Kevin Branton, Richard Smith, Audrey Cook, Alfred Cook and Maureen Cook

PFD Report Partially Responded Ref: 2020-0274
Date of Report 7 December 2020
Coroner Geraint Williams
Response Deadline est. 2 March 2021
1 of 3 responded · Over 2 years old
Response Status
Responses 1 of 3
56-Day Deadline 2 Mar 2021
Over 2 years old — no identified published response
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) That there is no national or central database which contains details of gas appliances manufactured, supplied or fitted to homes in the UK which would Information Classification: CONFIDENTIAL allow rapid identification and tracing of potentially dangerous items.

(2) That communication between manufacturers, suppliers, wholesalers, fitters and householders in connection with the supply etc of gas appliances is hindered by the lack of mandatory recording of the said manufacture, supply and fitting of such appliances.

(3) That the lack of a mandatory scheme for recording the supply etc of such items means that it is difficult and time consuming to trace potentially dangerous items when urgency is of the utmost importance.
Responses
MP BEIS
1 Feb 2021
The Minister has asked the Office for Product Safety and Standards (OPSS) to assess consumer behaviour regarding gas appliance safety and to engage with stakeholders to consider options for rapid communication and tracing of dangerous appliances, with the goal of developing an action plan. AI summary
View full response
Dear Mr Williams,

INQUESTS INTO THE DEATHS OF KEVIN BRANTON AND RICHARD SMITH AND JOHN, MAUREEN AND AUDREY COOK, DECEASED: PREVENTION OF FUTURE DEATHS REPORT

Thank you for your letter and Regulation 28 Report to Prevent Future Deaths, dated 7 December 2020, following your investigation and inquest into the deaths of Kevin Branton, Richard Smith and John, Maureen and Audrey Cook from carbon monoxide poisoning due to a design flaw in their cookers. You also sent a copy of the report to , the CEO of the Office for Product Safety and Standards (OPSS), which falls within my remit. I am responding as the Minister responsible for product safety policy for the Department for Business, Energy and Industrial Strategy (BEIS), including OPSS.

I would first like to say how deeply saddened I was on hearing of these tragic deaths. If you have an opportunity, please pass on my condolences to the families.

The Government is committed to ensuring that the UK has a product safety system that provides consumers with a high level of protection. This applies to the purchase of gas appliances as it does to all consumers products. I note that BERR (the predecessor to BEIS at the time of these deaths) took the initiative quickly to work with the European Commission, Member States, and through the CEN standard making process, to amend the standard relevant to the manufacture of gas cookers to include explicitly a closed-door test. In addition, the 2016 Regulation on gas appliances and fittings places clear responsibilities on manufacturers to ensure their products meet essential health and safety requirements before they are placed on the market. The findings of this inquest provide an opportunity to assess whether further lessons can be learned as we seek to ensure that the UK’s product safety system is continually improved. In particular, thank you for raising the importance of tracing owners and potentially dangerous appliances effectively.

In 2018 the Government created the Office for Product Safety and Standards (OPSS) as a new national regulator for product safety. Since then, OPSS has taken significant steps to ensure the UK product safety system is one of the most robust in the world. This has included creating a new national capacity including technical and scientific advisors and experts in intelligence, enforcement and product recalls and publication of an Incident Management Plan and a new national Product Safety Database.

The Incident Management Plan sets out how OPSS will support local authorities managing a product safety incident, and itself lead on an incident that is national in scale and a serious risk to health and life. The national product safety database has been designed to support regulators to capture and share information on unsafe goods, so that risks can be identified and action taken more quickly. Market surveillance authorities can report and share information relating to unsafe and non-compliant

products, identifying the product, describing the risks involved, recording the nature and duration of measures taken or decided on and information on supply chains.

OPSS supports and works with local authority Trading Standards on a day-to-day basis. Where an unsafe product results in a national incident, OPSS can designate this for investigation and enforcement at a national level. Where a local authority considers it does not have the expertise and resources necessary to carry out a complex investigation, it can ask OPSS for assistance. In 2019, Parliament enabled OPSS to use investigatory powers set out in Schedule 5 to the Consumer Rights Act 2015, and ensured these powers were available to OPSS and to local authority Trading Standards in relation to gas appliances, where products were deemed to be unsafe.

OPSS has also developed a Strategic Research Programme to commission and assure high quality strategic science-based research to strengthen the evidence base for enforcement. In particular, OPSS has commissioned research to understand how consumers engage with the safety of the products they purchase and into how to encourage greater registration of products to facilitate corrective actions and recalls. I have asked OPSS to specifically to assess whether there is more we can do to research consumer behaviour in relation to safety in the gas appliance sector.

In your report, you express concern that there is no national or central database, containing the details of gas appliances manufactured, supplied or fitted to homes in the UK, which would allow rapid identification and tracing of potentially dangerous appliances. You also expressed concern that the lack of mandatory recording of the manufacture, supply and fitting of gas appliances hinders effective communication between manufacturers, suppliers, wholesalers, fitters and householders and that it is difficult and time consuming to trace potentially dangerous products when urgency is required.

In response to your report, I have asked OPSS officials to engage with manufacturers, retailers and consumer groups, and relevant bodies in Government to consider the concerns you have raised, including the options for effective and rapid communication between manufacturers, suppliers and owners to locate potentially dangerous appliances, should a design fault be identified. I have asked them to discuss your report, subject to your agreement, with members of the Cross-Government Working Group on Gas Safety and Carbon Monoxide in order to develop an action plan to address your concerns. To inform these considerations, I have asked OPSS to draw on analysis of the gas appliances market, assess consumer trends towards purchase and advise on whether further areas of research are needed to help identify and change consumer behaviour towards greater gas safety.

Thank you again for bringing this matter to my attention.

PAUL SCULLY MP Minister for Small Business, Consumers & Labour Markets Minister for London
Report Sections
Investigation and Inquest
On 17/11/2010 an investigation was commenced into the deaths of Kevin David John Branton, 32 and Richard Lee Smith, 32. On the 01/03/2013 an investigation was commenced into the deaths of Maureen Henrietta Cook, 47, Alfred Henry Cook, 90 and Audrey Cook, 86. The investigations concluded at the end of the inquest on 23/11/2020. The conclusion of the inquest was accidental death as a result of carbon monoxide poisoning.
Circumstances of the Death
The 5 deceased died in 2 separate incidents with a common feature namely that a gas cooker at their homes had an inherent defect which meant that if the grill was used with the door closed fatal levels of carbon monoxide were produced.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.