry products through the “Keeping safe at home” leaflet.
Verbatim wording from the response “It is something that we have seen in previous future death notifications, and as a specialist dementia nursing charity we believe we have a key role in promoting safe use and storage of laundry products. We have undertaken a number of actions to raise awareness of the issue. Our leaflet (Keeping safe at home) provides information on this topic and how people with dementia, their families and professionals can keep safe in the home.” Source location Response from Dementia UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage with UKCPI to support development of a national laundry-product safety awareness campaign for the public and professionals.
Verbatim wording from the response “In addition, we have been actively engaging with the UK Cleaning Products Industry Association (UKCPI) to support them in their development of a wide-ranging safety awareness campaign that will seek to raise these issues further with the public and professionals alike. The campaign will involve several different activities, products and collateral that will be shared nationally.” Source location Response from Dementia UK
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have Dementia UK’s lived-experience panel review the campaign’s safety products and collateral for relevance to people with dementia, families and professionals.
Verbatim wording from the response “I have personally been involved in making sure that the campaign supports people with dementia, their families and professionals; and members of our Lived Experience Advisory Panel (made up people with dementia and carers) have actively been reviewing the campaign products and collateral. I hope that this UKCPI led campaign, supported by Dementia UK and others, will further reinforce the public safety messages around safe use and storage on laundry products.” Source location Response from Dementia UK
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a national social media campaign raising awareness of household chemical risks for people with dementia.
Verbatim wording from the response “• A targeted social media campaign to raise awareness about the risks posed by household chemicals to those with cognitive impairment” Source location Response from RoSPA
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Defra does not enforce product safety regulations and directs relevant product information to local authority trading standards.
Verbatim wording from the response “GB product safety regulations require all consumer products to be safe when they are placed on the market. This includes regulations covering products that could be mistaken for food items and may cause harm if ingested, as noted above. There is not enough detailed information in your report to determine the extent to which products have complied with all the regulations noted above. Defra does not hold responsibility for enforcement of these regulations, but I have made the Office for Product Safety and Standards aware of this case. You may wish to consider passing any relevant information about the specific product in this case to the relevant local authority trading standards department.” Source location Response from Department for Environment, Food & Rural Affairs
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CLP-related concerns are HSE’s responsibility, so HSE provided the response rather than Defra.
Verbatim wording from the response “Thank you for your Regulation 28 report in relation to the death of David Joseph Hayes, dated July 18th 2025. Your report was addressed to the Secretary of State for Defra (being the Government department with responsibility for the regulation of Detergents). I am responding as the Deputy Director with responsibility for Chemicals, which includes Detergents policy and regulation. I have consulted with the Health and Safety Executive (HSE) as some of the issues raised fall within their remit as a regulator for the supply of chemicals in Great Britain (GB). Specifically in reference in this response, HSE have responsibility for Classification, Labelling and Packaging (CLP) regulations so they and not Defra have provided the text for the response in relation to this area.” Source location Response from Department for Environment, Food & Rural Affairs
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HSE considers legislative change unnecessary because there is no evidence that this case represents a widespread problem.
Verbatim wording from the response “Compliance with the requirements of GB CLP Regulation is enforced by various authorities covering a range of different supply contexts. Instances of non-compliance are subject to proportionate and pragmatic enforcement action which ensures that the risk of harm emanating from chemicals supplied in GB is minimised. There is no evidence to demonstrate that the circumstances of this case represent a more widespread problem and therefore HSE do not consider that changes to the legislation need to be considered at this time.” Source location Response from Department for Environment, Food & Rural Affairs
Open published response
13 Aug 2024 Elizabeth Van Der Drift · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2
Failure of product appearance and packaging to avoid confusion with food View source Lack of packaging safety features restricting access to laundry capsules View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Health and Safety Executive Office for Product Safety and Standards Sainsbury’s Group Legal Services The UK Cleaning Products Industry Association (UKCPI
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Health and Safety Executive
Continue reviewing whether further regulatory measures are needed for laundry detergent packaging.
View source
Health and Safety Executive
Continue working with trading standards and local authorities to address breaches of the GB CLP Regulation.
View source
The UK Cleaning Products Industry Association (UKCPI
Maintain the Product Stewardship Programme’s safety requirements for liquid laundry detergent capsules, including child-resistant packaging, safety messaging and advertising controls.
View source
Sainsbury’s Group Legal Services
Replace plastic packaging with a cardboard box incorporating a child-impeding closure and test it against the AISE Child-Impeding Closures protocol.
View source See 1 more action
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action. 8
Health and Safety Executive
Existing regulatory provisions are considered an adequate response; no additional GB CLP provisions are proposed, though the position remains under review.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Health and Safety Executive
Parents, support staff and carers should identify hazards and implement safeguarding, including restricting access through safe storage, for vulnerable individuals.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action. View source
Sainsbury’s Group Legal Services
Existing packaging controls, safety labelling, bittering agent and voluntary product-safety guidance are considered sufficient, so no further action is required.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Office for Product Safety and Standards
There is no evidence that the laundry pods were non-compliant with product safety rules or chemical substance requirements.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
The UK Cleaning Products Industry Association (UKCPI
The evidence does not show that capsule colour causes accidental exposure or makes capsules likely to be confused with food.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
The UK Cleaning Products Industry Association (UKCPI
Existing regulatory and voluntary measures make the product and its packaging inherently safe, keeping accidental ingestion extremely unlikely across age groups.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed. View source
Sainsbury’s Group Legal Services
The packaging did have a child-impeding safety feature, contrary to the concern that no such feature was observed.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source
The UK Cleaning Products Industry Association (UKCPI
The sampled pouch packaging complied with GB CLP requirements and the industry safety programme, contrary to the concern about inadequate access protection.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it. View source See 7 more positions
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AI-generated summary
Elizabeth Van Der Drift · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elizabeth Van Der Drift, who had dementia, accessed brightly coloured laundry detergent capsules on the night of 13/14 March 2024, apparently mistaking them for sweets, and bit into at least one. She was taken to hospital and died on 19 March 2024 despite treatment. The report raised concerns that the product’s colours, appearance and packaging could lead to accidental ingestion by people with dementia or other cognitive impairment, and that its packaging lacked a safety feature making access particularly difficult.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of product appearance and packaging to avoid confusion with food
Wider context from the report “(1) The product in question, Sainsbury’s Tropical Escape Bio Laundry Capsules, due to its eye-catching colours, appearance, and packaging, is being confused with food and risks being accidently ingested by those with dementia or other cognitive impairment (as well as children) .
(2) There was no safety feature observed on the packaging that made accessing the content particularly difficult, which increases the risk of accidental or inadvertent ingestion.
” Source location Elizabeth Van Der Drift · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of packaging safety features restricting access to laundry capsules
Wider context from the report “(1) The product in question, Sainsbury’s Tropical Escape Bio Laundry Capsules, due to its eye-catching colours, appearance, and packaging, is being confused with food and risks being accidently ingested by those with dementia or other cognitive impairment (as well as children).
(2) There was no safety feature observed on the packaging that made accessing the content particularly difficult , which increases the risk of accidental or inadvertent ingestion .
” Source location Elizabeth Van Der Drift · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue reviewing whether further regulatory measures are needed for laundry detergent packaging.
Verbatim wording from the response “HSE is not proposing additional provisions to the GB CLP Regulation but will continue to keep the position under review, including whether further regulatory measures might be needed. HSE will continue to work with bodies that enforce CLP, including trading standards and local authorities to address breaches of the regulation.” Source location Response from HSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue working with trading standards and local authorities to address breaches of the GB CLP Regulation.
Verbatim wording from the response “HSE is not proposing additional provisions to the GB CLP Regulation but will continue to keep the position under review, including whether further regulatory measures might be needed. HSE will continue to work with bodies that enforce CLP, including trading standards and local authorities to address breaches of the regulation.” Source location Response from HSE
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the Product Stewardship Programme’s safety requirements for liquid laundry detergent capsules, including child-resistant packaging, safety messaging and advertising controls.
Verbatim wording from the response “a. Due to growing concern by the industry over the accidental exposures, in 2012 AISE, the European trade association for detergent manufacturers, established its own voluntary set of safety measures. This is named the Product Stewardship Programme (PSP) for Liquid Detergent Capsules.” Source location Response from UKCPI
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace plastic packaging with a cardboard box incorporating a child-impeding closure and test it against the AISE Child-Impeding Closures protocol.
Verbatim wording from the response “We have since changed our packaging to remove plastic packaging to a cardboard box with a child impeding closure. The new cardboard box has undergone testing in line with the AISE Test Protocol for Child-Impeding Closures (CIC) and the product continues to meet the LDC PSP guidance.” Source location Response from Sainsburys
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing regulatory provisions are considered an adequate response; no additional GB CLP provisions are proposed, though the position remains under review.
Verbatim wording from the response “I hope this information addresses your concerns and reassures you as to the existing regulatory provisions that are in place on the design and safety features of the packaging of laundry tablets/pods for consumers.” Source location Response from HSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Parents, support staff and carers should identify hazards and implement safeguarding, including restricting access through safe storage, for vulnerable individuals.
Verbatim wording from the response “Where an individual is unable to identify hazard communicated through the label, parents, support staff or carers for vulnerable persons should make that identification on their behalf and implement safeguarding measures for that individual, including restricting access through safe storage, whether in the home, residential care or care home.” Source location Response from HSE
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing packaging controls, safety labelling, bittering agent and voluntary product-safety guidance are considered sufficient, so no further action is required.
Verbatim wording from the response “Sainsbury’s and their suppliers adhere to the A.I.S.E. Liquid Detergent Capsule Product Stewardship Programme (LDC PSP) guidance in this area. For over 30 years, A.I.S.E. have made continual commitments on product safety that go beyond legislation and have launched a range of voluntary initiatives to engage with consumers and professional users on safe and sustainable habits, use and disposal of products and packaging. This voluntary product safety initiative includes guidance for retailers and producers of detergent capsules, which aims to support safe use and storage of LDCs by consumers to significantly reduce the incidence of accidental exposure to these products, in particular involving young children.” Source location Response from Sainsburys
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation There is no evidence that the laundry pods were non-compliant with product safety rules or chemical substance requirements.
Verbatim wording from the response “As you will know, the UK’s product safety laws require that only safe consumer products be placed on the market. Manufacturers or importers have obligations to ensure their products are safe. In addition, distributors must not supply products they know, or should know, are unsafe. OPSS has not been made aware of any evidence to suggest that the pods were non-compliant with relevant product safety rules, or did not meet the requirements in relation to the chemical substances the laundry pods contained.” Source location Response from OPSS
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The evidence does not show that capsule colour causes accidental exposure or makes capsules likely to be confused with food.
Verbatim wording from the response “a. The Coroner specifically references LLDC ‘as being colourful and potentially sweet-like in their appearance’.
The bright colour of capsules was also claimed to be a factor in infant poisonings and led to a body of research work and an EU Commission report concluding that there was no discernible colour preference when infants were exposed to a range of coloured household laundry products.” Source location Response from UKCPI
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing regulatory and voluntary measures make the product and its packaging inherently safe, keeping accidental ingestion extremely unlikely across age groups.
Verbatim wording from the response “This loss of inhibition can be gradual, intermittent i.e. extremely difficult to predict and as manufacturers have no control over the product use in the user environment, so the role of the care giver becomes critical in ensuring that the user environment is safe.” Source location Response from UKCPI
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The packaging did have a child-impeding safety feature, contrary to the concern that no such feature was observed.
Verbatim wording from the response “2. There was no safety feature observed on the packaging that made accessing the content particularly difficult, which increases the risk of accidental or inadvertent ingestion.” Source location Response from Sainsburys
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The sampled pouch packaging complied with GB CLP requirements and the industry safety programme, contrary to the concern about inadequate access protection.
Verbatim wording from the response “b. The Coroner specifically mentions ‘no obvious design feature, in terms of the packaging, that makes accessing the content particularly difficult’. This is confusing given the various measure previously described required under CLP.” Source location Response from UKCPI
Open published response
6 Apr 2017 John HAUGHEY · Prevention of Future Deaths report East Riding and Hull
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Concerns raised 1
Risk of confused patients consuming ubiquitous alcohol-based hand washing gels View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
John HAUGHEY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
John Haughey, who had increasing confusion, consumed a large amount of alcohol-based hand sanitiser while admitted to Hull Royal Infirmary in September 2015. He developed acute alcohol toxicity, later suffered aspiration and progressive respiratory deterioration, and died on 12 September 2015. The principal concern was the risk that confused patients or others could consume alcohol-based hand-washing gels, and that information about this hazard had not been disseminated widely enough.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Risk of confused patients consuming ubiquitous alcohol-based hand washing gels
Wider context from the report “There is a tension between the need to prevent cross infection in the hospital setting and the possibility of confused patients consuming preparations used to clean clinicians hands . There is increasing public awareness about the desirability of hand hygiene and the need to prevent infection and as a result alcohol-based hand washing gels are found in many public buildings other than hospitals. Whilst incidents such as John Haughey’s are thankfully rare, it is my view that similar tragedies could occur given the now ubiquitous presence of such hand washing gels and their dispensers . Whilst I am satisfied that the Hull & East Yorkshire Hospitals NHS Trust has implemented measures to prevent similar incidents occurring in the future, I am not convinced that information about this incident has been disseminated as widely within the NHS, the public sector in general and private sectors as it should be. Such organisations need to be aware of this potential hazard and take appropriate action that might include making formal risk assessments where such materials are deployed.
” Source location John HAUGHEY · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.