PFD report

Sindy Louise Woodhall · Prevention of Future Deaths report

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Issued 1 Jul 2014•Manchester North

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
3

Raised in this report

Recipients
4

Named on the report

Responses found
4

Of 4 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 raised3

  1. Lack of regulation of the sale of large amounts of toxic or potentially fatal gases
    Part of recurring concern: Inadequate controls on the sale and online access to highly toxic substances
  2. Risk to public health from toxic or potentially fatal gases
  3. Lack of Trading Standards powers to take action or prosecute
    Part of recurring concern: Inadequate controls on the sale and online access to highly toxic substances
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.2

  1. Action

    Work with the Department of Health to support restrictions on inappropriate access to volatile substances.

    Stated by Public Health EnglandStated in progressThe respondent said that this action was in progress when they made their response on 1 July 2014.
  2. Action

    Work with the Department of Health to support efforts to restrict inappropriate access to volatile substances.

    Stated by Public Health EnglandStated in progressThe respondent said that this action was in progress when they made their response on 1 July 2014.

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

  1. Position

    The private professional body has no powers to become involved in this matter.

    Stated by Chartered Trading Standards InstituteOutside remitThe respondent said that this matter was outside its role or authority.

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 regulation of the sale of large amounts of toxic or potentially fatal gases

Wider context from the report

“1. During the course of the inquest, it transpired that cans of the aforementioned gases were being sold to the deceased by local retailers who were fully aware of her addiction/problems. Whilst morally reprehensible, there was no law to prevent them from selling large amounts of the toxic/potentially fatal gases to the deceased. 2. Lack of regulation. ”

Is this part of a recurring concern?

Yes — Inadequate controls on the sale and online access to highly toxic substances.

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

Risk to public health from toxic or potentially fatal gases

Wider context from the report

“4. Risk to public health. ”

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 Trading Standards powers to take action or prosecute

Wider context from the report

“3. No powers afforded to Trading Standards to take action/prosecute. ”

Is this part of a recurring concern?

Yes — Inadequate controls on the sale and online access to highly toxic substances.

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 Department of Health to support restrictions on inappropriate access to volatile substances.

Verbatim wording from the response

“We share your concern about abuse of volatile substances (VSA) such as butane and propane and have been working with the Department of Health to support their efforts to restrict inappropriate access to these products. A large number of retailers already restrict access to butane lighter refills and some have committed to restricting the sale of multiple canisters in one transaction. The Association of Convenience Stores (ACS) was asked by the public health minister last year to urge its members to remove accessible displays and restrict sales to one can per customer. ACS reassured the minister that its members already had policies in place to restrict access to butane.”

Source location

2014-0292-Response-by-Public-Health-England
Page 1 · response
Published 1 July 2014

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 the Department of Health to support efforts to restrict inappropriate access to volatile substances.

Verbatim wording from the response

“We share your concern about abuse of volatile substances (VSA) such as butane and propane and have been working with the Department of Health to support their efforts to restrict inappropriate access to these products. A large number of retailers already restrict access to butane lighter refills and some have committed to restricting the sale of multiple canisters in one transaction. The Association of Convenience Stores (ACS) was asked by the public health minister last year to urge its members to remove accessible displays and restrict sales to one can per customer. ACS reassured the minister that its members already had policies in place to restrict access to butane.”

Source location

2014-0292-Response-by-Department-of-Health
Page 3 · response
Published 1 July 2014

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 private professional body has no powers to become involved in this matter.

Verbatim wording from the response

“I would like to take this opportunity to advise you that the Trading Standards Institute is a private company and professional body for trading standards officers, as such this matter is not something that we are able to get involved with as we have no powers, this would be a matter for trading standards departments that are run by local authorities.”

Source location

2014-0292-Response-by-Trading-Standards-Institute
Page 1 · response
Published 1 July 2014

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 this matter rests with trading standards departments run by local authorities.

Verbatim wording from the response

“I would like to take this opportunity to advise you that the Trading Standards Institute is a private company and professional body for trading standards officers, as such this matter is not something that we are able to get involved with as we have no powers, this would be a matter for trading standards departments that are run by local authorities.”

Source location

2014-0292-Response-by-Trading-Standards-Institute
Page 1 · response
Published 1 July 2014

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

Legislative action to regulate these products is a matter for the Department for Business, Innovation and Skills to consider.

Verbatim wording from the response

“I trust the letter you have written to the Department for Business, Innovation and Skills may prompt them to consider legislating in this area.”

Source location

2014-0292-Response-by-Oldham-Council
Page 1 · response
Published 1 July 2014

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

Trading Standards lacks powers to act against retailers selling these products, except where sales to children constitute an offence.

Verbatim wording from the response

“The Council was very sorry to note the death of Sindy under such circumstances. As outlined in your notice your concerns were around the lack of regulation or powers afforded to Trading Standards to take any action against a retailer who, in full knowledge of the addition in this matter, still sold products to her. Whilst it is an offence to sell to a child there are no other powers that we have to take any action. There is also no licensing regime in place to register or licence traders of such products, other than alcohol, and therefore we do not know who sells it.”

Source location

2014-0292-Response-by-Oldham-Council
Page 1 · response
Published 1 July 2014

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.6

  1. 1

    Refine National Drug Treatment Monitoring System data collection to include propane among substances recorded for people presenting with butane abuse.

    Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 1 July 2014.
  2. 2

    Improve national collection of drug-related mortality data, including volatile-substance deaths, from coroners.

    Stated by Public Health EnglandStated in progressThe respondent said that this action was in progress when they made their response on 1 July 2014.
  3. 3

    Publish the workforce survey online for public access.

    Stated by Chartered Trading Standards InstituteStated completedThe respondent said that this action was complete when they made their response on 1 July 2014.
  4. 4

    Conduct a workforce survey of trading standards services in England and Wales.

    Stated by Chartered Trading Standards InstituteStated completedThe respondent said that this action was complete when they made their response on 1 July 2014.
  5. 5

    Refine National Drug Treatment Monitoring System data collection to include propane among substances recorded for people presenting with butane abuse.

    Stated by Public Health EnglandStated completedThe respondent said that this action was complete when they made their response on 1 July 2014.
  6. 6

    Ensure officers visit and speak with the trader about product safety, addiction-related moral obligations, and sales of age-restricted products to minors.

    Stated by Oldham Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 1 July 2014.

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

Refine National Drug Treatment Monitoring System data collection to include propane among substances recorded for people presenting with butane abuse.

Verbatim wording from the response

“We have recently refined the information we collect on VSA as part of the National Drug Treatment Monitoring System in line with recommendations from Re-Solv, the national charity dedicated to the prevention of VSA, in part to add propane to the data collected routinely on people presenting with butane abuse.”

Source location

2014-0292-Response-by-Public-Health-England
Page 1 · response
Published 1 July 2014

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

Improve national collection of drug-related mortality data, including volatile-substance deaths, from coroners.

Verbatim wording from the response

“We are also looking to improve the national collection of drug-related (including VSA) mortality data from coroners so that action can be taken at a national and local level.”

Source location

2014-0292-Response-by-Public-Health-England
Page 2 · response
Published 1 July 2014

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 workforce survey online for public access.

Verbatim wording from the response

“On a separate matter you may be interested to hear that TSI has recently conducted a workforce survey of trading standards services in England and Wales. This demonstrates the severe and deep cuts to trading standards services which in turn has led to a reduction in activity and prioritisation. A copy of the survey can be viewed at: www.tradingstandards.gov.uk/policy/WorkforceSurvey2014.cfm.”

Source location

2014-0292-Response-by-Trading-Standards-Institute
Page 1 · response
Published 1 July 2014

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 a workforce survey of trading standards services in England and Wales.

Verbatim wording from the response

“On a separate matter you may be interested to hear that TSI has recently conducted a workforce survey of trading standards services in England and Wales. This demonstrates the severe and deep cuts to trading standards services which in turn has led to a reduction in activity and prioritisation. A copy of the survey can be viewed at: www.tradingstandards.gov.uk/policy/WorkforceSurvey2014.cfm.”

Source location

2014-0292-Response-by-Trading-Standards-Institute
Page 1 · response
Published 1 July 2014

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

Refine National Drug Treatment Monitoring System data collection to include propane among substances recorded for people presenting with butane abuse.

Verbatim wording from the response

“We have recently refined the information we collect on VSA as part of the National Drug Treatment Monitoring System in line with recommendations from Re-Solv, the national charity dedicated to the prevention of VSA, in part to add propane to the data collected routinely on people presenting with butane abuse.”

Source location

2014-0292-Response-by-Department-of-Health
Page 3 · response
Published 1 July 2014

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

Ensure officers visit and speak with the trader about product safety, addiction-related moral obligations, and sales of age-restricted products to minors.

Verbatim wording from the response

“I shall certainly ensure that the trader concerned is visited and spoken to by my Officers on the safety/health implications and the moral obligations in relation to those who suffer from addictions as well as a reminder about sales to minors of age restricted products in general.”

Source location

2014-0292-Response-by-Oldham-Council
Page 1 · response
Published 1 July 2014

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