Joseph Allison

Dear Sir Re: Inquest touching upon the death of Mr Joseph Allison We write further to your Regulation 28 Report to prevent future deaths sent under cover of your letter of 25th March 2015 and subsequent exchanges of correspondence regarding an extension of time in which to submit a response. This letter constitutes the response to your Regulation 28 Report: Before addressing the section of your Report which deals with Matters of Concern" itis felt appropriate to deal with two matters which arise out of our consideratior the section headed "Circumstances of Death" which We feel, as currently of beayehave the capacity to mislead someone reading theeRepordwhorerativotoededi benefit of the fuli background or having heard all of the evidence given atohe Inquest: Tbe first matter relates to paragraph 4(3) where it is respectfully use of the following phrase has the potential to misleed; submitted that the "Moreover the manufacturer's internal record of compliance was falsely show that the necessary work had been completed so as to carried out; Our concern is that the word "falsely" in the context of the sentence has the capacity to be interpreted in a way which as constructed act of dishonesty on the part of the suggested some deliberate act or Plainly that is not the company was involved in the factual narrative. case, was not the evidence given in or orally at the Inquest; and no witness was questioned on the basis that such case, as should have been done, really, if such could have been the a matter was to be in question; In our view the sentence would be more reflective of the given were it to read 'Moreover the actuality and the evidence which stairlifts had been records compiled by the manufacturer to capture successfully upgraded as part of the original upgrade programme were inaccurate in that showed some stairlifts as having upgraded which had in fact not been, as was later discovered been Registered in England Cardiff No. 4108172 VAT Registration No. GB 776 2889 86 Stairlifts, Moving & Handling and Bathing Solutions Registered in England No. -109393 VAT Registration No. 849 7575 59 Your the writing they Mobillty

The second matter relates to the sentence appearing at paragraph 4(5) which reads: "Furthermore no information regarding this defect and remedial actions was released to appropriate third parties such as independent installer or dealers:" Again, in our view, and respectfully, we say that this is capable of being misleading: As was clear from the evidence submitted in writing and the evidence given orally at the Inquest Bulletins 55 and 66 were mailed to our trade customers at the time of issue. This would include independent installers and dealers, and, in fact; as was explained, all those to whom we knew the business had supplied a stairlift or who were regularly maintaining stairlifts. What was not done at the time, and what we understood the concern to be directed to during the course of the Inquest; was to distribute such information to other independent installers and maintainers, outside of the group reached, in order to cover the potential scenario whereby a stairlift had been sold or installed second- hand outside the knowledge of the business or was being serviced by someone outside our known and identifiable network of installers, dealers, and maintainers In our respectful view the sentence would more reflective of the evidence if it read "Furthermore whilst efforts were made to provide information on the defect and remedial actions to those to whom the manufacturer had supplied stairlifts or it knew maintained stairlifts such information was not supplied to others who might have sold or installed stairlifts second-hand or who were maintaining stairlifts outside the manufacturers identifiable network of businesses which maintain stairlifts_ We will now address the matters set out in the section of your report entitled "Matters of Concern"_ "5(1) In-house service engineers have not been specifically trained to be aware of the defect in the Minivator 2000, nor issued with feeler gauges to implement the appropriate safety check Action Taken Handicare engineers have been made aware of the potential defect; issued with feeler gauges and have received a face to face briefing with regard to its use to out a trunnion inspection as detailed in Bulletin 66. The content of Bulletin 66 has also been issued to them: have also been issued with a list of recall batch serial numbers_ Training with the feeler gauge and a briefing on the top trunnion issue has been added to the new engineer training programme together with a list of the recall batch serial numbers, to ensure that any new employees are made aware Of the issue as part of their induction training: Itwill be recalled that Bulletin 66, which formed Appendix B to the statement of Mr explained what needed to be done to identify the defect and what action should be taken immediately if a defect was found, carry They

"5(2) In-house and third party service engineers are thereby exposed to the same risks which end users face if test ride serviced stairlifts themselves" Action Taken In relation to in-house service engineers please see the response to paragraph 5(1) above. We are contacting all dealers that have ordered stairlifts or spares since 2005 to raise awareness of the defect and upgrade programme. We are issuing the recall batch numbers with the request to contact us if come across any of these units in the field: We have also purchased a list of UK mobility retailers and are sending a similar communication to any of these dealers not already registered with us and covered by the communication referred to in the paragraph immediately above: First class mailing of these communications took place 11- and 12" June 2015 A communication covering similar ground will also be included as an insert; for ease of extraction and retention; in THIIS (stands for "The Homecare Industry Information Service" magazine; the primary trade publication. This is planned for the July issue of this monthly magazine. We attach examples of the communications which are being sent to our dealer network; are being sent to the list of dealers who are not part of our established dealer network, and are to be inserted into THIIS magazine marked as TMT TM2 and TM3 respectively: "508) No nationally publicised safety recall campaign has been undertaken to alert end users to the danger; or request that such users contact the manufacturer for to the remedial programme: access Action Taken We will be conducting national advertising campaign in the publications us by external specialists as having the highest readershiphand beict tatiaridentified to coverage iThis will run between Monday 15" June and Sunday 4" Julya Adverts will sun on various days in the following publications: The Sun (National) The Seottish the Daily Mail and the Mail on Sunday: We are also mailing all Local Authorities to raise awareness of this recall in have had anaffected stairlift installed by a third party: First class maeling case communications took place 11" and 12"h June 2015. of these We attach examples of the adverts which are to appear in the national and the communications to be sent to local authorities marked newspapers respectively. TM4, TM5 and TM6 ShetGroup function is also in the process of reviewing the viability of section on the Handicare website, to be accessible incorporating listing safety upgrades, including the by any visitor to the website, Minivator 2000 trunnion upgrade. This site is managed by Handicare Group's central marketing department not a local JK team they they Sun;, they

and serves a number of divisions s0 changes like this go through a consultation process. As matters stand we cannot confirm whether or not this is something for which we will get authority to proceed; "5(4) No adequate initiative has been taken to advise the stairlift industry generally of the risks inherent in unimproved Minivator 2000 Stairlifts;' Action Taken In relation to the generality of the concern expressed please see the responseslaction taken in relation to paragraphs 5(2) and 5(3) above: Asregards the topic of all manufacturers or all leading manufacturers sharing information on such issues within the sector generally, from our recollection, this was tabled by our representative at a meeting of the stairlift section of the BHTA once the original trunnion upgrade programme was initiated, to highlight the need to share safety information between companies At the time some manufacturing membees of the section were opposed to creating a formal system due to concerns about the requirement to share data or information which may be commercially confidential or commercially sensitive in its nature, and therefore this was rejected. te haveeraised the matter informally with the BHTA again; both before and following the Inquest There is a BHTA stairlift section meeting planned for the 9" July 2091,mhe first such meeting following the Inquest, Where this will be tabled once more for consideration We will raise the issue again with all manufacturers at this try to highlight the importance of sharing such informatioract order eotheduceethregts to users of stairlifts with potential safety issues. A letter will also the risks be sent to these manufacturers during the week commencing 15" June 2015, believe we have done all that we can to address the concerns identified in the Regulation 28 Report. As will no doubt be readily understood thessafety ousersof our products and of our staff who maintain them is of the utmost and that is why we always seek to review our processes importance to us reduction and improved accident to identify areas for risk drawing our attention prevention: We are, therefore, appreciative of your to the matters highlighted in the Regulation 28 Report: At the risk of repeating what has already been said publicly at the reiterate how deeply saddened we were at the Inquest we must involving Mr Allison following what circumstances of the accident was thought to have been a successful initial upgrade programme. Blthere is anything further with which we can help, or if any clarification is please get in touch: required; Yours faithful Sales & Marketing Director For and on behalf of Handicare Accessibility Ltd Encs: TM1 to TM6 We

Dear Mr Wade Re: Inquest touching upon the death of Josephl AuiSor Thank you for drawing our attention to your investigation and conclusions with regard to the above case_ To address your points: and 2 we are satisfied that Handicare has adjusted internal process and training to ensure Rhat appropriate training is provided to the in-house engineers on an ongoing basis. BHTA will remind all its manufacturer members that if training is necessary to address a field safety issue the training must continue to be provided until such time as all the products have been traced and the necessary action taken: 3 BHTA has been concerned for some time that there is no national system for notification of product recalls and field safety work for products such as stairlifts, We have noted that lis currently leading a review into the recall system for unsafe products to which we will be responding: brocu wwwegov ukgovernmentnewsconsumer-champion-lvnn-taulds-wood-to-lead: product-safety-review Clearly there is a need tor & national system , but we are also conscious that costs and effectiveness might be barriers . There is & weli-established system fun byatheostedicines & Healthcare Products Regulatory Agency (MHRA) for alerts regarding medicaledevicesnend this ensures wide circulation throughout the health and care sectors: We Will recommend that the Health & Safety Executive talk to the MHRA and see if might tap into the aleeting system for alerts regarding products which are not medicey devcesaDut hich bavee beeplsold into the care sector, provided to social services, or sold direct to frail elderly peplevfor the purpose of maintaining independence, preventing falls, and / or enabling mobility: New Loom House Suite 4.06 101 Back Church Lane London E1 IU continued overleaf_ Telephone: Fax= British Heathcare Email: bhta@bhta.com Trde Association Afproved CODE www,bhta.com British Healthcare Trades Association ttthe heart of healthcare since 1417 Reccerea m EngiencNoL;5412; VAT Registration No. 702 8455 45 May alerting they

2 The business did raise the matter at one of our meetings (minutes of which to all relevant members) and we have discussed how to are distributed operation throughout the supply chain; Iessereiterate ioprane notifications and CO- written agreement with their dealers setting manufacturers the need to a recall or the need for field out what will be expected of them in the event of the safety work; and that should make full use of ourselves and publications read by businesses in the sector to raise awareness; If we may be of any further assistance please do not hesitate to contact me_