Product related deaths
PFD Category
Reports: 131
Areas: 54
Earliest: Oct 2013
Latest: 5 Aug 2025
77% response rate (above 63% average). 31% of classified responses show concrete action taken. Reports rose 150% from 6 (2023) to 15 (2024).
PFD Reports
131 resultsShneur Kaye
All Responded
2020-0013
17 Jan 2020
Manchester (North)
Bury Council
Concerns summary (AI summary)
Safeguarding referrals were closed without parental contact, and referral information was not shared with other agencies due to data protection concerns. This practice potentially deprives social workers of vital context and undermines child protection.
Action Taken
(AI summary)
North Manchester Care Organisation outlines changes implemented after the incident, including revised discharge processes for children presenting to A&E with overdoses, new referral pathways for children with mental health needs, and mandatory safeguarding training for staff. Bury Council conducted a service review of the Multi Agency Safeguarding Hub (MASH) in early 2022, reinforcing strength-based practices and parental involvement unless safeguarding or legal reasons prevent it. The MASH also consults with referrers to clarify information and consider alternative support pathways.
Owen Carey
All Responded
2019-0335
30 Sep 2019
London Inner (South)
British Society for Allergy and Clinica…
Byron Hamburgers
Department of Environment, Food and Rur…
+3 more
Concerns summary (AI summary)
The restaurant's allergen training was inadequate, notices on menus lacked prominence to trigger discussions, and menus failed to clearly state key allergen information, creating false reassurance for customers.
Noted
(AI summary)
Byron has rectified the lack of records kept of on-job training immediately and each employee will now have records kept, and are investing in a market leading training system called "Flow" which is launched in the business from November where every employee will have their own personal training modules and records. BSACI will write to the chair of the FSA to advocate for funding for the UK Fatal Anaphylaxis Registry (UKFAR), which they are exploring closer working with to ensure its sustainability. National Trading Standards states that food safety and allergen regulation is outside their remit, which focuses on regional or national issues like complex consumer fraud. They note the Food Standards Agency is responsible for allergen legislation and policy. The FSA plans to develop an online reporting system and improve data sharing for allergic reactions, including those not resulting in death, to enable timely identification of trends and action by local authorities. DHSC will work to increase information prevalence on anaphylactic deaths and will support the FSA's reporting platform.
Macy Fletcher
Historic (No Identified Response)
2019-0227
27 Jun 2019
Manchester (North)
Ministry of Housing, Communities and Lo…
Concerns summary (AI summary)
A critical lack of national oversight and guidance for private landlords on updated blind cord safety regulations means many are unaware of risks from older blinds, leading to child strangulation deaths.
Ronald Clark
Partially Responded
2019-0151
8 Apr 2019
Portsmouth and South East Hampshire
Medicines and Healthcare products Regul…
NHS Improvement
Concerns summary (AI summary)
Stents supplied in identical packaging with only small labels pose a risk of using incorrect sizes during medical procedures.
Action Planned
(AI summary)
The National Patient Safety Team is reviewing the National Safety Standards for Invasive Procedures (NatSIPPs) and the NatSIPP on prosthesis verification is being updated to reflect developments in implant selection and verification processes, including the potential for future scanning for all prothesis/implants.
Bram Radcliffe
Historic (No Identified Response)
2019-0110
22 Mar 2019
West Yorjshire (West)
Ministry of Housing, Communities and Lo…
Stone Federation of GB
Concerns summary (AI summary)
Dangerous, substandard fireplace surround installations are unregulated as they are not deemed "building work." There is no British Standard for fixing these components, only for their manufacture, creating a safety gap.
Terence Penney
Historic (No Identified Response)
2019-0034
28 Jan 2019
Lincolnshire
Glen Dimplex Home Appliances Ltd
LEC Refrigeration
Office for Product Safety and Standards
Concerns summary (AI summary)
A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread safety risk with similar units in circulation.
Kenneth Bardsley
Historic (No Identified Response)
2018-0407
27 Dec 2018
Manchester (South)
Care Quality Commission
Department for Work and Pensions
Health and Safety Executive
+2 more
Concerns summary (AI summary)
The coroner raises concerns regarding the lack of minimum qualification standards for lift engineers, the absence of an escalation process for regulatory lift examination results, a lack of clarity on engineers following up on requirements, CQC's failure to identify unaddressed faults, and a lack of systems to ensure lift examination details are read and acted upon.
Savannah-Rose Owen
All Responded
2018-0367
22 Nov 2018
Manchester (South)
Department for Business
Department of Health and Social Care
Concerns summary (AI summary)
Multi-purpose nursing pillows lack specific safety regulations and have inconsistent, often misleading, warning labels that are easily lost, promoting unsafe sleep practices for infants.
Noted
(AI summary)
The Department has passed concerns about a nursing pillow lacking proper safety warnings to the Office for Product Safety and Standards (OPSS) for investigation and potential action with Local Authority Trading Standards. The Department clarifies that nursing pillows aren't medical devices and directs safety regulation concerns to the Department for Business, Energy and Industrial Strategy. They highlight existing guidance and resources from health visitors, midwives, Public Health England, the Lullaby Trust, Start4Life, and NHS Choices regarding safe sleeping and SIDS prevention.
Elizabeth Griffin
Partially Responded
2018-0072
7 Mar 2018
London Inner (West)
Chartered Trading Standards Institute
Wandsworth Watch Alarm
Office for Product Safety and Standards
+2 more
Concerns summary (AI summary)
No specific concerns for future deaths were detailed in the provided text.
Noted
(AI summary)
The Department highlights the launch of a new Code of Practice on product recalls (PAS 7100) and the development of a comprehensive digital service for consumer product safety information. They also support the 'Register My Appliance' site and are meeting with Whirlpool UK regarding their recall processes. Whirlpool outlines its product safety processes, including senior leadership oversight, and highlights the existence of a freephone number and prominent stickers on new products encouraging registration. They are also leading discussions within the industry on improving consumer awareness of the 'Register My Appliance' site. The CTSI states it is a professional body without powers to investigate and the matter is for local authority trading standards departments. They also highlight a workforce survey showing cuts to trading standards services.
Douglas McTavish
All Responded
2017-0311
31 Oct 2017
North Wales (East & Central)
Whirlpool (UK) Appliances
Concerns summary (AI summary)
Whirlpool's risk assessment processes may not fully appreciate the extent of fire risk with its appliances, and the company may be too reluctant to rely on 'soft data' such as reported fires. Additionally, public awareness of the risk of spontaneous combustion may be insufficient.
Action Taken
(AI summary)
Whirlpool will support initiatives to raise consumer awareness of risks such as spontaneous combustion and has added relevant usage instructions to the 'Register my appliance' website.
Bernard Hender
All Responded
2017-0311-wp25922
31 Oct 2017
North Wales (East & Central)
Whirlpool (UK) Appliances
Concerns summary (AI summary)
Whirlpool's risk assessments for appliance fires were inadequate, with a dismissive approach to field data like reported fires. This prevents timely learning and proactive measures to enhance product safety and save lives.
1 response
from Whirlpool UK Appliances Limited
Christina Fletcher
Historic (No Identified Response)
2017-0295
13 Oct 2017
Manchester (North)
General Pharmaceutical Council
Concerns summary (AI summary)
A lack of clear regulatory guidance on 'red flag' systems for pharmacies to identify patients with similar details and inconsistent chain of custody protocols for controlled drugs pose risks.
Brian Betterton
All Responded
2017-0224
11 Sep 2017
Bedfordshire and Luton
Department for Business, Energy and Ind…
Concerns summary (AI summary)
Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log installation locations or end-user details.
Action Taken
(AI summary)
The Department for Business, Energy & Industrial Strategy set up the Working Group on Product Recalls and Safety in October 2016, which published recommendations on improving recalls and reducing fires in white goods on 19 July. They have also supported the development of a new BSI code of practice on corrective action and recalls and commissioned research to understand how to increase the impact and effectiveness of product safety messages.
Isabella Pritchard
All Responded
2017-0261
16 Aug 2017
Berkshire
Department of Business, Energy and Indu…
Department of Communities and Local Gov…
Concerns summary (AI summary)
The unregulated fireplace industry lacks safety standards, leading to inherently dangerous designs and vague installation instructions. Absence of building control for installation significantly increases the risk of serious incidents.
Action Planned
(AI summary)
The department will ask the Building Regulations Advisory Committee to reconsider regulating stone fire surrounds and will alert registered installers to good practice guidance. Officials will also continue working with other agencies to keep guidance up to date.
Linda Baranowski
All Responded
2017-0341
22 Jul 2017
Hertfordshire
Hertfordshire Trading Standards
National Food Crime Unit, Food Standard…
Concerns summary (AI summary)
Widely available diet supplements and a hot slimming cream contributed to a fatal inflammatory response, raising concerns about the sale of products with unknown effects.
Action Planned
(AI summary)
Hertfordshire Trading Standards will liaise with national government agencies and regulators regarding food product safety, offering input into developing a national strategy if requested by the Food Standards Agency. The FSA Incidents Team investigated Mrs. Baranowski's case and the National Food Crime Unit has been actively working against the sale of dangerous food, including DNP, promoting awareness campaigns and monitoring the internet for sales.
John Wilson
Historic (No Identified Response)
2017-0445
12 Jul 2017
Manchester (South)
Beko Plc
Concerns summary (AI summary)
The product recall process was inadequate, relying on unrecorded standard mail that failed to inform the deceased, and lacked further robust efforts like registered post or follow-up visits, despite known increasing fire risk with product age.
Aaron McCaffrey
Historic (No Identified Response)
2017-0195
16 Jun 2017
Manchester (South)
Medicines and Healthcare products Regul…
Concerns summary (AI summary)
The lack of purchase limits for loperamide medication at retail stores enables bulk buying, increasing the risk of addiction and overdose.
Maurice Macdonnell
All Responded
2017-0188
14 Jun 2017
London Inner (South)
Medicines and Healthcare products Regul…
Concerns summary (AI summary)
A potential conflict of interest arose when a doctor, also a research investigator, administered a second drug dose despite adverse effects, raising concerns about patient safety safeguards in clinical trials.
Noted
(AI summary)
The MHRA reviewed the SUSAR report and determined that the symptoms were in line with the known safety profile for nivolumab, and no further action is required for participants in nivolumab clinical trials. They also stated that conflict of interest lies outside the remit of MHRA for clinical trials.
Howard Jeffers
All Responded
2017-0115
15 May 2017
London (North)
Pharmaceutical Chemistry, Drug Misuse a…
Concerns summary (AI summary)
The inability to accurately analyze and detect novel psychoactive substances (NPS) through toxicological testing poses an ongoing risk of future deaths.
Noted
(AI summary)
Imperial College London's Toxicology Unit acknowledges the difficulties in accurately analyzing and detecting NPSs due to their changing nature, lack of standards and pharmacological data, and states that no action is proposed. Alere Forensics describes its ongoing efforts to improve the analysis and detection of new psychoactive substances (NPS), including developing novel screening techniques, working with universities to obtain reference materials, and providing training to stakeholders. The Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit at the University of Hertfordshire is engaged in research to identify NPS and provide updated clinical guidelines, including using computational models to identify potential compounds before they appear on the market.
Richard Bull
Historic (No Identified Response)
2017-0154
10 May 2017
London (West)
Apple
Concerns summary (AI summary)
There is insufficient public perception of the risk associated with phone chargers in contact with water, requiring urgent and prominent safety warnings.
Grace Roseman
All Responded
2016-0455
19 Dec 2016
West Sussex
Bednest Ltd
Department for Business, Energy and Ind…
Concerns summary (AI summary)
Crib manufacturer failed to fully address the risk of death from an un-modified crib design, leaving a large number of potentially unsafe products in circulation with unaware customers.
Action Planned
(AI summary)
The Department for Business Energy and Industrial Strategy will discuss with BSI how to ensure paediatric advice is fed into the revision of the standard for cribs and cradles and will engage with stakeholders to gather further intelligence on products such as these. They will also engage with RoSPA on whether there is a need to improve general guidance and raise consumer awareness surrounding the sleep environment. Bednest has modified its cribs, sent modification kits to known purchasers, added additional labeling, ceased sales through retailers like NCT, and maintains information about the modification kit on their website. They continue to monitor second-hand sales and work with Trading Standards.
Roy Lawton
All Responded
2016-0441
9 Dec 2016
Staffordshire (South)
Marks and Spencer
Concerns summary (AI summary)
The deceased's dressing gown was highly inflammable regardless of fabric, raising concerns about product safety, the need for flammability warnings, or manufacturing improvements in clothing.
Noted
(AI summary)
M&S expresses condolences and states that the Gown was compliant with all legal requirements. M&S goes significantly beyond the legal requirements in its flammability testing of adult dressing gowns.
Benjamin Wylie
Partially Responded
2016-0407
14 Nov 2016
Berkshire
Federation of Piling Specialists
Health and Safety Executive
Soilmec Limited
Concerns summary (AI summary)
Design flaws in piling rig grease nipples, inadequate warnings, insufficient training, and manual deficiencies pose significant operator safety risks.
Action Planned
(AI summary)
The HSE will issue a Safety Alert regarding the risks associated with grease being expelled from grease nipples at high pressure, the risks associated with the re-use of damaged hydraulic components, and the need for proper training of persons required to undertake track tensioning.
Zane Gbangbola
Historic (No Identified Response)
2016-0328
13 Sep 2016
Surrey
Department for Work and Pensions
HAE Ltd
Health and Safety Executive
Concerns summary (AI summary)
Inadequate and misleading safety guidance for internal combustion engine equipment used in confined spaces, coupled with the misleading use of the HSE logo, increases the risk of harm.
Samantha Hopkins
All Responded
2016-0316
6 Sep 2016
Portsmouth and South East Hampshire
South Central Ambulance Service
Warwick Medical School
Concerns summary (AI summary)
Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these exclusions.
Action Planned
(AI summary)
New labels detailing exclusion categories will be placed on further issues of the trial drug packs. SCAS has committed that by January 2017 that all trial drugs in circulation will have the new labels affixed to the trial drugs bag or external bag. The University has instructed participating Ambulance Services to issue a reminder to all participating staff, to reiterate the inclusion and exclusion criteria for the trial. Compliance with this instruction shall be specifically audited during annual Quality Assurance Site visits.