5 Aug 2025 Mohsin Janjua · Prevention of Future Deaths report West Yorkshire (Western)
View report summary
Concerns raised 4 Lack of regulation of lithium-ion battery sales, especially e-bike conversion batteries sold through online marketplaces View source Availability of substandard or non-compliant lithium-ion batteries through online marketplaces View source Insufficient public awareness of life-threatening risks from e-bike lithium-ion batteries stored in domestic properties View source Failure of online marketplaces to accept responsibility for the safety of third-party goods View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 4
Action
Work with government departments, safety organisations, local authorities, emergency services and retailers to amplify e-bike and e-scooter safety messages through their networks and communication channels.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Prohibit UK sale and supply of two dangerous UPP battery models through withdrawal notices served on marketplaces, manufacturers and other sellers.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2025. View source
Action
Hold major online marketplaces to account for their e-bike product-safety responsibilities, including implementation of statutory battery-safety guidelines.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 August 2025. View source
Action
Produce, translate and share safety videos setting out five key safety steps for e-bike users, particularly food delivery riders, with gig-economy companies.
Stated completedThe respondent said that this action was complete when they made their response on 5 August 2025. View source See 1 more action
×
AI-generated summary
Mohsin Janjua · 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
Mohsin Janjua died on 02/12/2023 after a fire at his home, caused by the catastrophic failure of an ion-lithium battery charging an e-bike. The report raises concerns about the unregulated online sale of lithium-ion batteries, the responsibility of online marketplaces for product safety and legal compliance, and public awareness of the risks of e-bike batteries in domestic properties.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of regulation of lithium-ion battery sales, especially e-bike conversion batteries sold through online marketplaces
Wider context from the report “To review and reconsider the adequacy of the of the current unregulated sale of lithium-ion batteries, especially those intended for e-bike conversions through online market places , since they pose a significant and growing risk to public safety .
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Availability of substandard or non-compliant lithium-ion batteries through online marketplaces
Wider context from the report “Fires caused by substandard or non-compliant batteries have increased and many originate from online marketplaces .
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Insufficient public awareness of life-threatening risks from e-bike lithium-ion batteries stored in domestic properties
Wider context from the report “Consider further steps to increase the general publics awareness with regard to the life threatening risks involved with lithium ion batteries from e-bikes in this case stored in domestic properties .
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure of online marketplaces to accept responsibility for the safety of third-party goods
Wider context from the report “At the moment it is my understanding that online market places disclaim responsibility for the safety of 3rd party goods , so I ask that you give consideration to the appropriateness of regulations to make online marketplaces jointly responsible for ensuring the safety and legal compliances of products sold on their sites.
” 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 Work with government departments, safety organisations, local authorities, emergency services and retailers to amplify e-bike and e-scooter safety messages through their networks and communication channels.
Verbatim wording from the response “Public awareness
In 2024 the Government’s safety campaign ‘Buy Safe, Be Safe’ was launched, aimed at raising public awareness of the risks from dangerous e-bikes, e-scooters and their components with advice on safer purchasing and charging practices. OPSS is working closely with other Government departments, as well as safety charities Electrical Safety First and the Royal Society for the Prevention of Accidents, local authorities, fire and rescue services, and retailers, to amplify these important safety messages through their networks and communication channels.” Source location Response from Office for Product Safety and 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 Prohibit UK sale and supply of two dangerous UPP battery models through withdrawal notices served on marketplaces, manufacturers and other sellers.
Verbatim wording from the response “Enforcement Action
OPSS’ investigation into the safety of the lithium-ion battery involved in the fire which led to Mr Janjua’s death, and another serious fire in the West Midlands, identified the specific models of UPP battery involved. The evidence enabled OPSS to take enforcement action in January 2024 to prohibit the sale of these battery models in the UK, which included their supply by online marketplaces. 26 Withdrawal Notices were served on eight online marketplaces, two manufacturers and 16 other sellers, requiring them to immediately stop the supply of two dangerous models of UPP battery. OPSS also published public safety messages advising consumers not to use the models and how to dispose of them safely.” Source location Response from Office for Product Safety and 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 Hold major online marketplaces to account for their e-bike product-safety responsibilities, including implementation of statutory battery-safety guidelines.
Verbatim wording from the response “OPSS senior leaders regularly meet with the major online marketplaces operating in the UK market to hold them to account for their product safety responsibilities, including implementing these guidelines.” Source location Response from Office for Product Safety and 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 Produce, translate and share safety videos setting out five key safety steps for e-bike users, particularly food delivery riders, with gig-economy companies.
Verbatim wording from the response “OPSS has also produced Buy Safe, Be Safe videos with five key safety steps that users should take if they own or use e-bikes. These videos have been translated into several languages. They are aimed particularly at food delivery riders, based on insights from gig economy companies. OPSS has shared the videos with those companies and encouraged them to raise awareness with riders and couriers.” Source location Response from Office for Product Safety and Standards
Open published response
Concerns raised 3 Failure to make the safe room-dimension requirement obvious to potential heater users View source Operation of flue-less liquified petroleum gas cabinet heaters in rooms too small to prevent carbon monoxide build-up View source Absence of a visible external warning label on flue-less liquified petroleum gas cabinet heaters View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Thomas Oliver HILL · 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
Thomas Oliver HILL died on 28 October 2015 after inhaling a fatal quantity of carbon monoxide from a flue-less liquefied petroleum gas cabinet heater while preparing for a bath. The report identified concerns about the heater being used in an undersized room, the absence of a visible external warning label, and it not being obvious to all users that adequate room dimensions were required for safe use.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to make the safe room-dimension requirement obvious to potential heater users
Wider context from the report “The flue-less liquified petroleum gas cabinet heater was operated in a room which was too small dimension so to safely use the heater without causing a build-up of carbon monoxide. A warning label was affixed inside the cabinet heater in the space occupied by the liquified petroleum gas bottle.
There was an absence of a visible warning label on the outside of the heater.
It was not obvious to all potential users of the heater that the heater could only be used safely in a room of sufficient dimension.
The risk applies particularly so in the case of rented cottages and similar premises such as ████████
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Operation of flue-less liquified petroleum gas cabinet heaters in rooms too small to prevent carbon monoxide build-up
Wider context from the report “The flue-less liquified petroleum gas cabinet heater was operated in a room which was too small dimension so to safely use the heater without causing a build-up of carbon monoxide. A warning label was affixed inside the cabinet heater in the space occupied by the liquified petroleum gas bottle.
There was an absence of a visible warning label on the outside of the heater.
It was not obvious to all potential users of the heater that the heater could only be used safely in a room of sufficient dimension.
The risk applies particularly so in the case of rented cottages and similar premises such as ████████
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Absence of a visible external warning label on flue-less liquified petroleum gas cabinet heaters
Wider context from the report “The flue-less liquified petroleum gas cabinet heater was operated in a room which was too small dimension so to safely use the heater without causing a build-up of carbon monoxide. A warning label was affixed inside the cabinet heater in the space occupied by the liquified petroleum gas bottle.
There was an absence of a visible warning label on the outside of the heater.
It was not obvious to all potential users of the heater that the heater could only be used safely in a room of sufficient dimension.
The risk applies particularly so in the case of rented cottages and similar premises such as ████████
” 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 Request that the relevant British Standards Institution committee review warning placement and content requirements for portable gas appliances under foreseeable conditions of use.
Verbatim wording from the response “In addition, in light of the risks identified in this case, OPSS has written to the British Standards Institution, the UK’s standards-making body, to request the relevant committee(s) for BS EN 449:2002 +A1:2007 review the standard in relation to the placement and content of warnings on portable gas appliances, when considering all conditions of reasonably foreseeable use.” 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 There is no evidence that the product’s ventilation warning failed the applicable regulatory and voluntary standard requirements at the time.
Verbatim wording from the response “The 1995 Regulations and the voluntary standard for dedicated liquefied petroleum gas appliances (BS EN 449:2002) are not prescriptive about the location of warnings. There is no evidence to suggest that the warning on this specific product regarding sufficient ventilation did not meet the requirements of the regulations and the voluntary standard at the time. I understand the warning directed users to the product’s instructions, but these were not available to the tenants of the property.” Source location Response from Product Safety & Standards
Open published response
8 May 2025 Dorothy Gamby · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of warnings about risks from standing on or trapping wide and clawed ferrules on folding or collapsible walking sticks View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Dorothy Gamby · 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
Dorothy Gamby died on 30 April 2025 after falling at home when she stood on a wide claw-shaped rubber ferrule attached to her foldable walking stick. She sustained fractures and a small subarachnoid haemorrhage, later developed pneumonia and respiratory failure, and was transferred to palliative care. The principal concern was that such ferrules may pose a risk if stood on or trapped when used with folding or collapsible walking sticks, without a warning about this risk.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of warnings about risks from standing on or trapping wide and clawed ferrules on folding or collapsible walking sticks
Wider context from the report “Wide and clawed ferrules for walking sticks are widely available. They are described as providing stability, support, improved safety, ease of movement, etc. I am concerned that there is no warning that they may pose a risk if stood on or trapped when used on folding/collapsible walking sticks .
” 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 Work with MHRA to alert walking-stick supply stakeholders about the incident and request review of their risk assessments.
Verbatim wording from the response “I have asked my team to work with the MHRA to ensure stakeholders involved in the supply and provision of walking sticks are made aware of this incident and requested to review their risk assessment through contact with British Healthcare Trades Association. Businesses will be reminded to ensure appropriate warnings to mitigate risks are being provided to consumers alongside medical devices, and any products designed to be attached to them.” Source location Response from Office for Product Safety and 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 Remind businesses to provide appropriate warnings with medical devices and products designed for attachment to them.
Verbatim wording from the response “I have asked my team to work with the MHRA to ensure stakeholders involved in the supply and provision of walking sticks are made aware of this incident and requested to review their risk assessment through contact with British Healthcare Trades Association. Businesses will be reminded to ensure appropriate warnings to mitigate risks are being provided to consumers alongside medical devices, and any products designed to be attached to them.” Source location Response from Office for Product Safety and 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 Regulation of walking sticks supplied for medical purposes falls under the MHRA rather than OPSS.
Verbatim wording from the response “OPSS is the UK’s product regulator, responsible for the regulation of most consumer products. The regulation of medical devices, which include walking sticks supplied for a medical purpose, is led by the Medicines and Healthcare products Regulatory Agency (MHRA).” Source location Response from Office for Product Safety and Standards
Open published response
7 Feb 2025 Carla James · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Failure to provide warnings about highly poisonous and toxic products that can endanger life 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
Carla James · 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
Carla James died unexpectedly at her home address in Tottington, Bury, on 18 August 2024, aged 50. Evidence at the scene indicated she may have ingested material from a plant. The report raises concern that highly poisonous and toxic products were being imported and sold nationally without warnings that they could endanger 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to provide warnings about highly poisonous and toxic products that can endanger life
Wider context from the report “████████ are being imported and sold nationally with no warnings as to the fact they are highly poisonous and toxic and can endanger life .
” Open source report
12 Dec 2024 James Robert Michael ALDERMAN · Prevention of Future Deaths report West London
View report summary
Concerns raised 3 Lack of guidance on breastfeeding young babies in carriers/slings View source Risk of suffocation for young babies in carriers/slings View source Lack of safety and positioning information for young babies in carriers/slings View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
James Robert Michael ALDERMAN · 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
Jimmy was being breastfed in a baby carrier worn by his mother when he collapsed after five minutes. He died three days later in hospital from accidental suffocation after his airway was occluded while he was not held in a safe position. The report identified insufficient information and guidance for parents about safe positioning of young babies in carriers or slings, particularly when breastfeeding, and raised concerns about the need for industry safety standards.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance on breastfeeding young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Risk of suffocation for young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of safety and positioning information for young babies in carriers/slings
Wider context from the report “(1) There is very little information available to inform parents of safety and positioning advice of young babies in carriers/slings and in particular nothing in relation to breastfeeding in carriers/slings
(2) This notwithstanding a significant increase over recent years in the use of such equipment.
(3) The question of whether it is safe to breastfeed "hands free" is not addressed or referred to in the public domain or manufacturers literature.
(4) The NHS available literature provides no guidance or advice.
(5) The only current "tips" are provided on the National Childbirth Trust (NCT) website but these are in fact unhelpful
(6) Young babies are at risk of suffocation.
(7) Consideration should be given to industry standards to promote the safe use of slings/carriers, to warn users of the risks and whether any such standards should be voluntary or mandatory.
” Open source report
×
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 Department of Health and Social Care and NHS England are responsible for responding on baby-carrier and breastfeeding advice.
Verbatim wording from the response “You also raise matters of concern regarding the availability and promotion of advice on the use of baby carriers and breastfeeding. I understand that the Department for Health and Social Care and NHS England will write to you separately on this issue.” 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 changes to the voluntary baby-carrier safety standard.
Verbatim wording from the response “Should there be any updates to Government or NHS advice regarding the safety of infants when in a baby sling or carrier, OPSS will bring this to the attention of relevant trade associations, including the Baby Products Industry Association. OPSS would also review the designation of the voluntary standard, to consider whether any amendments, accompanying notes or restrictions to the standard may be required. Changes to the standard itself would be a matter for the British Standards Institution, who I understand also received a copy of your Report.” 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 Businesses remain responsible for ensuring product safety instructions reflect the latest safety advice.
Verbatim wording from the response “It will remain businesses’ responsibility to ensure that their product instructions for safe use take account of the latest safety advice.” Source location Response from OPSS
Open published response
9 Dec 2024 Luke Marshall ALBISTON O'DONNELL · Prevention of Future Deaths report Liverpool and the Wirral
View report summary
Concerns raised 2 Lack of public awareness of life-threatening risks from storing lithium iron battery appliances in domestic properties View source Lack of communication and media coverage about the dangers of storing electronic bikes and scooters in domestic properties View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Luke Marshall ALBISTON O'DONNELL · 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
Luke Marshall Albiston O'Donnell was an 8-year-old boy who died in hospital following a fire at his home. The fire began when an e-bike lithium battery ignited after coming into contact with combustible materials, and the battery-cell failure allowed the fire to develop rapidly. The report raises concerns that the public may not appreciate the life-threatening risks of storing e-bikes and similar appliances in domestic properties, and that communication about these dangers may be insufficient.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of public awareness of life-threatening risks from storing lithium iron battery appliances in domestic properties
Wider context from the report “The general public do not appreciate the life-threatening risks involved with having lithium iron batteries, from electronic bikes in this case, stored in domestic properties. There appears to be a lack of communication/media coverage about the dangers involved with storing appliances such as electronic bikes/scooters in domestic properties. There have already been 3 deaths associated with lithium batteries in the home in Merseyside and we have been informed there a number of similar fatalities across England.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of communication and media coverage about the dangers of storing electronic bikes and scooters in domestic properties
Wider context from the report “The general public do not appreciate the life-threatening risks involved with having lithium iron batteries, from electronic bikes in this case, stored in domestic properties. There appears to be a lack of communication/media coverage about the dangers involved with storing appliances such as electronic bikes/scooters in domestic properties. There have already been 3 deaths associated with lithium batteries in the home in Merseyside and we have been informed there a number of similar fatalities across England.
” 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 Continue raising awareness of unsafe e-bike, e-scooter and lithium-ion battery risks through stakeholder networks and communication channels.
Verbatim wording from the response “OPSS is currently working with other Government departments, as well as external stakeholders including Electrical Safety First, the Royal Society for the Prevention of Accidents, local authorities, fire and rescue services and retailers to amplify these important safety messages through their networks and communication channels.” Source location Response from OPSS
Open published response
6 Dec 2024 Champagauri Bhatt and Dipak Bhatt · Prevention of Future Deaths report North London
View report summary
Concerns raised 8 Inadequate information management for analysis and learning from white goods fires View source Failure by fire-investigating companies to notify authorities of investigation outcomes View source Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters View source Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire View source Failure of product risk assessments to account for occupants and their actions View source Lack of sharing of warranty replacement data for condensate pumps and RFI filters View source Failure to provide fire-durable identification plates on appliances View source Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Champagauri Bhatt and Dipak Bhatt · 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 29 March 2023, a fire caused by an electrical fault in a tumble dryer led to inhalation injuries and the deaths of Champagauri and Dipak Bhatt. Concerns included moisture ingress into condensate pumps causing faults and fire, and the need for improved data sharing, product safety standards, fire investigation reporting, risk assessment, and appliance identification.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Inadequate information management for analysis and learning from white goods fires
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires .
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure by fire-investigating companies to notify authorities of investigation outcomes
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations .
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of recall and replacement decision data and rationale for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Moisture ingress into condensate pumps causing tracking faults, resistive heating and fire
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire .
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure of product risk assessments to account for occupants and their actions
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates .
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of sharing of warranty replacement data for condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters .
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to provide fire-durable identification plates on appliances
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards.
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Inadequate manufacturing standards for mains- and sub-mains-operated condensate pumps and RFI filters
Wider context from the report “During the inquest a London Fire Brigade witness made suggestions for more effective data sharing and use and It was apparent future deaths may occur unless action is taken.
(1) That ingress of moisture into condensate pumps may result in tracking faults causing resistive heating and fire.
(2) That changes in information management would result in better analysis of, and learning from, white goods fires.
(3) Manufacturers to give the Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade (LFB) to support their fire prevention work data on parts replaced on warranty for condensate pumps and RFI filters.
(4) Working group CPL / 61 look at standards of manufacture of mains and sub mains operated condensate pumps and RFI filters, to improve standards .
(5) Manufacturers to share data on decisions and rationale behind recall / replacement of condensate pumps and RFI filters Office of Product Safety Standards (OPSS) as the regulator and London Fire Brigade to support their fire prevention work.
(6) Companies investigating fires to notify Trading Standards and the Office of Product Safety Standards (OPSS) of the outcome of those investigations.
(7) Manufacturers to be required to use the OPSS risk assessment methodology, PRISM, when conducting risk assessments to account for persons in a property and their actions, i.e. sleeping whilst a product is taking advantage of lower electricity rates.
(8) Identification plates on appliances that will not be destroyed by fire akin to those on vehicles.
” 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 Continue engaging with regulators and other stakeholders to identify and learn lessons with wider implications for the safety of similar products.
Verbatim wording from the response “I hope that Champagauri and Dipak’s family are reassured that this tragic incident is already being considered by product regulators. While North Yorkshire County Council is taking the lead in investigating this case, OPSS will continue to engage with them and other stakeholders, so that we can provide any support needed and can learn from any” Source location Response from Office for Product and 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 Operate and promote the Product-related Fire Notification process, supported by published guidance, to collect product-fire information from fire and rescue services.
Verbatim wording from the response “OPSS has also established a process of information sharing with London Fire Brigade (LFB) and other Fire and Rescue Services (FRS) to collect information about product-related fires, known as Product-related Fire Notifications (PFNs). In more serious cases, including those involving serious injuries or fatalities, fire investigators can undertake detailed investigations to determine the cause, defect or failure that led to a product-related fire breaking out. OPSS has been gathering this information in partnership with LFB since 2020, and other FRS since February 2023, when OPSS published guidance Product-Related Fire Incident Notifications - GOV.UK to assist and support FRS to report product-related fires.” Source location Response from Office for Product and 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 Work with BSI to update and improve relevant product standards where necessary to raise safety levels.
Verbatim wording from the response “I know that you have also addressed your report to the British Standards Institution (BSI) regarding your recommendation that BSI Committee CPL/61 should review the voluntary standards concerning the manufacture of mains and sub mains operated condensate pumps and RFI filters, to consider whether they should be improved. I would like to reassure you that OPSS is committed to supporting any changes to product standards that could help raise safety levels further. Representatives from OPSS attend this Committee, and we will work with BSI to update and improve the standard wherever necessary.” Source location Response from Office for Product and 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 Manufacturers already must conduct and document pre-market risk assessments, including risks arising from predictable human behaviour.
Verbatim wording from the response “You have raised the issue of manufacturer risk assessments. Those supplying electrical equipment such as tumble dryers are already required to carry out pre-market risk assessments when assessing the overall conformity of their products to the requirements in the regulations, and document these actions. This includes risks that might arise from the product’s use in instances of predictable human behaviour, such as when people are asleep. OPSS’ PRISM tool is a post-market risk assessment methodology for product regulators to use across the broad spectrum of consumer products. While businesses can consider the use of PRISM, it is their responsibility to determine how to fully identify and mitigate risks that might arise in their specific products before they are placed on the market, and fulfil their safety obligations in the regulations.” Source location Response from Office for Product and 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 Businesses remain responsible for fully identifying and mitigating risks in their specific products and fulfilling regulatory safety obligations.
Verbatim wording from the response “You have raised the issue of manufacturer risk assessments. Those supplying electrical equipment such as tumble dryers are already required to carry out pre-market risk assessments when assessing the overall conformity of their products to the requirements in the regulations, and document these actions. This includes risks that might arise from the product’s use in instances of predictable human behaviour, such as when people are asleep. OPSS’ PRISM tool is a post-market risk assessment methodology for product regulators to use across the broad spectrum of consumer products. While businesses can consider the use of PRISM, it is their responsibility to determine how to fully identify and mitigate risks that might arise in their specific products before they are placed on the market, and fulfil their safety obligations in the regulations.” Source location Response from Office for Product and 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 already require manufacturers to notify regulators and give regulators powers to obtain information and require corrective action.
Verbatim wording from the response “You have raised the issue of data and information sharing between manufacturers and regulators, particularly when manufacturers are investigating potential safety issues with their products. Under the Electrical Equipment (Safety) Regulations 2016, manufacturers of electrical goods are already required to notify regulators when they become aware of a safety issue with a product they have placed on the market. The Regulations also provide regulators with powers to require information from manufacturers or other persons in the supply chain regarding product safety issues, and to require corrective actions to ensure they are addressed.” Source location Response from Office for Product and 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 product-related fire notification arrangements enable OPSS to identify potentially unsafe products and take necessary action.
Verbatim wording from the response “OPSS has also established a process of information sharing with London Fire Brigade (LFB) and other Fire and Rescue Services (FRS) to collect information about product-related fires, known as Product-related Fire Notifications (PFNs). In more serious cases, including those involving serious injuries or fatalities, fire investigators can undertake detailed investigations to determine the cause, defect or failure that led to a product-related fire breaking out. OPSS has been gathering this information in partnership with LFB since 2020, and other FRS since February 2023, when OPSS published guidance Product-Related Fire Incident Notifications - GOV.UK to assist and support FRS to report product-related fires.” Source location Response from Office for Product and 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 already require electrical equipment to carry identification details and manufacturer contact information.
Verbatim wording from the response “You also raised the issue of product identification plates. The Electrical Equipment (Safety) Regulations 2016 require that before placing electrical equipment on the market, a manufacturer must ensure that it bears a type, batch or serial number or other element allowing its identification, and is marked with the contact details at which the manufacturer can be contacted. BSI have previously been asked by Ministers to consider the feasibility for fire resistant identification marking for large electrical appliances to be included in international standards. In response, BSI commissioned a working group to explore how a requirement for fire-resistant marking could work in practice. This working group is currently trialling a pilot approach to enabling the identification of fire-damaged appliances and supporting their traceability.” Source location Response from Office for Product and 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Office for Product Safety and Standards; 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
13 Aug 2024 Elizabeth Van Der Drift · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 5 Failure of product appearance and packaging to avoid confusion with food View source Production of laundry tablets/pods and packaging that can be confused with food by people with cognitive impairment View source Lack of packaging design features that make accessing laundry tablets/pods difficult View source Lack of packaging safety features restricting access to laundry capsules View source Food-imitation regulations insufficiently protective of people with cognitive impairment or insufficiently rigorously applied 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
Elizabeth Van Der Drift · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Elizabeth Van Der Drift, who had dementia, accessed brightly coloured laundry detergent capsules on the night of 13/14 March 2024, apparently mistaking them for sweets, and bit into at least one. She was taken to hospital and died on 19 March 2024 despite treatment. The report raised concerns that the product’s colours, appearance and packaging could lead to accidental ingestion by people with dementia or other cognitive impairment, and that its packaging lacked a safety feature making access particularly difficult.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure of product appearance and packaging to avoid confusion with food
Wider context from the report “(1) The product in question, Sainsbury’s Tropical Escape Bio Laundry Capsules, due to its eye-catching colours, appearance, and packaging, is being confused with food and risks being accidently ingested by those with dementia or other cognitive impairment (as well as children) .
(2) There was no safety feature observed on the packaging that made accessing the content particularly difficult, which increases the risk of accidental or inadvertent ingestion.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Production of laundry tablets/pods and packaging that can be confused with food by people with cognitive impairment
Wider context from the report “(1) During the course of hearing the evidence I was shown a picture of the packaging for the laundry tablets/pods in question. The packaging, in this instance, was predominantly bright pink and white, with orange, yellow and green also present. One witness (a carer experienced in caring for those living with dementia) gave me her view that the packaging bore more than a passing resemblance to a bag of sweets, and she considered that this was more likely to be the case when viewed from the point of view of a person living with dementia or some other cognitive impairment.
In my view, the packaging of this particular product is not alone among similar products, that also opt for bright, eye-catching colours. It was for this reason that I formed the view that sending this report to the individual manufacturer/retailer (under whose brand the product was labelled) would be short-sighted. The employment of eye-catching and bright colours appears to be an industry-wide phenomenon.
It has long been acknowledged that products of this nature can pose risks to children; however, there appears to be less acknowledgement of the risks posed to those living with dementia or other forms of cognitive impairment .
In terms of the laundry tablets/pods themselves, I note that these have a jelly-like appearance and again I regard them as being colourful and potentially sweet-like in their appearance . This again has the serious potential to render a highly toxic/hazardous product as appealing to those with dementia or other cognitive impairment (as well as children). There is a wealth of material available (media reports, scientific studies and research etc.) to document the relatively frequency that products of this nature are accidentally or inadvertently ingested.
I am well aware of The Food Imitations (Safety) Regulations 1989, UKSI 1989 No. 1291 and note Regulation 4, in particular. However, it seems to me either that the regulations themselves have insufficient regard to those living with dementia or other cognitive impairment or that the application of the regulations is not approached with sufficient rigour.
The overarching concern here is that laundry tablets/pods and their packaging are being produced in a way that, by virtue of their bright colouring, appearance, and packaging, are being confused with food by people living with dementia or other cognitive impairment . The issue is, in my opinion, compounded when one considers that the products themselves are far from innocuous in the event of their accidental ingestion.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of packaging design features that make accessing laundry tablets/pods difficult
Wider context from the report “(2) In this case, I also noted that there was no obvious design feature, in terms of the packaging, that makes accessing the content particularly difficult for someone with even the most basic of manual dexterity . In my view, this only adds to the risks.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of packaging safety features restricting access to laundry capsules
Wider context from the report “(1) The product in question, Sainsbury’s Tropical Escape Bio Laundry Capsules, due to its eye-catching colours, appearance, and packaging, is being confused with food and risks being accidently ingested by those with dementia or other cognitive impairment (as well as children).
(2) There was no safety feature observed on the packaging that made accessing the content particularly difficult , which increases the risk of accidental or inadvertent ingestion .
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Food-imitation regulations insufficiently protective of people with cognitive impairment or insufficiently rigorously applied
Wider context from the report “(1) During the course of hearing the evidence I was shown a picture of the packaging for the laundry tablets/pods in question. The packaging, in this instance, was predominantly bright pink and white, with orange, yellow and green also present. One witness (a carer experienced in caring for those living with dementia) gave me her view that the packaging bore more than a passing resemblance to a bag of sweets, and she considered that this was more likely to be the case when viewed from the point of view of a person living with dementia or some other cognitive impairment.
In my view, the packaging of this particular product is not alone among similar products, that also opt for bright, eye-catching colours. It was for this reason that I formed the view that sending this report to the individual manufacturer/retailer (under whose brand the product was labelled) would be short-sighted. The employment of eye-catching and bright colours appears to be an industry-wide phenomenon.
It has long been acknowledged that products of this nature can pose risks to children; however, there appears to be less acknowledgement of the risks posed to those living with dementia or other forms of cognitive impairment.
In terms of the laundry tablets/pods themselves, I note that these have a jelly-like appearance and again I regard them as being colourful and potentially sweet-like in their appearance. This again has the serious potential to render a highly toxic/hazardous product as appealing to those with dementia or other cognitive impairment (as well as children). There is a wealth of material available (media reports, scientific studies and research etc.) to document the relatively frequency that products of this nature are accidentally or inadvertently ingested.
I am well aware of The Food Imitations (Safety) Regulations 1989, UKSI 1989 No. 1291 and note Regulation 4, in particular. However, it seems to me either that the regulations themselves have insufficient regard to those living with dementia or other cognitive impairment or that the application of the regulations is not approached with sufficient rigour .
The overarching concern here is that laundry tablets/pods and their packaging are being produced in a way that, by virtue of their bright colouring, appearance, and packaging, are being confused with food by people living with dementia or other cognitive impairment. The issue is, in my opinion, compounded when one considers that the products themselves are far from innocuous in the event of their accidental ingestion.
” Open source report
×
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 Amending the Food Imitations (Safety) Regulations or guidance to include laundry pods would not be a proportionate response.
Verbatim wording from the response “In considering the issues raised in your report we, like you, have considered the requirements of the Food Imitations (Safety) Regulations 1989. The requirements extend to products in scope that any person, including but not restricted to children, could ingest, causing harm. The exact details of how Ms Van Der-Drift came to access the laundry pods, leading to this tragic incident, are unclear. OPSS is only aware of one other case on record where a person suffering from dementia has ingested a similar type of product leading to a similar outcome. I therefore do not think that an amendment to the Food Imitations (Safety) Regulations or its supporting guidance, to include laundry pods within their scope, would be a proportionate response to this incident.” 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 There is no evidence that the laundry pods were non-compliant with product safety rules or chemical substance requirements.
Verbatim wording from the response “As you will know, the UK’s product safety laws require that only safe consumer products be placed on the market. Manufacturers or importers have obligations to ensure their products are safe. In addition, distributors must not supply products they know, or should know, are unsafe. OPSS has not been made aware of any evidence to suggest that the pods were non-compliant with relevant product safety rules, or did not meet the requirements in relation to the chemical substances the laundry pods contained.” Source location Response from OPSS
Open published response
25 Jun 2024 Abdul Jabar Oryakhel · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of understanding of the dangers of lithium-ion batteries used for e-bikes and e-scooters View source Lack of British or European standards controlling lithium-ion e-bike batteries and chargers sold in the UK View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Abdul Jabar Oryakhel · 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
Abdul Jabar Oryakhel died on 25 September 2022 after falling from the window of his top-floor flat while trying to escape a fire. The fire was caused by overheating and ignition of a lithium-ion battery pack used for an e-bike, and concerns were raised about insufficient understanding of the dangers of such batteries and the absence of a British or European standard controlling the batteries and chargers sold in the UK.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of understanding of the dangers of lithium-ion batteries used for e-bikes and e-scooters
Wider context from the report “There appears to be a lack of understanding of the dangers with Lithium-ion batteries used for e-bikes and e-scooters .
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of British or European standards controlling lithium-ion e-bike batteries and chargers sold in the UK
Wider context from the report “I understand that there is currently no British or European (e.g. BSI or PAS) standard to control what lithium ion e-bike batteries and chargers can be sold in the UK .
” 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 Designate the BS EN 15194 e-bike standard, subject to stated restrictions, to provide a presumption of legal conformity.
Verbatim wording from the response “While the creation of new voluntary standards is a matter for the British Standards Institution (BSI), we will carefully consider any relevant recommendations made by WMG. OPSS has already commissioned BSI to develop a Publicly Available Specification for e-bikes, e-scooters, their batteries, and conversion kits and related products, which we hope to be in place in the next 18 months. OPSS has previously designated, with restrictions, the standard BS EN 15194 for e-bikes, which gives products that meet the standard a presumption of conformity with the law (except in regard to the clauses restricted under the designation). However, whether businesses choose to follow a standard remains voluntary, and they must still meet all their obligations in law.” 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 Launch a new consumer safety campaign about purchasing e-bikes and e-scooters.
Verbatim wording from the response “OPSS has also been actively raising awareness of the risks that these products can pose. In December 2023, OPSS published a Government safety message on e-bikes and e-scooters with recommendations on the steps consumers can take to reduce fire risks if they purchase, use or charge an e-bike or e-scooter. The steps include always following the manufacturer’s instructions for charging and using the products; checking and only using the manufacturer’s recommended battery and charger; never attempting to tamper with or alter the battery or charger; and unplugging the battery when charging has finished. We are planning a new safety campaign with consumer messaging on purchasing e-bikes and e-scooters, which we expect to be launched in the autumn.” 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 Engage major gig-economy delivery firms to encourage wider dissemination of e-bike and battery safety information to riders and couriers.
Verbatim wording from the response “OPSS is engaging with major gig economy delivery firms, such as Uber Eats and Deliveroo, to encourage wider dissemination of safety information about e-bikes and batteries to delivery riders and couriers, who are key users of these 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 Commission development of a publicly available specification covering e-bikes, e-scooters, batteries, conversion kits and related products.
Verbatim wording from the response “While the creation of new voluntary standards is a matter for the British Standards Institution (BSI), we will carefully consider any relevant recommendations made by WMG. OPSS has already commissioned BSI to develop a Publicly Available Specification for e-bikes, e-scooters, their batteries, and conversion kits and related products, which we hope to be in place in the next 18 months. OPSS has previously designated, with restrictions, the standard BS EN 15194 for e-bikes, which gives products that meet the standard a presumption of conformity with the law (except in regard to the clauses restricted under the designation). However, whether businesses choose to follow a standard remains voluntary, and they must still meet all their obligations in law.” 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 Coordinate with Government departments to support consumer safety messaging for e-bikes and e-scooters.
Verbatim wording from the response “OPSS has also joined up with other Government Departments to support consumer safety messaging for e-bikes, including Department for Transport guidance, published in February this year: www.gov.uk/government/news/new-guidance-to-enhance-e-bike-and-e-scooter-safety and ‘Fire England’ guidance published by the Home Office last year: www.fireengland.uk/news/how-keep-your-home-safe-when-charging-your-e-bike-or-e-scooter.” 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 Consider relevant recommendations from the commissioned research on potential changes to voluntary product standards.
Verbatim wording from the response “While the creation of new voluntary standards is a matter for the British Standards Institution (BSI), we will carefully consider any relevant recommendations made by WMG. OPSS has already commissioned BSI to develop a Publicly Available Specification for e-bikes, e-scooters, their batteries, and conversion kits and related products, which we hope to be in place in the next 18 months. OPSS has previously designated, with restrictions, the standard BS EN 15194 for e-bikes, which gives products that meet the standard a presumption of conformity with the law (except in regard to the clauses restricted under the designation). However, whether businesses choose to follow a standard remains voluntary, and they must still meet all their obligations in law.” 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 Conduct commissioned research into e-bike and e-scooter hazards, compatibility issues and relevant standards, pending independent peer review and publication.
Verbatim wording from the response “In your report, you have raised a concern over a lack of understanding of risks in this area and the lack of a specific British Standard for e-bike batteries and chargers. Our research and evidence points to complexity with the products and associated components, which may be safe when placed on the market but may become unsafe if modified or non-compatible replacement batteries or chargers are used. As part of our e-bike programme, OPSS commissioned a research study from Warwick Manufacturing Group (WMG) into potential hazards and risks from e-bikes and e-scooters, including their batteries. This includes compatibility issues as well as an assessment of all relevant standards, to identify any areas where changes to voluntary standards could assist businesses to comply with the law. We expect the research to be published soon, once it has completed independent peer reviews.” 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 Publish consumer safety messaging with recommendations to reduce e-bike and e-scooter fire risks.
Verbatim wording from the response “OPSS has also been actively raising awareness of the risks that these products can pose. In December 2023, OPSS published a Government safety message on e-bikes and e-scooters with recommendations on the steps consumers can take to reduce fire risks if they purchase, use or charge an e-bike or e-scooter. The steps include always following the manufacturer’s instructions for charging and using the products; checking and only using the manufacturer’s recommended battery and charger; never attempting to tamper with or alter the battery or charger; and unplugging the battery when charging has finished. We are planning a new safety campaign with consumer messaging on purchasing e-bikes and e-scooters, which we expect to be launched in the autumn.” 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 Creation of new voluntary standards is a matter for the British Standards Institution, while OPSS will consider relevant research recommendations.
Verbatim wording from the response “While the creation of new voluntary standards is a matter for the British Standards Institution (BSI), we will carefully consider any relevant recommendations made by WMG. OPSS has already commissioned BSI to develop a Publicly Available Specification for e-bikes, e-scooters, their batteries, and conversion kits and related products, which we hope to be in place in the next 18 months. OPSS has previously designated, with restrictions, the standard BS EN 15194 for e-bikes, which gives products that meet the standard a presumption of conformity with the law (except in regard to the clauses restricted under the designation). However, whether businesses choose to follow a standard remains voluntary, and they must still meet all their obligations in law.” Source location Response from OPSS
Open published response
4 Jan 2024 Bobby LEE otherwise known as Kim Sing Lee · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 6 Failure to supply chargers with lithium-ion batteries for e-bike conversion kits View source Insufficient controls governing the UK sale of lithium-ion batteries and chargers for electric powered personal vehicles and e-bike conversion kits View source Failure of chargers sold on online marketplaces to meet appropriate standards View source Lack of British or European standards specific to e-bike conversion kits and chargers View source Inferior quality and construction of lithium-ion batteries in e-bike conversion kits View source Universal charging connectors allowing over-rated chargers to be connected to lower-power batteries View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bobby LEE otherwise known as Kim Sing Lee · 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
Bobby Lee died at home on 6 July 2023 from smoke inhalation and severe burn injuries after a house fire caused by the over-charging of a lithium-ion e-bike battery with an unsuitable charger. The report identifies concerns about the safety and quality of e-bike conversion kits, battery chargers and online marketplace sales, including the absence of sufficient standards and controls and the risk of incompatible chargers causing battery fires and further deaths.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to supply chargers with lithium-ion batteries for e-bike conversion kits
Wider context from the report “• Lithium-ion batteries sold as part of e-bike conversion kits are regularly sold/supplied without a charger , thereby increasing the risk of an unsuitable charger being purchased and used.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Insufficient controls governing the UK sale of lithium-ion batteries and chargers for electric powered personal vehicles and e-bike conversion kits
Wider context from the report “In addition to the above, I am also aware that the OPSS established a multi-disciplinary safety study to understand data and evidence of risks in this area, as well as commissioning new research into battery safety, including compatibility issues, from Warwick Manufacturing Group (part of Warwick University). However, I do not know the progress or timescales involved in this review and research. It is clear to me though that there is a substantial existing, ongoing and future risk of further deaths while it continues to be the case that there are no, or insufficient, controls and/or standards governing the sale in the UK of lithium-ion batteries and chargers for electric powered personal vehicles and e-bike conversion kits .
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure of chargers sold on online marketplaces to meet appropriate standards
Wider context from the report “• Chargers for sale on online marketplaces, in particular, regularly fail to meet appropriate standards. In this case, the charger purported to carry the European ‘CE’ mark, which should be an indication that the product conforms to European health, safety and environmental protection standards; however, the Fire Investigation Officer noted that the mark was slightly different and therefore not genuine . It was used instead to denote ‘Chinese Export’.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of British or European standards specific to e-bike conversion kits and chargers
Wider context from the report “• There is currently no British or European (e.g. BSI or PAS) standard specific to e-bike conversion kits and/or chargers and consequently:
- It is relatively easy for people to buy, particularly from online marketplaces, e-bike conversion kits and/or lithium-ion batteries that are not of sufficient quality or otherwise not of an appropriate standard to charge safely.
- There is an increased risk of people mixing and matching lithium-ion batteries with chargers that carry a different voltage rating.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Inferior quality and construction of lithium-ion batteries in e-bike conversion kits
Wider context from the report “• That lithium-ion batteries sold as part of so-called e-bike conversion kits, tend to be of a significantly inferior quality and construction when compared to the battery packs manufactured and installed in purpose-built e-bikes.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Universal charging connectors allowing over-rated chargers to be connected to lower-power batteries
Wider context from the report “• The presence of universal charging connectors across batteries of different voltages means that there is a significant risk that over-rated chargers can be inadvertently connected to lower power batteries , which was the case in the fire that led to Mr Lee’s death.
” 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 Assess compliance among 60 UK-based businesses supplying e-bikes, e-scooters or conversion kits.
Verbatim wording from the response “OPSS is also assessing the compliance of 60 UK-based businesses involved in the supply chain of e-bikes, e-scooters or conversion kits.” Source location Response from Product Safety and 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 Hold initial discussions with BSI on preparing a fast-track publicly available specification for conversion-kit technical and safety standards.
Verbatim wording from the response “I am able to provide an update on a new fast-track standard for conversion kits. I can confirm we have held initial discussions with the British Standards Institution (BSI), the UK’s national standards-setting body responsible for introducing new standards, on the preparation of a publicly available specification (PAS) to cover technical and safety standards for conversion kits. This new standard will not change the existing legal requirements, and, like the vast majority of standards, it will be voluntary. However, it will function to create and communicate expectations in this important market area and assist businesses in meeting the existing legal safety requirements for conversion kits. All British Standards are drawn up by committees and made by consensus which necessarily takes time.” Source location Response from Product Safety and 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 Work with WMG to bring forward and share robust insights from research into e-bike and e-scooter batteries, including compatibility issues.
Verbatim wording from the response “In your report you refer to the research commissioned by OPSS from Warwick Manufacturing Group (WMG) into batteries used in e-bikes and e-scooters. This is a wide-ranging and comprehensive project and includes examination of compatibility issues. We are working with WMG to bring forward and share insights from this research as quickly as possible, while ensuring the evidence base is robust and rigorous. We expect WMG to deliver their final report later this year, but in the interim OPSS intends to share early insights from this work across government and through our stakeholder network so it can feed into our understanding of risk and our enforcement and policy priorities. We can write to you again and share this report once it has been published.” Source location Response from Product Safety and 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 Enforce product-safety requirements by removing unsafe or non-compliant e-bikes, e-scooters, batteries and conversion kits from the market.
Verbatim wording from the response “These requirements are enforced by both Local Authority Trading Standards and OPSS. Action is being taken to remove unsafe or non-compliant products from the market. Ten separate product recalls and nine other enforcement actions for unsafe or non-compliant e-bikes or e-scooters have been published by OPSS since March last year. Last month, OPSS took enforcement action to remove from the market two dangerous models of e-bike batteries manufactured by Unit Power Pack (UPP), which posed a serious risk to users, including potential fatalities. OPSS has issued Withdrawal Notices to 20 distributors and one manufacturer, including major online marketplaces, requiring them to stop the immediate” Source location Response from Product Safety and Standards
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.
×
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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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
×
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 Consider restricting the designation of EN71 because it lacks helium inhalation warnings.
Verbatim wording from the response “OPSS has powers to restrict designated standards and we are considering placing a restriction on EN71 given the current absence of helium inhalation warnings. We would set out our rationale for this restriction with accompanying guidance aimed at ensuring compliance with the TSR.” Source location Response from Product Safety and 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 Write to the British Standards Institution recommending consideration of updating EN71 to address helium inhalation risks to children.
Verbatim wording from the response “OPSS will write to the British Standards Institution, as the UK’s national standards setting body, to recommend it considers updating the standard to reflect the risks of helium inhalation to children.” Source location Response from Product Safety and 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 Responsibility for toy safety rests with businesses placing toys on the market, while voluntary standards only help demonstrate regulatory compliance.
Verbatim wording from the response “While standards are voluntary they can be used by businesses to help demonstrate how they comply with the law. The government is able to ‘designate’ certain voluntary standards which, when followed by manufacturers of relevant products, confer on those products a rebuttable presumption of conformity with relevant regulations. Overriding this, as above, is the essential safety requirement that all toys placed on the market are safe when it is reasonably foreseeable that they are intended to be used by children. While designated standards can help manufacturers understand and meet their obligations in those regulations, the responsibility of safety rests with those who place toys on the market. OPSS has identified that the Toy Safety Standard EN71, which is currently designated, does not require warnings to be provided on helium-filled balloons about the risks of helium inhalation.” Source location Response from Product Safety and Standards
Open published response
29 Aug 2023 Mizanur RAHMAN · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 2 Failure to prevent mixing lithium ion batteries with chargers carrying different voltage ratings View source Lack of standards controlling the sale of lithium ion e-bike batteries and chargers for safe charging quality View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Mizanur RAHMAN · 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
Mizanur Rahman died on 9 March 2023 at the Royal London Hospital after being overcome by smoke during a fire at the multi-occupancy flat where he lived. The fire was attributed to a faulty lithium ion e-bike battery, with evidence indicating that the battery and charger probably carried different voltage ratings. The report raised concerns about the absence of British or European standards governing the sale of lithium ion e-bike batteries, chargers and conversion kits, and the resulting risk of further deaths.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent mixing lithium ion batteries with chargers carrying different voltage ratings
Wider context from the report “That there is presently no British or European (e.g. BSI or PAS) standard to control what lithium ion e-bike batteries and chargers can be sold in the UK and that, consequently:
o It is easy for people to buy (including online) lithium ion batteries that are not of sufficient quality or otherwise not of an appropriate standard to charge safely.
o There is an increased risk of people mixing and matching lithium ion batteries with chargers that carry a different voltage rating.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of standards controlling the sale of lithium ion e-bike batteries and chargers for safe charging quality
Wider context from the report “That there is presently no British or European (e.g. BSI or PAS) standard to control what lithium ion e-bike batteries and chargers can be sold in the UK and that, consequently:
o It is easy for people to buy (including online) lithium ion batteries that are not of sufficient quality or otherwise not of an appropriate standard to charge safely.
o There is an increased risk of people mixing and matching lithium ion batteries with chargers that carry a different voltage rating.
” 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 Seek stakeholder input and expertise to understand and address complex e-bike safety issues.
Verbatim wording from the response “OPSS has established a multi-disciplinary safety study to understand data and evidence of risks in this area and we have commissioned new research into battery safety, including compatibility issues, from Warwick Manufacturing Group (WMG - part of Warwick University). We are seeking the input and expertise of stakeholders including Electrical Safety First, the Fire and Rescue Services, the National Fire Chiefs Council, and the London Fire Brigade so we can better understand and tackle the complex issues involved.” Source location Response from Product Safety and 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 Review relevant voluntary e-bike safety standards to identify where additional or updated standards would support legal safety requirements.
Verbatim wording from the response “I can also confirm that OPSS is reviewing all relevant voluntary standards in this area to identify any areas where additional or updated standards would be beneficial to support the essential safety requirements in the law.” Source location Response from Product Safety and 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 Establish a multidisciplinary safety study on risks associated with e-bikes, batteries, modifications and combinations of products.
Verbatim wording from the response “OPSS has established a multi-disciplinary safety study to understand data and evidence of risks in this area and we have commissioned new research into battery safety, including compatibility issues, from Warwick Manufacturing Group (WMG - part of Warwick University). We are seeking the input and expertise of stakeholders including Electrical Safety First, the Fire and Rescue Services, the National Fire Chiefs Council, and the London Fire Brigade so we can better understand and tackle the complex issues involved.” Source location Response from Product Safety and 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 Publish consumer information on safe purchasing, use and charging of e-bikes and e-scooters.
Verbatim wording from the response “Ensuring consumers have access to clear and accurate information on safety issues is also a priority. In September OPSS published information for consumers to raise awareness of safe purchasing, use and charging practices and to draw attention to the new Fire England guidance on safe charging published in August.” Source location Response from Product Safety and 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 Commission research into battery safety, including compatibility issues, through Warwick Manufacturing Group.
Verbatim wording from the response “OPSS has established a multi-disciplinary safety study to understand data and evidence of risks in this area and we have commissioned new research into battery safety, including compatibility issues, from Warwick Manufacturing Group (WMG - part of Warwick University). We are seeking the input and expertise of stakeholders including Electrical Safety First, the Fire and Rescue Services, the National Fire Chiefs Council, and the London Fire Brigade so we can better understand and tackle the complex issues involved.” Source location Response from Product Safety and 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 Publish the updated EN 15194:2017+A1:2023 standard for electrically power-assisted bicycles for designation.
Verbatim wording from the response “On 20 October OPSS published for designation, updated standard EN 15194:2017+A1:2023 for Electrically Power Assisted Bicycles. The previous version of this standard did not adequately address the safe integration of batteries into battery packs and the incorporation of battery packs into an end-device. As a result, it was designated by government with a restriction that meant that manufacturers had to go beyond the requirements of the standard to comply with the essential safety requirements in the law. Improvements to the standard have been made by the standards bodies and we are satisfied that it now meets the essential safety requirements with regards to battery safety. As a result, we plan to remove the restriction that applied to battery packs so that manufacturers who follow the designated parts of the standard would be presumed to comply with legal requirements for safety.” Source location Response from Product Safety and 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 Prioritise identifying and testing e-bikes, conversion kits and chargers, removing unsafe products from the market through enforcement.
Verbatim wording from the response “OPSS and Local Authority Trading Standards (LATS) have access to powers to enforce the law and we are prioritising action to identify and test e-bikes, modification kits and chargers so that products found to be unsafe are removed from the market.” Source location Response from Product Safety and Standards
Open published response
20 Apr 2023 CHESTER ALAN STANLEY MOSSOP · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Lack of national provision of safe bath-seat-use advice to healthcare professionals and parents or carers View source Bath seats creating a false sense of security despite not being safety devices View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
CHESTER ALAN STANLEY MOSSOP · 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
Chester was a nine-month-old baby who drowned after being left alone in a bath seat that became unfixed. He sustained a severe brain injury and died on 3 June 2022. The principal concern was that bath seats may create a false sense of security, despite not being safety devices, and that national advice about their risks and safe use may not be consistently provided.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Lack of national provision of safe bath-seat-use advice to healthcare professionals and parents or carers
Wider context from the report “I am aware of similar tragic deaths to Chester’s and inquests held by my fellow Coroners. RoSPA is also aware of fatal and non-fatal incidents.
The use of bath seats is of concern to RoSPA.
Whilst I am aware of the regional Bath Safety Advice (set out above), I am not aware that similar advice has been distributed on a national level to healthcare professionals and to parents / carers. I am not aware whether parents / carers are provided with advice about the safe use of bath seats as part of e.g. health visits.
I am concerned that bath seats may given parents a false sense of security that their child is safe. Bath seats are not safety devices.
” 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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Bath seats creating a false sense of security despite not being safety devices
Wider context from the report “I am aware of similar tragic deaths to Chester’s and inquests held by my fellow Coroners. RoSPA is also aware of fatal and non-fatal incidents.
The use of bath seats is of concern to RoSPA.
Whilst I am aware of the regional Bath Safety Advice (set out above), I am not aware that similar advice has been distributed on a national level to healthcare professionals and to parents / carers. I am not aware whether parents / carers are provided with advice about the safe use of bath seats as part of e.g. health visits.
I am concerned that bath seats may given parents a false sense of security that their child is safe. Bath seats are not safety devices.
” 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 Work with the Baby Products Association to remind members about safe-use instructions and improve the clarity and prominence of baby bath seat warnings.
Verbatim wording from the response “We will also work with the Baby Products Association (BPA), the relevant trade association for the sector, to ask them to remind their members of the requirements for including appropriate instructions for safe use and to ensure that any safety warnings for baby bath seats are suitably clear and prominent. We have worked closely with the National Health Service (NHS) on our programme of activity on the safety of baby products and will ask them to consider whether there is an opportunity to include safety messages related to baby bath seats through their communications with healthcare professionals and new parents.” 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 Ask the NHS to consider including baby bath seat safety messages in communications with healthcare professionals and new parents.
Verbatim wording from the response “We will also work with the Baby Products Association (BPA), the relevant trade association for the sector, to ask them to remind their members of the requirements for including appropriate instructions for safe use and to ensure that any safety warnings for baby bath seats are suitably clear and prominent. We have worked closely with the National Health Service (NHS) on our programme of activity on the safety of baby products and will ask them to consider whether there is an opportunity to include safety messages related to baby bath seats through their communications with healthcare professionals and new parents.” Source location Response from OPSS
Open published response
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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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.
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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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
28 Jan 2019 Terence Penney · Prevention of Future Deaths report Lincolnshire
View report summary
Concerns raised 1 Domestic fridges in circulation at risk of vapour leaks causing fires 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
Terence Penney · 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
Terence Penney received fatal injuries in a fire at his home on 21 February 2018. The fire followed the accidental ignition of leaking Iso-butane from a domestic refrigerator when he switched on an electric coffee machine. The principal concern was that similar leaks could occur in other refrigerators, including older units, with potentially similar consequences.
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 Office for Product Safety and Standards; that does not assign responsibility.
PFD Monitor interpretation Domestic fridges in circulation at risk of vapour leaks causing fires
Wider context from the report “1. This fire occurred as a result of a vapour leak from a domestic fridge
2. No issue had been detected with the unit previously
3. The unit was barely 5 years old.
4. There was no suggestion that the unit had been abused or worked upon or that the leak arose as a consequence of anything other than a failure of the unit
5. There is likely to be a significant number of these units in circulation, some of them older than that owned by Mr Penney. The possibility of similar leaks occurring elsewhere and with similar tragic consequences must be considered.
” 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.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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 Office for Product Safety and Standards; 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
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations