Investigation and inquest
On 24th February 2017 I commenced an Investigation into the death of BRIAN DAVID BETTERTON aged 79 years. The Investigation concluded at the end of the inquest on 24th August 2017. The conclusion of the Inquest was ACCIDENTAL DEATH. The medical cause of death was:
I (a) Carbon Monoxide Poisoning
I (b)
I (c)
II Atherosclerosis
Circumstances of the death
At an unknown date an unknown person fitted a new fuse box to the property known as ████████
Subsequently a Product Recall Notice was issued for Electrium Miniature Circuit Breakers due to a potential risk of burning.
On the morning of the 20th February 2017 the Electrium Miniature Circuit Breaker at the deceased’s home began to short and a small smouldering fire occurred resulting in carbon monoxide being released. The Deceased died in his bedroom from carbon monoxide exposure. His body was discovered several hours later when a passer-by noticed it was very dark in the deceased’s kitchen; in fact this was soot coating the glass. The fire had extinguished itself causing relatively little damage.
Coroner’s concerns
1. The Product Recall relates to a product supplied between April 2009 and February 2010.
2. The Product Recall did not come to the attention of the deceased.
3. In the majority of cases the end user of the product will not have purchased or fitted the product.
4. The Product Recall therefore is dependent upon identifying the person who actually purchased the product.
5. The purchaser is likely to be a professional electrician, yet is not required to keep a register of such items that he/she purchased and fitted nor is he/she required to inform the supplier/manufacturer of the details of the end user.
6. As a consequence it seems that the Product Recall was always likely to be ineffective. (It would be interesting to know how many products the manufacturer thought were affected and how many responses they had to the Product Recall Notice).
7. It seems to me that these concerns are not unique to fuse boxes, but that there are many potentially lethal products which are fitted into domestic properties which are purchased by a third party rather than the occupier.