Product related deaths

Noted (AI summary) The Lift and Escalator Industry Association (LEIA) published a safety notice on their website on behalf of Phoenix Lifting Systems regarding lifting platforms with one-touch platform controls and emailed it to all their members. HSE will raise the matter of platform lifts without hold-to-run controls at the national Local Authority Health and Safety Practitioner Forum and in a technical LA bulletin, and will share the circumstances with CQC and the wider healthcare industry. They are also aware that LEIA has raised the concerns with their relevant committees. LEIA published a further safety notice addressing similar hazards in other lifting platforms from other manufacturers and has made proposals for inclusion of recommendations for the revision of BS 5655-11 to cover legacy lifts with similar hazards. DHSC acknowledges the concerns regarding platform lifts in care settings, but states the responsibility lies with the Health and Safety Executive, who have already responded and are monitoring similar incidents. DHSC shares concerns about the incident but states the matters do not fall within their responsibilities; they have written to the HSE to monitor for similar incidents and review if further action is needed.

Noted (AI summary) MHRA acknowledges the concerns about support belts lacking warnings and guidance, provides background on its regulatory role, and explains existing device regulations and post-market surveillance activities, including Yellow Card scheme and collaborations. It highlights manufacturer responsibilities for safety and labeling. The response includes details on the product and its instructions for use. The DHSC acknowledges the concerns regarding the lack of warnings and information on lap belt products, states that the responsibility for these concerns sits within another organisation, and will be writing to the Office of Product Safety and Standards. OPSS has written to major online marketplaces (Amazon, eBay, Temu, Shein and Alibaba) to make them aware that certain products may not be provided with suitable instructions or warnings to assure safe use by likely users, and alerted online marketplaces to its Product Safety Report published for the ORTONES belt to make clear this product should not be supplied.

Noted (AI summary) The DHSC acknowledges concerns about guidance on self-neglect and hoarding disorder, pointing to existing NICE guidance and recent court judgements. They will continue to disseminate such guidance and caselaw through its partners and networks.

Noted (AI summary) Procter & Gamble expresses condolences, states its products comply with regulations and are safe when used as directed, and maintains a post-market surveillance system; they are not proposing changes to the product or packaging but will continue to monitor adverse events and respect the coroner's perspective about risk assessments in care homes. The CQC will feature the incident on its Learning from safety incidents webpage to raise awareness and share learning with providers, advising providers to consider denture adhesive gel in risk assessments and care planning, referencing HSE's COSHH Risk Assessment and CQC's Regulation 12.

Noted (AI summary) The Department for Transport acknowledges the concerns about e-cycle modification but states that existing regulations and enforcement powers are sufficient. They highlight regulations concerning e-cycles, the responsibilities of manufacturers and retailers, and the role of the Office for Product Safety and Standards and Local Authority Trading Standards.

Noted (AI summary) Defra acknowledges the coroner's concerns regarding the death related to imported plant material, but states they lack legislative powers to require health warnings. They have contacted the Department for Business and Trade (DBT), who will respond separately. The OPSS has met with Defra to discuss the regulation of toxic plants and seeds, and will continue to engage with Defra, DHSC and other stakeholders to assess if the case has wider implications for the regulation of similar products. The case will also be discussed at a cross-government suicide prevention strategy group.

Noted (AI summary) NHS England states that the contract with NRS Healthcare was managed by the London Community Equipment Consortium, to whom the Coroner may wish to refer concerns. They note that concerns about NRS Healthcare's services were escalated to the London Regional Quality Group. NRS Healthcare is providing additional training to customer service operatives, enhancing working arrangements, reorganizing Community Equipment Technician teams, and improving communication processes. The London Community Equipment Consortium completed an equipment review of lateral turning systems, and the TOTO should be phased out.

Noted (AI summary) Hotpoint states it will support the LFB/AMDEA initiative of digital identification and comply with any future industry-wide regulatory requirements. It will also work with government policy makers, regulators, fire services, manufacturers and other stakeholders to continue to raise the bar for appliance product safety in the UK. AMDEA acknowledges the coroner's concerns and states its commitment to collaborating with stakeholders to enhance product safety. They also note that fire incident data for key appliances is collated annually to identify trends and inform safety improvements. BSI acknowledges the coroner's concerns and explains its role in standardization. The CPL/61 committee considered the request to improve standards for condensate pumps and filters but needs more information regarding the fire investigation before a decision can be made. North Yorkshire Council, as primary authority for Hotpoint, states that testing was conducted on the part in question and that it passed all tests. They have arranged for further testing and state Hotpoint will comply with any changes in the law. OPSS is seeking an update from BSI on the progress of a pilot project trialing a fire-resistant marking approach to enable identification of fire-damaged appliances and supporting their traceability. The National Fire Chiefs Council states that receiving information from manufacturers on replaced or recalled parts is not within their remit. They support the single recall register and advocate for manufacturers to share risk assessments when patterns of faults are found. The Home Office acknowledges the report but states it cannot provide a specific response due to a lack of detail regarding which aspects of information management need to change. CTSI acknowledges the coroner's concerns and describes its role in consumer protection and its support for OPSS. It highlights the need for a national approach to product safety and consumer reporting mechanisms.

Noted (AI summary) Mid and West Wales Fire and Rescue Service supports increasing smoke alarm coverage to the highest standard in all new build premises in Wales and will support any proposals for legislative enhancement by the Welsh Government. They do not propose any action regarding police primacy at fire scenes. The Welsh Government acknowledges the concern regarding smoke alarms and refers to the Renting Homes (Wales) Act 2016, which mandates landlords to ensure rented homes are fit for habitation and to install a smoke alarm on each storey. The findings of the Regulation 28 report will be considered alongside findings from the independent evaluation of the Act.

Noted (AI summary) The HSE is publishing further guidance, aimed at installers, their managers and supervisors to remind them of the steps they must take to control the exposure risk. They are also working with the Worktop Fabricators Federation to support development of their own information leaflet which they can share amongst their networks. The Agglomerated Stone Manufacturers Association highlights existing efforts to promote safety and calls for governmental involvement, suggesting clear rules and/or a licensing program for fabricators. MHCLG is requesting an extension and states that the concerns fall within the remit of the HSE, offering to provide a formal response explaining the limitations of MHCLG's policy remit. DHSC states that they have no comments or suggestions and that responsibility for the Coroner's concerns sits with HSE. The Worktop Fabricators Federation provides a 'state of the art' positioning statement on silica dust risks associated with quartz worktops, highlighting the need for safe working environments and suggesting potential market controls.

Noted (AI summary) UKCPI expresses condolences and confirms that the laundry pouch packaging complies with GB CLP Regulation and industry PSP. They suggest that the packaging may have been left open or damaged. OPSS has spoken to the UKCPI, who are exploring a new awareness campaign for those with caring or safeguarding responsibilities, which OPSS will promote to local regulators. Sainsbury's states that their capsules already included a bittering agent and that the packaging adhered to A.I.S.E. guidelines. They have since changed their packaging to a cardboard box with a child-impeding closure, tested in line with AISE protocol. The HSE acknowledges the concerns regarding laundry tablet packaging and refers to existing regulations about the classification, labelling and packaging of hazardous substances, detailing specific requirements around outer and inner packaging.