Suggested Changes

CO-Gas Safety’s suggestions for changes to improve fuel safety

Many of these changes have been incorporated into our suggested amendments to the Energy Bill (now an Act) so please see under ‘Energy Bill’ https://www.co-gassafety.co.uk/information/energy-bill/.

CO-Gas Safety is an independent registered charity and was launched in 1995. The charity immediately started talking to victims and their families. Most of these suggestions (below) have come from such conversations and from reading reports of deaths and near misses. CO-Gas Safety has spent the time since its launch in 1995 trying to persuade industry and Government to work together to make these changes, which in CO-Gas Safety’s experience* would prevent unnecessary deaths and injuries from unintentional carbon monoxide poisoning and other gas dangers.

*reading about deaths, talking to victims and families, attending inquests, obtaining details of incidents from Coroners and talking to many members of the fuel industry.

1. Better awareness. There should be a sustained PR campaign of prime time TV public health warnings and other media about CO+ for all fuels, all appliances and all accommodation. This could be put out by the Cabinet office which is now responsible for such warnings. Holiday Travel Watch sent the Cabinet Office a letter asking for such warnings on the 31st October 2012 but has been ignored. Alternatively these warnings could be paid for by a levy on the fuel suppliers for £1-£2 per household per year. A levy on the gas suppliers was recommended by the Health & Safety Commission (now Executive) in 2000. 4% of household gas bills are ‘environmental costs’, surely imposed by levies? http://www.ofgem.gov.uk/Pages/MoreInformation.aspx?docid=126&refer=Media/FactSheets

It was reported in 2011 that 1/5th of our energy bills are for green levies but CO-Gas Safety is trying to find the authority for this and the legislation that allows it (for example the Climate Change Act 2008 and the Environmental Protection Act 1990 s. 153(y) which allows the Secretary of State to provide funding for the Energy Saving Trust). It would be helpful to find all the relevant legislation and the amounts levied. This is proving difficult. However, Ofgem sent us a document dated 31.05.2012 and called Factsheet 97 which stated that the green levy for the average gas bill by direct debit was £704 and the green levy was 4%, making that £26.16 per year.

We attended a meeting in Brussels in on 1st June 2016 at which we learned that in Southern Ireland i.e. Eire, there were prime time TV warnings about CO see https://www.youtube.com/watch?v=KVQ6_2OyKug  The funding for this was provided by the regulator.

On the 4th June 2016 Stephanie wrote an email seeking a meeting with Ofgem. It took over a year for such a meeting to take place on the 13th June 2017 because Ofgem was extremely reluctant to meet us. The meeting resulted in Ofgem stating that awareness action was up to the Gas Distribution Networks. What about the suppliers? They are much wealthier. However, the GDNs are also quite wealthy and indeed one of them saved £13 million in efficiency savings in just one year.

We therefore had little choice but to agree to have a meeting with the GDNs with a representative of Ofgem present. However, although Stephanie asked for Anthony Pygram, who is responsible for consumer to be present, he did not attend. The meeting was on 13th December 2017 and we have now written and sent a joint letter between CO-Gas Safety and Frank Brehany Consumer Champion dated 21.12.17. As of 09.01.18 we have not yet received any response.

The reluctance to even warn people about CO frankly seems scandalous as does the reluctance of HSE and Government to take action to prevent wholly unnecessary deaths and injuries which as well as the human tragedy cost £178 million a year (according to APPCOG see second para at https://www.publications.parliament.uk/pa/cm201314/cmselect/cmcomloc/50/50iii132.htm).

Surely one very small levy of £2 per household per year to raise awareness of CO would hardly be noticed amongst all these other levies?

2. Gas Emergency Service (Emergency Service Provider – ESP) personnel to have training and equipment to test gas appliances for CO and this should be free at the point of need. This could be paid for by an adjustment in the licence fee charged by Ofgem. Ofgem states that HSE must ask for this for Ofgem to impose it and HSE states that Ofgem can impose whatever condition it wishes to impose. We have continually asked for a resolution of this problem with no success.

However Scotia Gas Networks too the first step and provided Personal Alarm Monitors for CO and we think all the emergency service providers have followed this step. Some of the emergency service providers have Gasco seekers that will identify CO. However, the problem is that when the householder calls the emergency service provider on 088 111999 the householder is told to turn off all appliances and open the windows. So unless the CO is being emitted from an unsuspected appliance which has not been turned off (e.g. wood burner) or the CO is coming from next door, the CO will not be picked up by the PAM or Gasco seeker and the appliance emitting the CO will not be identified.

Of course if the First Call Operator from the gas emergency service did attend and test all the gas appliances, payment for this service would ultimately be made by the consumers. Again, (as in 1 above) this was recommended by the HSC in 2000. Government and industry have failed to act. Surely HSE could at least press for the need for equipment? In our opinion, Gerry Mills died, we argue, as a result of the lack of such equipment in 1999.

3. Checks should be made after visit from ESP to make sure the situation is safe and records kept.

4. Smart metering. The opportunity presented by Smart metering to test gas appliances for CO should not be missed. British Gas has told us that it is already testing appliances with Flue Gas Analysers when putting in a Smart meter. However on the 25th September 2012 BG told us that only visual means were being used. Recently I have asked if British Gas has equipped its employees with PAMs for CO and heard it has not (08.01.18). Why is there no legal requirement to do this? We first suggested this to DECC in 2011. We have heard that meter changers are being faced with gas appliances that haven’t been touched for decades.

Dr. Ben Croxford’s research in 2006 found that 8% of homes were judged to be at risk of dangerous levels of CO and 23% of homes had one or more defective gas appliance, so it is obviously a vital safety issue. Again HSE ignores this safety issue.

5. Gas Emergency Service personnel to be equipped with Personal Air/Alarm monitors. Cost is not high (about £35 per operative). Scotia Gas is to be congratulated for already doing this. All the other emergency service providers (i.e. the GDNs) are now apparently following suit.

6. All Registered Gas Installers should have PAMs and flue gas analyzing equipment. The need for this is demonstrated by the tragic death of Matthew Nixon, registered gas installer, aged 22, in December 2010 in Macclesfield. From this death we learned that there is no agreed material for teaching aspiring registered installers about CO. With the help of Roland Johns, retired gas investigator and trainer, we have got together a course in Matthew’s memory. This has been taught to all Scotia Gas apprentices in September 2014. Please see https://www.co-gassafety.co.uk/information/trainers-of-gas-installers/ The apprentices employed by Scotia Gas Networks and Northern Gas Networks are being taken through this course. However, Wales & West Utilities and Cadent are so far not participating as far as we know.

7. Better consultation with Registered Gas Installers many of whom feel ignored by industry and by HSE. They could also help hugely to raise awareness of the dangers of CO and this would help raise their professional status. CO-Gas Safety has asked them to raise awareness of the schools poster competition. Many registered installers assist us greatly.

8. Better training for all Registered Gas Installers. Most people seem to agree that there should be Continuing Professional/Personal Development (CPD), (as with solicitors for example), which would mean that registered gas installers would be updated regularly and the cost would be spread rather than doing this once every five years. Will this happen?

9. Work practice of leaving an appliance ‘at risk’ should be stopped.

This issue contributed to the death of Katie Haines. Discussions about this are apparently going on between British Gas and HSE. It does seem that more appliances are being left with labels stating ‘Immediately Dangerous’. However, there is still no automatic follow up. When most people don’t even know what CO is and even if they do, they don’t know how dangerous it is or how quickly CO can kill in less than 2% in the air, we think this is utterly wrong.

10. RIDDOR reports should be followed up, not just sent to HSE and ignored. This would probably require legislation.

11. All fuels to have the same rules as gas. So there should be compulsory registration of installers of appliances using other fuels such as oil, solid fuel and wood chip etc. i.e. any carbon based fuel that burns. We are hearing more and more horror stories about multi-fuel fires and boilers and wood burners.

12. Individual employed installers should be registered in their own right, not just listed as at present. This will require legislation. At the moment it is the firm employing the individual installers that must be registered, not the employees.

13. Improved resources for data collection, collation and publication. CO-Gas Safety has been doing this on a shoestring since 1995. Why isn’t this properly funded? This is the bedrock of research to prevent future deaths and injuries. CO-Gas Safety’s data on deaths and injuries is almost certainly the best in the UK because we include CO incidents from all fuels, we try to check every death with the Coroner concerned and we are the only body to have had its data validated by a statistician, Dr. Craggs. This data is vital in order to obtain information with regard to prevention.

We found out that an imported cooker had a grill door that shut and caused at least 6 deaths. It would have been helpful to have had a system that reported this earlier and for there to be a faster, better way to warn the public.

It would also be helpful to be able to find out for certain how many deaths are caused by registered gas installers as against unregistered. Although we can often guess whether a gas installer, who is involved is registered or unregistered, it would greatly assist to have the co-operation of the Gas Safe Register and HSE with regard to this issue, which should be of the utmost concern to both bodies. We notice that certain large companies seem to be able to keep their names out of the newspapers after a death by for example not connecting the flue (as occurred in the death of Zoe Anderson).

14. Help for victims and their families. CO-Gas Safety has been doing this on a shoestring since 1995. Why hasn’t industry and Government done this already? Victims are a research resource. This (along with 1 and 11 above) could be paid for by a levy on the industry (as recommended by the HSC in 2000) or by the social corporate responsibility funds of the big fuel companies, which profess to be so committed to safety.

Websites could also be more helpful and particularly the HSE website changed to warn about the dangers of having gas appliances changed when it is important to turn off the appliance but to preserve it untouched as evidence.

15. Landlord gas safety checks should be changed to or added to so that a ‘Person undertaking the check must either undertake a service according to manufacturer’s instructions or, following procedures outlined in BS7967 part 4, use Flue Gas Analysers meeting EN50379 (or subsequent replacing equipment and/or standard) to measure the combustion gasses for PPM (Parts Per Million) of CO and also the CO/CO2 ratio.’

See briefing paper click here.

It is surely totally ridiculous that a gas safety check to make sure a gas appliance is safe from CO which cannot be sensed using human senses is ‘checked’ by a Gas Safe Registered installer using only his or her human senses! Surely a gas safety check should be undertaken with equipment capable of testing emissions from gas appliances for carbon monoxide?

The charity CO-Gas Safety has support for this clarification/change from:-

Pimlico Plumbers; the Dominic Rodgers Trust; Katie Haines Memorial Trust; Frank Brehany, Consumer Campaigner; the National Landlords’ Association; The Gas Industry Safety Group; the Gas Safety Trust; the All Party Parliamentary Carbon Monoxide Group and the Institute of Gas Engineers & Managers (IGEM).

Please note that British Gas refuses to undertake gas safety checks without a contract to service as well which we think is sensible. However, it is also our information that a service from British Gas is usually just a check of the flue gasses, which if they are within the manufacturer’s instructions, mean the appliance can be left alone rather than stripped down, cleaned and put back together. Some Registered Gas Engineers disapproved of this lack of cleaning but CO-Gas Safety came across a death of a quite new appliance that having been stripped down, cleaned and put back together was not put back as it should have been. Therefore the charity favours the use of testing the flue gasses. There was one death where the flue gasses were tested and found the CO to be very high, but sadly that death was due to the RGE wrongly supposing his flue gas analyser was faulty plus his lack of caution in leaving the appliance working.

16. Landlords should be licensed and have to provide in date CO alarms to EN50291. This would provide worthwhile jobs and pay for itself. CO-Gas Safety has a cost benefit analysis which was sent to Hull County Council in 1999. Private landlords now have to provide smoke and CO alarms but only re solid fuel. This may change soon with regard to private landlords but why not all landlords? Why not all property? Why not all workplaces?

17. Better training of and awareness of CO by GPs & toxicologists and better, faster testing for medical emergencies.

There is an Algorithm used by GPs when they suspect CO poisoning see https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/485581/CO_diagnosis_algorithm_2015.pdf The problem is that neither NPIS nor PHE are registered gas installers qualified under CMDDA1 to test gas appliances for CO so unlike House (the TV programme with Hugh Laurie) the environmental poison cannot be found.

We would also like tests for the other toxins in those who survive, see here particularly because certain tests, treatments and drugs seem to exacerbate their symptoms. Doctors are supposed to do no harm yet we know many victims who have been made worse by treatment being given such as X rays with no realisation that poisoning has occurred.

18. Automatic testing for CO on death. This is not just for research purposes but to protect the living, e.g. the rest of the family where there has been an unexplained death, which was actually caused by CO, as in the case of Katie Overton, aged 11 in 2003. 10 days, after her death the rest of her family including her two younger sisters were poisoned. The pathologist had kept some blood samples after the post mortem and tests on these confirmed that Katie had died of CO.

Please also see https://www.newscientist.com/article/mg18424765-600-the-killer-with-no-name/

We have been told that the Gas Safety Trust has funded the putting together of a protocol to test all deaths in three Coronial areas but this was about 2015-6 and we have heard there has been no progress even with regard to the protocol. CO-Gas Safety asked Dr Sophie Duggan, victim, lawyer and medical doctor to undertake some voluntary research with regard to this and sent this to Public Health England 20.11.17. So far (January 8th 2018) this has not even been acknowledged.

We would also like tests on death for the other toxins in the products of combustion see here.

19. Independent trained people with equipment to test for CO. These could be paid for by those who need this service (e.g. for a court case) but at least tests on gas appliances could be provided free for those on social security etc.

We have been waiting for CMDDA1 for at least a decade. Even someone qualified under CMDDA1 could not provide an investigation that could be used in court but this would hopefully provide a good filtering system and be useful for medics etc. and perhaps for reporting CO incidents. However, we have recently been told that the cost is likely to be high. The other problem is identifying registered gas installers who have an employee who is qualified under CMDDA1. Stephanie Trotter undertook a mystery shopper exercise and found that the rearst registered gas installer who declared they could undertake ‘fumes investigation’ did NOT have a person qualified under CMDDA1. She has brought this to the attendion of the Gas Safe Register.

Submission to HSE made on 12.01.17 at 21.Could HSE please undertake a mystery shopper exercise to find someone qualified under CMDDA1 to test for CO and leave Parts Per Million in writing with the householder because even a solicitor, Debra Morris, found this almost impossible.

There is a further problem now in that it seems impossible to obtain the services of someone qualified under CMDDA1 unless you are a landlord. Stephanie Trotter found this in July 2017 while trying to help a victim who had lost her two year old Laura and viable baby, Chelsea (seven months pregnancy) in 1998.

Why is there no free test to identify the unsafe appliance emitting CO? Could it be that leaving a consumer/victim without the ability to prove exposure to CO suits industry and government?

20. All registered gas installers by law should be required to have Public Liability Insurance. This will require legislation. We think this should apply to all those who fit appliances powered by carbon based fuels.

21. Research should be undertaken to test the other products of combustion. Amounts of these are said to be tiny but some, such as the heavy metals, can build up in the body and could therefore be causing health problems such as symptoms similar to depression, ME, MS, Parkinson’s and Alzheimer’s disease. This issue has vast health implications and the charity is concerned about the death of a three year old, who died with 15 times the higher levels of manganese. This death was put down as natural causes and the concentration of manganese explained as pooling after death but the only research seemed to be on drugs, not heavy metals. Scientists expert in outside air seem well aware of these toxins in the atmosphere and the dangers, yet indoors, the concentrations are bound to be much higher.

22. Possibly a house MOT should be considered for all appliances powered by carbon based fuel that burns. It could be made illegal to supply carbon based fuel without proof of the MOT. However, none of the other suggestions have been implemented yet, so surely it would be better to try some suggestions as above first?

If anyone is interested in these suggestions or wishes to criticize or add to them please email Stephanie Trotter office@co-gassafety.co.uk

Updated 13.01.18