Dear Mrs Lee,

Regulation 28 letter – Coventry Coroner

Many thanks for your letter of 18 July. We take such matters very seriously and have been in email correspondence to clarify your expectation of what action we can take, and to understand more of the circumstances of the accident leading to Jacqueline Langworthy’s death. Many thanks for engaging with us and providing further details. The further details you provided indicated that the accident occurred on a lifting platform manufactured by Phoenix Lifting Systems. Phoenix Lifting Systems is not a member of our Association and so we have limited influence (our role as a trade association is advisory). Nevertheless, we have held a meeting with Phoenix Lifting Systems in our offices and have agreed a safety notice which we published on our website at: https://www.leia.co.uk/technical/product-information/ on 19 August when we also emailed it to all our members. In the email exchange, you agreed that we could make a limited response before 15 September and the details above form our limited response. The remainder of the letter looks at issues which we believe are needed for a fuller response to your letter. Owing to holidays and the frequency of our meetings, this would take us beyond 15 September so we would provide a fuller response on this point in due course. Our comments are made in relation to the three matters of concern you raised. (1) “Many platform lifts still in use in care settings and other premises do not have hold-to-run controls”. We understand that Phoenix Lifting Systems did supply some lifting platforms which did not have hold to run controls in the period indicated on their notice.

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We are working with our specialist committees to understand whether there might be other lifting platforms from other manufacturers which might not have hold to run controls – and if so what action we could take. (2) “Evidence was received indicating that such controls can be retrofitted at relatively low cost”. We understand that this evidence came from the care home owner (presumably after the accident). Our discussion with Phoenix Lifting Systems supports this for the lifting platforms that they manufactured and which still retain their original control systems. As above, if a similar issue applies to other manufacturers, we would need to understand whether they are readily retrofitted and then to consider action we could take. (3) “There is limited awareness of both the risks posed by the absence of hold-to-run devices”. LEIA previously published a homelift guide which included the use of constant pressure platform controls:

guide-fnl.pdf This guide was published after the introduction of BS EN 81-41 requiring platform control to be hold to run so would not have raised such risks. We are aware of HSE safety warnings for lifting platforms published in 2012 and 2019 but which did not deal with these risks. We note that your letter was sent also to the HSE and believe that a warning issued by the HSE on such risks would be very valuable. We have suggested this to the HSE and will have a meeting with HSE later in September when we will raise this.

In summary, we have published a warning notice on behalf of Phoenix Lifting Systems as an initial response and will continue to look into these three matters. We would most likely make a fuller response in October.

Many thanks again for your flexibility in this.

Dear Madam, REGULATION 28 PREVENTION OF FUTURE DEATHS – the death of Jacqueline Mary LANGWORTHY

Thank you for your Regulation 28 report to , HSE Chief Executive, in relation to the tragic death of Jacqueline Mary Langworthy whilst using a platform lift in her role as a care assistant. I am responding as the Head of the Local Authority and Entertainments Team at the Health and Safety Executive (HSE) which holds the operational policy lead for health and safety regulation of several of the local authority enforced sectors. Your report raises as matters of concern, that:
- many platform lifts still in use in care settings and other premises do not have hold-to-run controls;
- evidence was received indicating that such controls can be retrofitted at relatively low cost; and
- there is limited awareness of both the risks posed by the absence of hold-to-run devices and the feasibility of fitting such devices to existing platform lifts.

I will address each of these points in turn.

Lifts in other care homes do not have hold to run controls

There is currently no legal requirement to retrofit hold-to-run controls. As employers those managing/running care homes have responsibilities under health and safety law to ensure, so far as is reasonably practicable, the health and safety of their staff and others who might be affected, such as residents and visitors. They are required to carry out risk assessments. As a minimum the employer is expected to:
- identify what could cause injury or illness in the business (hazards);
- decide how likely it is that someone could be harmed and how seriously (the risk);
- take action to eliminate the hazard, or if this isn't possible, control the risk.

Assessing risk is just one part of the overall process used to control risks in the workplace, employers must share the findings of the risk assessment with their staff, instruct, train and supervise them.

2 Regarding the lift, Approved Code of Practice (ACoP) and Guidance L22, Safe use of work equipment. Provision and Use of Work Equipment Regulations 1998. Approved Code of Practice and guidance L22 describes measures which should be taken by a duty holder to prevent access to dangerous parts of work equipment, eg the trapping point between the lift platform and fixed parts of the lift shaft.

The hierarchy of control for preventing access to dangerous parts is described in paragraph 145 of L22: Regulation 11(2) specifies the measures that must be taken to prevent access to the dangerous parts of the machinery and achieve compliance with regulation 11(1). The measures are ranked in the order they should be implemented, where practicable, to achieve an adequate level of protection. The levels of protection are: a) fixed enclosing guards; b) other guards or protection devices such as interlocked guards and pressure mats; c) protection appliances such as jigs, holders and push-sticks etc. Information, instruction, training and supervision will be needed regardless of the level of protection chosen.

The risks relevant to this incident, of entrapment, shearing, crushing and trapping are readily foreseeable. They are referenced in BS 6440:1999, BS EN 81-41:2010, and reference is made in the lift user manual to “trapped between a fixed and moving part of the lift.” In this situation there was a pressure sensitive edge to the platform to prevent crushing and shearing and a slow travel speed so, in engineering terms, this is not the lowest level in the hierarchy, nevertheless, the dutyholder must still place a high reliance on robust non-engineering safeguards such as information, instruction, training and supervision.

This will be the case for any lift of this type in any business setting, including in the care sector, and the resultant risks must be addressed in the assessment and the controls in place with systems of work and engineering controls working in tandem.

Controls can be retrofitted at relatively low cost

The purpose of the legislation is to control the risk and this may be achieved in several ways. The law does not require retrofit of hold-to-run controls, but these may be one way of reducing risk and HSE supports the adoption of reasonably practicable measures that do this, particularly where it enhances safety and is feasible in the context of the specific lift installation, along with the necessary instruction in how they should be used, especially where this is reasonably practicable to do so. Dutyholders will need to consider this option as part of their risk assessment process, taking into account the design and operational characteristics of the lift, and ensuring that any modifications are accompanied by appropriate training and supervision. However, it may be that safe operation can also be achieved without installation of hold-to-run controls if part of an appropriate robust safe system of work.

3 Limited awareness of the feasibility of fitting hold-to-run controls to existing platform lifts Enforcement of the health and safety legislation is split between HSE and the local authorities, who are independent regulators in their own right. HSE and LAs work closely to ensure consistent enforcement of health and safety legislation. As noted above, this type of lift will be used in other settings and so the risks may not be specific to care homes. To increase awareness among local authority enforcement officers I have asked that this matter is raised at the national Local Authority Health and Safety Practitioner Forum (https://www.hse.gov.uk/lau/national-committees.htm) and in a technical LA bulletin. I have also asked that the circumstances be shared with CQC, from a patient safety perspective, in a healthcare bulletin, to the wider healthcare industry and widely within the industry. I am aware, through HSE’s contact with the Lift and Escalator Industry Association (LEIA), that they have raised your concerns with their relevant committees and that they have previously published a home-lift guide to help in selection of lift solutions (https://www.leia.co.uk/wp-content/uploads/2019/05/LEIA-home-lifts-guide-fnl.pdf). I hope that the above information addresses the matters raised.

Dear Mrs Lee,

Regulation 28 letter – Coventry Coroner

Many thanks for your letter of 18 July to which we sent an interim response dated 26 August. We take such matters very seriously and took immediate action as we reported to you in our letter of 26 August. As agreed are now writing with the further actions we have taken. We publish safety notices on our website at https://www.leia.co.uk/technical/product-information/ which is a resource to which those in our sector make reference. Following discussions with Phoenix Lifting Systems, we published a safety notice on our website on 19 August on their behalf which was emailed to our members. This notice is at:

Systems-Safety-Information-Lifting-platforms-with-one-touch-platform-controls.pdf . In our earlier email exchange, you agreed that we could make a limited response before 15 September and the details above formed our limited response. The remainder of this letter reports on the further measures we have taken. Our comments are made in relation to the three matters of concern you raised. (1) “Many platform lifts still in use in care settings and other premises do not have hold-to-run controls”. Since our earlier letter and publication of the safety notice on behalf of Phoenix Lifting Systems, we have worked with our specialist committees and understand that there might be lifting platforms installed from other manufacturers with latching/automatic platform controls. We published a further safety notice on 12 November which we circulated to our members and which is on our website at: https://www.leia.co.uk/wp-content/uploads/2025/11/00163-12- November-2025-lifting-platforms-with-one-touch-platform-controls.pdf

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(2) “Evidence was received indicating that such controls can be retrofitted at relatively low cost”. Please see our safety notice of 12 November which provides advice to lifting platform owners to seek the assistance of their lifting platform maintenance contractors to establish feasibility of making such changes. While we understand that in the case of unmodified lifting platforms manufactured by Phoenix Lifting Systems the modification might be straight forward, this might not be case for other manufacturers hence our advice. (3) “There is limited awareness of both the risks posed by the absence of hold-to-run devices”. Our safety notice of 12 November seeks to address this. We remain of the view that a warning issued by the HSE on such risks would be very valuable.

This addresses the issues raised in your letter in relation to lifting platforms. More broadly, we have recognized that prior to 1979 lifts might been installed without car doors and with latching/automatic controls. Most such lifts would have been entirely replaced or improved with safety measures to address these hazards; unmodified lifts might have similar hazards to the lifting platform addressed above. In case there are such lifts left unimproved, we have made proposals to address these hazards for the revision of BS 5655-11 (a standard for the modernization of existing lifts). This revision work at the British Standards Institution (BSI) and is subject to BSI’s revision, commenting and approval process: https://standardsdevelopment.bsigroup.com/projects/2024-00910.

In summary, we have:
• published a safety notice on behalf of Phoenix Lifting Systems as an initial response;
• published a further safety notice to address similar hazards in other lifting platforms from other manufacturers;
• made proposals for inclusion of recommendations for the revision of BS 5655-11 to cover legacy lifts with similar hazards to the those identified by this case.

I trust that this addresses the matters of concern in your letter. Please let us know if we can assist further.

Dear Ms Lee,

Thank you for the Regulation 28 report sent to the Secretary of State / the Department of Health and Social Care about the death of Jacqueline Mary Langworthy. I am replying as the Minister with responsibility for Adult Social Care.

Firstly, I would like to say how saddened I was to read of the circumstances of Miss Langworthy’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter.

The report raises concerns over the fact that many platform lifts are still in use in care settings without hold-to-run controls, which you note can be retrofitted at a relatively low cost, and that there is limited awareness of the risk posed by the absence of hold-to-run devices. Officials within the Department of Health and Social Care have considered your report carefully and concluded that the responsibility for these concerns sits within another

organisation. I understand that this report was also sent to the Health and Safety Executive, which has provided a comprehensive response, including the steps taken to increase the awareness of local authorities and the wider healthcare industry to the risks associated with this unfortunate incident. I have also written to the HSE to ask that they monitor for any similar incidents, and to keep under review whether any further action is necessary. Thank you for bringing these concerns to my attention.

Dear Ms Albon,

I am writing to you in relation to the Prevention of Future Deaths report issued by HM Assistant Coroner for Coventry and Warwickshire, Linda Lee, about the death of Jacqueline Mary Langworthy.

The incident that led to Ms Langworthy’s death is most concerning. While the matters of concern raised by the Coroner do not fall within the responsibilities of the Department of Health and Social Care, I nonetheless share the Coroner’s concern that future deaths in similar tragic circumstances are prevented.

I have seen the HSE’s comprehensive response to the Coroner and appreciate the responsibilities of employers to ensure there is robust assessment and mitigation of risks, as well as suitable instruction, training and supervision of staff operating work equipment. I also welcome the steps taken to raise awareness within local authorities and the healthcare sector of the risks associated with this case.

I am writing to both share my concern and to ask that the HSE monitor for any similar incidents and keep under review whether any further action may be necessary.

I am copying this letter to HM Assistant Coroner, Linda Lee, and the Minister for Social Security and Disability, Stephen Timms MP.