We are continually grateful for the support that we receive from Coroner’s offices in England, Wales and Northern Ireland, as well as the Scottish Fatalities Investigation Unit (Scotland does not have a Coronial system).

How Coroners and their staff assist us

  • We employ a monitoring service to provide us with all media articles they can find that make any mention of carbon monoxide. Using these leads we then approach the relevant Coroner (and any other appropriate organisations) for more detailed official documentation of fatalities.
  • Occasionally, we are sent details of fatalities that fall within our remit directly from Coroner’s offices. We are extremely grateful to those offices that remember our work and forward cases to us in this way.
  • Finally, we contact each Coroner’s office bi-annually to ask if they have any recent cases of unintentional carbon monoxide poisoning in their records. On average, around half of the Coroner’s Offices contacted each year send a reply.


Our primary aims are:

  • To have confirmation from the Coroner that unintentional carbon monoxide was indeed the Cause of Death
  • To establish either the deficiencies in the appliance and/or flueways, or the inappropriate use of an appliance or fuel that lead to the incident
  • To ascertain what measures could have prevented the fatality and whether there are any recurring trends in incidents that improved safety, awareness or legislation could rectify.


These aims are supported by the Chief Coroner of England and Wales, His Honour Judge Mark Lucraft QC, with whom CO-Gas Safety had a productive meeting in April 2018.


Working together before a case comes to inquest

We strive to contact the Coroner’s Office within a few days or weeks of the fatality. At this stage, we hope to remind the Coroner of the following points which we take interest in (even if we are not able to receive the answers to these questions until after the inquest, we hope it is helpful to raise them at the earliest stage possible):

  • Has the deceased been able to be tested for COHb and, if so, what is the % result?
  • Which official agencies were involved at the scene?
  • Did the deceased receive treatment at the scene, or elsewhere, or were they discovered deceased?
  • Were any other individuals injured or present during exposure?
  • What was the source of the carbon monoxide; has an incident investigation been carried out at the scene to record details of any relevant appliances/flueways and establish the levels of CO produced, the fuel used, what the circumstances of the incident were (were any vents blocked, doors and windows closed, appliance incorrectly used, flues incorrectly installed etc)?
  • If the property was rented, was the necessary level of servicing and documentation in place?
  • Were any carbon monoxide monitors, detectors (black spot type) or alarms present at the scene – if so, had they activated, were they in-date and operational, were they battery operated or mains-wired, where were they located, were they to EN50291 standard? The details of any devices present at the scene are not always routinely recorded by those investigating such deaths and thus we ask that this information is specifically requested from those at the scene. We wish to document the impact that increased use of alarms may or may not be having on CO incidents.


Once an inquest is completed

Much of the detail that we would wish to know is covered in our Coroner Form. However, we have found that Coroner’s Offices often find it less burdensome and more efficient to allow us access to the original official documentation, which we hold digitally and confidentially on our database of incidents and victims.


Ideally, documentation we would like to receive includes:

  • Record of Inquisition (or Certificate after Inquest)
  • Toxicology report showing carboxyhaemoglobin level (COHb %)
  • Incident Investigation Reports from relevant agencies, such as British Gas, HSE, HETAS, independent appliance engineers, MAIB, AAIB, Police…