Terence Penney · Prevention of Future Deaths report

On 19 March 2018 I commenced an investigation into the death of Terence Penney. He was 73 years of age. The investigation concluded at the end of the inquest on 17 January 2019. The conclusion of the inquest was that Mr Penney died as a result of an accident, the medical cause of death being:

1a. Multiple Organ failure

1b 48% total body surface area burn injury

1. On 21 February 2018 a fire occurred at Mr Penney's home in Mablethorpe, Lincolnshire within which he received fatal injuries.

2 The cause of the fire was identified as being a vapour cloud deflagration caused by the accidental ignition of R660A Iso-butane leaking from a LEC model R 5010W refrigerator owned by Mr Penney and used at the premises.

3 The unit had been purchased as new on 20.02.13 and was therefore 5 years old.

4 An examination of the unit after the fire identified 3 separate leaks within the unit;
a) 1 at the bottom of the dryer component
b) 1 on the suction pipe (side) out of the compressor
c) 1 on an inline joint.

5. The fire occurred when Mr Penney switched on an electric coffee machine. The spark produced ignited the flammable atmosphere of escaped Iso-butane causing a vapour explosion.

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.