Source · Prevention of Future Deaths

Elizabeth Griffin

Ref: 2018-0072 Date: 7 Mar 2018 Coroner: Fiona Wilcox Area: London Inner (West) Responses identified: 3 / 5 View PDF

No specific concerns for future deaths were detailed in the provided text.

Date 7 Mar 2018
56-day deadline 13 Aug 2018 est.
Responses identified 3 of 5
Product related deaths

Coroner's concerns

AI summary
No specific concerns for future deaths were detailed in the provided text.

Responses

3 respondents
Department for Business Energy Industrial Strategy Central Government
7 Mar 2018 PDF
Action Taken

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. (AI summary)

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Dear Tiaa Thank you for your Regulation 28 Report to Prevent Future Deaths, dated 7 March 2018 following your investigation and inquest into the death of Mrs Elizabeth Griffin, aged 71, due to accidental death caused by bronchopneumonia and smoke inhalation injuries a fire started by a Whirlpool dishwasher: am responding as the Minister responsible for product safety _ May first say how sorry | was to hear of this tragic incident: If you have the opportunity, please convey my deepest sympathies to Mrs Griffin's family. The Government and my Department takes the safety of all consumers very seriously. Dishwashers fall within scope of the Electrical Equipment (Safety) Regulations 1994 or 2016 depending when the product was placed on the market: Both sets of Regulations contain the same essential safety requirements which require that domestic electrical equipment are safe to use. Manufacturers have a responsibility to only safe products on to the market. In law, where they identify a safety issue with a product already on the market must take action which may, where appropriate, include a recall In assessing the safety of a product, account is taken of a number of factors including labelling, instructions for use and adherence to standards_ In your report you have expressed three main concerns relating to product safety: The length of time taken by Whirlpool UK to launch the repairlithdrawal campaign; from put they

That there should be a safety campaign encouraging owners of appliances to register through a central portal so they can be contacted promptly if a safety issue is identified with particular product; and That any such campaign should be also targeted at those who are less computer literate and consideration be given as to how to address their needs in relation to registration: The Government is clear that manufacturers, importers and distributors must act swiftly and with sufficient resource to ensure effective action when a safety issue is identified in a product that is already on the market and in use in consumers' homes_ As you know, the dishwasher that started the fire that caused Mrs Griffin's death was a model that was subject to a corrective action programme as it had been identified as representing a safety risk The manufacturer is responsible for ensuring the safety of their product and for taking corrective action when safety issues are identified. Sadly, in this case, Mrs Griffin's dishwasher was not identified by Whirlpool and had not been repaired or replaced. In January 2018, the Government announced an upgrade to the product safety system to be led by a new Office for Product Safety and Standards. recognise the issues you have set out in your report and want to assure you that these are issues we have taken action on and will continue to be a focus for the work of the new Office for Product Safety and Standards. Before the new Office was established, the Government had already taken several to deal with the issues you have identified_ note your concern about the apparent delay between the company being made aware of a potential problem with the product and formal action taken to initiate a modification programme_ The law requires manufacturers to notify enforcement authorities as soon as they identify a risk with a product have placed on the market: have asked the Office for Product Safety and Standards to work with local authorities and businesses to clarify expectations regarding the criteria for triggering a notification of risk to regulators; and this can be done more effectively with Office support in order to improve levels of consumer protection in the UK In October 2016 the Government set up a new central recalls website to provide consumers with information on recalls of all electrical goods and other products_ The recalls website was upgraded in June 2017 and provides a single portal for access to information about current product recalls, drawing on UK and international recall information: It provides a centralised up to date source of trusted advice and information that users can interact with. Government also advises consumers to register their electrical appliances, whether new or second-hand, with the manufacturer via the recalls website, SO they can be informed directly by the manufacturer should a recall or other corrective action subsequently be required. Future upgrades to the website expected by 2019 will involve the building of an extensive data hub of all corrective action and recall programmes affecting consumer products This will develop a comprehensive digital service that provides a centralised up to date source of trusted advice and information for consumers on product safety and recalls which users can interact with. they how

The Government also supports and encourages the use of the Association of Manufacturers of Domestic Appliances' 'Register My Appliance' site , which enables manufacturers to contact customers directly where a product fault has been identified_ The Office for Product Safety and Standards is leading work to improve businesses product recall processes. My Department commissioned the British Standards Institution (BSI) to create a new Code of Practice on product recalls (PAS 7100 Code of practice on consumer product safety related recalls and other corrective action): This was launched on 7 March: guides businesses and regulators through the process of planning for and handling a product safety incident for non-food consumer products_ The Code of Practice also sets out for Local Authorities the guidance and advice should be making available to enable businesses to meet their legal responsibilities and act in the public interest: The Code of Practice establishes best practice guidance for business on effective methods of reaching consumers , particularly for those consumers who do not have access to on-line methods_ You may also wish to be aware that will be meeting with the General Manager of Whirlpool UK in May regarding Whirlpool's approach to product recall and corrective action. Thank you for bringing this important issue to my attention, and to other parties The Government is committed to product safety for all consumers and believe that the steps we have taken will further strengthen the UK's product safety regime and help to avoid tragedies like this in future_
Whirlpool UK Other
7 Mar 2018 PDF
Action Taken

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. (AI summary)

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WHIRLPOOL UK APPLIANCES LIMITED'S RESPONSE TO REGULATION 28 REPORT TO PREVENT FUTURE DEATHS DATED 7 MARCH 2018 We are writing to provide Whirlpool's response to the Regulation 28 Report to Prevent Future Deaths dated 7 March 2018 arising out of the inquest into the death of Mrs Elizabeth Marion Griffin: Before we address the report; we would like to take the opportunity to how very sorry we were to learn of this tragic incident and would like to pass on our sincere condolences to the friends and family of Mrs Griffin_ We have reviewed carefully the comments of the Coroner set out in the Regulation 28 Report; and respectfully provide the following responses to the "Matters of Concern" raised in that report: WHIRLPOOL'S PRODUCT SAFETY PROCESSES The Coroner raised concerns over the length of timing of the safety campaign for the DWF Series 3 Dishwashers. We welcome the opportunity to provide some context to that safety campaign and Whirlpool's product safety processes_ The safety campaign was conducted in full cooperation with Trading Standards by Indesit Company UK Limited. At all times Indesit responded promptly to the information that was available to it: In terms of Whirlpool's systems and procedures to deal with future issues that may arise, we take the opportunity to outline the following details of those systems and procedures which now apply following Whirlpool's acquisition of Indesit: Whirlpool has a comprehensive set of policies, procedures, and guidelines in place for field monitoring, field safety investigations, analysis, risk assessment; and reporting potential safety hazards associated with its products in order to inform an expeditious decision on a field corrective action. These systems have been developed and refined over decades, and Whirlpool keeps those systems under review as part of its commitment to continual improvement: Whirlpool's approach to product safety governance starts with senior leadership oversight;, with specially designated Executive Safety Committee. The membership of Whirlpool's Executive Safety Committee includes members of the Whirlpool senior leadership team from a cross-section of the company: This team is responsible for the decisions regarding the need to undertake field corrective actions for potential product risks that have been identified. Whirlpool's Governance Model is implemented through formal corporate policies which define Whirlpool's position and philosophy on product safety, formally puts in place the product system , defines clear roles and responsibilities for all employees and functional groups, requires pre-market risk assessments, post-sale monitoring of product performance and safety, requires risk assessment of potential issues that are identified on units already with consumers, defines required communication protocols for these risks. The Governance Model is supported and implemented through multiple corporate and functional policies and procedures_ Another important aspect of product safety governance at Whirlpool is the built-in system of checks and balances. Whirlpool has established an independent Global Product Safety Team which operates separately from product development; engineering; and commercial teams. The independence from the product development; engineering, and commercial teams allows this team to make unbiased decisions that are focused first on safety: This team has a direct Iink to the Whirlpool senior leadership team_ Whirlpool requires a continual assessment of risk of potential safety hazards throughout the lifecycle of the product, from product development; to marketing; to disposal: This includes formal and comprehensive pre-market risk assessment and safety audit, and continuous field monitoring of field hazard incidents and allegations 3985859 v1 say safety safety and

Whirlpool's approach to monitor product performance in the field is a broad approach, practiced globally, that considers all reports that we receive involving our product where the consumer perceives their safety may be at risk. Whirlpool receives information and data about potential product incidents from multiple sources , including among others, consumers, Trading Standards, Fire & Rescue Services and insurance companies. When this initial contact occurs, every effort is made to gather as much information as possible regarding the appliance, the consumer, and the alleged incident: This allows us to both assist the consumer wherever we can, and it also allows us to investigate the matter in more depth: Regardless of the source of the information, all such cases are channelled through to a dedicated team in the UK to ensure that we have a consistent approach with our initial investigation process throughout We wish to make it clear that there is no reluctance on the part of Whirlpool to consider, and, as appropriate, place due reliance on information received from sources external to Whirlpool. Indeed, information from external sources is vitally important; including information received from experts not appointed by or on behalf of Whirlpool: If an alleged incident description references any concerns of safety, efforts are made to arrange a visit to the consumer's home by a qualified service engineer to further assess the reported experience; to gain additional facts; and to better understand the alleged event: This access to the product allows for further assessment of the consumer's description and provides a better understanding and refinement of the physical facts to determine if our product may have behaved in a potentially unsafe manner: If the information provided continues to lead the team to believe that the product's behaviour may have resulted in it failing in a potentially unsafe manner; then, wherever possible, arrangements are made to retrieve the product and return it to our Product Safety Team for a detailed inspection, here in the UK Retrieving the product allows Whirlpool to conduct a more robust engineering inspection in a laboratory environment with the intent to identify and confirm the root cause that may or may not be consistent with the consumer's reported experience. If retrieval of the product is not possible (for example where the product cannot be released to us for legal reasons), where appropriate, throughout the country Whirlpool routinely uses third party, (independent) forensic engineers to support this work and examine the appliance on our behalf: In some instances, the physical product may not be available or may not require a field replacement; however, the details of the report are still documented in our system and can be used qualitatively when an engineering investigation is performed: Whirlpool's process is structured to funnel, along with other pertinent information, all machine inspection reports into one central database, irrespective of whether the report was generated by a Whirlpool employee or an independent forensic expert alleged incident that is reported to Whirlpool is investigated and at the end of the investigation, if safety-related in nature, is reviewed by the team of dedicated product safety engineers, and is judged on the merit of the information available, irrespective of the source of that information (be it internally or externally gathered information) including where appropriate with the further support of external experts. After this review, the incidents are categorised into a structured and searchable database so potential field safety hazards, that may require further action, can be identified, monitored, and assessed. Action taken or proposed to be taken Whirlpool continues to apply the processes described above on an ongoing basis, and will continue to carefully monitor reports from the field, and from other sources, which may involve risks associated with its products_ These reports are dealt with promptly and without undue delay: We trust that this additional information and further explanation helps in addressing any concerns that were raised during the course of evidence at the inquest: 3985859 v1 safety Every

ENCOURAGING REGISTRATION FOR ALL CONSUMERS The AMDEA (Association of Manufacturers of Domestic Electrical Appliances) 'Register My Appliance' scheme (at wwregistermyappliance org Uk) provides a central portal for consumers to register not only their kitchen appliances but also all electrical appliances in their home: Whirlpool continues to be a prominent advocate within AMDEA both to promote consumer awareness of the scheme and to communicate to consumers why registration is So important; It features on our websites and across our consumer literature. are proud to have the highest consumer appliance registration rate in the industry and one of the largest consumer databases Action taken or proposed to be taken Whirlpool participates in 'Register My Appliance' day, which takes place annually in January: The event provides the ideal opportunity to promote the purpose and benefits of the scheme and to encourage registration by consumers We use the event as a platform to launch specific Whirlpool initiatives around registration of appliances. For example, in the lead up to the last campaign, Whirlpool offered prizes to encourage registration among consumers_ Whirlpool encourages registration of its products via both online and offline methods. Consumers are able to call a freephone number (0800 597 8557) if they do not feel comfortable using the online portal and prefer human interaction. Consumers who call the freephone number will speak to dedicated trained advisors who are available seven days a week The advisors will login to the online registration portal to enter the consumer's details Whirlpool places prominent coloured sticker on the front of every new product sold, which encourages consumers to register their products. Consumers are encouraged to call the freephone number or to register online. The sticker has been designed to make it highly visible to consumers, so they are more likely to register: As part of its ongoing commitment to encouraging registration, Whirlpool includes details of the registration freephone number in its marketing materials both before and after sale. Whirlpool continues to pursue initiatives to improve registration rates both for its own products, and within the industry generally. Over the past year Whirlpool has engaged in dialogue with stakeholders including consumer advocacy groups and government agencies to consider options for addressing this important issue. For example, Whirlpool is actively leading discussions within the industry on how to improve consumer awareness of the 'Register My Appliance' site, make the site easier to navigate , and make the importance of registration clearer. In recent consumer communications, Whirlpool has also worked with consumer advocacy groups and charities to encourage registrations among more vulnerable members of society who may prefer human interaction to online registration. Whirlpool will continue that dialogue, and intends to work to maintain its role as a leading industry player in this area: PUBLICATION OF THIS RESPONSE As the Regulation 28 Report was published, Whirlpool thinks it appropriate for this Response to be published. For and on behalf of Whirlpool UK Appliances Limited Dated: 2 May 2018 3985859 v1 We key
CTSI
23 Mar 2018 PDF
Noted

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. (AI summary)

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Dear Dr Wilcox Mrs Elizabeth Marion Griffin Thank you for your sending a copy of the report into the death of Mrs Elizabeth Marion Griffin to the Chartered Standards Institute_ would like to take this opportunity to advise you that the Chartered Trading Standards Institute is a private company and professional body for trading standards officers, as such this matter is not something that we are able to get involved with as we have no powers, this would be a matter for trading standards departments that are run by local authorities. On a separate matter you may be interested to hear that CTSI has recently conducted a workforce survey of trading standards services in England and Wales. This deronstrates the severe and deep cuts to trading standards services which in turn has led to a reduction in activity and prioritisation; copy of the survey can be viewed at https IlwWW tradingstandards uklmedialdocumentslnews- policylsurveyslctsi-workforce-survey-201Z am sorry that our organisation is not able to be of any further assistance in this matter;

Report sections

Investigation and inquest
On 2Oth February 2018, evidence was heard touching the death of Mrs Elizabeth Marion Griffin. Mrs Griffin had died on 21s August 2017 in St George's Hospital following an admission for smoke inhalation from a house fire on 14ih July 2017 . She was 71 years old at the time of her death: The findings of the court were as follows: Medical Cause of Death 1 (a) Bronchopneumonia (b) Smoke inhalation injuries
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action. It is for each addressee to respond t0 matters relevant to them

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Report details

Reference
2018-0072
Date of report
7 March 2018
Coroner
Fiona Wilcox
Coroner area
London Inner (West)

Responses identified

Responses identified 3 of 5
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Aug 2018 (estimated).

Sent to

Chartered Trading Standards Institute
Wandsworth Watch Alarm
Office for Product Safety and Standards
Wandsworth Borough Council
Whirlpool UK

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