Isabella Pritchard

PFD Report All Responded Ref: 2017-0261
Date of Report 16 August 2017
Coroner Peter Bedford
Coroner Area Berkshire
Response Deadline est. 2 January 2018
All 1 response received · Deadline: 2 Jan 2018
Response Status
Responses 1 of 3
56-Day Deadline 2 Jan 2018
All responses received
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
(1) It appears to me that both the manufacturer and installation of stone fireplaces are an unregulated industry.

(2) There appears to be no quality/safety standard that applies to fireplaces. The British Standards (BS1251) appears to relate purely to flues and combustible properties of the chimney itself. I am aware of no BSI kite mark applicable to fireplaces. It therefore seems possible to design and manufacture a product with dangerous design features that are cosmetically attractive but inherently dangerous. The fireplace that struck and killed Isabella Pritchard incorporated a stone mantle weighing 86kg with a design relying on gravity and adhesive to keep it in place. In addition, the installation instructions provided by the manufacturer by their own installer were vague in detail, generic and covered their whole range of products. I understand that most high street DIY warehouses sell fireplaces, some weighing as much as 125kg where the design, if untested, could have the same design faults.

(3) I understand that there is no regulation or building control around the installation of fireplaces. I believe building regulations do not cover this area as they are deemed to be a decorative item. While I understand that

Classification: OFFICIAL-SENSITIVE

Classification: OFFICIAL-SENSITIVE
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

the NHBC now mandatorily require the use of mechanical fixings, this does not cover every instance. Also, that the Stone Federation issued guidelines but are guidelines only. Further, they are a non-regulatory trade body where membership is optional and adherence to their guidelines is entirely voluntary.

(4) I understand that building regulations are the responsibility of the Department of Communities and Local Government. I would invite consideration of an amendment to building regulations that might not only ensure safe installation at new builds but could also encompass installations where a fireplace is retrofitted, for example, in the course of the renovation. Might it also be possible to include installation of fire surrounds into the GasSafe or HETAS Scheme?

(5) I understand that general product safety, including safe design and products requiring to be marked as compliant, fall under the Department for Business Energy and Industrial Strategy. I ask if powers under that sphere of responsibility could be considered in the context of the circumstances of Isabella Pritchard’s death with a view to taking steps to prevent the risk of a repeat tragedy in the future.
Responses
Department for Communities Local Government
25 Oct 2017
Response received
View full response
The Rt Hon Sajid Javid MP Secretary of State for Communities and Local Department for Government Communities and Department for Communities and Local Local Government Government Building 2 Marsham Street Mr Peter Bedford London Senior Coroner for Berkshire SWIP 4DF Reading Town Hall Tel: 0303 444 3450 Blagrave Street Fax: 020 7035 0018 Reading wWWgov.uk/dclg Berkshire RGI 1QH Our Ref: 3465158 Your ref: PJB/PRITCHARDI 25 October 2017 D- M + Bedae-d Thank you for your letter of 18 August following your investigation into the death f six year old Isabella Pritchard in 2012 who was struck by a stone You have provided me with a copy of your Regulation 28 Report Tfortelpiece. my response that sets out actions taken or proposed to prevent future deaths: I stress at the outset how sorry I was to hear about the tragic death of this giri Although such events are thankfully rare my departmentag awere 084 Smsayoung number of similar instances and has previously considered and worked with others to act upon this. The Building Regulations do not control fixtures such as decorative fireplace surrounds The issue was previously considered by the Building Regulations Advisory Committees industry experts and technical specialists from my department who looked at optionseor revising the statutory guidance in relation to compliance with the Building Regulations requirements on structures (Approved Document A) At the time, it was considered unlikely that regulation would be the most effective of "controlling this type of work, much of which is decorative in natureosnd isoftee way carried out by householders rather than professionals It was felt that it would be difficult to enforce requirements on householders and awareness of ! "building regulations amongst this group is low: Instead it was considered that there was a need to more general guidance on the of fireplace surrounds taa wider vadienecedS6 get my department has worked with others to make such good practice guidance on fireplace installations more widely available. Fry falling calling May fixing

Agencies and external partners who have published guidance include: The Royal Society for the Prevention of Accidents has promoted the importance of safe installation of stone fireplace surrounds In April 2013,the Health and Safety Executive issued a safety alert aimed at suppliers of stone fireplace surrounds of the to provide adequate fixings as well as instructions on safe installation. In October 2013,the National House Building Council issued standards in relation to fixing fireplace surrounds for new homes. In 2012,the Stone Federation of Great Britain made best practice guidance on the fixing of stone fireplace surrounds publicly available on its website and updated this guidance in January 2015. The Standing Committee on Structural Safety (SCOSS) issued Report 145 drawing structural engineers' attention to the issue. A lot has been done to raise awareness however; given the tragic nature of this incident will ask the Building Regulations Advisory Committee to re-consider their previous advice not to for stone fire surrounds (and other heavy decorative items that require substantial fixings for their safety; such as large mirrors Additionally I will make arrangements through authorised schemes; including the Gas Safe Register HETAS, to alert their registered installers of gas fires and wood burning stoves to practice guidance on the fixing of stone fireplace surrounds. I will also ask my officials to continue to work with other agencies and external partners to keep guidance on fireplace installations Up to date and available: I note that report was also sent to the Rt Hon Greg Clark MP, Secretary of State for Business; Energy and Industrial Strategy and his office separately on 29 August 2017. 1 would be if you could convey my sympathy onto Isabella' $ family. RT HON SAJIDJAVID MP need regulate and good your responded grateful
Report Sections
Investigation and Inquest
I was informed of the death of 6 year old Isabella Pritchard who died at Wexham Park Hospital, Slough, Berkshire on the 7th July 2012 from catastrophic head injuries suffered when the marble mantelpiece in the lounge of her home at fell and struck her. Following a lengthy investigation involving the Health & Safety Executive and Thames Valley Police, a conviction was secured against the contractor who originally installed the mantelpiece. Having opened and adjourned my Inquest Investigation into this young lady’s death under Schedule 1 of the Coroner’s and Justice Act 2009, as a result of the prosecution I was not required to resume the Inquest as the criminal proceedings stood in its stead.

However, it is clear that a Coroner’s powers under Regulation 28 to issue a Report to Prevent Future Deaths are not restricted to matters revealed in evidence at an Inquest. The matter giving rise to concern may be something revealed at any stage of a Coroner’s Investigation.

Classification: OFFICIAL-SENSITIVE

Classification: OFFICIAL-SENSITIVE
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REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
Circumstances of the Death
Isabella Pritchard was found in the lounge with fatal head injuries and with three pieces of a marble mantelpiece lying around her. The incident was not witnessed but it is clearly understood that the mantelpiece had come away from the wall and struck her. A forensic post mortem examination revealed the cause of death of “severe head injury.”

Despite lengthy and detailed Investigations, only the contractor who installed the mantelpiece could be prosecuted under the existing regulations and legislation. The information supplied to me raises concerns with regard to a potential faulty design of the fireplace that was not required to be mechanically fixed to either the wall or some other part of the fire surround and also the apparent situation whereby installation of fireplaces are completely unregulated.
Copies Sent To
Classification: OFFICIAL SENSITIVE Classification: OFFICIAL SENSITIVE 16th August 2017 Peter J. Bedford Senior Coroner for Berkshire
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.