PFD report

David Joseph HAYES · Prevention of Future Deaths report

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Issued 18 Jul 2025•Manchester West

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.

View original report
Concerns
4

Raised in this report

Recipients
2

Named on the report

Responses found
3

Of 2 recipients

Stated actions
8

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 raised4

  1. Failure of washing detergent containers to restrict access by vulnerable adults or children
    Part of recurring concern: Failure to prevent vulnerable people from ingesting hazardous cleaning products
  2. Insufficient labelling warnings about risks to vulnerable adults and children
    Part of recurring concern: Failure to prevent vulnerable people from ingesting hazardous cleaning products
  3. Washing detergent packaging resembling items that vulnerable adults may confuse it with
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.8

  1. Action

    Review detergents regulations with industry, considering legislative amendments and alternative measures to improve consumer safety.

    Stated by Department for Environment, Food & Rural AffairsStated plannedThe respondent said that this action was planned when they made their response on 25 July 2025.
  2. Action

    Have Dementia UK’s lived-experience panel review the campaign’s safety products and collateral for relevance to people with dementia, families and professionals.

    Stated by Dementia UKStated in progressThe respondent said that this action was in progress when they made their response on 25 July 2025.
  3. Action

    Provide home-safety information on laundry products through the “Keeping safe at home” leaflet.

    Stated by Dementia UKStated completedThe respondent said that this action was complete when they made their response on 25 July 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Defra does not enforce product safety regulations and directs relevant product information to local authority trading standards.

    Stated by Department for Environment, Food & Rural AffairsRedirects 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 washing detergent containers to restrict access by vulnerable adults or children

Wider context from the report

“1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge. 2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease. 3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death. 4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because: a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk b. The shape of the packaging could be misconstrued in these circumstances c. The screw top lid with no child or resistance protection is easily accessible. 5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children. 6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible. ”

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

Insufficient labelling warnings about risks to vulnerable adults and children

Wider context from the report

“1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge. 2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease. 3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death. 4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because: a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk b. The shape of the packaging could be misconstrued in these circumstances c. The screw top lid with no child or resistance protection is easily accessible. 5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children. 6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible. ”

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

Washing detergent packaging resembling items that vulnerable adults may confuse it with

Wider context from the report

“1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge. 2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease. 3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death. 4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because: a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk b. The shape of the packaging could be misconstrued in these circumstances c. The screw top lid with no child or resistance protection is easily accessible. 5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children. 6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible. ”

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 public awareness of the need to safeguard detergents from vulnerable adults

Wider context from the report

“1. During the course of evidence it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge. 2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child enabling the contents able to be consumed with apparent ease. 3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death. 4. In my judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because: a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused - here milk b. The shape of the packaging could be misconstrued in these circumstances c. The screw top lid with no child or resistance protection is easily accessible. 5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children. 6. The public knowledge of these risks is not likely to be at a level where households in which vulnerable adults reside are aware of the need to safeguard detergents and make them less accessible. ”

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 respondent action was interpreted

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

PFD Monitor interpretation

Review detergents regulations with industry, considering legislative amendments and alternative measures to improve consumer safety.

Verbatim wording from the response

“Whilst both regulatory and non-regulatory measures already exist to provide consumer protections, including for vulnerable people, Defra, working with colleagues across government as needed, will consider whether there are opportunities for improvements to these measures. In line with the UK government’s ‘new approach to ensure regulators and regulation support growth’, Defra aims to review our detergents regulations to consider whether any amendments are needed to improve our detergents regime. We will engage with the detergents industry to inform this work. In line with the Better Regulation Framework, whilst our policy review aims primarily to consider legislative changes, we will also consider alternative measures to regulation such as industry codes of conduct or standards that may be applicable.”

Source location

Response from Department for Environment, Food & Rural Affairs
Page 4 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Have Dementia UK’s lived-experience panel review the campaign’s safety products and collateral for relevance to people with dementia, families and professionals.

Verbatim wording from the response

“I have personally been involved in making sure that the campaign supports people with dementia, their families and professionals; and members of our Lived Experience Advisory Panel (made up people with dementia and carers) have actively been reviewing the campaign products and collateral. I hope that this UKCPI led campaign, supported by Dementia UK and others, will further reinforce the public safety messages around safe use and storage on laundry products.”

Source location

Response from Dementia UK
Page 1 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide home-safety information on laundry products through the “Keeping safe at home” leaflet.

Verbatim wording from the response

“It is something that we have seen in previous future death notifications, and as a specialist dementia nursing charity we believe we have a key role in promoting safe use and storage of laundry products. We have undertaken a number of actions to raise awareness of the issue. Our leaflet (Keeping safe at home) provides information on this topic and how people with dementia, their families and professionals can keep safe in the home.”

Source location

Response from Dementia UK
Page 1 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Engage with UKCPI to support development of a national laundry-product safety awareness campaign for the public and professionals.

Verbatim wording from the response

“In addition, we have been actively engaging with the UK Cleaning Products Industry Association (UKCPI) to support them in their development of a wide-ranging safety awareness campaign that will seek to raise these issues further with the public and professionals alike. The campaign will involve several different activities, products and collateral that will be shared nationally.”

Source location

Response from Dementia UK
Page 1 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Promote safe household chemical storage through guidance and public messaging, including original containers, separation from food and medicines, and marked cupboards.

Verbatim wording from the response

“Our guidance promotes safe storage practices, such as keeping chemicals in their original containers, storing them separately from food and medicines, and using clearly marked cupboards with written or visual signage to indicate their contents. We also encourage manufacturers and regulators to review packaging and labelling practices——avoiding designs that resemble food or drink containers in particular - and to expand existing warnings and plain-language instructions to include the risk posed to vulnerable adults.”

Source location

Response from RoSPA
Page 2 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop practical guidance for carers on safely storing and handling hazardous household substances.

Verbatim wording from the response

“• The development of practical guidance for carers on safer storage of these products within the home.”

Source location

Response from RoSPA
Page 2 · response
Published 25 July 2025

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Deliver a national social media campaign raising awareness of household chemical risks for people with dementia.

Verbatim wording from the response

“• A targeted social media campaign to raise awareness about the risks posed by household chemicals to those with cognitive impairment”

Source location

Response from RoSPA
Page 2 · response
Published 25 July 2025

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 manufacturers and regulators to encourage packaging that avoids food or drink resemblance and clearer warnings addressing risks to vulnerable adults.

Verbatim wording from the response

“Our guidance promotes safe storage practices, such as keeping chemicals in their original containers, storing them separately from food and medicines, and using clearly marked cupboards with written or visual signage to indicate their contents. We also encourage manufacturers and regulators to review packaging and labelling practices——avoiding designs that resemble food or drink containers in particular - and to expand existing warnings and plain-language instructions to include the risk posed to vulnerable adults.”

Source location

Response from RoSPA
Page 2 · response
Published 25 July 2025

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Defra does not enforce product safety regulations and directs relevant product information to local authority trading standards.

Verbatim wording from the response

“GB product safety regulations require all consumer products to be safe when they are placed on the market. This includes regulations covering products that could be mistaken for food items and may cause harm if ingested, as noted above. There is not enough detailed information in your report to determine the extent to which products have complied with all the regulations noted above. Defra does not hold responsibility for enforcement of these regulations, but I have made the Office for Product Safety and Standards aware of this case. You may wish to consider passing any relevant information about the specific product in this case to the relevant local authority trading standards department.”

Source location

Response from Department for Environment, Food & Rural Affairs
Page 4 · response
Published 25 July 2025

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

HSE considers legislative change unnecessary because there is no evidence that this case represents a widespread problem.

Verbatim wording from the response

“Compliance with the requirements of GB CLP Regulation is enforced by various authorities covering a range of different supply contexts. Instances of non-compliance are subject to proportionate and pragmatic enforcement action which ensures that the risk of harm emanating from chemicals supplied in GB is minimised. There is no evidence to demonstrate that the circumstances of this case represent a more widespread problem and therefore HSE do not consider that changes to the legislation need to be considered at this time.”

Source location

Response from Department for Environment, Food & Rural Affairs
Page 3 · response
Published 25 July 2025

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Packaging design concerns requiring action must be considered under detergent-specific legislation, which is Defra’s responsibility, rather than CLP.

Verbatim wording from the response

“The GB CLP Regulation, which is the responsibility of HSE, supports sector specific legislation. HSE have advised that any action deemed necessary to resolve the concerns raised in this case would need to be considered in relation to legislation specific to detergents, which supersedes the general legislative provisions of GB CLP. For example, for concern 6, CLP does not seek to identify or communicate risk factors (e.g. exposure to vulnerable adults).”

Source location

Response from Department for Environment, Food & Rural Affairs
Page 3 · response
Published 25 July 2025

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Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

CLP-related concerns are HSE’s responsibility, so HSE provided the response rather than Defra.

Verbatim wording from the response

“Thank you for your Regulation 28 report in relation to the death of David Joseph Hayes, dated July 18th 2025. Your report was addressed to the Secretary of State for Defra (being the Government department with responsibility for the regulation of Detergents). I am responding as the Deputy Director with responsibility for Chemicals, which includes Detergents policy and regulation. I have consulted with the Health and Safety Executive (HSE) as some of the issues raised fall within their remit as a regulator for the supply of chemicals in Great Britain (GB). Specifically in reference in this response, HSE have responsibility for Classification, Labelling and Packaging (CLP) regulations so they and not Defra have provided the text for the response in relation to this area.”

Source location

Response from Department for Environment, Food & Rural Affairs
Page 1 · response
Published 25 July 2025

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