21 Nov 2022 Celia Lindsey MARSH · Prevention of Future Deaths report Avon
View report summary
Concerns raised 12 Potentially unsafe exposure to undeclared allergens for people at significantly higher risk of fatal reactions View source Potentially misleading food-labelling wording and public understanding of allergen absence View source Lack of a robust system for capturing and recording anaphylaxis cases View source Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination View source Lack of adequate education for doctors and patients in anaphylaxis risk groups View source Delays in raising suspected anaphylaxis deaths with the Senior Coroner View source Lack of robust confirmation of allergen absence in ingredients and production View source Outdated pathology guidance for suspected anaphylaxis deaths View source Lack of a standard protocol for timely and appropriate sampling in suspected anaphylaxis deaths View source Failure to retain hospital blood samples in suspected anaphylaxis cases View source Failure to prioritise post-mortem examinations in suspected anaphylaxis deaths View source Failure to obtain and store an early post-death blood sample for later analysis View source See 9 more concerns
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Celia Lindsey MARSH · 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
Celia Lindsey Marsh died on 27 December 2017 after suffering fatal anaphylaxis caused by milk protein in a wrap she believed was safe to eat. The principal concerns included the investigation and retention of evidence in suspected anaphylaxis deaths, education for doctors and patients, systems for reporting anaphylaxis, and potentially misleading “dairy-free” and other allergen-labelling claims.
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. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Potentially unsafe exposure to undeclared allergens for people at significantly higher risk of fatal reactions
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group .
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Potentially misleading food-labelling wording and public understanding of allergen absence
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust system for capturing and recording anaphylaxis cases
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis , to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and preserve stomach contents and tissue samples at post-mortem examination
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate education for doctors and patients in anaphylaxis risk groups
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Delays in raising suspected anaphylaxis deaths with the Senior Coroner
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Lack of robust confirmation of allergen absence in ingredients and production
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim .
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Outdated pathology guidance for suspected anaphylaxis deaths
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old , the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Lack of a standard protocol for timely and appropriate sampling in suspected anaphylaxis deaths
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Failure to retain hospital blood samples in suspected anaphylaxis cases
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise post-mortem examinations in suspected anaphylaxis deaths
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and store an early post-death blood sample for later analysis
Wider context from the report “Concerns were raised in relation to the immediate investigation into a suspected death from anaphylaxis, that the evidence obtained at this time, with the right approach, can be invaluable to preventing deaths, but that to achieve this changes are required. This would need changes in the death investigation process and the wider investigation which would need assistance from the Food Standards Agency (FSA).
I was made aware that there needs to be better education both to doctors and to patients in risk groups to prevent future deaths
I was also advised that whereas the FSA would be required to assist with the above areas it could also assist in relation to the current practices of food labelling.
Firstly in relation to Pathology, I am told that the current guidance is 10 years old, the suggestion is for this to be revisited and specifically:
• If bloods are taken at hospital that they are not destroyed in a suspected case but retained for testing
• That an early blood sample is taken after death and stored for late analysis
• That the possibility that a death is due to anaphylaxis is raised with the Senior Coroner for the area where the death occurred at the earliest opportunity
• That an early blood sample is taken after death
• The post mortem examination should be prioritised.
• At the post mortem examination: that stomach contents are taken and frozen to enable testing and that tissue samples are taken
A standard protocol should be available to ensure appropriate samples are taken at the correct time to assist later investigation.
In relation to doctors/patients:
• To highlight, through public awareness and to the medical profession, that while the majority of food-allergic individuals are at very low risk of fatal reactions, a small subset of food-allergic individuals may be at significantly higher risk. These persons must be given appropriate advice as to the dangers of inadvertent exposure, since there may be no detectable safe level of allergen that can be present in a product for this group.
• To be aware that avoidance of foods in adults does not improve eczema and may result in more severe allergy to the food avoided particularly to cow’s milk but tolerance can be maintained by continued regular exposure.
In relation to the FSA, the UK Health Security Agency and the Department of Health and Social Care:
• To establish a robust system of capturing and recording cases of anaphylaxis, and specifically, fatal and near-fatal anaphylaxis, to provide an early warning of the risk posed to allergic individual by products with undeclared allergen content.
• Such a system could involve mandatory reporting of anaphylaxis presenting to hospitals, analogous to the current system used for notifiable diseases (including some food-borne illnesses) whereby registered medical practitioners have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team of suspected cases of certain infectious diseases. An example of such a reporting system for anaphylaxis already exists in the state of Victoria in Australia, and also allows for rapid alerts of serious cases to public health authorities to expedite investigation and evaluate the public health risk.
In relation to the FSA, the British Retail Consortium, Food and Drink Federation and British Hospitality:
• The wording used on food products, and the public’s understanding of these phrases in terms of implying the absence of a particular allergen, can be potentially misleading. Examples include: “free-from” and “vegan”. Foods labelled in this way must be free from that allergen, and there should be a robust system to confirm the absence of the relevant allergen in all ingredients and during production when making such a claim.
• With respect to those with the most severe food allergies, it may be necessary in the interim to clarify that foods labelled “free-from [X allergen]” may not be safe to consume.
In relation to the FSA:
• A hotline to the FSA to provide guidance in fatal cases due to suspected anaphylaxis, although a mandatory reporting system (suggested above) would address this need.
• Nationally recognised best practice and technical advice to assist those investigating such cases;
” Open source report
×
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 Developed and published guidance on manufacturing and labelling free-from products, with input from regulators and allergy charities.
Verbatim wording from the response “In the absence of more specific requirements, the BRC, jointly with the Food and Drink Federation (FDF), worked on a guidance document on how to manufacture and label ‘free-from’ products**. The Food Standards Agency and allergy charities were consulted during the development process of the document. The document is used by our members and is publicly available for other companies to use.” Source location Response from British Retail Consortium
Open published response
×
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 majority of allergic people can safely consume free-from products, so a universal warning could mislead consumers and restrict choices.
Verbatim wording from the response “Regarding the second recommendation - including a statement that ‘free-from’ products are not safe for all allergic consumers - we believe such an explanation should be given by practitioners and allergy clinicians, after patient diagnosis, when explaining and guiding allergic patients on how to manage their diets. The statement could have unintended consequences confusing customers and potentially contradicting what their medical teams have advised and limiting their food choices.” Source location Response from British Retail Consortium
Open published response
×
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 Practitioners and allergy clinicians should explain that free-from products are not safe for all allergic consumers after diagnosis.
Verbatim wording from the response “Regarding the second recommendation - including a statement that ‘free-from’ products are not safe for all allergic consumers - we believe such an explanation should be given by practitioners and allergy clinicians, after patient diagnosis, when explaining and guiding allergic patients on how to manage their diets. The statement could have unintended consequences confusing customers and potentially contradicting what their medical teams have advised and limiting their food choices.” Source location Response from British Retail Consortium
Open published response
×
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 Individual retail businesses, rather than the trade association, are responsible for decisions about product labels and associated policies.
Verbatim wording from the response “We support our members with their decision process on what appears on labels and associated policies, but it is their individual company responsibility to make the decision.” Source location Response from British Retail Consortium
Open published response
5 Nov 2014 Santosh Benjamin Muthiah · Prevention of Future Deaths report North London
View report summary
Concerns raised 10 Insufficient capacitor safety requirements to prevent hazards on failure View source Lack of requirements to isolate or protect refrigeration-appliance insulation from ignition View source Failure to identify appliance fire causes and appliance identifiers after fire damage View source Lack of second-hand market controls for recalled or safety-notice products View source Failure to routinely pass identified domestic appliance fire information to Trading Standards or manufacturers View source Underestimation of capacitor-related fire risk in Beko fridge-freezer risk assessment View source Inconsistent guidance on product risk notification and corrective action View source Lack of awareness of the safety notice for recalled Beko fridge-freezer models View source Inconsistent product safety risk assessments omitting or variably weighting serious injury factors View source Lack of requirements for less flammable or better-contained plastic materials in refrigeration appliances View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Santosh Benjamin Muthiah · 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
Santosh Benjamin Muthiah died after a fire spread through his home while he and his family were sleeping, with the medical cause recorded as cerebral anoxia due to inhalation of fire fumes. The report raised concerns about the identification and communication of appliance-fire information, risks from recalled and second-hand refrigeration appliances, product safety risk assessments, guidance and notification practices, and the construction and components of refrigeration appliances, including capacitors.
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. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Insufficient capacitor safety requirements to prevent hazards on failure
Wider context from the report “24. I heard evidence for the LFB witnesses, in particular ████████, who gave evidence about the serious concerns they hold about the ongoing risk posed by capacitor failures resulting in fires. These concerns are twofold, relating generally to capacitors and the industry standards and in relation to Beko appliances.
25. Paragraph 24.8 of British Standard BS EN 60335-1:2012 ‘Household and similar electrical appliances; Safety; Part 1 - General requirements.’ applies to the type of capacitors used in refrigeration appliances. It states that they shall not cause a hazard in the event of failure.
26. This requirement is considered to be met by one or more of the following conditions:
a. The capacitors are of a class of safety protection P2 according to IEC 60252-1;
b. The capacitor is housed within a metallic or ceramic enclosure that will prevent the emission of flame or molten material resulting from failure of the capacitor;
c. The distance of separation of the outer surface of the capacitor to adjacent non-metallic parts exceeds 50mm;
d. Adjacent non-metallic parts within 50 mm of the outer surface of the capacitor withstand the needle-flame test of Annex E;
e. Adjacent non-metallic parts within 50 mm of the outer surface of the capacitor are classified as at least V-1 according to IEC 60695-11-10, provided that the test sample used for the classification was no thicker than the relevant part of the appliance.
27. I accept and agree with the concern raised by the LFB that the above requirement does not ensure that capacitors do not pose a hazard . This creates a risk to the safety of consumers.
28. The LFB FIT has experience of failures of P2 capacitors and failures leading to ignition of metal casing capacitors (contrary to a. and b. above).
29. Further, it is clear that the mechanisms of failure of a capacitor can bypass the required 50mm distance (contrary to c. above). Furthermore, in the case of a refrigeration appliance, the base of the compressor compartment is often two metal bars used for mounting components, leaving the floor surface exposed (for example a flammable carpet).
30. The LFB believes that the requirements regarding capacitors referred to in paragraph 50 above (citing paragraph 24.8 British Standard BS EN 60335-1 : 2012) are not robust enough to prevent capacitors from presenting a hazard , which creates a risk to the safety of consumers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements to isolate or protect refrigeration-appliance insulation from ignition
Wider context from the report “20. I heard evidence from the LFB witnesses who gave evidence concerning the inherent risks that refrigeration appliances present due to their construction. The polyurethane insulation material used in most refrigeration appliances represents a high fuel load, is highly flammable and when on fire burns to create dangerous gases.
21. There is no legal requirement or industry standard that this insulation material is isolated from or protected from ignition by a failure in another component within the appliance , which represent a risk of ignition, such as the compressor, capacitor or ancillary components. This represents a serious risk to the safety of consumers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Failure to identify appliance fire causes and appliance identifiers after fire damage
Wider context from the report “1. I heard evidence from various witnesses, including the LFB but also from Beko and ████████ formerly of Intertek, that there are often problems in identifying, not just the specific cause of an appliance fire, but even the manufacturer, model and serial number of the appliance in question due to the severity of the fire damage . This has a knock on effect on Fire & Rescue Services’ (“FRS’s”), Trading Standards (“TS”) and manufacturers’ ability to accurately identify a pattern or trend within fires from appliances which may evidence a specific manufacturing or component problem.
2. This creates a risk that the nature and extent of a potential problem with a particular manufacturer or particular appliance is not fully known and therefore underestimated with the consequence that the risk to the lives of consumers may also be underestimated.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Lack of second-hand market controls for recalled or safety-notice products
Wider context from the report “8. I heard evidence from the LFB witnesses who gave some evidence that defective products on the second hand market pose a continuing risk to consumers.
9. There is no clear system in place to ensure that products subject to a safety notice or recall are not sold, unmodified, on the second hand market . By way of example, the LFB has recently identified several unmodified Beko fridge freezers which are subject to the safety notice, for sale in a second hand retailer. This lack of regulation or market surveillance of the second hand market poses a risk to consumers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely pass identified domestic appliance fire information to Trading Standards or manufacturers
Wider context from the report “6. This is not the case routinely elsewhere in the country. There may be a variety of reasons for this, including the difficulty in identifying the appliances due to fire damage, and the more limited resources and expertise in the investigation of the causes of fires that other FRS’s have in contrast to the fortunate position of the LFB.
7. Whatever the reasons there is a risk in existence where such information that is gathered by FRS’s in relation to fires involving domestic electrical appliances (where the appliance can be identified) is not routinely passed to the appropriate TS Home or Primary Authority or indeed to the manufacturer . TS is taking decisions on whether to take any action in relation to a particular manufacturer or a particular appliance on less than all the available information. If they were provided with more accurate information about the incidences of appliance fires they would be in a better position to take action where necessary.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Underestimation of capacitor-related fire risk in Beko fridge-freezer risk assessment
Wider context from the report “31. I heard evidence from LFB witnesses who gave evidence of their concerns that serious failures in Beko Frost Free Fridge Freezers (“FFFF’s”) manufactured between 2000 and 2006 are continuing resulting in a serious risk to the safety of consumers. ████████ gave evidence of the numbers of fires which the LFB FIT have investigated to date, the appliance models and the causes of the fires. The LFB have written to Beko concerning these fires and the risk the appliances represent. This concern relates in large part to capacitor failures.
32. Although it is right to say that there was some evidence that there may be an “industry wide problem” i.e. that this risk is not specific to Beko, this alone does not address the risk which exists in Beko products and nor have the LFB been concerned enough in relation to the risk presented by other manufacturer’s products to write to any of them.
33. The LFB were provided with a risk assessment from Beko dated 26 April 2012 which states that the risk is “low” such that no action is necessary or proposed. The LFB is concerned that this underestimates the risk to the safety of consumers , particularly as Beko witnesses’ own evidence seemed to highlight that they consider the capacitor as a potential ignition source in fires .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Inconsistent guidance on product risk notification and corrective action
Wider context from the report “16. I heard from Beko witnesses and also, in particular, ████████ that there are inconsistencies between the EU Commission Guidance and the UK Trade Association Guidance on corrective action and the requirement to notify an enforcement authority .
17. The AMDEA guidance says that if the outcome of the risk assessment is that there is a “moderate” risk, the manufacturer is not required to notify TS but the BIS guidance says that a “moderate” risk outcome requires notification to TS.
18. Manufacturers therefore are in difficulty in consistently applying guidance and in carrying out their notification obligations where there is the requisite level of risk to consumers.
19. I accept the LFB submissions that such inconsistency creates a risk that TS not being notified and therefore action not being taken in circumstances when it arguably should be highlighting a risk to consumers.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of the safety notice for recalled Beko fridge-freezer models
Wider context from the report “10. I heard evidence from the LFB witnesses of their concerns that serious failures in Beko Frost Free Fridge Freezers (“FFFF’s”) manufactured between 2000 and 2006 are continuing resulting in a serious risk to the safety of consumers. ████████ gave evidence of the numbers of fires which the LFB FIT have investigated to date, the appliance models and the causes of the fires.
11. The LFB submits that there remains a risk in relation to the lack of or minimal awareness of the current safety notice in relation to these Beko models .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Inconsistent product safety risk assessments omitting or variably weighting serious injury factors
Wider context from the report “12. I heard a great deal of evidence concerning the process of risk assessment and the factors to be taken into account when considering the potential seriousness of injury and the likelihood of a risk eventuating.
13. It is the view of the LFB that the following matters should always be taken in to account when carrying out a product safety risk assessment:
a. Sleeping risk – i.e. the fact that a person is more vulnerable to the risks of fire when asleep;
b. The most serious consequence of a product failure i.e. in the case of fire, serious injury or death;
c. The potential long term physical impact on persons who have suffered burns injuries;
d. The possible psychological impact on persons who have suffered the trauma of a fire.
14. It was clear from the evidence that there have been and continue to be different approaches to risk assessment adopted . The evidence from ████████ and the evidence from the face of the Arcelik and Intertek Risk Assessments (in documentary form) made at the material times over a period of a number of years show that some of these factors are not taken into account and some may be taken into account to a variable degree .
15. Failing to take these factors into account expressly creates a risk that the seriousness of injury, and consequently, potentially the seriousness of the overall risk is underestimated .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Retail Consortium; that does not assign responsibility.
PFD Monitor interpretation Lack of requirements for less flammable or better-contained plastic materials in refrigeration appliances
Wider context from the report “23. The plastic materials which are used for filling, strengthening and insulating refrigeration appliances are highly flammable and increase the fuel load of these appliances posing a continuing risk to consumers . It is possible to use alternate, non-flammable or less flammable materials. It is also possible to better contain such combustible components or insulation. There is no such requirement at present which creates a risk to the safety of consumers .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations