Concerns raised 3 Children working alone at night delivering to private homes View source Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles View source Lack of oversight of the rental of food delivery licences to children under 18 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
Leonardo Cardoso Machado · 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
Leonardo Cardoso Machado, aged 17, died on 16 April 2023 after losing control of a motorcycle while travelling at speed and colliding with metal railings. The report raised concerns about limited oversight of rented food delivery licences being provided to children under 18, and the resulting risks of lone night work and road traffic collisions.
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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Children working alone at night delivering to private homes
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position ;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Risk of road traffic collisions involving children working at night on powered two-wheeled vehicles
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit. This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age, which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death .
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Lack of oversight of the rental of food delivery licences to children under 18
Wider context from the report “1. During the inquest evidence was heard that:
i. There is significant national concern about the “rental” of food delivery licences to under 18s. In general terms, food delivery platforms place age restrictions on those who can obtain a licence to deliver food. However, there appears to be no oversight of the rental of these licences to those under the age limit . This places children in a vulnerable position: lone working, often at night, riding electric or motorised scooters, mopeds or motorcycles and delivering to individuals that are not known to the drivers.
2. I have concerns with regard to the following:
i. There appears to be no or limited oversight of the practice of “renting” a food delivery licence to children under 18 years of age , which I hear is a national issue;
ii. As a consequence, children are working in the food delivery economy, which involves lone working at night, with deliveries being made to the home addresses of private individuals, placing the children in a vulnerable position;
iii. That placing a child in a lone working environment at night and on the roads on electric or motorised scooters, mopeds or motorcycles also increases the risks of them coming to harm through a road traffic collision, leading to a risk of death.
” Open source report
Concerns raised 5 Failure of anti-locking braking systems to reliably recognise tyre detachment View source Lack of regulatory requirements for under-run protection device strength View source Lack of industry testing and data collection on braking following tyre detachment View source Insufficient strength of under-run protection devices View source Failure of anti-locking braking regulations to specify requirements for tyre detachment 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
Lisa Marie Bowen · 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
Lisa Marie Bowen died instantaneously from fatal injuries after her Toyota Corolla’s tyre detached while she was driving on the M25, and the vehicle failed to stop before colliding with a stationary lorry. The principal concerns were that the anti-locking braking system substantially reduced braking after tyre detachment, and that the lorry’s under-run protection device was insufficiently strong to prevent or reduce the under-run. The report also raised concerns about the adequacy of relevant testing, regulations and protection requirements.
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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Failure of anti-locking braking systems to reliably recognise tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated.
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof , not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven .
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen.
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory requirements for under-run protection device strength
Wider context from the report “Concern 2
This concern relates to the catastrophic failure of the under-run protection bar (“the Device”) that was in place on the piece of the lorry with which Ms Bowen collided. At the inquest I heard and accepted expert evidence which established that:
(i) The Device was compliant with all relevant regulations and legal requirements, save only that fixing bolts of an incorrect strength had been used to attach it to the lorry’s chassis.
(ii) The strength of the Device was grossly insufficient, either to have prevented any underrun, or even to have reduced the extent of the Toyota’s under-run.
(iii) The Device would not have been strong enough to do so even if the correct fixing bolts had been used.
One expert stated that he was aware that some under-run protection devices are capable of providing protection against much greater forces than is currently required under the law and he expressed disappointment that the relevant legislation and regulations are not more robustly framed, so as to require the use of these much stronger devices.
I am concerned that, in the absence of more stringent requirements in relation to the degree of force that an under-run protection device should be capable of withstanding , a risk of future death arises.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Lack of industry testing and data collection on braking following tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated .
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof, not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven.
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen.
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Insufficient strength of under-run protection devices
Wider context from the report “Concern 2
This concern relates to the catastrophic failure of the under-run protection bar (“the Device”) that was in place on the piece of the lorry with which Ms Bowen collided. At the inquest I heard and accepted expert evidence which established that:
(i) The Device was compliant with all relevant regulations and legal requirements, save only that fixing bolts of an incorrect strength had been used to attach it to the lorry’s chassis.
(ii) The strength of the Device was grossly insufficient, either to have prevented any underrun, or even to have reduced the extent of the Toyota’s under-run.
(iii) The Device would not have been strong enough to do so even if the correct fixing bolts had been used.
One expert stated that he was aware that some under-run protection devices are capable of providing protection against much greater forces than is currently required under the law and he expressed disappointment that the relevant legislation and regulations are not more robustly framed, so as to require the use of these much stronger devices.
I am concerned that, in the absence of more stringent requirements in relation to the degree of force that an under-run protection device should be capable of withstanding, a risk of future death arises.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Failure of anti-locking braking regulations to specify requirements for tyre detachment
Wider context from the report “Concern 1
As stated above, the brakes on the Deceased’s Toyota Corolla did not work effectively because, when the brake pedal was pressed, the vehicle’s anti-locking braking system was activated, and it operated to reduce the braking effect almost entirely. At the inquest I heard evidence that:
(i) Following the tyre detachment, the speed of the wheel with a detached tyre was much higher than the speed of the three other wheels with undamaged tyres.
(ii) The anti-locking braking system recognised this differential in speed, but perceived that the problem lay with the three slower wheels and assumed that they had locked or were at risk of doing so.
(iii) Consequently, each time the brake was applied, the anti-locking braking system immediately released the braking pressure to the three slower wheels in order to avoid them locking, thereby prioritising the preservation stability and steerability over braking.
(iv) In this way, the anti-locking braking system was working in accordance with its design.
(v) The system was unable to recognise that the problem in fact lay with the fourth wheel which was rotating much more quickly than the other wheels because its tyre had detached.
(vi) The outcome was an unintended effect of the system’s design which arose because the specific scenario, of tyre detachment occurring whilst the vehicle was being driven, which was thought to be a rare occurrence, had not been taken into account in the design process.
(vii) Testing of anti-locking braking systems and braking performance, following a tyre detachment, is not undertaken by the industry as a whole and, therefore, relevant data is not collated.
At the inquest and PFD hearing I was informed that –
(i) A large number Toyota Corolla motor cars continue to be driven on the roads of the UK with the same anti-locking braking system as was in Ms Bowen’s vehicle.
(ii) Anti-locking braking systems are developed by a small number of specialist companies and it may well be that other vehicles currently on the roads of the UK have systems similar to that in Ms Bowen’s car.
(iii) The company which developed the anti-locking braking system used in Ms Bowen’s car (Advics) has since developed and improved its system so that it is better able to recognise if one wheel speed is so different from the others that the data from that wheel should be ignored as unreliable. However, the improvements are not foolproof, not least because acceleration or deceleration of the vehicle affects this function.
(iv) The anti-locking braking system now used in Toyota Corolla motor cars has been developed by a different company (Bosch) and it is not known by Toyota precisely how it would respond following a tyre detachment whilst the vehicle is being driven.
(v) It seems that relevant regulations concerning anti-locking braking systems do not address or specify requirements relating to the scenario faced by Ms Bowen .
Although the detachment of a tyre whilst a vehicle is being driven is thought to be a rare occurrence, I am concerned that that may not be the case and that if it were to happen again, in the same or similar circumstances, the risk of future death continues.
” Open source report
Concerns raised 5 Inadequate visibility and wording of aerosol inhalation warnings View source Failure of social media platforms to control dangerous challenge content View source Lack of age restrictions on aerosol products and other products containing butane/propane propellant View source Failure to control toxic social media algorithms View source Age restrictions for social media platforms failing to account for hazardous content exposure View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Luke Gorman · 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
Oliver Luke Gorman, aged 12, died at home on 5 May 2025 after inhaling butane gas from an aerosol spray. The report raised concerns about the lack of age restrictions on some products containing butane or propane, the adequacy of warnings about inhalation risks, and social media content promoting dangerous challenges.
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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Inadequate visibility and wording of aerosol inhalation warnings
Wider context from the report “2. Adequacy of Warning
The warnings on the cans of ████████ of the danger/risk of inhaling the aerosol spray were, in my opinion, inadequate in terms of visibility and wording.
The warning was set in an area outline of about 12mm x 12mm, in black or white writing depending on the background colour of the can. It was lost amongst all the other information and writing on the can. At least the ‘inflammable content’ warning was outlined in red.
The warning stated “SOLVENT ABUSE CAN KILL INSTANTLY”.
Many people (both adults and children) may not equate inhalation of aerosol spray with solvent abuse. Thus, the warning does not appear to properly describe the risks of using/misusing using the product. That risk being inhalation of this aerosol spray can cause instant death.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Failure of social media platforms to control dangerous challenge content
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Lack of age restrictions on aerosol products and other products containing butane/propane propellant
Wider context from the report “1. No Age Restriction
The age restriction on the purchase of butane for refilling cigarette lighters (and the like) is 18 years of age. I understand the legislation is primarily aimed at preventing the misuse of butane.
The age restriction on the purchase of aerosol paints is 16 years of age. I understand that the legislation is aimed at reducing incidents of graffiti and preventing the misuse of butane/propane - ████████ as above.
There is no age restriction on the purchase of aerosol ████████ or other products containing butane/propane as the propellant, ████████ yet their misuse is as equally dangerous.
An age restriction on such products would also likely heighten parental awareness of the dangers of such products.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Failure to control toxic social media algorithms
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed, again via any toxic algorithms or any searches they may make.
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Age restrictions for social media platforms failing to account for hazardous content exposure
Wider context from the report “3. Social media content and access
The posting of challenges such as those listed above, and no doubt others, on social media platforms will continue to take the lives of young, impressionable and/or vulnerable children/teenagers unless the platform providers take responsibility fortheir content and/or toxic algorithms either voluntarily or through Government action. The former seems unlikely.
Further the age restriction of 13 years for most social media platforms appears to have been determined in relation to data protection laws rather than of the nature of the content to which they will be exposed , again via any toxic algorithms or any searches they may make.
” 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 Monitor voluntary uptake of the updated warning and communicate expectations for industry adoption.
Verbatim wording from the response “OPSS, with the BAMA’s support, will monitor the progress on the voluntary uptake of the new labelling and we will make clear that we expect industry to be following this updated best practice for products where it is most relevant.” Source location Response from Product Safety & Standards
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 Encourage aerosol manufacturers to adopt the updated inhalation-risk warning.
Verbatim wording from the response “I understand that one of the UK market leaders in this industry will implement the new messaging from January 2026, meaning a significant proportion of aerosol products in the UK will soon carry the new label. While this will be voluntary, we expect other businesses to follow suit, and OPSS will be encouraging all aerosol manufacturers to take up the new warning. I understand the BAMA will also encourage their membership to make the change as soon as possible.” Source location Response from Product Safety & Standards
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 Existing regulations and industry measures are not shown to be less effective than introducing an age limit for aerosol deodorant purchases.
Verbatim wording from the response “While I share your concern at the circumstances of Oliver’s tragic death, it is not clear the available evidence proves that placing an age limit on the purchase of aerosol deodorants would be more effective than the measures currently in place under the existing regulations, or the additional steps the industry is taking on warnings, which I have set out below.” Source location Response from Product Safety & Standards
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 Other departments are best placed to address harmful content accessible across social media platforms.
Verbatim wording from the response “In relation to your matters of concern regarding harmful content accessible across social media platforms, I know you have sent your report to the Department for Culture, Media and Sport and Department for Science, Innovation and Technology, which are best placed to respond to these matters.” Source location Response from Product Safety & Standards
Open published response
Concerns raised 1 Gas piston bed mechanisms presenting a risk to life on failure View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Helen DAVEY · 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
Helen DAVEY died after the mattress platform of an Ottoman-styled gas-lift bed descended unexpectedly while she was leaning over its storage area, trapping her neck and causing positional asphyxia. The principal concern was the existence and use of gas-piston bed mechanisms whose failure presents a risk to life.
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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Gas piston bed mechanisms presenting a risk to life on failure
Wider context from the report “The existence and use of gas piston bed mechanisms whose failure presents risk to life.
” 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 Write to relevant trade bodies to disseminate awareness of the incident and lifting-mechanism risks for consideration in similar products.
Verbatim wording from the response “OPSS is writing to relevant trade bodies, including the National Bed Federation, the British Furniture Manufactures Association and British Furniture Confederation, to ask that they make their members aware of the incident and the potential risk should a lifting mechanism fail, so that they can ensure that risk has been considered and addressed in any similar products.” Source location Response from OPSS
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 Request that BSI review relevant furniture standards to address Ottoman-bed safety and unexpected descent after lifting-mechanism failure.
Verbatim wording from the response “OPSS has also contacted the British Standards Institution (BSI), the UK’s national standards body, about this incident. BSI are responsible for independently producing national and international technical standards, and I know they have already raised awareness of this with their counterparts in the international and European standards bodies. OPSS has written to request that BSI reviews relevant UK furniture standards, including standards for furniture testing methods, to ensure they adequately address the safety of Ottoman-style beds, including how they prevent beds from descending unexpectedly should a lifting mechanism fail. While product standards are voluntary, they can assist businesses in complying with their legal safety obligations.” Source location Response from OPSS
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 British Standards Institution is responsible for independently producing and reviewing relevant technical standards for Ottoman-style beds.
Verbatim wording from the response “OPSS has also contacted the British Standards Institution (BSI), the UK’s national standards body, about this incident. BSI are responsible for independently producing national and international technical standards, and I know they have already raised awareness of this with their counterparts in the international and European standards bodies. OPSS has written to request that BSI reviews relevant UK furniture standards, including standards for furniture testing methods, to ensure they adequately address the safety of Ottoman-style beds, including how they prevent beds from descending unexpectedly should a lifting mechanism fail. While product standards are voluntary, they can assist businesses in complying with their legal safety obligations.” Source location Response from OPSS
Open published response
Concerns raised 2 Unrestricted marketing and supply of publications providing clear instructions on methods of ending life View source Failure to regulate the supply of publications providing information on ending life View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Deborah Jane Cooper · 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
Deborah Jane Cooper, aged 61, died in circumstances suspected to involve carbon monoxide poisoning after apparatus was found and notes indicated an intention to end her life. The concern was that publications giving instructions on methods of ending one’s life were freely available through Amazon UK, with potentially inadequate regulation of their supply.
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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Unrestricted marketing and supply of publications providing clear instructions on methods of ending life
Wider context from the report “That duty has arisen in this case when I discovered that books giving clear instructions as to how an individual might want to end his or her life was freely available on the open market on the Amazon.co.uk website . I am concerned that the marketing and supply of such a book giving such clear instructions and advice as regards different methods for an individual to end his or her life at their own hands is of the utmost concern as is the regulation as regards the supply of such publications whose sole purpose is to provide information to those contemplating on ending their lives.
I have identified 2 publication that give such advice and there may be more currently being marketed on the Amazon.co.uk website .
” 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Failure to regulate the supply of publications providing information on ending life
Wider context from the report “That duty has arisen in this case when I discovered that books giving clear instructions as to how an individual might want to end his or her life was freely available on the open market on the Amazon.co.uk website. I am concerned that the marketing and supply of such a book giving such clear instructions and advice as regards different methods for an individual to end his or her life at their own hands is of the utmost concern as is the regulation as regards the supply of such publications whose sole purpose is to provide information to those contemplating on ending their lives .
I have identified 2 publication that give such advice and there may be more currently being marketed on the Amazon.co.uk website.
” 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 Ofcom is the independent regulator responsible for implementing the Online Safety Act with the Department for Science, Innovation and Technology.
Verbatim wording from the response “In addition, the new Online Safety Act requires all in-scope services, including in-scope marketplaces, to rapidly remove regulated content, including suicide content, where they have reasonable grounds to consider that it crosses the criminal threshold. I understand that” Source location Response from Department for Business and Trade
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 consumer protection legislation has limited scope because it primarily protects economic interests and does not ban sales of the products concerned.
Verbatim wording from the response “There is limited scope to address the issues raised in your Report through existing consumer protection legislation. For example, while the scope of the protection offered to consumers by the unfair trading legislation (referred to above) is broad, its focus is primarily to protect consumer’s economic interests. This legislation does not impose a blanket ban on the sale of the particular products in issue.” Source location Response from Department for Business and Trade
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 Legislation more directly relevant to the issues falls outside the Department’s responsibilities.
Verbatim wording from the response “However, there is legislation, which falls outside of the scope of my Department’s responsibilities, which is more directly relevant including section 2(1) of the Suicide Act 1961 (as amended), which makes it an offence for a person to commit an act capable of encouraging or assisting the suicide or attempted suicide of another person, with the intention that their act will encourage or assist suicide or an attempt at suicide. It is a matter for the Police and Crown Prosecution Service to consider and, where appropriate, pursue prosecutions.” Source location Response from Department for Business and Trade
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Police and Crown Prosecution Service are responsible for considering and, where appropriate, pursuing prosecutions under the Suicide Act.
Verbatim wording from the response “However, there is legislation, which falls outside of the scope of my Department’s responsibilities, which is more directly relevant including section 2(1) of the Suicide Act 1961 (as amended), which makes it an offence for a person to commit an act capable of encouraging or assisting the suicide or attempted suicide of another person, with the intention that their act will encourage or assist suicide or an attempt at suicide. It is a matter for the Police and Crown Prosecution Service to consider and, where appropriate, pursue prosecutions.” Source location Response from Department for Business and Trade
Open published response
Concerns raised 3 Lack of awareness among parents and child supervisors of the risks posed by helium-filled balloons to young children View source Unrestricted availability of helium-filled balloons at children's entertainment venues View source Failure of helium-filled balloons to display warnings about potential risks to young children 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
Karlton Donaghey · 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
Karlton Donaghey, a five-year-old boy, placed a large helium-filled balloon over his head while briefly alone at home on 23 June 2022. He was overcome by helium, suffered a hypoxic brain injury and died in hospital on 29 June 2022; concerns included unrestricted availability of such balloons, limited awareness of their risks to young children, and the absence of a warning on the balloon.
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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Lack of awareness among parents and child supervisors of the risks posed by helium-filled balloons to young children
Wider context from the report “- the balloon which caused the death are freely available to purchase without restriction, particularly at locations of places of entertainment for children.
- Parents and those responsible for supervision of children are not fully aware of the risks posed to young children of helium filled balloons .
- the balloon in question displayed no warning as to the potential risk to young 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Unrestricted availability of helium-filled balloons at children's entertainment venues
Wider context from the report “- the balloon which caused the death are freely available to purchase without restriction, particularly at locations of places of entertainment for children .
- Parents and those responsible for supervision of children are not fully aware of the risks posed to young children of helium filled balloons.
- the balloon in question displayed no warning as to the potential risk to young 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, Innovation, Science and Trade; that does not assign responsibility.
PFD Monitor interpretation Failure of helium-filled balloons to display warnings about potential risks to young children
Wider context from the report “- the balloon which caused the death are freely available to purchase without restriction, particularly at locations of places of entertainment for children.
- Parents and those responsible for supervision of children are not fully aware of the risks posed to young children of helium filled balloons.
- the balloon in question displayed no warning as to the potential risk to young children
” Open source report
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Addressed to Department for Business and Trade, now represented here by Department for Business, Innovation, Science and Trade.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations