PFD report

Elizabeth Van Der Drift · Prevention of Future Deaths report

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Issued 13 Aug 2024•Inner North London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 recipients

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure of product appearance and packaging to avoid confusion with food
    Part of recurring concern: Failure to prevent vulnerable people from ingesting hazardous cleaning products
  2. Production of laundry tablets/pods and packaging that can be confused with food by people with cognitive impairment
  3. Lack of packaging design features that make accessing laundry tablets/pods difficult
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Continue working with trading standards and local authorities to address breaches of the GB CLP Regulation.

    Stated by Health and Safety ExecutiveStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2024.
  2. Action

    Continue reviewing whether further regulatory measures are needed for laundry detergent packaging.

    Stated by Health and Safety ExecutiveStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2024.
  3. Action

    Replace plastic packaging with a cardboard box incorporating a child-impeding closure and test it against the AISE Child-Impeding Closures protocol.

    Stated by Sainsbury’s Group Legal ServicesStated completedThe respondent said that this action was complete when they made their response on 14 August 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.9

  1. Position

    Parents, support staff and carers should identify hazards and implement safeguarding, including restricting access through safe storage, for vulnerable individuals.

    Stated by Health and Safety ExecutiveRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to prevent vulnerable people from ingesting hazardous cleaning products.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to prevent vulnerable people from ingesting hazardous cleaning products.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 working with trading standards and local authorities to address breaches of the GB CLP Regulation.

Verbatim wording from the response

“HSE is not proposing additional provisions to the GB CLP Regulation but will continue to keep the position under review, including whether further regulatory measures might be needed. HSE will continue to work with bodies that enforce CLP, including trading standards and local authorities to address breaches of the regulation.”

Source location

Response from HSE
Page 3 · response
Published 14 August 2024

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

Continue reviewing whether further regulatory measures are needed for laundry detergent packaging.

Verbatim wording from the response

“HSE is not proposing additional provisions to the GB CLP Regulation but will continue to keep the position under review, including whether further regulatory measures might be needed. HSE will continue to work with bodies that enforce CLP, including trading standards and local authorities to address breaches of the regulation.”

Source location

Response from HSE
Page 3 · response
Published 14 August 2024

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

Replace plastic packaging with a cardboard box incorporating a child-impeding closure and test it against the AISE Child-Impeding Closures protocol.

Verbatim wording from the response

“We have since changed our packaging to remove plastic packaging to a cardboard box with a child impeding closure. The new cardboard box has undergone testing in line with the AISE Test Protocol for Child-Impeding Closures (CIC) and the product continues to meet the LDC PSP guidance.”

Source location

Response from Sainsburys
Page 2 · response
Published 14 August 2024

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

Maintain the Product Stewardship Programme’s safety requirements for liquid laundry detergent capsules, including child-resistant packaging, safety messaging and advertising controls.

Verbatim wording from the response

“a. Due to growing concern by the industry over the accidental exposures, in 2012 AISE, the European trade association for detergent manufacturers, established its own voluntary set of safety measures. This is named the Product Stewardship Programme (PSP) for Liquid Detergent Capsules.”

Source location

Response from UKCPI
Page 2 · response
Published 14 August 2024

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

Parents, support staff and carers should identify hazards and implement safeguarding, including restricting access through safe storage, for vulnerable individuals.

Verbatim wording from the response

“Where an individual is unable to identify hazard communicated through the label, parents, support staff or carers for vulnerable persons should make that identification on their behalf and implement safeguarding measures for that individual, including restricting access through safe storage, whether in the home, residential care or care home.”

Source location

Response from HSE
Page 3 · response
Published 14 August 2024

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 regulatory provisions are considered an adequate response; no additional GB CLP provisions are proposed, though the position remains under review.

Verbatim wording from the response

“I hope this information addresses your concerns and reassures you as to the existing regulatory provisions that are in place on the design and safety features of the packaging of laundry tablets/pods for consumers.”

Source location

Response from HSE
Page 2 · response
Published 14 August 2024

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 packaging did have a child-impeding safety feature, contrary to the concern that no such feature was observed.

Verbatim wording from the response

“2. There was no safety feature observed on the packaging that made accessing the content particularly difficult, which increases the risk of accidental or inadvertent ingestion.”

Source location

Response from Sainsburys
Page 2 · response
Published 14 August 2024

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 packaging controls, safety labelling, bittering agent and voluntary product-safety guidance are considered sufficient, so no further action is required.

Verbatim wording from the response

“Sainsbury’s and their suppliers adhere to the A.I.S.E. Liquid Detergent Capsule Product Stewardship Programme (LDC PSP) guidance in this area. For over 30 years, A.I.S.E. have made continual commitments on product safety that go beyond legislation and have launched a range of voluntary initiatives to engage with consumers and professional users on safe and sustainable habits, use and disposal of products and packaging. This voluntary product safety initiative includes guidance for retailers and producers of detergent capsules, which aims to support safe use and storage of LDCs by consumers to significantly reduce the incidence of accidental exposure to these products, in particular involving young children.”

Source location

Response from Sainsburys
Page 1 · response
Published 14 August 2024

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

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
Page 1 · response
Published 14 August 2024

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
Page 1 · response
Published 14 August 2024

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 evidence does not show that capsule colour causes accidental exposure or makes capsules likely to be confused with food.

Verbatim wording from the response

“a. The Coroner specifically references LLDC ‘as being colourful and potentially sweet-like in their appearance’. The bright colour of capsules was also claimed to be a factor in infant poisonings and led to a body of research work and an EU Commission report concluding that there was no discernible colour preference when infants were exposed to a range of coloured household laundry products.”

Source location

Response from UKCPI
Page 7 · response
Published 14 August 2024

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 regulatory and voluntary measures make the product and its packaging inherently safe, keeping accidental ingestion extremely unlikely across age groups.

Verbatim wording from the response

“This loss of inhibition can be gradual, intermittent i.e. extremely difficult to predict and as manufacturers have no control over the product use in the user environment, so the role of the care giver becomes critical in ensuring that the user environment is safe.”

Source location

Response from UKCPI
Page 4 · response
Published 14 August 2024

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 sampled pouch packaging complied with GB CLP requirements and the industry safety programme, contrary to the concern about inadequate access protection.

Verbatim wording from the response

“b. The Coroner specifically mentions ‘no obvious design feature, in terms of the packaging, that makes accessing the content particularly difficult’. This is confusing given the various measure previously described required under CLP.”

Source location

Response from UKCPI
Page 7 · response
Published 14 August 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Promote the awareness campaign to local regulators across the UK through Trading Standards and Environmental Health relationships.

    Stated by Office for Product Safety and StandardsStated plannedThe respondent said that this action was planned when they made their response on 14 August 2024.
  2. 2

    Deliver the Take Action Today home-safety campaign promoting safe storage of household cleaning products to families with infants.

    Stated by The UK Cleaning Products Industry Association (UKCPIStated completedThe respondent said that this action was complete when they made their response on 14 August 2024.
  3. 3

    Explore how an industry-supported safe-storage campaign for caregivers of elderly or cognitively impaired people could be executed through care-sector agencies and charities.

    Stated by The UK Cleaning Products Industry Association (UKCPIStated plannedThe respondent said that this action was planned when they made their response on 14 August 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    The Health and Safety Executive owns the CLP requirements and will separately consider whether they have been met.

    Stated by Office for Product Safety and StandardsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    Care homes are responsible under existing fundamental standards for ensuring premises are safe, including safe chemical storage.

    Stated by The UK Cleaning Products Industry Association (UKCPIRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. 3

    Caregivers are responsible for maintaining a safe user environment because manufacturers cannot control product use in individual care settings.

    Stated by The UK Cleaning Products Industry Association (UKCPIRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Promote the awareness campaign to local regulators across the UK through Trading Standards and Environmental Health relationships.

Verbatim wording from the response

“OPSS will ensure that this campaign is promoted to local regulators across the UK, through our relationships with Trading Standards in Great Britain and Environmental Health in Northern Ireland.”

Source location

Response from OPSS
Page 2 · response
Published 14 August 2024

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

Deliver the Take Action Today home-safety campaign promoting safe storage of household cleaning products to families with infants.

Verbatim wording from the response

“f. In the UK, and in addition to the above voluntary and regulatory requirements, we established a home safety campaign with RoSPA (The Royal Society for the Prevention of Accidents), to promote safe storage in the home.”

Source location

Response from UKCPI
Page 3 · response
Published 14 August 2024

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

Explore how an industry-supported safe-storage campaign for caregivers of elderly or cognitively impaired people could be executed through care-sector agencies and charities.

Verbatim wording from the response

“We believe that in partnership with the appropriate agencies or charities we could research, develop and tailor such a campaign to target care givers in assisted living, independent living, care homes, residential care and in the home of the sufferer to ensure that they are fully aware of the need to ensure safe and secure storage of household cleaning products including LLDC.”

Source location

Response from UKCPI
Page 6 · response
Published 14 August 2024

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 Health and Safety Executive owns the CLP requirements and will separately consider whether they have been met.

Verbatim wording from the response

“ingesting the products such as laundry pods, by requiring manufacturers to take reasonable steps to provide that protection. I know that the Health and Safety Executive, who have ownership of CLP, will be responding to you separately on the consideration of whether the CLP requirements have been met.”

Source location

Response from OPSS
Page 2 · response
Published 14 August 2024

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

Care homes are responsible under existing fundamental standards for ensuring premises are safe, including safe chemical storage.

Verbatim wording from the response

“Speaking to the CQC and charities including RoSPA, Age UK, Dementia UK and The Alzheimer’s Society, there does not seem to be any clear guidance on the safe use or storage of cleaning chemicals in a care environment - be that in the home of a sufferer or in a care home setting (unlike for medicines).”

Source location

Response from UKCPI
Page 5 · response
Published 14 August 2024

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

Caregivers are responsible for maintaining a safe user environment because manufacturers cannot control product use in individual care settings.

Verbatim wording from the response

“This loss of inhibition can be gradual, intermittent i.e. extremely difficult to predict and as manufacturers have no control over the product use in the user environment, so the role of the care giver becomes critical in ensuring that the user environment is safe.”

Source location

Response from UKCPI
Page 4 · response
Published 14 August 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026