David Hayes

Dear Mr Pemberton, Response to coroner's report in relation to the death of David Joseph Hayes Thank you for your Regulation 28 report in relation to the death of David Joseph Hayes, dated July 18th 2025. Your report was addressed to the Secretary of State for Defra (being the Government department with responsibility for the regulation of Detergents). I am responding as the Deputy Director with responsibility for Chemicals, which includes Detergents policy and regulation. I have consulted with the Health and Safety Executive (HSE) as some of the issues raised fall within their remit as a regulator for the supply of chemicals in Great Britain (GB). Specifically of relevance in this response, HSE have responsibility for Classification, Labelling and Packaging (CLP) regulations so they and not Defra have provided the text for the response in relation to this area.

Before I address your concerns, may I take this opportunity to express my condolences regarding the tragic circumstances that gave rise to the report.

Your report highlights the following matters of concern.:
1. During the course of evidence, it was noted that the plastic bottle like packaging in which the white liquid washing detergent was contained was confused by the deceased as a milk carton. He suffered from dementia and appeared to have poured the liquid into a cup of tea he had made, subsequently placing the detergent container in the fridge.
2. The container had a screw top with no safety features meaning that it would be easily accessible by a person with reduced capacity or dementia, or even a child, enabling the contents to be consumed with apparent ease.

3. Whilst the liquid was deemed to have low toxicity, on the evidence it led to vomiting and aspiration causing damage to the lungs and subsequent breathing difficulties. In this case this was causative of death.
4. In your judgment, there is a risk of similar events in respect of the ingestion of a liquid washing detergent because:
a. The colouring of the liquid is similar to items which a person suffering from an infirmity such as dementia may get confused – here milk
b. The shape of the packaging could be misconstrued in these circumstances
c. The screw top lid with no child or resistance protection is easily accessible.
5. The level of printed warnings on the labelling was not explored during the hearing, but this may not specify that the item could be a risk to vulnerable adults as well as the need to keep out of the reach of children.
6. The public knowledge of these risks is not likely to be at a level where households, in which vulnerable adults reside, are aware of the need to safeguard detergents and make them less accessible. A response from both Defra and HSE which aims to address the above concerns and sets out applicable policy is provided below.

Chemical Hazards, Labelling and Packaging

Your concerns 1, 3, 4a, & 4b above relate to the chemical hazard, communication of these hazards and designs of products that may be mistaken for foodstuffs. This is covered under the assimilated Regulation (EC) No 1272/2008 on the classification, labelling and packaging of chemical substances and mixtures (‘the GB CLP Regulation’) which HSE are responsible for and have provided the below response:

The GB CLP Regulation imposes requirements on chemical suppliers to ensure that the hazards of chemicals, including those used in detergents, are identified and communicated effectively and that chemicals are packaged safely and securely. Prior to placing chemicals on the market, suppliers are required under Article 4 of the GB CLP Regulation to classify, label and package their chemicals in accordance with the Regulation. To avoid misleading consumers, Article 35(2) of the GB CLP Regulation prohibits the packaging of hazardous chemicals supplied to the general public from having a design used for foodstuffs, animal feeding stuffs, medicinal or cosmetic products. The toxic effects of chemicals are covered by a number of different hazard classes under the GB CLP Regulations. Your report does not include the composition or classification of the detergent ingested by Mr. Hayes, but states that the detergent was deemed to be of low toxicity. The GB CLP classification system provides effective means by which to accurately identify the human health and environmental hazards of chemicals, including detergents. This includes the aspiration hazard class which is applied to substances and mixtures that cause severe acute effects such as chemical pneumonia, pulmonary injury or death following aspiration. Evidence

of hazards not reflected on the label should be reported to the supplier, who has a duty under Article 15 of GB CLP to conduct a new evaluation once they become aware of such information. Compliance with the requirements of GB CLP Regulation is enforced by various authorities covering a range of different supply contexts. Instances of non-compliance are subject to proportionate and pragmatic enforcement action which ensures that the risk of harm emanating from chemicals supplied in GB is minimised. There is no evidence to demonstrate that the circumstances of this case represent a more widespread problem and therefore HSE do not consider that changes to the legislation need to be considered at this time.

Design features on laundry detergent packaging

Your concerns 2, 4c, 5 & 6 related to design features on the packaging that contribute to the safe use of detergents, including in households with vulnerable people. The GB CLP Regulation, which is the responsibility of HSE, supports sector specific legislation. HSE have advised that any action deemed necessary to resolve the concerns raised in this case would need to be considered in relation to legislation specific to detergents, which supersedes the general legislative provisions of GB CLP. For example, for concern 6, CLP does not seek to identify or communicate risk factors (e.g. exposure to vulnerable adults).

Detergents Regulations

The Detergents Regulations (Regulation (EC) No 648/2004 of the European Parliament and of the Council of 31 March 2004 on detergents (as amended)) aim to achieve the free movement of detergents throughout Great Britain. Defra is responsible for this policy area. These regulations establish technical standards and requirements in relation to detergents and surfactants for detergents. This encompasses rules on the biodegradability of surfactants in detergents, provisions for the additional labelling of detergents including fragrance allergens and sets out the information that manufacturers must hold.

Physical packaging for additional consumer safety is currently beyond the scope of the Detergents Regulations as they apply in Great Britain. However, in addition to regulatory measures, we work with industry who operate voluntary measures and initiatives which promote best practices to ensure a high degree of protection to consumers. These include safety measures on packaging to provide safeguards to vulnerable consumers and communications campaigns to make the public aware of measures to be taken.

Actions to be taken

GB product safety regulations require all consumer products to be safe when they are placed on the market. This includes regulations covering products that could be mistaken for food items and may cause harm if ingested, as noted above. There is not enough detailed information in your report to determine the extent to which products have complied with all the regulations noted above. Defra does not hold responsibility for enforcement of these regulations, but I have made the Office for Product Safety and Standards aware of this case. You may wish to consider passing any relevant information about the specific product in this case to the relevant local authority trading standards department.

Whilst both regulatory and non-regulatory measures already exist to provide consumer protections, including for vulnerable people, Defra, working with colleagues across government as needed, will consider whether there are opportunities for improvements to these measures. In line with the UK government’s ‘new approach to ensure regulators and regulation support growth’, Defra aims to review our detergents regulations to consider whether any amendments are needed to improve our detergents regime. We will engage with the detergents industry to inform this work. In line with the Better Regulation Framework, whilst our policy review aims primarily to consider legislative changes, we will also consider alternative measures to regulation such as industry codes of conduct or standards that may be applicable. This could include consideration of voluntary (non-legislative) safety measures that look to address the concerns you have raised. I am aware that industry bodies have already begun some consideration of measures aimed at protecting vulnerable adults with dementia.

I hope this response helps to address the concerns set out in your report and explains our position.

Dear Mr Pemberton

Re: Section 28 Report – Prevention of Future Deaths – Mr David Joseph Hayes

The Royal Society for the Prevention of Accidents (RoSPA) expresses our sincere condolences following the tragic death of David Hayes, who mistakenly added washing detergent to a cup of tea instead of milk. We note that the inquest concluded with the medical cause of death determined as pneumonitis and aspiration following the ingestion of a chemical substance, and that the death was recorded as accidental. We thank you for highlighting the serious issues raised in your report and welcome the opportunity to outline the actions RoSPA and others are taking to help prevent similar incidents in future. We note your observation that public knowledge of these risks is unlikely to be at a level where households with vulnerable adults are fully aware of the need to safeguard detergents and limit their accessibility.

RoSPA has long been focused on improving consumer awareness around product safety. Since 2013, we have collaborated with the UK Cleaning Products Industry Association (UKCPI) to reduce accidental poisoning in children through our Take Action Today campaign. This programme has been highly successful, contributing to an almost 50 per cent reduction in related hospital admissions across the UK.

In 2024, RoSPA submitted a proposal to the UK Cleaning Products Industry Association (UKCPI) to develop a similar initiative focused on vulnerable adults. While that bid was not formally taken forward, we understand that UKCPI is now pursuing activity in this area, including a campaign with organisations such as Age UK, Dementia UK and Alzheimer’s Society. This work is exploring improvements in labelling, awareness- raising materials for households, and enhancements to training for the social care workforce, and is expected to begin delivering from Autumn 2025.

As the trade association for the cleaning products sector, UKCPI plays an important role in supporting safe product use, advising members on labelling and regulatory compliance, and promoting consumer safety. RoSPA welcomes their work in this area and sees it as complementary to our own initiatives.

RoSPA is also working in partnership with the Office for Product Safety and Standards (OPSS) to deliver an educational initiative focused on preventing accidental poisoning among individuals living with dementia.

This project includes:
• A targeted social media campaign to raise awareness about the risks posed by household chemicals to those with cognitive impairment
• The development of practical guidance for carers on safer storage of these products within the home.

The project is currently in progress and is scheduled for completion in Quarter 4 of the 2025/26 financial year.

We believe that regular assessment of home environments, combined with appropriate training and practical tools for carers, is essential to balancing safety with independence. We also recognise that timely and accurate diagnosis is crucial for planning effective care and support, particularly for individuals living with dementia. While many retain decision-making capacity, safeguarding measures must go beyond simply storing chemicals out of reach, as is typically advised in households with young children.

Our guidance promotes safe storage practices, such as keeping chemicals in their original containers, storing them separately from food and medicines, and using clearly marked cupboards with written or visual signage to indicate their contents. We also encourage manufacturers and regulators to review packaging and labelling practices—- avoiding designs that resemble food or drink containers in particular - and to expand existing warnings and plain-language instructions to include the risk posed to vulnerable adults.

We are committed to taking the following actions in response to the issues identified in your report:
• Deliver a national social media campaign to raise awareness of the risks household chemicals pose to individuals with dementia. → By Quarter 4 of the 2025/26 financial year (funded by OPSS)
• Develop practical guidance for carers on the safe storage and handling of hazardous substances in the home. → By Quarter 4 of the 2025/26 financial year (funded by OPSS)
• Promote safe storage practices through our guidance and public messaging, including: o Keeping chemicals in original containers o Storing them separately from food and medicines o Using clearly marked cupboards with written or visual signage → By Quarter 4 of the 2025/26 financial year (funded by OPSS)

• Engage with manufacturers and regulators to encourage: o Packaging that avoids resemblance to food or drink o Clear warnings and plain-language instructions addressing risks to vulnerable adults → Initial engagement during 2025; ongoing advocacy thereafter.

RoSPA is committed to reducing accidents in the home, particularly among those most at risk. We thank you for your attention to this matter and assure you that we are taking active steps to reduce the likelihood of future tragedies such as the one involving Mr Hayes.

Please do not hesitate to contact us should you require any further information.