Source · Prevention of Future Deaths

Janet Jasper

Ref: 2020-0014 Date: 17 Jan 2020 Coroner: Tanyka Rawden Area: Rutland and North Leicestershire Responses identified: 2 / 5 View PDF

Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding protocols for inspecting adjoining properties after an incident.

Date 17 Jan 2020
56-day deadline 4 Apr 2020 est.
Responses identified 2 of 5
Product related deaths

Coroner's concerns

AI summary
Hundreds of properties face a risk of floor failure, and there is inconsistency across gas distribution networks regarding protocols for inspecting adjoining properties after an incident.
View full coroner's concerns
The MATTER OF CONCERN is as follows. –

The Court heard that there are two hundred and fifty four properties within the immediate area of the incident which are at risk of floors failing in a similar manner

The Court also heard there is inconsistency in the policies of the four gas distribution networks with some requiring first call operatives to inspect adjoining properties for gas and some permitting the operative to make that decision based upon the circumstance and findings on scene

In my opinion there is a risk that future deaths may occur unless the risk to the other properties within the immediate area of the incident is properly and quickly addressed, and a consistent approach to inspecting adjoining properties is developed

Responses

2 respondents
Health and Safety Executives Regulator / Inspectorate
12 Mar 2020 PDF
Action Taken

Following a review, Gas Distribution Networks (GDNs) have agreed on a revised EM72 policy for responding to gas leak callouts, particularly "no trace" declarations. HSE also undertook communication with residents and gas engineers in the local area, including hosting a residents meeting and providing leaflets to explain potential risks and actions. (AI summary)

View full response
Dear Mrs Rawden, I am writing in response to the Regulation 28 – Report to Prevent Future Deaths issued by you on 17 January 2020 in relation to the Janet Shirley Inquest. In your report you highlighted the following area of concern: The Court heard that there are two hundred and fifty four properties within the immediate area of the incident which are at risk of floors failing in a similar manner. The Court also heard that there is inconsistency in the policies of the four gas distribution networks with some requiring first call operatives to inspect adjoining properties for gas and some permitting the operative to make that decision based on the circumstances and findings on scene. In my opinion there is a risk that future deaths may occur unless the risk to the other properties within the immediate area of the incident is properly and quickly address, and a consistent approach to inspecting adjoining properties developed. I am writing to confirm the activity that has taken place and/or been agreed since the incident.

1. GDN policies and procedures The Gas Distribution Networks met 5 February 2020 to review their current EM72 policies, the policies that describe the action that should be taken when responding to a callout about a possible gas leak. In particular, the meeting was looking at the policies in relation to “no trace” declarations when attending a reported internal smell of gas and whether these were -fit for purpose, consistent between each GDN, and consistent with their approach to investigating CO incidents. At this meeting all GDNs agreed, in principle, to adopt a new and consistent policy: If at an internal PRE and there is no trace at the reported address then the operative:  MUST check those properties which are immediately adjoined or adjacent including building line, points of ingress, letterbox and knock for entry.  If access is gained ask questions about whether a smell of gas has been noticed.  If no smell of gas reported, carry out gas detection checks (tightness test not required).  If a smell of gas is reported or detected undertake a tightness test and follow normal gas escape procedures. If no readings are found either inside or via letterbox checks, then report work as no trace. This new policy will bring the policy in relation to reported internal smell of gas in line with those on external gas smells and for CO response, which in turn should provide a significant improvement in safety. Each GDN will now agree these new policies with their relevant Director’s and legal departments prior to implementation. HSE has agreed that if any changes are made to the revised policy prior to rollout this must be discussed and agreed with HSE first.
2. Other properties in the immediate area at risk HSE, along with the Gas Safe Register, undertook extensive communication activity with both residents and gas engineers in the local area to advise them of the cause of the incident, the risk to their own properties and the action the could take to mitigate this. This included:  Hosting a residents meeting,  Providing leaflets for residents to explain the potential risk and actions. These leaflets were dropped through the letterboxes of affected properties and additional copies were provided to the local authority.

 Providing information from Gas Safe Register specifically for local gas engineers to explain what should consider and do when attending these properties  Providing additional briefing and material for HSE and Gas Safe Register staff that might deal with calls from concerned residents and/or engineers Both HSE and the GDNs have taken your concerns seriously and taken action to address the issues raised.
Cadent Gas Northern Gas Scotland Gas Wales and West Utilities
PDF
Action Planned

Gas Distribution Networks (GDNs) clarified procedures for checking adjoining properties during internal gas escape investigations, focusing on external sources. The GDNs will brief operational teams on the revised requirements, expected to be in place across all networks by mid-summer 2020. (AI summary)

View full response
Dear Mrs Rawden Inquest touching the death of Mrs Janet Jasper Response to Regulation 28 Report – Prevention of Future Deaths

Following the Inquest touching the death of Mrs Janet Jasper, this letter sets out the joint response to the Regulation 28 Report from the Gas Distribution Networks (GDNs), namely Cadent Gas Limited, Northern Gas Networks Limited, Scotland Gas Networks PLC, Southern Gas Networks PLC and Wales and West Utilities Limited (the “GDNs”). The sympathies of all GDN’s remain with Mrs Jasper’s family following this tragic accident. The Regulation 28 Report sets out two separate matters of concern: (1) that there are two hundred and fifty-four properties within the immediate area of the incident which are at risk of floors failing in a similar manner; and (2) that there was inconsistency in the GDNs’ requirements for checking adjoining and adjacent properties when responding to reports of internal gas escapes. As explained during the inquest, the GDNs had a pre-arranged meeting with the Health and Safety Executive (“HSE”) on 23 January 2020 and had added to the agenda the consistency of procedures for responding to reports of internal gas escapes (and specifically the checking of adjacent or adjoining properties). This meeting was attended by the engineering policy leads for each of the GDNs, together with Steve Critchlow and Caroline Lane of the HSE. At this meeting, it was agreed that the GDNs did not have any power to take action in relation to the two hundred and fifty-four properties which were at risk of floors failing and the HSE would consider this point separately. In relation to the GDN procedures, when the documents were reviewed as a whole and side by side, it was agreed that there was already a consistent approach to checking adjoining and adjacent properties when investigating an internal escape. However, detailed discussions continued in relation to whether the industry could clarify its existing procedures in this regard. The GDNs met again on 5 February 2020 at the Energy Networks Association and agreed an aligned form of wording, which would further clarify existing procedures in relation to investigating reports of internal escapes. Existing procedures already require operatives to consider whether gas may be leaking from alternative sources, including from adjoining and adjacent properties. The agreed wording going forward is that operatives shall take all reasonable, practicable and proportionate measures to

Mrs Tankya Rawden Assistant Coroner Rutland and North Leicestershire Coroner’s Court Southfield Road, Loughborough LE11 2TR

13 March 2020

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investigate the possibility of gas leaking from external sources before confirming a “no trace” result. As part of this investigation, operatives must check immediately adjoined and adjacent properties where it could be reasonably assumed, based on site conditions, that they are a possible cause of the reported smell of gas. Where it is not possible to gain access to immediately adjoined and adjacent properties, gas detection checks will be undertaken at accessible building ingress points, such as letterboxes, air bricks, vents, windows etc. A “no trace” result can only be recorded under the clarified procedures where no gas has been detected at the original property and where no gas has been detected following all reasonable, practicable and proportionate measures to investigate the possibility of gas leaking from external sources. In February 2020, the GDNs met again with Steve Critchlow of the HSE to report back on their proposed approach. Steve Critchlow agreed with the proposed changes and considered that they would meet the Coroner’s aims. All of the GDNs will be briefing their operational teams on the revised requirements, which are expected to be in place across all networks by mid-summer. Although it cannot be concluded that Mrs Jasper’s tragic death could have been prevented had these revised procedures been in place at the time, we trust that the approach being adopted by the industry going forward addresses any concerns that may have arisen during the Inquest.

Report sections

Investigation and inquest
On 2 January 2018 an investigation commenced into the death of Janet Shirley Jasper aged 79 years. The investigation concluded with an inquest heard before a jury between 13 and 17 January 2020. The conclusion of the inquest was accidental death
Circumstances of the death
Mrs Janet Shirley Jasper was born on 10.10.38. She resided in a semi-detached property at in Birstall, Leicestershire with her husband , and their son

The adjoining house, number in Birstall, Leicestershire, was vacant, having been owned by the father of the witness who died in August 2017

On 10 December 2017 reported the smell of gas in his hallway and a first call operative from Cadent Gad Ltd attended the property. The first call operative found no evidence of a gas leak in Birstall, Leicestershire

On 11 December 2017 arrived at number at approximately 7.20am. He noticed a smell whilst on the driveway which became stronger as he entered the conservatory, and then the kitchen, of the property. He described lifting the glass lid of the hob and then finding himself lying on the kitchen floor covered in rubble

The Court heard from that at approximately 7.30am on 11 December 2017 he got out of bed leaving his Mrs Janet Jasper in bed. He was standing the bottom of the bed when there was an “enormous flash and a bang”. Plaster board fell on top of him pinning him to the floor

Mrs Janet Jasper was taken to Walsgrave Hospital where she died on 12 December 2017

The Court heard from Consultant in Intensive Care Medicine that the medical cause of death was:

1a. Multi organ failure 1b. Thoracic trauma 1c. Explosion

The Court heard from gas investigation officer for the Health and Safety Executive, that the gas leak originated in the hallway of Birstall, Leicestershire. A full separation of the gas pipe in the concrete floor of the hallway had occurred due to ground movement caused by subsidence. His evidence was that poor construction of the floor was a major contributing factor in the subsidence and the failure of the pipe was unable to assist the court with exactly when the gas pipe failed. He estimated a time period of between five and ten hours but was clear that the time period could have been shorter or longer than that estimate. He was unable to say whether the gas leak had occurred before, or during, the first call operative’s visit to number , Birstall, Leicestershire

His evidence was that the spark which ignited the gas and caused the explosion was likely to have omitted from the light switch or the spark ignition on the hob of the cooker in the kitchen

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Report details

Reference
2020-0014
Date of report
17 January 2020
Coroner
Tanyka Rawden
Coroner area
Rutland and North Leicestershire

Responses identified

Responses identified 2 of 5
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 4 Apr 2020 (estimated).

Sent to

Cadent Gas Ltd
Gas Safe Network
Institution of Gas Engineers
Scotia Gas Network
Wales and West Utilities

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