Dear Sir,

Terrence Taylor: Prevention of future deaths report I. Introduction

1. This letter constitutes BSI’s response to your regulation 28 report arising out of the death of Mr Terrence Taylor (“the Report”).

2. BSI would like at the outset to express its deepest sympathy and condolences for the family of Mr Taylor.

3. The Report includes the following:

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2 “Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes. Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors.”
4. In accordance with its usual practice, BSI passed the Report to the responsible expert committees, who have replied as detailed below. We believe that constitutes compliance with the required actions, but would be pleased to assist if the coroner has any further questions.

II. The role of BSI

1. BSI’s role as the NSB is established by Royal Charter. BSI has several governing documents (available online at

a. BSI’s Royal Charter and Bye-laws 1981;
b. A Memorandum of Understanding (MoU) of 20 June 2002 between the United Kingdom government and BSI in respect of BSI’s activities as the United Kingdom’s NSB;
c. BS 0: 2021 ‘A standard for standards – Principles of standardization’ (BS 0)

2. Article 1.2 of the MoU provides that BSI’s role as the NSB should be interpreted to include the management, co-ordination and understanding of:

a) “British Standards” and “other standardization products”;

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3 b) participation by BSI in European and international standards bodies, and other international activity undertaken in the interests of BSI as the United Kingdom’s NSB; c) promotion, marketing, distribution and information activities concerned with British Standards, BSI’s other standardisation products, and standardisation generally; d) support any corporate infrastructure activities intended, wholly or in part, to enable paragraph 9(a) to (c) above. The Director of Standards has the primary responsibility for the activities set out in paragraph 9(a) to (d). BSI’s present Director of Standards is (his full title is ‘Director–General, Standards’, which incorporates the role of Director of Standards).
3. BSI develops and distributes standards in response to the needs of UK stakeholders, which include UK Government and business. Standards are technical documents representing good industry practice. They are voluntary documents drafted by independent experts.

III. Standards committee structure

4. Each individual standard is the responsibility of one technical committee. A technical committee may be responsible for more than one standard, and may establish subcommittees to deal with individual standards or other discreet areas of its work.

5. Technical committees and sub-committees consist primarily of experts who are independent of BSI, and who are often nominated by trade associations, professional bodies, research/scientific institutions, government or other entities (see BS 0, para 7.2). They have an independent chair and BSI provides a committee manager and other support including an editorial project manager for each standard.

6. The committees referred to in this letter are examples of such committees.

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4 IV. Status of Standards

7. The defining characteristic of standards is that they are voluntary, agreed by industry experts and users, including manufacturers, health and safety representatives, regulators and consumer groups. They do not have the status of legislation or regulation (unless specifically referred to in a statute or regulatory instrument), although they may be used as one means of demonstrating compliance in appropriate circumstances. They may also become privately enforceable between individual entities by being incorporated into a contract (see paras 4.14 and 9.2 of BS 0).

V. BSI expert committee feedback

8. BSI considered the following committees would have relevant expertise:

a. B/538, Doors, windows, shutters, hardware and curtain walling
b. B/538/1, Windows and Doors
c. B/538/4, Building Hardware

9. Representatives of all those committees have jointly considered BS 6375-2. Their response is as follows, which we are quoting in full:

“A committee was formed of members from, B/538, Doors, windows, shutters, hardware and curtain walling B/538/1, Windows and Doors B/538/4, Building Hardware

We were all saddened to hear of the death of Mr Taylor under what must have been such difficult circumstances for everyone concerned and we are determined

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5 to make appropriate changes to standards to reduce the risk of deaths under similar circumstances in the future.

Amendments to BS 6375-2

Our proposal is to amend clause 5.3 of BS 6375-2:2009 so that it includes a requirement for situations when the window is to be used for the purposes described in the Coroner’s report. We will need a descriptive term for the mode of use. We have considered, “deprivation of liberty,” but this may be too severe and not appropriate for our purpose.

The test will be undertaken on a sample of the window to be used to ensure that the window, the restrictor and any fixings securing it to the window will be tested as a system.

When open, with the maximum opening gap limited to 89mm by a restricting device, the window shall be capable of resisting a load of 850 N applied anywhere on the window in a manner intended to open the casement or sash with the objective of obtaining egress.

This load shall be applied via a 50 mm x 50 mm pad and can be located at various places on the casement or sash, for example

• at the location of the restrictor
• at the hinge points
• at a point the maximum distance from the restrictor The load shall be applied, for example

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6

• perpendicular to the plane of the open casement or sash
• parallel to the direction of opening of sliding sashes.

As BS EN 14609 does not cover loads applied to restricted sliding sash windows we will need to introduce a new annex to BS 6375-2 describing the test method to be used for such windows.

If loads are to be applied to the casement or sash then it will be necessary to upgrade the glazing so it can withstand comparable loads. We therefore propose that the glazing should be able to support the 850 N point load (applied via the pad) but also be grade 1(B)1 or 1(C)1 when tested in accordance with BS EN 12600. This will reduce the risk of egress being achieved by breaking the glass.

Steel-framed windows

Clause 12.2, safety device loading, of the national product standard for steel windows, BS 6510, will be amended so that it refers to clause 5.3 of BS 6375-2 and doesn’t refer directly to a load of 350 N supported for 60 S as it does now.

The other material specific product standards for windows, BS 644, BS 7412 and BS 4873 refer to clause 5.3 of BS 6375-2 without stating loads or durations.

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7 Existing European Standards

BS EN 14351-1, the European product standard for windows and external pedestrian doors, doesn’t, as appears in for example the HSE report RR1150, limit the load bearing capacity of a safety device to 350 N but instead sets 350 N as the minimum, or threshold, value for such devices. It would be for the EU member state, or country in which the product is used, to set the national requirements for such products.

The load bearing capacity of safety devices is an essential characteristic of windows (reference Table ZA.1) therefore, when such a device is fitted to a window the loadbearing capacity of the window, when tested in accordance with BS EN 14609, must be stated on the manufacturer’s declaration of performance in accordance with article 4 (2) of the assimilated EU Regulation 305/2011 (The Construction Products Regulation).

However, as this characteristic falls under AVCP System 3, it is possible that, the function of a restrictor as intended in BS EN 14351-1 is not life-safety-critical because, if it was, it would fall under AVCP System 1 as is the case for fire characteristics. This could mean that our proposed amendment to BS 6375-2 would not conflict with existing European Standards. This will, however, need to be checked.

BS EN 14609, is referred to by BS EN 14351-1 as the test method to determine the load bearing capacity of safety devices, but it only covers casement windows not sash windows, clause 7 calls for the restrictors to be disengaged and figures A.1 to A.6 show the movement of the casement to be limited by a “block” stopping the movement of one corner. We will discuss the possible need to amend EN 14609

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8 with the European working group CEN/TC 33 WG1 that is responsible for this standard.

List of standards

• BS 644:2012, Timber windows and doorsets. Fully finished factory-assembled windows and doorsets of various types. Specification
• BS 4873:2016, Aluminium alloy windows and doorsets. Specification
• BS 6375-2:2009, Performance of windows and doors - Classification for operation and strength characteristics and guidance on selection and specification
• BS 6510:2010, Steel-framed windows and glazed doors. Specification
• BS 7412:2024, Windows and doorsets. Unplasticized polyvinyl chloride (PVC- U) extruded hollow profiles. Specification
• BS EN 12600:2002, Glass in building. Pendulum test. Impact test method and classification for flat glass
• BS EN 14351-1:2006+A2:2016, Windows and doors. Product standard, performance characteristics - Windows and external pedestrian doorsets
• BS EN 14609:2004, Windows. Determination of the resistance to static torsion”

10. Please note that the committee’s proposals will have to be implemented by the usual standards development process (as set out in BS 0), which among other things means there will be a period of public consultation. The final version of the standard will therefore be informed by that consultation and may differ from the committee’s proposals accordingly. Nonetheless the intention of the process will be to improve the standard, informed by the Coroner’s Report and the committee’s expertise.

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11. BSI believes that the above is self-explanatory and constitutes a full reply to the Coroner’s Request. Again, however, if the Coroner has any further questions or requires clarification, BSI would be pleased to assist.

Dear Mr Morton,

Thank you for the Regulation 28 report of 21st June 2024, sent to the Department of Health and Social Care (DHSC), about the death of Mr Terrence Roy Hubert Taylor. 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 Mr Taylor’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning, and I am grateful to you for bringing these matters to my attention.

The report raises concerns over:

1. Current guidance for residential care homes on the British Standard for window restrictors. The guidance does not factor in situations where a resident deliberately attempts to defeat the restrictor.

2. DHSC and NHSE’s best practice guidance, Health Building Note 00-10 Part D: Windows and associated hardware. This guidance does highlight that the British Standard for window restrictors does not factor in deliberate attempts to defeat the restrictor using impact forces. However, Health Building Notes are written for the design and planning of new healthcare buildings and/or the adaptation or extension of existing facilities. As such, this guidance, though relevant, has not been directed to residential care home providers and was not known or understood by care home operators, manufacturers, or suppliers of window restrictors.

3. Research by the Health and Safety Executive (HSE) in 2019, which is not known by care home operators or window restrictor manufacturers and suppliers, advises that window restrictors should withstand forces greater than the British Standard.

Regarding these concerns, you had two requests for action. The first related to raising awareness of the latest guidance regarding window restrictors, including the limitations of the British Standard, amongst residential care home operators. Your second request was to review the British Standard to consider whether changes were required.

In preparing this response, Departmental officials have made enquiries with the Care Quality Commission (CQC).

In response to your first request, CQC are a named responder to this case. CQC’s separate response will address concerns related to raising awareness amongst residential care home operators of the latest guidance on window restrictors. CQC expect providers and registered managers to be aware of, and follow, best practice guidance. In 2022, CQC published a ‘Learning From Safety Incidents’ webpage on window restrictors. This can be found, alongside relevant, up to date guidance on complying with the relevant health and safety precautions, here:

providers/learning-safety-incidents/issue-7-falls-windows. The webpage also links to the latest HSE guidance on risks to vulnerable members of the public from falling from height from windows. It can be found here: www.hse.gov.uk/safetybulletins/windowrestrictors.htm. Having discussed the case of Mr Taylor with CQC, they have updated their ‘Learning From Safety Incidents’ webpage with a link directing providers to the Health Building Note 00-10 Part D: Windows and associated hardware. CQC have also committed to publish a note in their bulletin to providers in August 2024 to remind providers of the CQC’s ‘Learning From Safety Incidents’ webpage. In response to your second request for action, reviewing the British Standard is not within the scope of my Department's responsibilities. However, my officials have contacted HSE on this matter and await their reply.

I hope this response is helpful. Thank you again for bringing these concerns to my attention.

Dear HM Coroner Keith Morton KC, Prevention of future death report following the inquest into the death of Terrence Roy Hubert Taylor. We write to acknowledge receipt of the Regulation 28 report of 21 June 2024, sent to the Care Quality Commission (CQC), in relation to the death of Mr Terrence Roy Hubert Taylor. Firstly, the CQC would like to express our deepest sympathy and sincere condolences to the family of Mr Taylor. We understand that you want action taken to ensure that; (1) Operators of care homes are provided with reliable, up to date guidance on the use of window restrictors; and (2) Operators of care homes are made aware of the limitations of the British Standards in that they were developed to prevent accidental falling from windows as opposed to deliberate attempts to bypass window restrictors. HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA

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As you are aware, the CQC is the independent regulator of health and social care in England. The CQC publishes guidance on how providers and managers can meet the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the 2014 Regulations”) and the Care Quality Commission (Registration) Regulations 2009 (“the 2009 Regulations”). There is a link on our website to the 2013 guidance, and then further information and guidance on meeting the specific regulations can be found under separate headings. Under the heading of Regulation 12: safe care and treatment, there is a link to guidance issued by the Health and Safety Executive (HSE) on Health and Safety in Care Homes www.hse.gov.uk/pubns/books/hsg220.htm. Chapter 7 of this guidance specifically addresses Falls from Height. In addition, to accidental falls, this guidance also refers to;
• Falls arising out of confused mental state, including where an individual is trying to escape from an environment they perceive to be hostile, and
• Deliberate self-harm. It sets out control measures that may be taken by care homes to ensure that people are kept safe. In 2022, CQC published a ‘Learning From Safety Incidents’ page on our website on the use of window restrictors. This can be found, alongside relevant, up to date guidance on complying with the relevant health and safety precautions, here:

This webpage also has links to the latest HSE guidance on risks to vulnerable members of the public from falling from height from windows;

This guidance repeats that which is set out in Chapter 7 (see above) and also makes reference to the Department of Health Building Note 00-10 Part D Windows and associated hardware. In August 2024 we published a note in our bulletin to providers (a regular update for providers and professionals working in adult social care) highlighting the tragic loss of life following a deliberate attempt to bypass a window restrictor and to remind providers of the CQC’s ‘Learning From Safety Incidents’ webpage. This publication has been updated on the CQC website to reflect the Health Building Note published

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by NHS England, which highlights that the British Standard for window restrictors does not factor in deliberate attempts to defeat the restrictor using impact forces. We are currently undertaking work to improve how we signpost providers to sources of good practice, to support our Single Assessment Framework. Good practice that is applicable across all sectors is already available, and we signpost to the HSE 2012 information sheet on Falls from windows or balconies in health and social care under the Quality Statement on ‘safe environments’, under the Safe key question. In time this will be supplemented by guidance that is applicable to specific sectors (such as ASC or health), or to specific service types (such as care home). Whilst the CQC will publish and expect providers and registered managers to be aware of, and follow, best practice when it comes to British safety standards, the CQC relies upon guidance issued. If either HSE or The British Standards Institution update their guidance around window restrictors, the CQC will take steps to ensure providers are signposted to it both through our website and published bulletins to providers. We hope this response is helpful but if you have any questions arising, please do not hesitate to contact us.