Kathleen Holme

PFD Report All Responded Ref: 2017-0212
Date of Report 18 September 2017
Coroner Robert Chapman
Coroner Area Cumbria
Response Deadline ✓ from report 14 November 2017
All 1 response received · Deadline: 14 Nov 2017
Coroner's Concerns (AI summary)
The automatic air freshener lacked prominent warnings about fire risks near naked flames, with critical safety information being too small on packaging and absent from the device itself.
View full coroner's concerns
(1) Whether the manufacturer is aware and understands the extent of the risks of the use of a Glade Automatic Air Freshener Spray near to naked flames, and specifically the distance which the flame can extend: (2) Whilst there are both warning signs wording on the box containing a new spray on the aerosol to be fitted to it, am concerned that the words warning of the dangers of use near a naked flame is not sufficiently large and prominent to draw the dangers to a users attention.

(3) There were no warning signs on the body of the automatic air freshener: Once the box containing the new air freshener was discarded a user would have only the information printed on the aerosol as a warning and and and

AcTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths believe you SC Johnson Son have the power to take such action:
Responses
SC Johnson Other
Noted
SC Johnson states that their Glade Automatic Air Fresheners meet or exceed current regulatory requirements regarding labeling and classification, and therefore no action needs to be taken. They will keep the matter under review. (AI summary)
View full response
Johnson FAMiLY CoMPANY S, CJohnson &Son; Inc. 1525 Howe Strcet Racine WI 53403-2236
262.260.2000 Private & Confidential Robert Chapman HM Assistant Coroner Fairfield Station Road Cockermouth CAI3 9PT Thank you for your letter dated September 18, 2017 enclosing the Regulation 28 Rcport concerning the death_of Kathleen Eica Holme who died tragically in the fire at on March 26,2017 (Rcport)_ On behalf' of SC Johnson Son and all companies in the SC Johnson group (including SC Johnson Ltd') (SC Johnson). we take this opportunity t0 express Our sincere condolenccs to the family of Mrs. Holmes who so sadly lost her life in this ineident Introductory comments Within SC Johnson it is the responsibility o the Global Safety Assessment and Regulatory Aflairs division (GSARA) to ensure the safely and regulatory compliance for SC Johnson products. This responsibility is for the complete product lifecycle from development lo placement in the marketplace and onto use in consumers homes_ GSARA reviewed thc safety and regulatory labelling requirements of the Glade@ Automatic Air Freshener prior to marketing; On an on-going basis, and it has done so in light ol this tragic incident, We have carefully considered your concerns as set ut in section 5 of the Report and ofler the following response. The recipient of the Report again Page

Background regarding Glade@ Automatic Air Freshener The Gladc@ Automatic Air Freshcncr (thc "air frcshener in the Report) is a battery powered, motorized indoor air freshener device that USCS an acrosol refill canister to fragrance an area within a home. The air freshener device has been thoroughly tested to a comprehensive test plan, based on tests taken from standards UL 2832, IEC 60335-1 and IEC 60335-2-101 that included tests (or over-temperature conditions motor locked rolor; and electromagnelic compalibilily & radio- frequency emission testing (EN 55014-1 and EN 55014-2)5 , chemical compatibility, and other tests to verify that the devicc mccts all of electrical device physical safety requirements. All the tests performed on the devicc had acceptable results. The purpose of the test plan was t0 minimize the lire, thermal burn, and mechanical hazards (such as laceration) of the newly developed Glade() air freshener device. The air freshener device meets all applicable safely regulations and industry guidelines related to Low Vollage Directive (2014/35/EU), Restriction o[ the use of Hazardous Substances (RoHS) Directive (2011/6S/EU), Electromagnelic Compatibility (2014/30/EU), and Waste Electrical & Electronic Equipment (2012/19/EU): Similarly, the air freshener refill canister has becn thoroughly tested to comprchensivc test plan that includes tests (or (lammability (ASTM D 30656 Flame Projection and Closcd Drum tests, UN 31.4 & 31.57 Ignition Distance & Enclosed Space Ignition tests, and ASTM D93-088 Flash Point Measurement) , canister rupture (FEA 621 E' can pressure test) , general product safety (ASTM F963 consumer safetylo), as well as corrosion and weight loss (ASTM GI and
646)" and gasket swell (ISO 500-011 solvent immersion)/2 testing: The tests evaluate the air frcshener refill canister" for the risk of fire, canister rupture, and mechanical hazards such as laceration. UL; "Standard For Safety, Air Fresheners and Deodorizers" (UL 283) IEC, Houschold and simnilar electrical appliances Safety Part I; General requirements" (IEC 60335-1) IEC, "Houschold and simnilar electrical appliances Safety Part 2-101 Particular requirements for vaporizers" (IEC 60335-2-101) CENELEC. Electromagnetic compatibility. Requirements for household appliances, electric tools similar apparatus" (EN 55014-| and EN 55014
2) ASTM, "Standard Test Methods for Flammability of Aerosol Products" , (ASTM D 3065) UN; Classification Procedures, Test Methods and Criteria Relating to Class 2, Class 3 , Class 4, Division 5.1 , Class 8 and Class 9" . (UN 31,4 & 31,5" (UN 31.4 & 341,5) ASTM; "Standard Test Methods for Flash Point by Pensky-Marlens Closed Tester" , (ASTM D93-08) FEA, Measurement of internal pressure resistance of empty containers without valves (FEA 62/ E) ASTM, "Standard Consumer Salety Specilication for Salety" , (ASTM F9653) ASTM, "Standard Practice for Preparing, Cleaning; and Evaluating Corrosion Test Specimnens. G[, Amual Book ofASTM Standards, 03.02. & Standard Guide (or Examnination and Evaluation ol" Corrosion, G46, Amnual Book of ASTM Standards, 03.02_ (ASTM Gl and 646) Action T Technology Company, Thickness Swell" . (ISO 500-01/) Page 2 drop; the and Cup Toy Pitting

The air ficshener relill canister also mects the applicable safety regulalions and industry guidelines related t0 the Aerosol Dispensers Directive " The ait freshenet relill canister has a metered-valve thal was tested for flame projection (ASTM D 306514 Flame Projection) to minimize the risk t0 consumers of inadvertent of' the canister contents The metered-valve design dispenses just %ul (equivalent to less than 2 drops) of the relill contents every 9, 18 or 36 minutes_ To educate and warn consumers about the dangers of the air (reshener refill canister near lo naked flames, we mark the refill with safety warnings and labelling: The warnings and labelling that we apply to the air (reshener refill canister (and t0 the packaging of the Gladew Automatic Air Freshener) meet Regulation (EC) No 1272/2008 of the European Parliament and of the Council of 16 December 2008 on Classification, Labelling and Packaging of Substances and Mixtures (CLP Regulation). Importantly; morc than 5 million of these air fresheners and relill canisters have been sold over the past 12 months throughout the UK. We would wish to emphasise that SC Johnson has never received any report, consumer complaint or allegation of asimilar nature rclatcd t0 the air (reshener device 0r" rcfill. Basedon the comprehensive of the air freshener device and the refill canisters, their history of safe the regulatory standards and industry guidelines that are followed for the warnings and labelling; it is SC Johnson s considered view thal the risk posed to consumers by the Glade@ Automatic Air Freshener and refill even ncar t0 naked (lames is extremely low. That is all to say: SC Johnson is fully aware of how Our producl perlorms and its safety in relation to exposure to a widc varicty of environments, USCS and polential misuses, and SC Johnson lirmly believes that the air freshener has always been; and remains, sale: The Coroner' $ Concerns (section 5 of the Report) For ease of reference your concerns as set Out in section 5 of the Report are set Out immediately below: Council Directive of 20 May 1975 on (he law of Member States relating to aerosol dispensers (75/324/EFC) ASTM; "Standard Test Methods for Flammability of Aerosol Produets" (ASTM D 3065) Page 3 leakage using testing uSsC . The

Whether the manufacturer is aware and understands the extent of the risks of the use of u Glade Automatic Air Freshener Spray near t0 naked flames, and specifically the distance which the flume can extend (Concern I) Whilst there are both warnings signs and wording on the box containing & new spray and on the aerosol t0 be fitted t0 it, am concerned that the words warning of the dangers of use near & naked flame is not sufficiently and prominent t0 draw the dangers to the user '$ attention (Concern 2) There were no warning signs On the body of the automatie air freshener: Once the containing the new air freshener was discarded 4 user would have only the information printed on the aerosol aS & warning: (Concern 3) Concern 1: Evaluation of the fire risks associated with Glade@ Air Freshener SC Johnson considers that as a result of the testing regime for the product as detailed above; it is fully aware and understands thc extent of the risks of the use of the air freshener near t0 naked flamcs, and specifically the distance which the flame can extend. In this regard, SC Johnson refers specifically t0 thc refill s ~extremely flammable" classification listed 0n the refill canisters" safety data sheet and the ASTM D 3065 Flame Projection Test thal was conducled aerosol refill development: Further; as a result of the air freshener refill having a metered-valve that only releases 9ul o/ flammable material with each valve actuation (as relerred t0 above), this also ensures thal any flame is limited. While SC' Johnson does not in any Way seek t0 challenge the findings of the Coroner concerning thc circumstanccs of the dcath of Mrs Holme as set out in section 4 of the Report, SC Johnson would respectully ask the Corner to notc that it did not have an opportunity t0 give evidence 0r" be represented at the Inquest and therefore was not able to consider with the Coroner the findings ol' Roger the Fire Investigator with the Cumbria Fire and Rescue Service who attended investigated the fire and who gave evidence aL the Inquest. If it had done so SC' Johnson would have raised its concerns about the as set Oul in the Report that based on "the positon of the candles; the automatic air freshener and the elothes; the spray from the automatie air freshener could have been ignited by the candles and the resultant flame then See footnote 6 above_ Page 4 large box during Exley- and lindings

ignite the clothes" in light of what SC Johnson considers t0 be (he significant uncertainties in the evidence as to, among other The pre-(ire location of the candle Or candles: The pre-fire position o/ the clothing; Whether a single or multiple candles were lit; The pre-lire position of the air freshener device: Whether the ait freshener device was activated; The time interval the air (reshener device was sel at; The proximity ol the air freshencr device t0 a lit candle; The proximity of any clothing to the candle and air freshener device; The first material ignited; and Whether the first fuel ignited was competent to spread the fire to the secondary fuel. Concerns 2 and 3: Evaluation of the warning signs and labels associated with Glade@ Air Frcshcncr The labelling 0n the Glade@ Automatic Air Freshener has been assessed the regulatory requirements and guidelines and industry standards to address Concerns 2 and 3 in the Report: The labelling requirements for the Glade@ Automatic Air Freshener are governed by the CLP Regulation and and thc Council Directive of 20 1975 on the law of Member States relating to aerosol dispensers (75/324/EEC) A detailcd review ol the labelling requirements is set out wilhin Appendix Gladee Automatic Air Fresheners (0n the packaging and on the refill canister itself) are labelled in accordance with the applicable regulatory requirements: To ensure the legibility of the label, the safety text is high contrast black font on white background The font used is not italicised nor compressed and is in line with regulatory guidance and with industry practice. The hazard pictograms are black within a red frame. It is important t0 nole that the Hammable hazard pictograms used on the Gladed Automatic Air Fresheners are larger than required by the regulation guideline: It is to be noled that the device itsell is not labelled as this is nol requirement ol the CLP Regulation. Article 31 of the CLP Regulation states that the labels shall be firmly allixed t0 one O1 more surfaces of the packaging immediately containing the substance or mixlure. The devicc is classed as thc dispenser and not the container: This is the case because the regulators recognise the fact that formulations (and their classifications) may change belween the various fragrance variants Or over time: Labelling dispenser (the device) could therefore eventually lead to mis-labelling creating both an Out o/" compliance situalion and mis-information t0 the consumner On the hazard and safety requirements of the product especially when all packaging layers are labelled: Page 5 things: against May

Concluding comments To conclude, SC Johnson is fully aware of the extcnt of the risks of the use of a GladcQ Automatic Air Freshencr near to naked flames and specifically the distance which the flame can extend The text and symbols warning of the dangers of use near & naked Ilame on the aerosol relill are high contrast black-on-white text; The Mlammability' piclogram is black within a red (rame Importantly, the pictograms used Onl the Gladed Automatic Air Fresheners are larger than legislative requirements_ The device itself is not labelled. as this could be misleading and it is not requirement 0f the CLP Regulation_ The Gladew Automatic Air Fresheners and refills meet 0" exceed the current regulatory requirements regarding labelling and classification: Finally, SC Johnson notes that section 7 ol' the Report asks that the response to the Rcport includes details of any action taken Or proposed to be taken [or| you must explain why no action is proposed regard t0 the matters set Out in this letter and the accompanying appendix SC Johnson respecllully considers that no action needs to be taken by it in response to the matters ol concern raised in the Report: However; we would wish to assure YOu (and all other recipients of the Report noted in Section 8) that the GSARA will continue to this mattcr under revicw and that we remain fully committed t0 working with all relevant stakcholders to respond to any matters may wish t0 raise with uS: We trust that this letter together with its appendix responds fully to Your concerns aS set out in the Report: However; we remain available to assist with any further questions YOu have and you should not hesitatc to contact US, Yours sincercly 08 Deceabes 20 (7 Director; Global Product Safety Global Safety Assessment and Regulatory Affairs SC Johnson Having keep they may Page
Sent To
  • SC Johnson and Son
Response Status
Linked responses 1 of 1
56-Day Deadline 14 Nov 2017
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

Report Sections
Investigation and Inquest
On 20/04/2017 commenced an investigation into the death of Kathleen Erica Holme investigation concluded at the end of the inquest on the 29th August 2017. The Inquest conclusions, as recorded on the attached Record of Inquest was The cause of death:
1.a. Burns and smoke inhalation 1b. Fire at her home The circumstances that were found to have been proved were: Mrs Holme liked to use candles in her bedroom and also an automatic aerosol air freshener. On the 26 March 2017 there was a fire in her bedroom at her home address. She was rescued and taken t0 the Royal Lancaster Infirmary, but was certified dead there. She died from burns and smoke inhalation: The conclusion of the inquest was that: Mrs Holme died an accidental death CIRCUMSTANCES OF The DEATH Mrs Holme and her son had been drinking alcohol on the 25 March 2017 in a public house in Kendal: The amount that she had to drink may have affected her ability to save herself when the house was on fire: After leaving the public house they went home and subsequently Mrs Holme went to bed: She was a frequent user of candles in her bedroom, and had some on a tray on the floor. In her bedroom she used a Glade automatic battery operated air freshener. There was a fire at her home in the early hours of the 26 March 2017, and neighbours tried to rescue her. Fire officers attended and were able to extract her from the house, but she died of burns and smoke inhalation Fire Investigator with the Cumbria Fire and Rescue Service attended and investigated the The seat of the fire, where Mrs Holme was found, was near to the door from the bedroom into the upstairs hallway: At the seat of the fire they found the tray with candles and also in the immediate vicinity, Glade automatic battery operated air freshener and some clothes, all of which were badly burned in the fire: A number ofother Glade air freshener aerosols for use in the automatic air freshener, were found in other areas of the bedroom and some had been burnt: Tests undertaken at the Barrow Fire Station found that if the contents of the automatic air freshener were sprayed across a naked flame then a large llame was produced approximately 2Ocm long (approximately 8 inches): The evidence from) given at the Inquest; was that in view of the position of the candles, the automatic air freshener and the clothes the spray from the automatic air The fire.

freshener could have been ignited by the candles and the resultant flame then ignited the clothes_ have spoken again tol and he said that they found in their tests that even if the distance between the candle and the air freshener was further extended, it was possible to get a flame 12 inches or more long; and that could ignite flammable materials. The nearer the distance the stronger the flame; and the further away the more likely that the flame would be a flash flame: have seen that both the box containing a new Glade automatic air freshener the aerosol itself have warning signs and words, warning that the spray is not to be used near naked flames:
Related Inquiry Recommendations

Public inquiry recommendations addressing similar themes

Allow Advisory Board to monitor individual compensation cases
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Publish Advisory Board meeting reports within 21 days
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Make monitoring full and fair compensation a core Board duty
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Increase Advisory Board membership if needed for capacity
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Seek court directions for GLO compensation in bankruptcy cases
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Publish proposals for equal tax treatment of compensation payments
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Amend Limitation Act to extend GLO deadline if needed
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Set agreed closing date for Horizon Shortfall Scheme applications
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Respond to recommendations by 10 October 2025
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny
Establish standing public body to administer future redress schemes
Post Office Horizon Inquiry
Weak Government Accountability & Scrutiny

Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.