Elizabeth Aurora Kerr

AllParty Parliamentary Gas Safety Group (APPGSG): Alltthe recommendations of the All Party Parliamentary Gas Safety Group (APPGSG) Reducing death by Carbon Monoxide Report of 2011(copy attached) have not been adopted or enacted: The APPGSG should consider undertaking a review of progress made in the 2 years since the report 2 Guidance on _the_potential movement ot CO within a building: There appears to be a lack of understanding and detailed guidance on the potential movement of CO within a building from its original source and how it can penetrate and move within it. The HSE could provide more inforation on its site and provide specific guidance or warnings. There is no HSE guidance to landlords and agents as to what independent validation has taken place of the gas and other fuel safety equipment provided in rented property may be appropriate. Such information could also be disseminated to and within all Fire and Rescue Services. 3 The_Role of Fire and Rescue Services_in Carbon Monoxide_Safety: The Fire and Rescue Services currently have no statutory role in Carbon Monoxide safety; regulation and enforcement: This could be reviewed and considered by the Department for Communities and Local Government. It is appreciated that this is far straight forward and wider issues would need to be taken into account: For the year web ietting from example Fire and Rescue Services have no statutory role in other gases or substances which cause death: This may require a more detailed analysis and assessment of issues and complications which may then come to light: In the absence of a statutory role, and possibly through the Chief Fire Officers Association "Blue Watch" initiative, Fire and Rescue Services could be encouraged to voluntarily engage in local and national Carbon Monoxide campaigns: Such campaigns may benefit from closer working at a local level with relevant CO charities and at a national level between the Gas Safety Trust; the Gas Safe Charity and the Chief Fire Officers Association; 3 _Ofgem: They have a public safety role in relation to piped gas safety in that "The regulator shall, subject to primary duties, carry out functions in a manner best calculated To protect the public from dangers" . Mrs Kerr died in 2008 and there are about 50 deaths a year Carbon Monoxide and many more non-fatal incidents. It is understood that this year alone there have been some 30 deaths, albeit the majority of them were not a result of leaks from the piped gas system: _ However, in view of the continuing fatalities and incidents, which is a matter of concern Ofgem andlor the appropriate government departments may be a need to revisit and recalculate the regulatory response required by all fuel suppliers and regulators so as to reduce the avoidable deaths and non-fatal incidents. 4 Piped Gas Supplierg: It is understood that there are specific conditions of a licence to supply gas as summarised below: It is not clear how gas suppliers define and determine who is a "vulnerable and priority" customer and how is it established that they have been offered a free annual gas safety check; and have taken advantage or not) of such an offer ? Nor who actually checks what steps a gas supplier takes in practice to raise the awareness of danger and who judges the reasonability of the steps or who actually checks what steps other fuel suppliers take in practice to raise the awareness of danger and who judges the reasonability of the steps? 5_Enforcement and Intormation; There is no requirement that in the case of a carbon monoxide death, a clear audit trail is available of the steps taken by the relevant fuel supplier to ensure the specific customer in question was aware of the dangers of carbon monoxide poisoning and the benefits of an audible alarm. At the moment there is no specific information that fuel suppliers are required to give: from fitting

"The licensee must take all reasonable steps to provide, free of charge, the information required by paragraph 30.6 to each Domestic Customer at least once each vear and must provide it when requestedto do so by a Domestic Customer: 30.6 The information referred to in paragraph 30.5 is information sufficient to inform each of the licensee'$ Domestic Customers about: a) the safe use of gas appliances and other gas fittings; b) the dangers of carbon monoxide poisoning; c) the benefits of fitting an audible carbon monoxide alarm that complies with a relevant British or European safety standard; d) the benefits of gas safety checks; and e) where to seek advice if gas appliances are condemned as a result of a gas safety check: 6_Theinstallation use maintenance and correct positioning of fixed hard wired or battery operated CQ alarms: From October Ist 2010 Building Regulations Approved Document J "Combustion appliances and fuel storage systems' sets out a number of legal requirements in England and Wales. For the first time carbon monoxide (CO) alarms were mandatory "where a new or replacement fixed solid fuel appliance is installed in dwelling; a CO alarm should be provided in the room where the appliance is located: However Building Regulations only cover the processes used during the 'building' or 'installation' phases, of a solid fuel appliance and do not have any power to talk about on-going maintenance processes or the inspection of existing appliances. CLG could consider whether a safety performance certificate that included gas safety, along the lines of an energy performance certificate would promote an improved on-going attitude towards carbon monoxide safety amongst landlords and lettings agents, and thereby lead to reduction in carbon monoxide incidents in rented property: There is at least one national, voluntary, independent system already available and such a certificate would be a clear demonstration of compliance with carbon monoxide safety measures. The_use and availability ot CGL meters bY Fire and Rescue Services and having suitable_training in their operation as well as the_Use of personal protective equipment CQ alarms GMFRS did some research in the use of such equipment by all Fire and Rescue Services. Please see the attached. It is suggested that if all Fire and Rescue Services carried such equipment on front line appliances and used them on both emergency responses and preventative work that would reduce the risk of death to Fire Fighters and the public: The Chiet Fire Officers Association Blue_Watch Initiative" This is voluntary initiative to be encouraged and supported. It Offers an independent safety validation service for landlords and letting agents. http Ilwww bluewatch co.ukl: The investigation established that incomplete flue piping had not been identified on routine inspection visits despite the regulatory regime created by the The Gas Safety Installation and Use Regulations 1988.At present there is no duty imposed on the owner of a boiler or a gas supplier _ who makes a from the supply that in the case of a multi occupancy building to allow the other occupants through recognised engineers to inspect the boiler and be wared to install CO alarms Action should be_taken In my opinion action should be taken to prevent future deaths and believe you andlor organisation have the power to take such action. Your response You are under a duty to respond to this report within 56 days of the date of this report; namely by 13 December 2013. /, the coroner; may extend the period: Your response must contain details of action taken or proposed to be taken; setting out the timetable for action_ Otherwise you must explain why no action is proposed Copies and publication have sent a copy of my report to the Chief Coroner and to the following Interested Persons: The Family of the deceased GVA Grimley RBS Bank Plc ACE Gas Services Greater Manchester Police have also sent it to: CO Awareness CO Gas Safety am also under a duty to send the Chief Coroner a copy of your response. profit your

The Chief Coroner publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest You may make representations to me; the Coroner; at the time of your response, about the release or the publication of your response by the Chief Coroner. Wxl M_Lu~ N S Meadows Date 18th October 2013 H.M. Senior Coroner Manchester area IO may City -