4 Jan 2022 Sylvia Frances PRICE · Prevention of Future Deaths report Suffolk
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Concerns raised 1 Lack of an enforceable requirement for appropriate signage identifying accessible toilet facilities in public access buildings View source
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.
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AI-generated summary
Sylvia Frances PRICE · 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
Sylvia Frances Price died after falling down stairs while using toilet facilities at Ufford Park Hotel and Spa, sustaining cerebral haemorrhages and spinal injuries. She later developed aspiration pneumonia while being treated in hospital, which was recorded as the medical cause of death. The report identified inadequate signage for an accessible toilet as a contributing factor and expressed concern that similar deaths could occur because such signage was not required or enforceable.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of an enforceable requirement for appropriate signage identifying accessible toilet facilities in public access buildings
Wider context from the report “Evidence was heard that Sylvia had underlying medical issues that required an easily accessible toilet facility.
The jury concluded that the lack of appropriate signage, to readily identify an easily accessible toilet facility , was a directly contributory factor leading to Sylvia’s death.
The Local Authority Food and Safety Officer who investigated this case identified no other contributing factors, with the stairs themselves meeting building and safety regulations.
The officers report contained only one recommendation for the premises owner, which was the provision of more adequate signage.
However, the officer stated in evidence that there was no statutory power to enforce the provision of such signage , and should a premises owner wish to ignore such a recommendation, they could (it is acknowledged that the premise owner in this case has put new signage in place). In addition, current building regulations do not require any such signage to be fitted into new buildings .
The court was informed that the provision of accessible toilet facilities is now a legal requirement for the majority of buildings designed for public use, but as detailed above there is no requirement for these facilities to be clearly identified with appropriate signage .
As a failure to provide adequate signage was found to be a contributing factor in this case, and there is no enforceable requirement that such signage should be provided , I am concerned further deaths may occur in other public access buildings, should similar circumstances arise in the future.
” Open source report
14 Apr 2021 Richard John Dyson and Simon Brian Midgley · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 2 Failure to ensure that the guest list is taken or remains available during evacuation View source Lack of readily accessible and accurate establishment occupant lists for emergency services View source
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.
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AI-generated summary
Richard John Dyson and Simon Brian Midgley · 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
Richard John Dyson and Simon Brian Midgley were guests at the Cameron House Hotel when a fire broke out on 18 December 2017. They were found unresponsive by firefighters and pronounced dead later that morning; the inquest concluded that both were unlawfully killed as a result of inhalation of smoke and fire gases and the hotel fire. The principal concerns were the lack of a readily accessible and accurate guest list and the resulting delay in identifying that the two men were missing, which impeded rescue efforts.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that the guest list is taken or remains available during evacuation
Wider context from the report “(1) Every hotel should have a readily accessible and accurate list of the guests and staff members in the establishment on a particular night. In an emergency situation it is imperative that the Fire and Rescue Service are provided with accurate information speedily in case anyone remains trapped in the building. It is a situation where every second counts.
(2) It is foreseeable that in the stressful atmosphere of an emergency, people may hesitate or make mistakes. In this case, forgetting to take the guest list as the building was evacuated . In consequence, although the Fire and Rescue Service had arrived at the hotel by 6.51 am, it was not until sometime after 8am that it was established two guests were missing . Critical time was lost before rescue efforts began to find them . The precise times cannot be provided as the Procurator Fiscal was not willing to disclose copies of witness statements or reports on the ground they were confidential.
(3) To avoid needless impediments to rescue efforts, it would be prudent for hotels to have an electronic system such as SharePoint which would enable the emergency services to gain prompt access to such vital information.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of readily accessible and accurate establishment occupant lists for emergency services
Wider context from the report “(1) Every hotel should have a readily accessible and accurate list of the guests and staff members in the establishment on a particular night . In an emergency situation it is imperative that the Fire and Rescue Service are provided with accurate information speedily in case anyone remains trapped in the building. It is a situation where every second counts.
(2) It is foreseeable that in the stressful atmosphere of an emergency, people may hesitate or make mistakes. In this case, forgetting to take the guest list as the building was evacuated. In consequence, although the Fire and Rescue Service had arrived at the hotel by 6.51 am, it was not until sometime after 8am that it was established two guests were missing. Critical time was lost before rescue efforts began to find them. The precise times cannot be provided as the Procurator Fiscal was not willing to disclose copies of witness statements or reports on the ground they were confidential.
(3) To avoid needless impediments to rescue efforts, it would be prudent for hotels to have an electronic system such as SharePoint which would enable the emergency services to gain prompt access to such vital information.
” Open source report
Concerns raised 2 Lack of a national or central database for gas appliance manufacture, supply and fitting details View source Lack of mandatory recording of gas appliance manufacture, supply and fitting View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Kevin David John BRANTON and 4 others · 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
Five people died in two separate incidents involving defective gas cookers that produced fatal levels of carbon monoxide when the grill was used with the door closed. The concerns were the absence of a central database and mandatory recording system for gas appliances, making it difficult and time-consuming to identify and trace potentially dangerous appliances and hindering communication across the supply and fitting chain.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of a national or central database for gas appliance manufacture, supply and fitting details
Wider context from the report “(1) That there is no national or central database which contains details of gas appliances manufactured, supplied or fitted to homes in the UK which would allow rapid identification and tracing of potentially dangerous items .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory recording of gas appliance manufacture, supply and fitting
Wider context from the report “(2) That communication between manufacturers, suppliers, wholesalers, fitters and householders in connection with the supply etc of gas appliances is hindered by the lack of mandatory recording of the said manufacture, supply and fitting of such appliances .
(3) That the lack of a mandatory scheme for recording the supply etc of such items means that it is difficult and time consuming to trace potentially dangerous items when urgency is of the utmost importance .
” 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 Commission research on consumer engagement with product safety and product registration to support corrective actions and recalls.
Verbatim wording from the response “OPSS has also developed a Strategic Research Programme to commission and assure high quality strategic science-based research to strengthen the evidence base for enforcement. In particular, OPSS has commissioned research to understand how consumers engage with the safety of the products they purchase and into how to encourage greater registration of products to facilitate corrective actions and recalls. I have asked OPSS to specifically to assess whether there is more we can do to research consumer behaviour in relation to safety in the gas appliance sector.” Source location 2020-0274-Response-from-MP-BEIS-Redacted
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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 Publish an Incident Management Plan and establish a national Product Safety Database for managing and sharing unsafe-product information.
Verbatim wording from the response “In 2018 the Government created the Office for Product Safety and Standards (OPSS) as a new national regulator for product safety. Since then, OPSS has taken significant steps to ensure the UK product safety system is one of the most robust in the world. This has included creating a new national capacity including technical and scientific advisors and experts in intelligence, enforcement and product recalls and publication of an Incident Management Plan and a new national Product Safety Database.” Source location 2020-0274-Response-from-MP-BEIS-Redacted
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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, retailers, consumer groups and government bodies to consider rapid communication options for locating potentially dangerous appliances.
Verbatim wording from the response “In response to your report, I have asked OPSS officials to engage with manufacturers, retailers and consumer groups, and relevant bodies in Government to consider the concerns you have raised, including the options for effective and rapid communication between manufacturers, suppliers and owners to locate potentially dangerous appliances, should a design fault be identified. I have asked them to discuss your report, subject to your agreement, with members of the Cross-Government Working Group on Gas Safety and Carbon Monoxide in order to develop an action plan to address your concerns. To inform these considerations, I have asked OPSS to draw on an analysis of the gas appliances market, assess consumer trends towards purchase and advise on whether further areas of research are needed to help identify and change consumer behaviour towards greater gas safety.” Source location 2020-0274-Response-from-MP-BEIS-Redacted
Open published response
22 Nov 2018 Savannah-Rose Michelle Owen · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Lack of specific safety regulation for multi-purpose nursing pillows View source Misleading warning leaflet imagery about leaving babies unattended on multi-purpose nursing pillows View source Failure to keep safety warnings attached to multi-purpose nursing pillows through resale or recycling View source Lack of assurance that health visitors and midwives flag the risks of babies being propped on multi-use pillows for naps View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Savannah-Rose Michelle Owen · 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
Savannah-Rose Michelle Owen was a healthy baby born on 16 February 2018 who fell asleep on a nursing pillow on a sofa at home on 22 April 2018 and later became unresponsive. Resuscitation attempts were unsuccessful, and the post-mortem found no cause of death, with the death recorded as due to natural causes. Concerns included the lack of specific safety regulation for multi-purpose nursing pillows, potentially misleading imagery and warnings, the warning label not being attached to the pillow, and uncertainty about whether community health professionals were highlighting the risks of unsupervised sleeping on such pillows.
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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. The report was sent to Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of specific safety regulation for multi-purpose nursing pillows
Wider context from the report “1. Unlike many items associated with babies/young children such as high chairs/cots there was no specific safety regulation for such items . Instead manufacturers had to interpret the all-embracing safety policy. This risked inconsistent safety warnings/labelling ;
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Misleading warning leaflet imagery about leaving babies unattended on multi-purpose nursing pillows
Wider context from the report “3. On the warning/information leaflet were 5 pictures of a baby positioned on the pillow. In only 2 images was the baby with an adult. On the other 3 the baby was alone. The inquest was told that this could be misleading as to the importance of never leaving a baby unattended on the pillow ; and
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to keep safety warnings attached to multi-purpose nursing pillows through resale or recycling
Wider context from the report “4. The warning label was not attached to the item therefore; once the package had been opened, there was a high risk that the warning label would be lost . On resale/recycling of baby items this meant that second hand users/purchasers were unlikely to see the warning .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of assurance that health visitors and midwives flag the risks of babies being propped on multi-use pillows for naps
Wider context from the report “2. It was unclear if Health Visitors/ Midwives in the community seeing multi-use pillows being used were flagging up the risks of allowing babies to be propped on them for naps and that their use in such a way was wholly inconsistent with safe sleeping advice ;
” 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 Refer concerns about the nursing pillow to the Office for Product Safety and Standards’ Product Safety Enforcement Team.
Verbatim wording from the response “I have passed your concerns regarding the nursing pillow on to OPSS’s Product Safety Enforcement Team but in order to investigate further they have asked that any details you have of the specific product involved, including information about the distributor be shared with them. If you have any further information that would assist their assessment, I would be grateful if you could pass it directly to Graham Russell, Chief Executive, OPSS, Victoria Square House, Birmingham B2 4AJ. This would allow OPSS to work with Local Authority Trading Standards to determine whether further action is needed, based on all the evidence available.” Source location 2018-0367-Response-by-Department-for-Business-Energy-Industrial-Strategy
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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 Nursing pillows are already regulated under the General Product Safety Regulations 2005, requiring safety in normal or reasonably foreseeable use.
Verbatim wording from the response “You raise the concern that there are no specific safety regulations for nursing pillows. The safety of nursing pillows, along with many other products, is regulated by the General Product Safety Regulations 2005 (GPSR). Under the GPSR, products are required to be safe in normal or reasonably foreseeable use when placed on the market.” Source location 2018-0367-Response-by-Department-for-Business-Energy-Industrial-Strategy
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 OPSS and local authority Trading Standards are responsible for determining and taking any further enforcement action on the nursing pillow.
Verbatim wording from the response “Both the Office for Product Safety (OPSS) and Local authority Trading Standards have powers to act where unsafe products are identified including, requiring changes to safety information and instructions for use and, where appropriate, issuing a recall of the product.” Source location 2018-0367-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
28 Sep 2018 Donald Berry · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure of relevant authorities to identify high voltage power lines over event sites View source Lack of nationally replicated site visits for large events View source Failure to identify high voltage power lines over event sites View source Failure to minimise risks from high voltage power lines over event sites View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Donald Berry · 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
Donald Berry suffered severe injuries after being electrocuted while working at the Kendal Calling Festival on 22 July 2010, and died from ongoing health complications on 23 August 2016. The inquest heard concerns that a clearly visible high-voltage power line over the site had not been identified or addressed, despite an Event Safety Plan and the licensing process. It also heard that the issue had not been noted by any of the authorities involved and that site-visit arrangements were not replicated nationally.
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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. The report was sent to Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure of relevant authorities to identify high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue . Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of nationally replicated site visits for large events
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to identify high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to minimise risks from high voltage power lines over event sites
Wider context from the report “1. The inquest heard that the organisers of the event Kendal Calling had not identified that a clearly visible high voltage power line was running over the site and no steps had been taken to minimise the risk although an Event Safety Plan had been submitted to the licensing authority.
2. the inquest heard that the lack of identification of such a significant risk and need to take steps had been missed despite all the steps required by law to licensing such an event had taken place and an indication that the guidance in the Purple Book had been adhered to by the organisers . None of the authorities involved had noted the issue. Eden District Council (EDC)had now taken steps to do site visits for similar events within their area but this was not replicated nationally and was only done within EDC’s area for large events such as this.
” Open source report
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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 Responsibility for health and safety risks at work rests with the Health and Safety Executive.
Verbatim wording from the response “I note that in your report you identify that the organisers of the event did not properly consider the health and safety risk of high voltage electrical installation at the place of the event. This is not an issue relating to the safety of an electrical appliance, which would fall within my Department’s remit. As this is a health and safety at work issue, it falls within the remit of the Health and Safety Executive (HSE), who are sponsored by the Department for Work and Pensions. I note you have sent this notice to the Acting Chief Executive of the HSE. My officials have contacted the Principal Inspector at the Health and Safety Executive (HSE) to inform him of your letter.” Source location 2018-0324-Response-by-Department-for-Business-Energy-Industrial-Strategy
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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 Health and safety risks from high-voltage electrical installations fall outside the department’s product-safety remit.
Verbatim wording from the response “I note that in your report you identify that the organisers of the event did not properly consider the health and safety risk of high voltage electrical installation at the place of the event. This is not an issue relating to the safety of an electrical appliance, which would fall within my Department’s remit. As this is a health and safety at work issue, it falls within the remit of the Health and Safety Executive (HSE), who are sponsored by the Department for Work and Pensions. I note you have sent this notice to the Acting Chief Executive of the HSE. My officials have contacted the Principal Inspector at the Health and Safety Executive (HSE) to inform him of your letter.” Source location 2018-0324-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
7 Mar 2018 Venkata Naga Lakshyasi KAGGA · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 11 Lack of national reinforcement of paediatric assessment for young children View source Lack of understanding of button-battery risks among people responsible for small children View source Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service View source Failure to sustain and nationally reinforce the button-battery safety alert View source Failure to follow the policy for children under 5 View source Failure to complete or fully document child assessments View source Lack of POAU audit systems for detecting noncompliance View source Lack of understanding of the risks of subjective assessments in young children View source Failure to follow the POAU system View source Failure to value-check subjective assessments in young children View source Lack of child-resistant safety features for button batteries in commonly used household devices View source See 8 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.
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AI-generated summary
Venkata Naga Lakshyasi KAGGA · 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
Venkata Naga Lakshyasi KAGGA died on 9 July 2017 after a button battery lodged in her oesophagus and caused an oesophageal arterial fistula. Before her death, she was seen by doctors and ambulance staff, but the battery was not identified. Concerns included failures to examine and assess her, non-compliance with ambulance policy for children under five, inadequate information sharing, and limited understanding of the risks posed by button batteries.
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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. The report was sent to Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of national reinforcement of paediatric assessment for young children
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of button-battery risks among people responsible for small children
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure of NHS information-sharing systems to share detailed illness histories beyond the OOH GP service
Wider context from the report “7. The 111 service obtained detailed accounts of the history of illness. However systems for sharing information across the NHS are such that this information was not shared beyond the OOH GP service .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to sustain and nationally reinforce the button-battery safety alert
Wider context from the report “2. NHS England issued a safety alert across the NHS in December 2014 relating to button batteries. During the inquest it was clear that the impact of that alert had lessened over time across the Trusts involved . The Trusts involved in the inquest had taken steps to highlight and reinforce the safety alert amongst their workforce but no such national work had taken place .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy for children under 5
Wider context from the report “3. NWAS had a policy in place in relation to children under 5 that was not followed. Work had been carried out within NWAS subsequent to the death to reinforce the importance of young children been seen by paediatricians. Similar work had not occurred nationally.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to complete or fully document child assessments
Wider context from the report “5. The importance of carrying out a full assessment of a child or documenting fully why it was not carried out on 6ᵗʰ July was not recognised by the medical staff involved .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of POAU audit systems for detecting noncompliance
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the risks of subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata. The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the POAU system
Wider context from the report “4. The Hospital’s POAU did not follow their system on 6th July and the Doctor on 6ᵗʰ July did not undertake an examination. This was not picked up by the Trust until an internal investigation post death. There was not at the time an audit system in place to ensure that systems in the POAU were being complied with. It is unclear if other POAUs will have audit systems to allow them to pick up on noncompliance with a recognised system.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to value-check subjective assessments in young children
Wider context from the report “6. NWAS staff partly based decision making on 9ᵗʰ July on subjective assessment, which was not value checked with those who knew Venkata . The risks around subjective assessments particularly with young children with no basis on which to make a value comparison did not appear to be fully understood.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of child-resistant safety features for button batteries in commonly used household devices
Wider context from the report “1. The button battery was likely to have come from a remote control. Button batteries once ingested can lead to catastrophic consequences for a child. They are used with increasing frequency in every day household devices which are often easily accessible by children. The remote control had no safety feature to prevent a child having easy access to the battery without the parents knowledge. Risks of button batteries to small children are not widely understood. Whilst there are precautions in place for children’s toys similar precautions are not in place for commonly used household devices, which can easily be accessed by small children.
” Open source report
7 Mar 2018 Mrs Elizabeth Marion Griffin · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 13 Failure to provide accessible appliance registration for people with limited computer literacy View source Delays in launching appliance repair or withdrawal campaigns View source Failure to make linked fire alarms a contractual requirement for telecare clients View source Failure to escalate fire-alarm activations to the fire brigade within 30 seconds View source Artificially differentiated fire-safety treatment of watch-only and wider telecare clients View source Failure to visibly flag unlinked fire alarms in client records View source Unlinked household fire alarms in telecare users' homes View source Failure to identify and replace unlinked fire alarms in a timely and auditable manner View source Lack of working relationships with local fire brigades to facilitate client home fire-risk assessments View source Inadequate staff training on standards-compliant fire-alarm response View source Failure to train staff to recognise and escalate linked and unlinked fire-alarm sounds View source Lack of a central appliance-owner registration and contact mechanism View source Failure of telecare systems to maintain communication throughout clients' properties View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Elizabeth Marion Griffin · 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
Mrs Elizabeth Marion Griffin, who was wheelchair bound due to advanced multiple sclerosis, was alone at home in bed when a dishwasher fire started on 14 July 2017. She activated her pendant alarm, but the responder did not recognise the smoke alarm, could not communicate effectively with her, and did not call the fire brigade; Mrs Griffin later died in hospital on 21 August 2017 from smoke inhalation injuries and bronchopneumonia. The concerns included delayed action by the dishwasher manufacturer, lack of appliance-owner registration and contact, and shortcomings in telecare arrangements, including unlinked fire alarms, responder training, communication, and escalation procedures.
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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accessible appliance registration for people with limited computer literacy
Wider context from the report “3. That any such campaign be also targeted at those who are less computer literate and consideration be given as to how to address their needs in relation to registration .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Delays in launching appliance repair or withdrawal campaigns
Wider context from the report “1. That it simply took too long for Whirlpool UK to launch the repair/withdrawal campaign .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to make linked fire alarms a contractual requirement for telecare clients
Wider context from the report “8. That telecare systems providers and WWA in particular, insist that their clients, who by definition are vulnerable, have linked fire alarms as a contractual requirement for both new and existing clients in the same way that such providers insist on the provision to them by the client of keys to the clients’ homes.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate fire-alarm activations to the fire brigade within 30 seconds
Wider context from the report “7. That telecare system operators and WWA in particular, apply the British Standards Institute requirement to call for the help of the fire brigade after 30 seconds maximum of trying to contact a client if the client’s fire alarm goes off .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Artificially differentiated fire-safety treatment of watch-only and wider telecare clients
Wider context from the report “4. That there is an artificial distinction between service users and clients who are “watch” only services, and those with wider telecare support . Either type of client would be vulnerable to fire .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to visibly flag unlinked fire alarms in client records
Wider context from the report “12. That telecare systems providers and WWA in particular, highlight on the front screen of the client details, if that client has an unlinked fire alarm , until such a time as the unlinked alarm is replaced by a linked one, so as to alert call responders that sounds heard in the back ground or call may represent an activated fire alarm and thus the fire brigade may need to be called to the client’s home by the call responder.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Unlinked household fire alarms in telecare users' homes
Wider context from the report “5. That users of telecare systems have the fire alarms in their homes directly linked to the telecare systems .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and replace unlinked fire alarms in a timely and auditable manner
Wider context from the report “9. That telecare systems providers and WWA in particular, take active steps to identify clients without linked fire alarms and arrange for them to be replaced with linked fire alarms and that this should be done in a timely and auditable fashion .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of working relationships with local fire brigades to facilitate client home fire-risk assessments
Wider context from the report “13. That telecare systems providers and WWA in particular, develop working relationships with their local fire brigades to facilitate fire risk assessments visits to the homes of the clients by the fire brigade being offered to telecare clients and accepted by them.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training on standards-compliant fire-alarm response
Wider context from the report “10. That telecare systems providers and WWA in particular, train their staff on the appropriate response to the activation of a fire alarm and that this should be according to the standards laid down by the British Standards Institute .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to train staff to recognise and escalate linked and unlinked fire-alarm sounds
Wider context from the report “11. That telecare systems providers and WWA in particular, train their staff as to what fire alarm activation sounds like whether from a linked or unlinked alarm and that they should call the fire brigade appropriately if they are heard by the responder to be activated .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of a central appliance-owner registration and contact mechanism
Wider context from the report “2. That there should be a safety campaign encouraging owners of appliances to register their details through a central portal such as AMBIA so that if concerns about an appliance arise they may be promptly contacted .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure of telecare systems to maintain communication throughout clients' properties
Wider context from the report “6. That telecare systems be organised such that a client operating a pendant alarm can talk with the responder no matter where the client is within their property such as to allow a client with mobility problems to be in proper communication with their telecare system operator at all times .
” 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 Improve businesses’ product-recall processes through Office-led work.
Verbatim wording from the response “The Office for Product Safety and Standards is leading work to improve businesses product recall processes. My Department commissioned the British Standards Institution (BSI) to create a new Code of Practice on product recalls (PAS 7100 Code of practice on consumer product safety related recalls and other corrective action). This was launched on 7 March. It guides businesses and regulators through the process of planning for and handling a product safety incident for non-food consumer products. The Code of Practice also sets out for Local Authorities the guidance and advice they should be making available to enable businesses to meet their legal responsibilities and act in the public interest.” Source location 2018-0072-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
×
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 Advise consumers to register new and second-hand electrical appliances through the recalls website for direct recall notifications.
Verbatim wording from the response “In October 2016 the Government set up a new central recalls website to provide consumers with information on recalls of all electrical goods and other products. The recalls website was upgraded in June 2017 and provides a single portal for access to information about current product recalls, drawing on UK and international recall information. It provides a centralised up to date source of trusted advice and information that users can interact with. Government also advises consumers to register their electrical appliances, whether new or second-hand, with the manufacturer via the recalls website, so they can be informed directly by the manufacturer should a recall or other corrective action subsequently be required. Future upgrades to the website expected by 2019 will involve the building of an extensive data hub of all corrective action and recall programmes affecting consumer products.” Source location 2018-0072-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
×
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 Publish and implement the PAS 7100 Code of Practice for consumer product-safety recalls and corrective action.
Verbatim wording from the response “The Office for Product Safety and Standards is leading work to improve businesses product recall processes. My Department commissioned the British Standards Institution (BSI) to create a new Code of Practice on product recalls (PAS 7100 Code of practice on consumer product safety related recalls and other corrective action). This was launched on 7 March. It guides businesses and regulators through the process of planning for and handling a product safety incident for non-food consumer products. The Code of Practice also sets out for Local Authorities the guidance and advice they should be making available to enable businesses to meet their legal responsibilities and act in the public interest.” Source location 2018-0072-Response-by-Department-for-Business-Energy-Industrial-Strategy
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 Manufacturers are responsible for ensuring product safety and taking corrective action when safety issues are identified.
Verbatim wording from the response “As you know, the dishwasher that started the fire that caused Mrs Griffin’s death was a model that was subject to a corrective action programme as it had been identified as representing a safety risk. The manufacturer is responsible for ensuring the safety of their product and for taking corrective action when safety issues are identified. Sadly, in this case, Mrs Griffin’s dishwasher was not identified by Whirlpool and had not been repaired or replaced.” Source location 2018-0072-Response-by-Department-for-Business-Energy-Industrial-Strategy
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 product-recall Code of Practice provides methods for reaching consumers without online access, addressing accessibility concerns.
Verbatim wording from the response “The Office for Product Safety and Standards is leading work to improve businesses product recall processes. My Department commissioned the British Standards Institution (BSI) to create a new Code of Practice on product recalls (PAS 7100 Code of practice on consumer product safety related recalls and other corrective action). This was launched on 7 March. It guides businesses and regulators through the process of planning for and handling a product safety incident for non-food consumer products. The Code of Practice also sets out for Local Authorities the guidance and advice they should be making available to enable businesses to meet their legal responsibilities and act in the public interest.” Source location 2018-0072-Response-by-Department-for-Business-Energy-Industrial-Strategy
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 central recalls website provides a single source of recall information and enables consumers to register appliances for direct notifications.
Verbatim wording from the response “In October 2016 the Government set up a new central recalls website to provide consumers with information on recalls of all electrical goods and other products. The recalls website was upgraded in June 2017 and provides a single portal for access to information about current product recalls, drawing on UK and international recall information. It provides a centralised up to date source of trusted advice and information that users can interact with. Government also advises consumers to register their electrical appliances, whether new or second-hand, with the manufacturer via the recalls website, so they can be informed directly by the manufacturer should a recall or other corrective action subsequently be required. Future upgrades to the website expected by 2019 will involve the building of an extensive data hub of all corrective action and recall programmes affecting consumer products.” Source location 2018-0072-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
11 Sep 2017 BRIAN DAVID BETTERTON · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 4 Lack of purchaser records for products purchased and fitted by professional electricians View source Failure of product recalls to reach end users when products are purchased or fitted by third parties View source Potentially lethal products fitted in domestic properties after purchase by a third party rather than the occupier View source Failure to require purchasers to provide suppliers or manufacturers with end-user details View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
BRIAN DAVID BETTERTON · 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
On 20 February 2017, a short-circuiting Electrium Miniature Circuit Breaker caused a small smouldering fire at Brian David Betterton’s home, releasing carbon monoxide. He died in his bedroom from carbon monoxide exposure. The report raised concerns that the product recall did not reach the deceased and was dependent on identifying purchasers, who were often professional electricians not required to keep records or notify suppliers of end users.
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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of purchaser records for products purchased and fitted by professional electricians
Wider context from the report “1. The Product Recall relates to a product supplied between April 2009 and February 2010.
2. The Product Recall did not come to the attention of the deceased.
3. In the majority of cases the end user of the product will not have purchased or fitted the product.
4. The Product Recall therefore is dependent upon identifying the person who actually purchased the product.
5. The purchaser is likely to be a professional electrician, yet is not required to keep a register of such items that he/she purchased and fitted nor is he/she required to inform the supplier/manufacturer of the details of the end user.
6. As a consequence it seems that the Product Recall was always likely to be ineffective. (It would be interesting to know how many products the manufacturer thought were affected and how many responses they had to the Product Recall Notice).
7. It seems to me that these concerns are not unique to fuse boxes, but that there are many potentially lethal products which are fitted into domestic properties which are purchased by a third party rather than the occupier.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure of product recalls to reach end users when products are purchased or fitted by third parties
Wider context from the report “1. The Product Recall relates to a product supplied between April 2009 and February 2010.
2. The Product Recall did not come to the attention of the deceased.
3. In the majority of cases the end user of the product will not have purchased or fitted the product.
4. The Product Recall therefore is dependent upon identifying the person who actually purchased the product.
5. The purchaser is likely to be a professional electrician, yet is not required to keep a register of such items that he/she purchased and fitted nor is he/she required to inform the supplier/manufacturer of the details of the end user.
6. As a consequence it seems that the Product Recall was always likely to be ineffective. (It would be interesting to know how many products the manufacturer thought were affected and how many responses they had to the Product Recall Notice).
7. It seems to me that these concerns are not unique to fuse boxes, but that there are many potentially lethal products which are fitted into domestic properties which are purchased by a third party rather than the occupier.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Potentially lethal products fitted in domestic properties after purchase by a third party rather than the occupier
Wider context from the report “1. The Product Recall relates to a product supplied between April 2009 and February 2010.
2. The Product Recall did not come to the attention of the deceased.
3. In the majority of cases the end user of the product will not have purchased or fitted the product.
4. The Product Recall therefore is dependent upon identifying the person who actually purchased the product.
5. The purchaser is likely to be a professional electrician, yet is not required to keep a register of such items that he/she purchased and fitted nor is he/she required to inform the supplier/manufacturer of the details of the end user.
6. As a consequence it seems that the Product Recall was always likely to be ineffective. (It would be interesting to know how many products the manufacturer thought were affected and how many responses they had to the Product Recall Notice).
7. It seems to me that these concerns are not unique to fuse boxes, but that there are many potentially lethal products which are fitted into domestic properties which are purchased by a third party rather than the occupier.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to require purchasers to provide suppliers or manufacturers with end-user details
Wider context from the report “1. The Product Recall relates to a product supplied between April 2009 and February 2010.
2. The Product Recall did not come to the attention of the deceased.
3. In the majority of cases the end user of the product will not have purchased or fitted the product.
4. The Product Recall therefore is dependent upon identifying the person who actually purchased the product.
5. The purchaser is likely to be a professional electrician, yet is not required to keep a register of such items that he/she purchased and fitted nor is he/she required to inform the supplier/manufacturer of the details of the end user.
6. As a consequence it seems that the Product Recall was always likely to be ineffective. (It would be interesting to know how many products the manufacturer thought were affected and how many responses they had to the Product Recall Notice).
7. It seems to me that these concerns are not unique to fuse boxes, but that there are many potentially lethal products which are fitted into domestic properties which are purchased by a third party rather than the occupier.
” 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 Establish a product recalls and safety working group to identify improvements to recalls and product safety.
Verbatim wording from the response “I recognise that the public needs to be reassured that the system for consumer product safety is working and that where unsafe electrical goods are identified they are dealt with swiftly and effectively. Product safety is a priority of this Government and we already have comprehensive legislative regulation to ensure products are safe before being placed on the market. In addition, in October 2016 I set up the Working Group on Product Recalls and Safety to bring together product safety experts, the fire service and trading standards professionals to identify where improvements could be made to the system of product recalls and safety.” Source location 2017-0224-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
×
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 Support development of a BSI code of practice on corrective action and product recalls.
Verbatim wording from the response “The Working Group published its recommendation on how to improve recalls and reduce fires in white goods on 19 July. The Government will be responding shortly but we have already taken action to implement many of the Working Group’s recommendations. We have supported the development of a new BSI (the British Standards Institution) code of practice on corrective action and recalls which was recently the subject of public consultation. We have also commissioned research to understand how to increase the impact and effectiveness of product safety messages, so that more consumers respond to recalls.” Source location 2017-0224-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
×
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 Respond to the Working Group’s recommendations on improving recalls and reducing white-goods fires.
Verbatim wording from the response “The Working Group published its recommendation on how to improve recalls and reduce fires in white goods on 19 July. The Government will be responding shortly but we have already taken action to implement many of the Working Group’s recommendations. We have supported the development of a new BSI (the British Standards Institution) code of practice on corrective action and recalls which was recently the subject of public consultation. We have also commissioned research to understand how to increase the impact and effectiveness of product safety messages, so that more consumers respond to recalls.” Source location 2017-0224-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
×
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 Upgrade the Government recalls website to provide current recall information and enable direct contact about future appliance recalls.
Verbatim wording from the response “The Government’s recalls website at www.productrecall.campaign.gov.uk has been further upgraded so that consumers can quickly check for the latest recalls and register their appliances to allow them to be contacted directly about any future recalls of their products.” Source location 2017-0224-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
×
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 Commission research into increasing the impact and effectiveness of product safety messages and recall responses.
Verbatim wording from the response “The Working Group published its recommendation on how to improve recalls and reduce fires in white goods on 19 July. The Government will be responding shortly but we have already taken action to implement many of the Working Group’s recommendations. We have supported the development of a new BSI (the British Standards Institution) code of practice on corrective action and recalls which was recently the subject of public consultation. We have also commissioned research to understand how to increase the impact and effectiveness of product safety messages, so that more consumers respond to recalls.” Source location 2017-0224-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
×
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 Take action to implement recommendations from the Working Group on Product Recalls and Safety.
Verbatim wording from the response “The Working Group published its recommendation on how to improve recalls and reduce fires in white goods on 19 July. The Government will be responding shortly but we have already taken action to implement many of the Working Group’s recommendations. We have supported the development of a new BSI (the British Standards Institution) code of practice on corrective action and recalls which was recently the subject of public consultation. We have also commissioned research to understand how to increase the impact and effectiveness of product safety messages, so that more consumers respond to recalls.” Source location 2017-0224-Response-by-Department-for-Business-Energy-Industrial-Strategy
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 Building Regulations matters are the responsibility of the Department for Communities and Local Government, which is conducting a review.
Verbatim wording from the response “These changes, while aimed at consumers, will also make it easier for tradespeople to check for any safety recalls of products they are installing. I have fed the important points that you raise into the development of the BSI code of practice and I have also asked my officials to share your concerns with colleagues in the Department for Communities and Local” Source location 2017-0224-Response-by-Department-for-Business-Energy-Industrial-Strategy
Open published response
16 Aug 2017 Isabella Pritchard · Prevention of Future Deaths report Berkshire
View report summary
Concerns raised 5 Lack of regulatory oversight of stone fireplace manufacture View source Failure to regulate and control fireplace installation View source Lack of regulatory oversight of stone fireplace installation View source Inadequate specificity of fireplace installation instructions View source Lack of quality and safety standards for fireplaces View source See 2 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
Isabella Pritchard · 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
Isabella Pritchard, aged six, died from catastrophic head injuries after a marble mantelpiece in her home fell and struck her. The report raised concerns that fireplaces and their installation were unregulated, with no applicable quality or safety standard and potential dangers arising from design and inadequate fixing.
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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of stone fireplace manufacture
Wider context from the report “(1) It appears to me that both the manufacturer and installation of stone fireplaces are an unregulated industry .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to regulate and control fireplace installation
Wider context from the report “(3) I understand that there is no regulation or building control around the installation of fireplaces . I believe building regulations do not cover this area as they are deemed to be a decorative item. While I understand that the NHBC now mandatorily require the use of mechanical fixings, this does not cover every instance. Also, that the Stone Federation issued guidelines but are guidelines only. Further, they are a non-regulatory trade body where membership is optional and adherence to their guidelines is entirely voluntary .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory oversight of stone fireplace installation
Wider context from the report “(1) It appears to me that both the manufacturer and installation of stone fireplaces are an unregulated industry .
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Inadequate specificity of fireplace installation instructions
Wider context from the report “(2) There appears to be no quality/safety standard that applies to fireplaces. The British Standards (BS1251) appears to relate purely to flues and combustible properties of the chimney itself. I am aware of no BSI kite mark applicable to fireplaces. It therefore seems possible to design and manufacture a product with dangerous design features that are cosmetically attractive but inherently dangerous. The fireplace that struck and killed Isabella Pritchard incorporated a stone mantel weighing 86kg with a design relying on gravity and adhesive to keep it in place. In addition, the installation instructions provided by the manufacturer by their own installer were vague in detail, generic and covered their whole range of products . I understand that most high street DIY warehouses sell fireplaces, some weighing as much as 125kg where the design, if untested, could have the same design faults.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of quality and safety standards for fireplaces
Wider context from the report “(2) There appears to be no quality/safety standard that applies to fireplaces . The British Standards (BS1251) appears to relate purely to flues and combustible properties of the chimney itself. I am aware of no BSI kite mark applicable to fireplaces . It therefore seems possible to design and manufacture a product with dangerous design features that are cosmetically attractive but inherently dangerous. The fireplace that struck and killed Isabella Pritchard incorporated a stone mantel weighing 86kg with a design relying on gravity and adhesive to keep it in place. In addition, the installation instructions provided by the manufacturer by their own installer were vague in detail, generic and covered their whole range of products. I understand that most high street DIY warehouses sell fireplaces, some weighing as much as 125kg where the design, if untested, could have the same design faults.
” Open source report
3 Mar 2017 Alan Walsh · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 2 Risk of ladder spigots being inadvertently sheared off during premature opening View source Lack of awareness of ladder spigot safety role and shearing risk during premature opening View source
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
Alan Walsh · 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
Alan Walsh fell from a 2.5-metre ladder while inspecting a fault in a ceiling void at Eltham Leisure Centre and died the same day from injuries sustained in the fall. The report raised concern about a lack of awareness of the safety-critical role of the ladder’s spigots and the possibility that they could be inadvertently sheared off, although their absence was not found to have caused the accident.
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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. The report was sent to Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Risk of ladder spigots being inadvertently sheared off during premature opening
Wider context from the report “There would appear not be awareness of the safety critical role of the spigots on this ladder, nor the fact that they can easily and inadvertently be sheared off, on premature opening of the ladder . Whilst the absence of these spigots was not found to be the cause of this accident, they may have had a role in the injuries sustained and the implications of the lack of awareness may create risks to health and safety.
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness of ladder spigot safety role and shearing risk during premature opening
Wider context from the report “There would appear not be awareness of the safety critical role of the spigots on this ladder, nor the fact that they can easily and inadvertently be sheared off, on premature opening of the ladder . Whilst the absence of these spigots was not found to be the cause of this accident, they may have had a role in the injuries sustained and the implications of the lack of awareness may create risks to health and safety .
” Open source report
19 Dec 2016 Grace Joy Roseman · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 8 Inadequate informed assessment and consideration of risks from bedside sleeper cribs View source Failure to keep crib and cradle safety standards up to date with bedside sleeper developments View source Failure to ensure modification of Bednest cribs in the marketplace View source Failure to ensure customers understand the mandatory need for crib modification View source Failure by industry to recognise the risk of infant head and neck entrapment at partially lowered sides View source Infant products with partially lowered sides posing entrapment risk View source Inadequate consultation with paediatric medicine and child development experts in child product safety standards View source Failure to fully accept the risk of infant death when using the crib with the half lowered side View source See 5 more concerns
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Grace Joy Roseman · 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
Grace Joy Roseman died on 9 April 2015 after being found with her head over the half-lowered side of an NCT Bednest crib. The medical cause of death was amended to pressure on the carotid sinus leading to positional asphyxia. The principal concern was that unmodified cribs remained in use or could be passed on or sold, including where customers were unaware that modification was needed or believed it was optional.
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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. The report was sent to Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Inadequate informed assessment and consideration of risks from bedside sleeper cribs
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed, in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side.
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to keep crib and cradle safety standards up to date with bedside sleeper developments
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed, in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side.
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure modification of Bednest cribs in the marketplace
Wider context from the report “(a) Whilst it is accepted that following Grace death (and the issue of an earlier Prevention of Future death report) that Bednest have now modified their crib there has throughout my investigation been reluctance by the Company to fully accept that there was any real risk of death of infants when using the crib with the half lowered side.
No new cribs are being issued without this modification however I am concerned that out in the marketplace there are a large number of these cribs without the modification . In particular:-
(i) Where Bednest Cribs are still in the hands of customers who are unaware of the need to modify the crib
(ii) Where customers have the modification kit but who still think that it is an optional feature
(iii) Those cribs being passed on or are being sold in the second hand market.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure customers understand the mandatory need for crib modification
Wider context from the report “(a) Whilst it is accepted that following Grace death (and the issue of an earlier Prevention of Future death report) that Bednest have now modified their crib there has throughout my investigation been reluctance by the Company to fully accept that there was any real risk of death of infants when using the crib with the half lowered side.
No new cribs are being issued without this modification however I am concerned that out in the marketplace there are a large number of these cribs without the modification. In particular:-
(i) Where Bednest Cribs are still in the hands of customers who are unaware of the need to modify the crib
(ii) Where customers have the modification kit but who still think that it is an optional feature
(iii) Those cribs being passed on or are being sold in the second hand market.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure by industry to recognise the risk of infant head and neck entrapment at partially lowered sides
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed, in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side .
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Infant products with partially lowered sides posing entrapment risk
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed , in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side.
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Inadequate consultation with paediatric medicine and child development experts in child product safety standards
Wider context from the report “(a) The current BS EN 1130 -1:1997 & 2:1996 Cribs and Cradles for Domestic Use has not kept up with the recent development of infants bedside sleepers. Therefore there has been inadequate and properly informed assessment and consideration of the risks to infants from this new type of bedside sleeper cribs.
(b) There are currently a number of other products currently being marketed, in addition to the Bednest Crib, with a partially lowered side which in my mind poses a similar risk to that faced by Grace Roseman.
(c) There is a real reluctance from the industry to accept the possible risk of death of infants (and in particularly those with enhanced development skills) by being able to manoeuvre themselves into a position where their head and neck could become trapped over the edge of the partially lowered side.
(d) It appears that that the standards which relates to the safety of products for children are being drafted or revised without the authors of those standards adequately consulting with those who have the necessary expertise in paediatric medicine and child development to ensure that the standard properly reflects current scientific knowledge .
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Department for Business, Energy & Industrial Strategy; that does not assign responsibility.
PFD Monitor interpretation Failure to fully accept the risk of infant death when using the crib with the half lowered side
Wider context from the report “(a) Whilst it is accepted that following Grace death (and the issue of an earlier Prevention of Future death report) that Bednest have now modified their crib there has throughout my investigation been reluctance by the Company to fully accept that there was any real risk of death of infants when using the crib with the half lowered side .
No new cribs are being issued without this modification however I am concerned that out in the marketplace there are a large number of these cribs without the modification. In particular:-
(i) Where Bednest Cribs are still in the hands of customers who are unaware of the need to modify the crib
(ii) Where customers have the modification kit but who still think that it is an optional feature
(iii) Those cribs being passed on or are being sold in the second hand market.
I consider that the issues raised in this case should be addressed so that future deaths do not occur in similar circumstances and that action should be taken to reduce the risk of deaths of other infants..
” 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 Discuss with BSI how to incorporate paediatric advice into the revision of the childcare product standard.
Verbatim wording from the response “as well as and a convenor of the CEN TC252 WG 4, early learning and protection working group and has been involved in standardisation for more than 20 years. Other members of the Committee include a broad cross-section of industry such as Mamas, Mamas & Papas, Mothercare, Furniture Industry Research Association, Bureau Veritas, and The Lullaby Trust amongst others. The committee members are experts with considerable skill and experience in their fields. My officials at BEIS will discuss with BSI how to ensure that paediatric advice is fed into the revision of the standard.” Source location 2016-0455-Response-by-Department-for-Business-Energy-and-Industrial-Strategy
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 Work with industry stakeholders to ensure members understand their duties to produce safe products and promptly notify and remove unsafe products.
Verbatim wording from the response “I believe that the majority of manufacturers take the safety of their products and the intended end users very seriously. I have recently tasked the Working Group on Product Recalls and Safety to explore how to increase both business and consumer awareness on the issues of product safety. My officials at BEIS will work with industry stakeholders such as the British Retail Consortium and the Baby Products Association to ensure their members are aware of their obligations under product safety legislation not only to produce only safe products but also their obligation to notify and remove unsafe products as quickly as possible.” Source location 2016-0455-Response-by-Department-for-Business-Energy-and-Industrial-Strategy
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 product-safety legislation requires similar products to be safe and permits competent authorities to remove products considered unsafe.
Verbatim wording from the response “All products supplied or placed on the UK market are required to be safe under the General Product Safety Regulations. This includes similar products to bedside sleepers; competent authorities can use the GPSR to remove products they consider unsafe. The Government recognises the seriousness of this issue, and my officials at BEIS will work with stakeholders to review the guidance currently available to retailers and manufacturers to determine if it is fit for purpose, which will help to ensure they fully understand their responsibilities and how to comply with them.” Source location 2016-0455-Response-by-Department-for-Business-Energy-and-Industrial-Strategy
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations