Source · Prevention of Future Deaths

Thomas Hill

Ref: 2025-0387 Date: 29 Jul 2025 Coroner: Jason Pegg Area: Hampshire, Portsmouth and Southampton Responses identified: 1 / 1 View PDF

A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. The lack of an external warning label obscured safe usage requirements from users.

Date 29 Jul 2025
56-day deadline 23 Sep 2025 est.
Responses identified 1 of 1
Product related deaths

Coroner's concerns

AI summary
A flue-less gas heater was unsafely operated in a too-small room due to a hidden warning label, leading to carbon monoxide build-up. The lack of an external warning label obscured safe usage requirements from users.
View full coroner's concerns
The flue-less liquified petroleum gas cabinet heater was operated in a room which was too small dimension so to safely use the heater without causing a build-up of carbon monoxide. A warning label was affixed inside the cabinet heater in the space occupied by the liquified petroleum gas bottle. There was an absence of a visible warning label on the outside of the heater. It was not obvious to all potential users of the heater that the heater could only be used safely in a room of sufficient dimension. The risk applies particularly so in the case of rented cottages and similar premises such as .

Responses

1 respondent
Product Safety Standards Other
26 Sep 2025 PDF
Action Planned

OPSS is working with BEIS and is planning to conduct further testing of portable gas heaters and review associated standards, and has written to the British Standards Institution to request a review of the standard BS EN 449:2002 +A1:2007 regarding warnings on portable gas appliances. (AI summary)

View full response
Dear Mr Pegg, Thank you for sharing your Regulation 28 Report to Prevent Future Deaths, dated 29 July 2025, following your investigation into the death of Mr Thomas Hill on 28 October 2015, caused by inhalation of a fatal quantity of carbon monoxide from a portable liquified petroleum gas (LPG) cabinet heater. I am responding in my role as Chief Executive of the Office for Product Safety and Standards (OPSS), which is part of the Department for Business and Trade. Thank you for granting a short extension to OPSS as we carefully considered this tragic case, and our response. OPSS is the UK’s product regulator, responsible for the product safety framework covering most consumer products, except food, vehicles and medicines. This framework requires that all consumer products, including gas appliances, are safe when they are placed on the market, when used as intended and in foreseeable conditions of use. At the time the product in this case was manufactured, the legislation in force was the Gas Appliances (Safety) Regulations 1995 (the 1995 Regulations). The manufacturer was required, through the design and construction of the appliance, as well as provision of instructions and warnings placed on the product and its packaging, to eliminate, reduce or guard against potential risks. The essential requirements in the current legislation (Regulation 2016/426 on appliances burning

Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham

B4 6BS

The Office for Product Safety and Standards (OPSS) delivers consumer protection and supports business confidence, productivity and growth. It is part of the Department for Business and Trade. gov.uk/opss gaseous fuels) require there to be instructions for use (intended for the user) and appropriate warning notices, which must also appear on the packaging, when products are placed on the market. You raise concerns that the placement of warning labels on the product may have contributed to Mr Hill’s death, as safe use of the portable LPG heater may not be obvious to all potential users such as those in temporary residential settings like a holiday property. The 1995 Regulations and the voluntary standard for dedicated liquefied petroleum gas appliances (BS EN 449:2002) are not prescriptive about the location of warnings. There is no evidence to suggest that the warning on this specific product regarding sufficient ventilation did not meet the requirements of the regulations and the voluntary standard at the time. I understand the warning directed users to the product’s instructions, but these were not available to the tenants of the property. Manufacturers have a legal duty to monitor the safety of their products on the market and to take action if they become aware of any safety issues. OPSS has written to BSH Home Appliances Ltd in the UK to ensure the business is aware of this incident, and to ask how they monitor for any safety issues with this or similar models of LPG heaters that may occur in reasonably foreseeable conditions of use, including use in rental accommodation. In addition, in light of the risks identified in this case, OPSS has written to the British Standards Institution, the UK’s standards-making body, to request the relevant committee(s) for BS EN 449:2002 +A1:2007 review the standard in relation to the placement and content of warnings on portable gas appliances, when considering all conditions of reasonably foreseeable use. Alongside the product safety regime for gas appliances, there is a separate regime led by the Health and Safety Executive (HSE) – the Gas Safety (Installation and Use) Regulations 1998 – that provides protections for users of leased or rented accommodation, in relation to gas safety, including safe gas appliances. This regime places responsibilities on landlords which we understand were not properly carried out for the property in which Mr Hill died. The HSL report, and subsequent criminal investigation, makes clear that the product that caused Mr Hill’s death should not have been available for tenants’ use. You have sent a copy of this Prevention of Future Deaths report to the National Residential Landlords Association. I will be contacting them to understand their views and the information they share with their members, and I am copying this letter to the HSE, so that we can consider their position on landlords’ responsibilities for gas safety in all cases of reasonably foreseeable use, alongside the product safety regulations that apply to appliances, to ensure the regimes work properly in tandem to protect people from harm.

Office for Product Safety and Standards Multistory 18 The Priory Queensway Birmingham

B4 6BS

The Office for Product Safety and Standards (OPSS) delivers consumer protection and supports business confidence, productivity and growth. It is part of the Department for Business and Trade. gov.uk/opss Thank you for writing to OPSS and bringing Mr Hill’s very sad death to my attention.

Report sections

Investigation and inquest
On 11th November 2015 I commenced an investigation into the death of Thomas Oliver HILL aged 18. The investigation concluded at the end of the inquest on 2nd June 2025.
Circumstances of the death
The deceased died on 28th October 2015 in the rear of an ambulance on a road between Brechin and Dundee, Scotland. The deceased inhaled a fatal quantity of carbon monoxide whilst in the bathroom of , Glenesk, Angus, Scotland whilst preparing for a bath. The carbon monoxide had been expelled from a lit liquified petroleum gas cabinet heater. The bathroom was of insufficient size for the flue-less liquified petroleum gas cabinet heater to be safely used without causing a build-up of carbon monoxide. The liquified petroleum gas cabinet heater burner plaques were cracked which contributed to the death by exacerbating the build-up of carbon monoxide.

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Report details

Reference
2025-0387
Date of report
29 July 2025
Coroner
Jason Pegg
Coroner area
Hampshire, Portsmouth and Southampton

Responses identified

Responses identified 1 of 1
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 23 Sep 2025 (estimated).

Sent to

Office for Product Safety and Standards

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