Law, Practice and Prevention of
Unintentional Carbon Monoxide (CO) Poisoning
and Other Gas Dangers in the UK

by

Stephanie Trotter, OBE
President & Director of CO-Gas Safety*

 

INTRODUCTION

Charon McNabbs of the National Carbon Monoxide Awareness Association in the USA (NCOAA https://www.ncoaa.us/ ), and I met in summer 2022. I think we were both surprised to learn that the UK and the USA have somewhat different approaches to laws, best practice and ways to prevent exposure to carbon monoxide (CO). Charon asked me to write about the UK system. We hope the USA and other countries may find this document useful. However, in the opinion of the charity, while the UK does have a system to deal with CO, the UK still has some glaring omissions and opportunities for improvement.

I was asked to list the UK laws and practice, rather than to comment. However, without some context, I thought this would be incomprehensible. We’ve also added ‘prevention’ because prevention was, and is, the aim of independent registered charity CO-Gas Safety.

Please note that this is written from the point of view of victims, survivors and family members. Sadly, this seems to us to be a rare perspective.

As I wrote this, I realised that the existing UK system has been shaped by the history of the fuel industry in the UK, so I’ve briefly included that.

I’ve also found from talking to numerous people about CO since 1995, that many, even those working in the fuel industry, have some gaps in their knowledge of CO; how CO is created and most importantly, how to prevent it. Most of our material was originally created for primary school children so it’s basic but should be easy to understand.

This document is very much a ‘work in progress’. It’s easy to leave something out or to find that the law or practice has changed. Indeed, change is what we have been lobbying for since 1995! Please note that although I am a barrister, I am not practising, nor do I have a practising certificate. So, if you find anything you disagree with or we have left anything out that you think matters, please let us know by emailing office@co-gassafety.co.uk . We would be most grateful to hear from you.

I’d like to thank Charon and NCOAA for asking me to do this. I’d also like to thank all who have kindly added valuable material or helped me to write/check this. I also thank all our voluntary directors/trustees, particularly the survivors and families. We are all volunteers.

Note : CO-Gas Safety has been supported by Kane International for decades, both morally and financially. Before this support the charity believed that testing for CO is vital. The charity continues to believe this.

*For more information about the charity CO-Gas Safety see Appendix 1 and www.co-gassafety.co.uk

 

CONTENTS

Executive Summary	4
1. Brief history of the gas industry in the UK	7
2.What is carbon monoxide (CO)?	7
3. Awareness of the dangers of CO	9
4. Research A. How many people are exposed to unintentional CO and why? B. Medical research into the effects of CO	10
5. Prevention Legislative framework – criminal law versus civil law Criminal law Health & Safety at Work Act 1974, including the HSE and the Gas Safe Register    The Gas Safety (Management) Regulations 1996    Gas Safety (Installation and Use) Regulations 1998    Duty on landlords – Gas Safety (Installation and Use) Regulations 1998 Reg. 36    Enforcement RIDDOR	11
Other government bodies Ofgem Local Authorities    Building Regulations on new build properties and installation of new solid fuel appliances, and new gas appliances    The Smoke and Carbon Monoxide Alarm (Amendment) Regulations 2022    The Gas Appliances (Safety) Regulations 1995    The Gas Appliances Regulations (EU 2016/426)    New gas installations in the UK – what has to be done on a new gas installation New appliances – Trading Standards Office for Product Safety and Standards The General Product Safety Regulations 2005	14
Inquests Reports to Prevent Future Deaths	17
Government and Parliamentary groups Cross Government Group on Gas Safety and Carbon Monoxide (CO) Awareness APPCOG – The All-Party Parliamentary Carbon Monoxide Group	19
Trade bodies BSI – British Standards Institution IGEM – Institution of Gas Engineers and Managers Energy and Utilities Alliance Energy UK CoGDEM HHIC	19
Prevention by individuals	22
Prevention: our work in Holland and in the EU Parliament and Commission	23
6. Training and competency of engineers Gas – Gas Safe Register & EU Skills Oil Solid fuels Chimney sweeping	23
7. CO alarms and other devices Smoke and CO alarm regulations New gas appliances Flame supervision devices: The Oxygen Depletion System (ODS) Cut-off systems	25
8. Emergencies	27
9. Proof of CO	28
10. Public Liability Insurance (PLI)	29
11. Victim support	29
12. Data A. Deceased people B. Survivors	29
13. CO-Gas Safety’s suggestions for improvements to UK legislation and practice	30
14. CO-Gas Safety’s template for legislation and practice in other countries	34
Appendix 1  Brief history of CO-Gas Safety and CV of Stephanie Trotter, OBE, President & Director of CO-Gas Safety and author of this document	37
Appendix 2  Ofgem	41
Appendix 3  Enforcement	43
Appendix 4  Numbers affected by CO+ – impact on UK population in the UK	44
Appendix 5  Research by Dr Connolly at Liverpool John Moores University , 2019	49
Appendix 6  Our work in Holland and in the EU Parliament and Commission	51

 

EXECUTIVE SUMMARY

The UK gas industry was a nationalised industry from 1948 to 1986, when it was privatised. ‘Safety is paramount’ was often stated in the Houses of Parliament.

Carbon monoxide (CO) is a product of combustion and can be created by burning any carbon-based fuel, including wood, with insufficient oxygen at the flame. CO is deadly at a concentration of less than 2% in the air. CO cannot be sensed using human senses. Burning fuel indoors is an obvious hazard. In the UK, we spend about 90% of our time indoors.

CO can be tested for in the air and in the products of combustion using various equipment. The most important for engineers is the flue gas analyser. The standards are BS EN 50379 for their manufacture and BS EN 7967 for their use.

Low levels of CO over a long period can cause brain and neurological damage. WHO guidelines are being reduced all the time and currently state approximately 4 parts per million for 24 hours. See https://www.coresearchtrust.org/media-information/three-year-project-looking-at-risk-of-co-to-older-people-reveals-concerning-findings

The system in the UK started when testing for CO was the province of universities and equipment cost a huge amount. Now a flue gas analyser can be purchased for under £400 and every Registered Gas Safe Engineer is taught how to use one.

When the charity was launched, I knew nothing about carbon monoxide. I talked to survivors and family members of those who had died of CO. They had also never heard of CO. One mother said, ‘If only I had known about CO, I could have protected my child’. Awareness became our first aim, and we started lobbying for prime-time TV warnings. We were told there were not enough deaths and injuries from CO to justify this.

Without testing for CO, you cannot prove exposure to CO; you cannot know how many parts per million (PPM) of CO are being emitted or identify which appliance is emitting CO. Testing the survivor is usually done too late, so recreating the exposure safely in the home or workplace was the obvious solution. Sadly, the gas industry did not seem to agree.

Testing for CO also provides data, which is so loved by governments to justify spending public money. Medical research cannot be carried out without knowing whether or not a person has been exposed to CO and, ideally, by how much CO and for how long.

CO remains stable in a dead person, so the charity concentrated primarily on recording deaths from CO. Under UK law deaths from CO must have an inquest. Therefore, evidence is given in court and can be quoted. Since 1995 we have collected, collated and published the named deaths of UK citizens in the UK and overseas from unintentional CO poisoning that we know about (www.co-gassafety.co.uk/data-menu/deaths/). We exclude house fires and suicides. From this work we have concluded that most deaths were either due to a lack of maintenance or lack of awareness about how to use an appliance. The data is limited by the fact that there was/is insufficient testing of air in homes and no automatic testing of the dead for CO, so we suspect there are more unidentified CO-related deaths.

Legal Framework in the UK

Health and safety in the UK made huge progress due to the Health & Safety Act 1974 (see page 11). This imposed a statutory duty on employers to take reasonable care of both their employees and members of the public affected by work done. It also established the Health & Safety Executive (HSE). This Act also made it illegal to undertake gas work without being a member of a registration body, now the Gas Safe Register. This body is licensed by the HSE. Training of gas engineers followed. But sadly engineers of other fuels such as coal, wood, oil etc. were not required to be registered by law. Nor were chimney sweeps.

The HSE drafted regulations about the safety of gas conveyed through pipes and the constituency of the gas. HSE also drafted detailed regulations setting out how Registered Gas Engineers (RGEs) should undertake their work. One regulation set out that landlords must keep their gas appliances, pipes etc. in a safe condition, and another later one states they must provide an annual inspection for safety by a RGE and a certificate proving this.

HSE was provided with powers of investigation and prosecution, as well as to issue notices. We think HSE is underfunded and underappreciated. Enforcement has been starved of resources and of its importance, resulting in too few legal actions against those who do not follow the regulations.

Under RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013), deaths and serious injuries have to be reported to the HSE. However, HSE itself does not seem to be under a duty to subsequently investigate or prosecute (see page 14).

If a RGE is found guilty of an offence under the Gas Regulations s/he can be struck off the Gas Safe Register.

Other bodies were set up. While HSE deals with safety, Ofgem was set up to deal with security of supply and the cost of gas (see Appendix 2). Ofgem licenses the suppliers and transporters of gas. Ofgem has a duty to protect the interests of consumers from the use of gas through pipes. Ofgem was also provided with special powers and duties with regard to ‘customers in vulnerable situations’. This is usually interpreted as those who are eligible for the Priority Service Register (e.g. the old, disabled, sick, poor, those with children etc.)

But all humans are vulnerable to CO, however healthy, wealthy or wise.

New gas appliances must be safely manufactured and comply with a CE marking in the UK and EU. However, that does not stop negligence and fraud leading to preventable deaths (at least five people died using Beko gas cookers because the grill door could be shut www.bbc.co.uk/news/uk-england-cornwall-55015910). The Office for Product Safety and Standards can assist with recalls of faulty products (see page 17).

Local Authorities have duties under Planning and Building Regulations with regard to ensuring a CO alarm is fitted for a solid fuel appliance. Also, new gas installations must be approved by Local Authorities and have a certificate and benchmark document, which allows maintenance to be recorded (see pages 15 & 16).

The Smoke and Carbon Monoxide Alarm (Amendment) Regulations 2022now mean that all rented properties need a CO alarm fitted if there is a combustion appliance in the property. In England, worryingly, a CO alarm is still not required if there is only a gas cooker. The four countries of the UK all have slightly different rules on these regulations (see page 25).

The cross-departmental government body on CO works to bridge the gaps between some eight government departments, including health, and across the four countries of the UK.

The All-Party Parliamentary Carbon Monoxide Group (APPCOG) and Advisory Board is a forum made up of parliamentarians (see page 19). There is a stakeholder group, under the Advisory Board, made up of industry members, but it includes only CO-Gas Safety and one other group (the Katie Haines Memorial Trust) representing those who have been affected by unintentional CO (consumers, victims/survivors and members of families who have lost relatives to CO).

Various trade bodies play a vital part in helping to prevent CO. For example, if you are going to test for CO, you need to be sure your flue gas analyser or CO alarm is to a good standard and works. The British Standards Institution sets these standards (see page 19).

The trade body of professional gas engineers, IGEM, writes guidance documents for engineers, assisted by other bodies, and could be pivotal in leading the gas industry in safety (see page 20). However, in our opinion, IGEM could do far more to lead the raising of standards and looking to the future with regard to monitoring and testing for CO. Hydrogen is signposted as the answer, as CO will be hugely reduced, but it seems NOx will not. It seems natural gas may well be used for many years yet.

Other trade bodies include Energy UK (the trade association of the energy suppliers), CoGDEM (Carbon Monoxide, Gas Detection and Environmental Monitoring), and HHIC (Heating and Hotwater Industry Council). See pages 21 & 22.

AICO has produced a CO alarm to EN BS 50291 which records and stores CO levels. Reports can be downloaded and used as proof for tenants, landlords, doctors, lawyers etc.

In section 13 we’ve listed suggested improvements to the law and practice in the UK (see pages 30-33). Section 14 suggests a template for other countries (see pages 33-35).

Conclusion

Without testing for CO, nobody knows whether they are safe from CO or not. Combustion appliances should be relit and CO tested for in the air. If CO is found, surely it is vital to find the source of the CO to prevent further exposure? Without knowing whether, or by how much, a person has been exposed to CO, how can medics possibly treat patients properly? Without more routine testing for CO, data is scarce. Without testing, finding and studying exposure to CO, it is much harder to raise awareness. Data is needed for research. Without reliable data and research, it is difficult to make necessary safety improvements.

CO alarms have gained in popularity and are now a legal requirement for most rented property in the UK. This is a huge step forward and will save lives, provided alarms are not ignored when they sound. However, in the opinion of CO-Gas Safety, the levels required to activate them are too high and so they are death/serious injury alarms, not health monitors. A particular standard (at present EN BS 50291) is not mandated, as we think it should be.

Monitors used in research, and results of CO found, show that, extrapolated across the UK, 13 million people are probably being exposed to levels of CO above 50 parts per million (see Appendix 4). The future should surely involve the widespread use of more sensitive monitors, (perhaps including VOCs, NOX, etc.) manufactured to improved standards and independently tested to prove they have reached those standards?

CO could explain why some people were so ill and died from Covid or have long Covid. With the WHO guidelines now being approximately 4 parts per million over 24 hours, all countries in the world should surely be legislating to remove CO from their indoor air. Toxins in indoor air build up; but indoor air is easier to control.

Stephanie Trotter, OBE and all at CO-Gas Safety

 

1. BRIEF HISTORY OF THE GAS INDUSTRY IN THE UK

The gas industry was nationalised in 1948. https://tinyurl.com/mffx54pk This is probably why the UK has the systems it has. Coal gas (sometimes called ‘town gas’) was a mixture of hydrogen, methane and carbon monoxide (CO), created from burning coal in a low-oxygen enclosure. https://tinyurl.com/3ut6pecr

In 1967 the first gas from the North Sea was brought ashore. It took about ten years to completely convert the system from ‘town gas’ to ‘natural gas’. ‘Natural gas’ was almost entirely methane and therefore safer. Carbon monoxide (CO) was still a danger as it could be created by burning the gas with insufficient oxygen to create carbon dioxide, CO².

When the industry was privatised in December 1986, there were frequent statements in the Houses of Parliament that ‘safety was paramount’.

 

2. WHAT IS CARBON MONOXIDE (CO)?

CO is a deadly gas that can be emitted from faulty cooking and heating devices, or any other appliances (e.g. generators) that are powered by any carbon-based fuel that burns.

Fuels include gas, coal, wood, petrol, diesel etc.

CO cannot be sensed using human senses of smell, taste, sight or touch

Less than 2% of CO in the air can kill in between one and three minutes.
www.hse.gov.uk/foi/internalops/hid_circs/technical_osd/spc_tech_osd_30/spctecosd30.pdf
(Paragraph 74 table 23 page 26)

Firefighters, when talking about CO in smoke (which you can smell), say it takes only three breaths to be fatal: the first you do not know there is a problem, the second you might suspect there is something wrong but by the third you are unable to take any action.

 

Without smoke, CO alone has no smell and so is even more dangerous. CO is produced by burning fuel when there is not enough oxygen present in the air around the flame. It builds up quickly in an enclosed space because the very action of burning fuel uses up what little oxygen is still in the air, thus producing even more CO.

This is why no carbon-based combustion appliances should be used indoors without good ventilation. It isn’t just cooking and heating appliances that are a danger but also, for example, power tools, lawnmowers and vehicle engines powered by diesel/gasoline, camping lamps powered by oil/paraffin etc.

Why is CO so lethal?
Because it binds to the haemoglobin in the blood which normally carries oxygen, so it suffocates.

What is the difference between CO and CO²?
CO²(carbon dioxide) consists of one atom of carbon and two of oxygen.

CO (carbon monoxide) also contains one atom of carbon but only one atom of oxygen. CO is created when there is a lack of oxygen at the flame, causing what is called ‘incomplete combustion’.

Exposure to low levels of CO over a long period can make people ill but GPs rarely diagnose this as CO poisoning. Symptoms of low level poisoning include: –

You may also generally feel unwell and depressed, which means symptoms are similar to many viral illnesses, including Covid-19.

Different members of the same family can suffer different symptoms.

Please make sure you are safe from CO and other products of combustion.

In an emergency, please ring 0800 111 999 for the Gas Emergency Service but please be aware that they do not test indoor air, or emissions from gas appliances, for carbon monoxide as a standard procedure. We hope for change on this soon.

Please watch our one-minute film about Sue who had carbon monoxide poisoning – it could save your life or that of a loved one:
https://www.co-gassafety.co.uk/one-survivors-story/

Please also watch our animation: https://www.co-gassafety.co.uk/animation/

Open air carbon monoxide poisoning – deaths in the USA

It is possible for CO to have sufficient effect in the open air to cause death. We have recently become aware of the following tragic cases in the USA, which all involved boats.

Little Andy Free, aged nine, had been “curled up” at the back of his family’s Malibu Skier boat at Lake Eufaula in Oklahoma in early June 2020. He was “slowly dying” of open-air carbon monoxide poisoning. His devastated mom wrote on Facebook. mom shares warning after son dies of carbon monoxide poisoning (today.com)

UC Bearcats midfielder Ally Sidloski, 21, drowned at East Fork Lake in Ohio on May 22 2021. She’d been hanging onto the swim platform of a boat. CO was a contributory cause of death. Boat carbon monoxide poisoning: Woman, 21, drowns on lake trip (today.com)

Afton Taylor, aged 7, died in June 2019 in Northeast Ohio after being exposed to carbon monoxide poisoning on a routine boat trip. His parents want to warn others.

https://www.news5cleveland.com/news/local-news/oh-stark/northeast-ohio-couple-spreading-awareness-of-boating-dangers-after-losing-son-to-carbon-monoxide-poisoning

 

3. AWARENESS OF THE DANGERS OF CO

In the UK people spend about 90% of their time indoors http://tinyurl.com/5aj6d93r.

Toxins in indoor air tend to build up but at least toxins from combustion are more controllable by the individual, provided they know about CO and how to prevent it .

CO-Gas Safety realised almost immediately from talking to survivors and family members of victims that awareness is key. Back in 1995, when the charity first started, we were struck by families saying, ‘if only I’d known about CO, my child would still be here’.

CO-Gas Safety lobbied for prime-time TV warnings very soon after our launch and later for social media etc. These were opposed by both industry and government, for many years cited as too expensive for the numbers of proved deaths and injuries. There are still no prime time TV warnings about CO, yet many big companies still advertise on TV.

This led us to try to find out the statistics. We had, and still have, all sorts of difficulties due to: –

1. Confusion with deaths from CO in house fires.
2. Confusion with intentional deaths like suicide, although that was easier to deal with because all UK deaths with CO recorded on the death certificate have inquests, where evidence is given and reported. However, the coding used by our Office of National Statistics* still means it is not possible to use ONS statistics.
3. Difficulties with testing leading to lack of data.

* We are only concerned with unintentional, preventable deaths that are primarily a result of a lack of knowledge or negligence, whereas the ONS stats deal with medical cause of death and their definition of ‘accidental’ does not align with ours for a number of reasons. In order to ascertain whether a fatality falls within our remit we need to know the circumstances of the incident, which we cannot research without a name and date of death. ONS are either not willing or are unable to give us that information.

So, we resorted to what we could do.
1.We collected collated and published known and reported deaths from unintentional CO from 01.09.1995 and ongoing. See https://www.co-gassafety.co.uk/data-menu/

2.We started a primary school poster competition. We ran this for nine years, with a prize-giving at the Houses of Parliament to raise awareness amongst MPs (Members of Parliament) and members of the House of Lords. This competition was finally taken over by the Gas Distribution Networks, and they still run it and have expanded it well. But, at the time of writing, the competition no longer has a prize-giving event at the Houses of Parliament, as we did every year. We think the competition therefore lacks the effectiveness of bringing carbon monoxide dangers to the attention of MPs, members of the House of Lords and government. It also lacks the cachet of inviting a child and the family to the Houses of Parliament.

 

4. RESEARCH There are two main types of research: –

A. How many people are exposed to unintentional CO and why?

There is no automatic test on a dead person for CO. But it is worth remembering that CO remains stable in a dead body for a long time, so could be tested for quite easily/cheaply.

In survivors breathing fresh air or oxygen, CO quickly leaves the blood and breath, although CO can continue to cause injury to the brain and other tissues. So, testing the survivor is unreliable. Testing the home for CO would be more reliable but is unfortunately not generally done. Testing the home would involve re-creating the situation, i.e. turning on gas and other carbon-fuelled appliances. This is possible but, sadly, is not done as standard. This is something we have lobbied for since we started. Also, people are not exposed to CO alone but to many other products of combustion, as well as other chemicals such as cleaning products, pesticides etc. https://www.co-gassafety.co.uk/about-co/other-toxins/

A great deal of effort and funding has been put into trying to find biomarkers to ascertain whether or not a survivor has or has not been exposed to CO in the past. Some progress seems to be being made. We have always taken the view that the vital issue is to do what we can now, i.e. to test the environment of the exposure for CO, having re-created the situation as much as possible.

Proof matters, because medics tend to ignore CO as a possible cause of symptoms unless presented with parts per million (PPM) of CO in writing or digitally by a Registered Gas Safe Engineer. Medics usually then react well.

Some research was done by UCL in 2005 https://www.ucl.ac.uk/ and Liverpool John Moores University in 2011 https://www.ljmu.ac.uk/ using Lascar data loggers. The UCL research was published in 2006. CO-Gas Safety has been unable to access the original research by John Moores but has the press release and also accessed another article which used its data. See ‘Numbers affected by CO+’ in Appendix 4.

B. Medical research into the effects of CO

Without reliable testing for CO providing numbers of exposures to CO and amount of CO in PPM (parts per million), medical research cannot seem to be achieved to the accuracy needed, except on rats etc. in the laboratory, but these are exposed to CO only.

Many bodies undertake research, from universities to medical schools, and also CORT (Carbon Monoxide Research Trust https://www.coresearchtrust.org/ ). CORT has funded some excellent work on the effects of low levels of CO and also on possible bio markers.

 

5. PREVENTION

Legislative framework – criminal law versus civil law

It’s important to explain the difference between criminal and civil law. Criminal laws, such as murder or manslaughter, are generally governed by statute. Crimes are prosecuted by the relevant prosecuting authority. In most cases the police investigate and gather evidence, and the Crown Prosecution Service prosecutes. The police sometimes work with other bodies, such as the Health & Safety Executive (HSE), during their investigation.

To summarize, the state or other government department (e.g. HSE) usually prosecutes a criminal offence in criminal courts but this is to punish the offender, not compensate the victim. Some compensation is possible from the Criminal Injuries Compensation Authority https://www.gov.uk/government/organisations/criminal-injuries-compensation-authority . Amounts are usually quite small, from £1,000 to £250,000.

The criminal offence may also give rise to a civil case for breach of statutory duty. In these cases, the claim will be for damages (financial compensation) in a civil court.

Under civil law, being exposed to carbon monoxide may also provide the claimant with a cause of action in tort, usually negligence. The claim is usually for financial compensation.

Criminal law

Health and Safety at Work Act 1974

The Aberfan disaster occurred in South Wales in 1966 (144 people died, 116 of whom were children aged just 7 to 10). Please read the very informative article about this at https://www.shponline.co.uk/safety-management/flawed-hero-aberfan-hswa/

This national tragedy led to the Robens report in 1972. This resulted in the Health & Safety at Work Act 1974, which created the Health & Safety Commission and Executive – now just the Executive, known as HSE.

The Health and Safety at Work Act 1974: –

• Imposed a legal duty on employers to take reasonable care of their employees and those members of the public affected by their work, and
• Made it illegal to work on gas without being a Registered Gas Engineer.

The Gas Safe Register is licensed by the HSE.
The HSE can issue Improvement and/or Prohibition notices to companies and individuals.
Local Authorities can also issue such notices, e.g. against private landlords.

HSE also drafts secondary legislation (including the regulations about gas described below), prosecutes and makes recommendations to government and other bodies.

The Gas Safety (Management) Regulations 1996
https://www.legislation.gov.uk/uksi/1996/551/contents/made
These Regulations apply to the conveyance of natural gas through pipes to domestic premises and other consumers, and places duties on those conveying gas via a safety case regime. The safety case must be submitted to HSE; HSE must accept this before conveyance of gas can begin.

The regulations also outline the actions to be taken in gas supply emergencies and during gas escapes. In addition, they set specified values for the gas composition permitted to be conveyed. See also The Gas Safety (Management) (Amendment) Regulations 2023.
https://www.legislation.gov.uk/uksi/2023/284/contents/made

Gas Safety (Installation and Use) Regulations 1998
https://www.legislation.gov.uk/uksi/1998/2451/regulation/36/made
These regulations deal with safe installation, maintenance and use of gas systems , including fittings, appliances and flues. They are very specific and also contain regulations (Reg. 36) ** about the duties of landlords with regard to gas and carbon monoxide safety.

Duty on landlords –**Gas Safety (Installation and Use) Regulations 1998 Reg. 36

1. The landlord must keep the gas appliances etc. he owns or controls in a safe condition.
2. The landlord must also have these gas appliances checked once a year by a Registered Gas Engineer and provide a gas safety certificate.

CO-Gas Safety comment
What is not specified in Reg. 36 is the requirement to ‘service’ a gas appliance. In the UK, a service is a maintenance check, test and, if necessary, clean of an appliance to ensure it runs safely, efficiently and within regulations.

Reg 36 does not even specifically require appliances be tested using equipment such as a flue gas analyser, which would detect emissions of carbon monoxide. Yet CO cannot be sensed using human senses. See https://www.co-gassafety.co.uk/a-hidden-killer-published-by-the-new-law-journal-march-2018/ . We received a great deal of support for this change to require mandatory testing for CO, but no action has followed.

Most Gas Safe Registered Engineers (RGEs) do use flue gas analysers and all are trained to use them under CPA1 (a training module). But, suppose a RGE finds that a tenant has been exposed to high levels of CO: Will the RGE tell the tenant? Will the RGE tell the tenant’s medics? In our experience, a RGE employed by the landlord does not tell the tenant or the tenant’s medics. Yet medics react well to a documented parts per million reading of CO from a Gas Safe RGE and ensure the patient is treated or advised appropriately.

Enforcement

See Appendix 3. Sadly, enforcement is lacking in the view of the charity, mainly due to a lack of sufficient funding of the HSE.

CO-Gas Safety received an answer from HSE to a FOI (Freedom of Information) request re Reg. 36. In the year 2021/22 HSE laid only 7 charges, with 5 successful convictions, for breaches of Reg. 36(3). Average fine £45,500, highest £120,00 and lowest £4,500. In the same period, HSE served 11 improvement notices re Reg. 36(3). There were 8.6 million rented properties in England 2021-2022. https://www.gov.uk/government/statistics/english-housing-survey-2021-to-2022-headline-report/

RIDDOR

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
See https://www.hse.gov.uk/riddor/

RIDDOR imposes duties on employers, the self-employed and people in control of work premises (the Responsible Person) to report certain serious workplace accidents, occupational diseases and specified dangerous occurrences (i.e. near misses) see https://www.hse.gov.uk/riddor/reportable-incidents.htm
Incidents that occur in Northern Ireland should be reported to HSE NI.

Gas incidents
Under RIDDOR, distributors, fillers, importers and suppliers of flammable gas must report incidents where someone has died, lost consciousness, or been taken to hospital for treatment of an injury arising in connection with that gas. Such incidents should be reported using the Report of a Flammable Gas Incident – online form .

Registered gas engineers (RGEs under the Gas Safe Register) must provide details of any gas appliances or fittings that they consider to be dangerous to such an extent that people could die, lose consciousness or require hospital treatment. The danger could be due to the design, construction, installation, modification or servicing of that appliance or fitting, which could cause: –

• an accidental leakage of gas;
• incomplete combustion of gas or;
• inadequate removal of products of the combustion of gas, which includes CO.

Unsafe gas appliances and fittings should be reported using the Report of a Dangerous Gas Fitting – online form .

Who should report?
An employer or person in control of premises
Employment agency
Self-employed
A member of the public, employee, injured person or their representative
A gas supplier
A gas engineer
The responsible person (in most cases this will be the gas conveyor).

CO-Gas Safety comment
The problem is that there is only a duty to report.

HSE does not seem to be under any duty to investigate or to act.
The gas suppliers do investigate but in our opinion these investigations tend to be cursory and are privileged. This means that until all inquiries by HSE are completed, the survivors/families do not usually receive them. This may take years. The investigations are also paid for by the gas suppliers rather than by HSE directly. In our opinion, this is a conflict of interest. Gas Safety Management Regs. 1996 Reg. 7 (14) & (16).

What happens if a Gas Safe registered engineer is alleged to have done a job so badly that a customer has been killed or injured by CO?
If there is a criminal investigation and prosecution, and the engineer is found guilty, then the Gas Safe Register may, and usually does, strike off an engineer.

What if a Gas Safe engineer does a bad job but there is no criminal investigation?
A customer who has had work done in the past 6 months by a Gas Safe registered engineer can complain to the Gas Safe Register. The GSR may send an inspector but if the person contacting the GSR is a tenant, the inspector won’t test for CO without the landlord’s permission (8.2 of the GSR’s consumer policy, see https://www.gassaferegister.co.uk/about-us/our-policies/ ). CO-Gas Safety has objected to this policy for many years.

 

Other government bodies

Ofgem see https://www.ofgem.gov.uk and Appendix 2.

When the gas industry was privatised in 1986, safety was said to be ‘paramount’.
Ofgem has a statutory duty to have regard to the interests of customers who are disabled, chronically sick, of pensionable age, on low incomes or living in rural areas . Ofgem also has to take into account guidance from the government on social and environmental issues.

CO-Gas Safety comment
Ofgem deals with money, while HSE’s function is safety.
In CO-Gas Safety’s opinion, Ofgem has less power than assumed, although it does mediate between the supply companies and recently has new powers regarding price caps.

Ofgem has a special duty towards customers in vulnerable situations. Ofgem has provided funds for CO and testing for CO in homes of vulnerable customers.
BUT, all are vulnerable to CO, however healthy, wealthy or wise they may be.

Please note that if HSE stated that testing for CO was a safety issue (and how can it not be?) then under the legislation setting up both HSE and Ofgem, Ofgem has informed us that it would have to fund the testing.

Local Authorities

Building Regulations on new build properties and installation of new solid fuel appliances, and new gas appliances https://tinyurl.com/2b9bwv5r

This has been updated to include the compulsory provision of smoke and carbon monoxide alarms and states that a new home with combustion appliances should have both a smoke alarm (which should conform to BS EN 14604) and a carbon monoxide alarm (which should conform to BS EN 50291).

Solid fuel appliances: under the Building Regulations, solid fuel appliances should have a CO alarm installed and an inspection from the Local Authority and certificate to prove this.

CO-Gas Safety comment
Often the inspectors don’t seem to have the training to understand the importance of the alarm, or the need for the alarm to be to EN 50291 and be fitted in the correct place.

The Smoke and Carbon Monoxide Alarm (Amendment) Regulations 2022
https://www.legislation.gov.uk/uksi/2022/707/contents/made
https://www.gov.uk/government/publications/smoke-and-carbon-monoxide-alarms-explanatory-booklet-for-landlords/the-smoke-and-carbon-monoxide-alarm-england-regulations-2015-qa-booklet-for-the-private-rented-sector-landlords-and-tenants

These alarm regulations apply to rented property only. Therefore, home owners do not have to have CO alarms installed.

The Gas Appliances (Safety) Regulations 1995
https://www.legislation.gov.uk/uksi/1995/1629/note/made
Basically, appliances must be safe to use and have a CE marking. CE marking is the product manufacturer’s claim that a product meets the essential requirements of all relevant European directives or regulations. These directives or regulations outline the safety and performance requirements for certain products that are placed on the market in the European Union (EU). The CE mark is a legal requirement for certain products placed on the market in the EU.
See https://www.cemarkingassociation.co.uk/ and https://tinyurl.com/27avvrtc

The Gas Appliances Regulations (EU 2016/426)
https://www.legislation.gov.uk/eur/2016/426/body
These form part of retained EU law within the UK Statute. These regulations do not apply to second-hand (pre-owned) gas appliances.

CO-Gas Safety comment
Second-hand gas appliances should not be sold or given away, except possibly through a licensed seller/or other licensed body.

New gas installations in the UK – what has to be done on a new gas installation
The manufacturer’s instructions should be followed.

Ben Bayliss of Engineering Forensics (https://engineering-forensics.co.uk/ ) kindly set out the following copy which was the result of correspondence between Stephanie Trotter and Ben Bayliss 27.10.22:

1. A new gas installation has to have a building compliance certificate from the Local Authority (Planning Department – part of Building control).
2. The Registered Gas Engineer who has commissioned the gas appliance has to send details of the appliance to the Gas Safe Register. This costs about £6. This is traditionally completed using an online account (via the Gas Safe website). The details of the appliance are filled in on a ‘benchmark commissioning check list’. This list will contain all details of the appliance; make, model, date installed, CO, CO/CO2 ratio, gas rate, burner operating pressure, burner flow return temperature, cold water temperature at outlet and hot water temperature at outlet.
3. The Local Authority will then send a ‘Building Compliance Certificate’ to the homeowner and/or Landlord to keep.
4. Any future maintenance (which is periodic) should be written onto the service section of the Benchmark document, which is a piece of paper kept with the manufacturer’s instructions. This also makes various guarantees regarding the boiler valid.
5. Some manufacturers do this online, or it can be done online. This is so other gas installers can access the history and this also helps with any guarantees.

New appliances – Trading Standards

https://www.nationaltradingstandards.uk/what-we-do/
For local offices see https://www.gov.uk/find-local-trading-standards-office
and also https://www.businesscompanion.info/en/quick-guides/miscellaneous/trading-standards-powers-enforcement-and-penalties , from which the following summary is quoted:

‘People working for Trading Standards services are employees of a local authority (council) and are authorised to carry out their functions to enforce Trading Standards laws. Job titles and qualifications vary between different local authorities and between different functions, but for the purposes of this guide they are referred to as Trading Standards officers, or TSOs.

Trading Standards services enforce the law across a range of subject areas, including: –

• age restricted products
• agriculture
• animal health and welfare
• fair trading, which includes:
  • pricing
  • descriptions of goods, digital content and services
  • terms and conditions
• food standards and safety*
• petrol and fireworks storage
• intellectual property (for example, counterfeiting)
• product safety
• weights and measures

[*Some types of Trading Standards services, including London boroughs, do not enforce food law.]

Trading Standards services visit business premises for a number of reasons, but the underlying purpose of a visit is generally to check and ensure that the business is complying with the law as well as to address or investigate any non-compliance.’

Office for Product Safety and Standards

The General Product Safety Regulations 2005
See https://www.gov.uk/government/organisations/office-for-product-safety-and-standards , which gives details of the OPSS and its role. In summary, it states:

‘Our purpose is to make regulation work, so that it protects people and enables businesses to understand their obligations. Office for Product Safety and Standards is part of the Department for Business and Trade .’

See https://www.gov.uk/guidance/product-recalls-and-alerts, for more information on the product recall process of the OPSS, including:

‘The regulation of product safety in the UK is the responsibility of market surveillance authorities (MSAs), including OPSS and local trading standards authorities. Where MSAs identify that a product is unsafe through investigations, or where they have been notified by a business that a product they have placed on the market is unsafe, this must be notified on the Product Safety Database.

Products which present a serious or high risk and those which have been recalled are published on the above list. MSAs may also submit other products for publication by notifying this to the UK Product Safety Contact Point within the OPSS Incident Management team ukproductsafetycp@beis.gov.uk ’

CO-Gas Safety comment
See the following article for an instance where a product design fault led to multiple CO fatalities in separate incidents: https://www.theargus.co.uk/news/18892577.beko-inquest-find-serious-errors-five-carbon-monoxide-deaths/ . More recently, our attention was drawn to some barbecue fuel being sold without warnings of CO. Also in 2023, OPSS investigated safety issues with gas hobs and instructed 11 companies to take corrective action (https://www.which.co.uk/news/article/government-intervenes-with-gas-hob-manufacturers-due-to-safety-risks-aLi0z8J7oW2P).

Inquests

https://www.judiciary.uk/courts-and-tribunals/coroners-courts/
An inquest is an investigation into a death which appears to be due to unknown, violent or unnatural causes. An inquest is designed to find out who the deceased was, and where, when and how (meaning by what means) they died. CO deaths have to have an inquest by law because CO is not a natural cause of death.

Note – it is also possible to have an inquest when a death is from natural causes.
https://www.gov.uk/after-a-death/when-a-death-is-reported-to-a-coroner https://coronerscourtssupportservice.org.uk/
https://www.legislation.gov.uk/uksi/2013/1616/made
For state-related deaths (e.g. death in prison) see https://www.inquest.org.uk/
The presence of the body in the jurisdiction provides the Coroner with the power and the duty to conduct an inquest. In other words, the inquest takes place in the Coronial Area in which the person died or, if the death occurred to a UK citizen abroad, the area into which the body arrives in England, Wales or N. Ireland. This may therefore not be near the home of the deceased or their surviving relatives.

CO-Gas Safety comment
CO deaths have to have a jury, although the failure to provide a jury is not in itself a reason for a new inquest.

However, it is vital for any interested party (usually relatives of the deceased but can be businesses, Government or Local Authorities, CO-Gas Safety or other ‘interested party’) to realise that it’s the work done before the inquest that can make the difference to the outcome. This work is usually the gathering of evidence; for example, finding out if a Registered Gas Engineer was employed to install or maintain the gas appliance.

Most families do not know or appreciate how important the pre-inquest work is. They think the inquest will provide the answers but if the evidence is not gathered and presented, the chances are that the inquest will not provide the answers the family seeks.

CO-Gas Safety’s comment is that any family should consult a lawyer, who is expert and experienced in inquest law, as soon as possible after the death. It is extremely difficult to obtain a second inquest, but see section 13 (1) (b) of the Coroners Act 1988 & https://www.lexology.com/library/detail.aspx?g=75d1fe3b-2bf7-4ac3-8b72-c9dc8114b2e5

Reports to Prevent Future Deaths

https://www.judiciary.uk/guidance-and-resources/revised-chief-coroners-guidance-no-5-reports-to-prevent-future-deathsi/

The Coroner has a right and a duty not just to decide how somebody came by their death but also, where appropriate, to report to relevant organisations about that death with a view to preventing future deaths. These are known as Prevention of Future Death Reports. More information, including the facility to search for reports, can be found at: https://www.judiciary.uk/courts-and-tribunals/coroners-courts/reports-to-prevent-future-deaths/

There are inquests in England, Wales and N. Ireland, but in Scotland there are no inquests. If there is a death in Scotland that requires an inquiry it will be a Fatal Accident Inquiry (FAI). This tends to be more thorough but there are far fewer FAIs than inquests. These FAIs are undertaken by the Procurator Fiscal. https://www.scotcourts.gov.uk/search-judgments/fatal-accident-inquiries

Inquests are useful because evidence is given in court and can be repeated/quoted without risk of defamation. Evidence at the inquest can be helpful to a civil claim for damages.

CO-Gas Safety comment
CO-Gas Safety has collected, collated and published deaths from unintentional CO since 1995, that we know about. Excluding both suicides and deaths from CO related to house fires has proved far easier than we thought it would have been at the start. This is thanks to the Coroners and their officers, who realised that our work was vital with regard to prevention and have helped us hugely by providing the needed detail. We are very grateful.

From the deaths which we have collected since 01.09.1995, we conclude that most deaths are caused by a lack of maintenance or lack of chimney/flue sweeping. Some are caused by a lack of awareness and incorrect understanding of the dangers, e.g. using a generator or BBQ indoors. A few are caused by dangerous appliances, poor practice or negligent engineers.

Government and Parliamentary Groups
Cross Government Group on Gas Safety and Carbon Monoxide (CO) Awareness https://www.hse.gov.uk/gas/domestic/cross-government-group.htm

Consists of 8 Government departments, from Business and Home Office to Department of Health, with 5 more departments for Wales, Scotland and Northern Ireland. As far as CO-Gas Safety can tell, however, there is no regular representation by victims or survivors.

CO-Gas Safety has given a presentation to this group in the past.

The group usually brings out a yearly report. The latest report as of the date of writing this is 2021/22.

APPCOG – The All-Party Parliamentary Carbon Monoxide Group

https://www.policyconnect.org.uk/appcog

This is a group of Parliamentarians from all political parties. The Advisory Board is made up of Members of Parliament (MPs). Administrative work is undertaken by a not-for-profit organisation, Policy Connect. As of the time of writing, financial support for this administrative work is mainly from members of the gas industry.

CO-Gas Safety is a member of the stakeholder group, which is mostly made up of members of the gas industry. The stakeholder group is under the Advisory Board.

CO-Gas Safety comment
Although there is transparency, we think the influence of industry is too strong. However, this group has done valuable work. We hoped that the helpful recommendations made by Baroness Finlay in 2011 would achieve preventative action.

APPCOG’s inquiry ‘Preventing Carbon Monoxide Poisoning’, 2013 heard evidence CO poisoning causes 50 deaths a year (now revised to 40 in a report by the Cross Government Group on Gas Safety and Carbon Monoxide Awareness), 200 serious injuries and 4000 minor injuries – costing the Department for Health in England & Wales approximately £178m a year in medical and care costs, and creating immeasurable human suffering.
https://www.policyconnect.org.uk/research/report-preventing-carbon-monoxide-poisoning

Trade bodies
BSI – British Standards Institution

See https://www.iso.org/member/2064.html , from which the following summary is quoted:
‘The British Standards Institution (BSI) was established in 1901 as the Engineering Standards Committee.

A Royal Charter was granted in 1929, with the organization’s aims and objectives including:

• promoting trade – by developing common industrial standards;
• reducing waste – by simplifying production and distribution;
• protecting the consumer – through the use of licensed marks to identify conformity to standards.

The British Standards Institution was adopted as the organization name in 1931. BSI has a Memorandum of Understanding with the UK Government, which establishes the position of BSI as the recognized UK National Standards Body.

BSI’s ESSAC (Electrotechnical Standardization Strategic Advisory Council) is the national committee of the IEC for the UK.

BSI is a non-profit distributing organization and offers global services in the linked fields of standardization, systems assessment, product certification, training and advisory services.’

The most important standards with regard to CO are:-

1. BS EN 50379-3 or BS 7927:1998 incorporating Amendment No.1:1999 for flue gas analysers.
2. BS EN 7967 for the guidance of the use of flue gas analysers.
3. BS EN 50291 for CO alarms.
4. BS EN 50543 for portable apparatus for the detection and measurement of CO/CO².
5. BS 40102-1:2023 includes for ‘acceptable’ CO:-
   • 15 min: 35-100 mg/m ³ versus WHO 100 mg/m ³
   • 1 hour: 10-35 mg/m ³ versus WHO 35 mg/m ³
   • 8 hour: 4-10 mg/m ³ versus WHO 10 mg/m ³
   • 24 hour: 2.3 – 4 mg/m ³
6. BS EN 1860-2:2023 Appliances, solid fuels and firelighters for barbecuing — Part 2: Barbecue charcoal and barbecue charcoal briquettes — Requirements and test methods.

Standards are not mandatory so, unless referred to in legislation, they are guidance/best practice.

If a product such as barbecue briquettes are unsafe this is an issue for Trading Standards and the General Product Safety Regulations 2005.

IGEM (The Institution of Gas Engineers and Managers)

See https://www.igem.org.uk/, from which the following summary is quoted:

‘IGEM is the professional engineering institution for gas, here to support individuals and organisations connected with the industry. As advocates of excellence, our core aim is to help all those involved with gas to achieve and maintain the highest standards of professional competence.’

IGEM has a Royal Charter which can be downloaded from https://www.igem.org.uk/about-us/royal-charter.html

IGEM writes guidance documents for engineers with other representatives.

CO-Gas Safety comment
CO-Gas Safety has made many recommendations to this body on behalf of survivors and families. Recently (2022-23) CO-Gas Safety has made representations with regard to

IGEM’s technical standard IGEM/IG/1 Supplement 3 – Metering/Emergency Service Provider Natural Gas Training Specification – Utilisation Sector. This basically provides guidance on what a Registered Gas Safe Engineer should do on a visit, when CO is suspected or a CO alarm has sounded. We also made comments about the IGEM Unsafe Situations Procedure. CO-Gas Safety would like IGEM to be more proactive and call for testing for CO whenever practicable, using correct equipment.

Energy and Utilities Alliance

See https://eua.org.uk, from which the following summary is quoted:
‘The Energy and Utilities Alliance (EUA) is a not-for-profit trade association that provides a leading industry voice to help shape the future policy direction within the energy sector. It acts to further the best interests of its members and the wider community in working towards a sustainable, energy secure and energy efficient future.’

Energy UK

See https://www.energy-uk.org.uk/ , from which the following summary is quoted:
‘We are the trade association for the UK energy industry with over 100 members covering the breadth of the sector including suppliers, generators, aggregators, flexibility providers, electric vehicle charging operators and software companies.
We work with the sector, government, regulators and wider stakeholders to champion a sustainable UK energy industry.’

CoGDEM (Council of Gas Detection and Environmental Monitoring)

See http://www.cogdem.org.uk/, from which the following summary is quoted:
‘Our goal is to advance and develop the gas detection, gas analysis and environmental monitoring industries.

CoGDEM serves our members and their industries by

• Expressing the collective views of our Member Companies
• Contributing to British, European, and International Standards
• Being the single UK voice for our industries
• Maintaining good relations with Government Departments
• Working with Certification Bodies and other Trade Associations
• Promoting the value of high quality equipment and services
• Supporting education and training in our industries
• Providing the helpline for domestic CO alarms’

HHIC

See https://www.hhic.org.uk/about , from which the following summary is quoted:

‘The Heating and Hotwater Industry Council (HHIC) is a member organisation committed to using our knowledge and expertise to define practical solutions for decarbonising heat & hot water in UK homes and businesses. **for consumer advice please contact either the product manufacturer or the Gas Safe Register.

What do we do?

• Represent the UK residential supply chain for heating and hot water appliances and installation
• Support the decarbonisation of heating & hot water in UK homes and businesses
• Lobby & provide expert advice to government on practical solutions in support of decarbonisation policy
• Provide technical expertise and authority across all heating & hot water technologies
• Provide communication and ensure understanding of technical and regulatory changes in the sector
• Help consumer protection by encouraging best practice
• Provide unbiased market data collection and analysis

HHIC manage a wide range of industry working groups, they are;

• Benchmark Steering Group
• Benchmark Spares
• Benchmark Water Treatment Product Manufacturers Group
• Controls Group
• Fire Group
• Heating & Hot Water Appliance Manufacturers
• Heating & Hot Water Systems Group
• Heating & Hot Water Technical Panel
• Heat & Hot Water Policy Group
• Installer Committee
• Installers, Training, Skills & Standards (IST)
• Water Treatment’

CO-Gas Safety comment
The Heating and Hotwater Industry Council, HHIC, allows 350 PPM of CO in the flue . CO-Gas Safety considers this is far too high.
A weather inversion could blow this back into the living space.

HHIC is roughly equivalent to AHRI in USA
i.e. The Air-Conditioning, Heating and Refrigeration Institute https://www.ahrinet.org/

Prevention by individuals

Could be more effective if there was increased awareness of the dangers of CO, better systems, testing for CO using equipment whenever practicable and financial help for appliance servicing and chimney sweeping etc.

See Appendix 6.

 

6 . TRAINING AND COMPETENCY OF ENGINEERS

Work carried out on any installation fuelled by mains or bottled gas is regulated by law in the UK and must be carried out by qualified, registered engineers, trained to work on the specific types of appliances in question. There is no equivalent law about engineers working with other fuels, or regarding chimney sweeps. However, per user, the risk of unintentional death from CO generated by a solid fuel is, according to CO-Gas Safety records, higher. We know we do not receive notification of all the deaths from unintentional CO, so cannot be certain about exact figures.

Gas

By law, work on gas can only be done by a Registered Gas Engineer (RGE).
The ‘register’ for this trade is the Gas Safe Register https://www.gassaferegister.co.uk/.

EU Skills – Energy & Utility Skills
See https://www.euskills.co.uk/about/ , from which the following summary is quoted:

‘We provide membership, assurance and skills solutions to help employers attract, develop and retain a sustainable, skilled workforce to ensure the seamless delivery of essential services to 65 million people each day and UK Industry.

Our UK-wide membership is comprised of the major infrastructure companies within water, power, gas and waste management and their top tiers of delivery partners. Our membership brings companies together to collectively identify and address the unique workforce renewal and skills challenges the sector faces, while engaging governments, regulators and other senior stakeholders to help them develop an informed and supportive policy and regulatory environment.’

Energy & Utility Skills Partnership is owned and led by sector employers who recognise that investment in infrastructure and core utility services is a vital part of improving UK productivity and growth.’

This is the leading body, but it is possible to attend many other training bodies and colleges to study to become a gas engineer. Training takes as little as 25 weeks. There is a huge shortage of qualified gas engineers. All Registered Gas Engineers have to be updated every five years.
https://www.skillstg.co.uk/blog/how-long-does-it-take-to-become-a-gas-engineer/

Oil

See https://www.oftec.co.uk/, from which the following summary is quoted:
‘OFTEC stands for the Oil Firing Technical Association. It is a ‘competent persons scheme’ which recognises installers who are approved to install oil, solid fuel and renewable heating equipment and to maintain oil and solid fuel systems.’

Solid fuels

See www.solidfuel.co.uk, from which the following summary is quoted:
‘Operating as a centre of expertise, the Solid Fuel Association has become a recognised authority on matters concerning solid fuels both for domestic consumers and professionals such as heating installers and architects.’
See https://www.hetas.co.uk/, from which the following summary is quoted:

‘HETAS is a not for profit organisation offering a competent person scheme for installers of biomass and solid fuel heating, registration for retailers and chimney sweeps and approval of appliances and fuels.’
See also the Burnright campaign: https://www.burnright.co.uk/

Chimney sweeping

See http://www.federationbcs.com/ , from which the following summary is quoted:
‘The Federation of British Chimney Sweeps (FBCS) provides a unified voice to lobby and promote the interests of the professional chimney sweep, whilst providing a single point of contact for the wider industry as well as central and local government. FBCS comprises of the main chimney sweeping trade associations and the industry’s NVQ provider. The member associations collectively represent the majority of registered chimney sweeps in the UK.’

The sweeps are to be congratulated for this and also for their protocol of not sweeping when CO is suspected, allowing an investigation to be undertaken.

7. CO ALARMS AND OTHER DEVICES

Smoke and CO alarm regulations

We welcomed new UK smoke and CO alarm regulations recently. For England, new regulations came into force on 1 ^st Oct 2022.

The regulations are different for the four countries that make up the UK. For two good summaries please see https://hhic.org.uk/uploads/65B8BEE378CDC.pdf and https://www.policyconnect.org.uk/news/carbon-monoxide-alarm-regulations-are-changing-are-you-ready

Levels of CO that CO alarms are set at in the UK

PPM CO	UL 2034 USA	BS 7860 British (old)	BS EN 50291 European
30	NO ALARM tested for 30 days	–	NO ALARM tested for 120 mins
45	–	NO ALARM tested for 60 mins	–
50	–	–	within 60-90 minutes
70	within 60-240 minutes	–	–
100	–	–	within 10-40 minutes
150	within 10-50 minutes	within 10-30 minutes	–
300	–	–	before 3 minutes
350	–	before 6 minutes	–
400	within 4-15 minutes	–	–

CO-Gas Safety comments

1. These alarm standards in the chart above are in chronological order, i.e. UL came first, then BS 7860 (now old) and then EN 50291 which has replaced the old BS.
2. The British levels were set too high at the time, which we stated at the time.
3. The European one was set at a slightly lower level but in the charity’s opinion, the no alarm (not even an indication) for two hours at 30 PPM now looks wrong. Low levels of CO are now known to cause brain damage https://tinyurl.com/58au77he
4. Some alarms have digital read outs and start showing CO at, say, 5 PPM. However, these are not to a standard and not certificated by an independent test house to be accurate at anything other than the levels for the particular alarm, e.g. BS EN 50291.
5. The Smoke and Carbon Monoxide Alarm Regulations do NOT specify or require an alarm at any standard, or one that has been tested by a test house. What a missed opportunity!
6. The Smoke and Carbon Monoxide Alarm Regulations do NOT require buying an alarm from a reputable supplier (e.g. direct from the manufacturer or from a well known supermarket or DIY store). Again, what a missed opportunity!
7. A battery operated CO alarm will only work if you get it out of the packet and pull the tab to connect the battery. Katie Haines died in 2010 with a good CO alarm still in its package.

WHO Global Air Quality Guidelines update 22.09.21
The World Health Organisation AQG level (Air Quality Guideline level) for CO has been reduced to 4 mg/m ³ (equates to approx. 3.5 parts per million) over 24 hours.
See https://www.who.int/publications/i/item/9789240034228 and https://iris.who.int/bitstream/handle/10665/345329/9789240034228-eng.pdf , page xvii

As previously stated, the levels that UK CO alarms are set to activate at are:

PPM CO	EN 50291
30	NO ALARM – tested for 120 mins
45	–
50	within 60-90 minutes
70	–
100	within 10-40 minutes
150	–
300	before 3 minutes
350	–
400	–

So, you could have 29 PPM forever.
You could have up to 49 PPM intermittently.
You could have 150 PPM intermittently for nine minutes at a time.
You could have 400 PPM for two minutes or nearly 3 minutes intermittently.

This is why we have a love/hate relationship with CO alarms; We love them because we are sure they save lives, but we hate them because they lull people, including Registered Gas Engineers, into a false sense of security. CO alarms are excellent at preventing death or serious injury but are NOT health monitors. They do not prevent long-term low level exposures, which can have significant medical consequences.

AICO has produced a CO alarm which can produce records of detected CO levels via an app. These records can bedownloaded to use as proof for tenants or landlords.However, in the experience of CO-Gas Safety, this does not seem to be easy for ordinary people to use yet.

Honeywell has apparently produced a similar product, but at the time of writing it is only available wholesale and wired-in, rather than battery operated.

 

New gas appliances

Flame supervision devices: The Oxygen Depletion System (ODS)

The following summary was kindly written by Ben Kuchta, a Registered Gas Engineer, Chartered Engineer and IGEM Fellow:

‘ODSs are designed to detect a lack of oxygen, rather than specifically detect carbon monoxide (CO) in atmosphere. They work well unless they have been tampered with or the appliance has not been serviced.

It’s important to note that ODSs operate at a threshold higher than the activation threshold of a CO alarm, i.e. they are less sensitive than a CO alarm built to EN 50291 standards.

CO alarms to EN 50291 are designed NOT to alarm until it detects 30 parts per million (PPM) of CO for two hours. The WHO guidelines are about 4 PPM over 24 hours (see Appendix 4).

ODSs activate because of a lack of oxygen leading to vitiation at the pilot assembly. As this happens, the pilot flame fails to stay in contact with the thermocouple and after a short period of time the thermocouple will cool, leading to a reduction in the electromotive force holding the gas valve open. The valve thus closes and stops the combustion of gas.’

Cut-off systems

Various systems have been created and patented. Ben Kuchta, a British Registered Gas Safe Engineer and entrepreneur has invented a device, called Project SOTER, which he describes as a CO Interlock.

It undoubtedly has the potential to save lives in incidents that involve any fuel-burning appliance that relies on electricity for part of its operation; for example, gas or oil boilers, gas grills and cookers. In layman’s terms, it is a cut-off switch that activates when it ‘hears’ a CO alarm sounding. It isolates the electricity supply to the appliance, therefore shutting it down automatically if raised CO levels are detected by a CO alarm.

Some cut-off systems can alert the emergency services, but the gas industry in the UK has not seemed to be very keen to take these further. This could be because there is a lack of recognition of the dangers of CO in the UK, due to a lack of testing for CO whenever practicable.

 

8. EMERGENCIES

CO-Gas Safety comment
Approaching this from the point of view of an ordinary member of the public: –

If a person feels so ill that they need help then they call an ambulance and/or fire service and/or if they guess it might be caused by gas or CO in the UK, they’ll call the gas emergency service.

Advantages of Fire Service
Fire fighters know about CO and have equipment to sense it so, if CO is present, they should be able to find it. However, often everything has been turned off and windows and doors have been opened, so it can be similar to the problems with the gas emergency service, i.e. no CO remains in the air at the time the fire fighter arrives.

Disadvantages of Fire Service
Fire fighters in the UK are not able to test the gas pressure etc. in the supply pipes or turn gas appliances back on and test for CO. However, they can ask the customer to call out the gas emergency service.

The Fire Service in the UK works under the Home Office, i.e. the Government.

Gas Emergency Service
This could work well IF the gas emergency service carried and used equipment to test gas appliances for CO whenever practicable.

When an ordinary member of the public calls the UK gas emergency service on 0800 111 999, they are told to turn everything off, open windows and doors and get outside. So, by the time the First Call Operator (FCO) from the gas emergency service turns up, any CO will nearly always have disappeared.

Sadly, there is, as yet, no legal duty on the gas emergency service to put the gas appliances back on and, if necessary, relight them and test for CO. Consumers are therefore left not knowing if they have a CO issue, or which appliance may be causing it.
If the FCO suspects a problem then they will disconnect appliances and leave, telling the customer to call a Registered Gas Engineer to service the appliances. But will they? Can the customer afford this? Do they really understand how important it is?

 

9. PROOF OF CO

CO-Gas Safety comment
Why does this matter?
Because without something in writing, or digitally, from a gas engineer (or perhaps downloaded from an AICO alarm) showing how many parts per million (PPM) of CO is being emitted by the appliances, medics think CO is rare.Medics are correct that at the moment proved CO is very rare due to a lack of a duty to test.

Proof of CO
Couldn’t CO be proved by testing survivors?
No, because usually by the time a test is done on breath or blood the survivor will have been exposed to fresh air/oxygen and the CO will usually have left the breath/blood but will still be causing injury.

What recourse does an ordinary customer have if they think they’ve been exposed to CO?
The customer can try the Gas Safe Register to find a Gas Safe Registered engineer who has a qualification called CMDDA1, or a court witness expert in gas, who can come and test and identify the source of the CO. If the customer can find such a person, this costs from £500 to about £2,000 or tens of thousands.
Morgan Lambert, who undertake investigations for their social housing clients, charge about £350 per job. https://morganlambert.com/

In our experience (since 1995), it is almost impossible for an ordinary person to find such an expert. Even CO-Gas Safety finds this virtually impossible too.

Gas Safe Registered Engineers seem to think they are bound by section 8.2 of the Gas Safe Register’s Consumer policy (see https://www.gassaferegister.co.uk/about-us/our-policies/ ). This is binding on inspectors employed by the Gas Safe Register. Gas Safe Registered Engineers are not bound by it because they are not employed by the Gas Safe Register, only licensed by it.

 

10. PUBLIC LIABILITY INSURANCE (PLI)

CO-Gas Safety comment
For gas work to be done legally, the law requires gas engineers to be registered by a body licensed by HSE. This is now ‘The Gas Safe Register’. But the law did not require PLI for the licensees. Therefore, there is no legal power to insist on this for Gas Safe Registered Engineers. A legal opinion obtained by the previous register, CORGI, established that legislation would be needed to make PLI mandatory. Presumably, however, HSE could have recommended legislation. A consumer could insist on seeing the Gas Safe Registered Engineer’s PLI, if they knew to ask.

Most Gas Safe Registered Engineers do have PLI, and they are encouraged to do so by the Gas Safe Register, but this was a missed opportunity. Why not rectify this?

 

11. VICTIM SUPPORT

CO-Gas Safety comment
There is no special victim support for survivors of CO other than what CO-Gas Safety, an independent registered charity, provides. But CO-Gas Safety has no guaranteed funding, is run by volunteers and is treated by the authorities as an ‘unauthorised body’.

CO-Gas Safety has asked how it becomes an authorised body but has received no response. The charity often asks for it’s contact details to be sent on.

This is another missed opportunity because we can help victims/survivors and families, plus each incident can teach so much. For example, new dangers such as BBQ huts or swimming platforms and even open-air CO poisoning are coming to light. We also collect data and lobby for safety improvements.

Citizen Advice Bureaus are supposed to help but, as many people at the CAB are unaware of the existence of CO or how to gather evidence of CO, and as the gas emergency service does not test for CO as standard, we suspect the CAB are unable to assist many people who seek their help.

CO-Gas Safety would be happy to help, and is helping, but could be overwhelmed.
Surely survivors of CO incidents are a rich research resource?
See https://www.co-gassafety.co.uk/case-studies/

Everything that CO-Gas Safety has suggested needs to be changed has been learned from talking to survivors and families of victims. The charity then runs ideas past industry to check these ideas are workable.

 

12. DATA

A. Deceased people – CO-Gas Safety has collected and collated deaths from unintentional carbon monoxide poisoning since 01.09.1995

See https://www.co-gassafety.co.uk/data/

CO remains stable in a deceased person. Cardiff Laboratories told us the cost to test for CO is about £32.00. It would therefore be easy to test all deceased persons automatically, at least those who have an autopsy/post mortem. Surely the more testing that is done, the cheaper testing will be?

Note if the person has been in hospital, it is likely that they will have been on a blood gas machine that automatically tests for CO. Therefore, the hospital records should show this. We know the records show CO for some people who have died of CO.

B. Survivors

Testing survivors is unreliable because CO quickly leaves the blood and breath if the survivor breathes fresh air/oxygen. Therefore, it is more reliable to recreate the circumstances around the exposure; then investigate the circumstances by relighting the carbon-fuelled appliances that were on at the time of the exposure and test the air. See https://vimeo.com/727002257/939926c093 . If CO is found, an investigation should be carried out to find the source of the CO.

Cadent, one of the four companies that together provide the gas emergency service in the UK, is now doing this for vulnerable customers. Northern Gas Networks, another of the four companies, is following this example from April 2023. SGN is doing something similar, using a third party. Wales & West Utilities is following. This is happening thanks to millions being provided by Ofgem. However, this isn’t standard for all customers, despite all being vulnerable to CO, however healthy, wealthy or wise. Obviously, all these actions will assist each other. For example, data will assist awareness and prevention, provided data is properly and fully collected, recorded and collated.

CO-Gas Safety comment
CO is deadly and can’t be sensed using human senses.
CO should be tested at every opportunity, particularly by the gas emergency service.
The data could then be collected, collated and used in research.

 

13. CO-GAS SAFETY’S SUGGESTIONS FOR IMPROVEMENTS TO UK LEGISLATION AND PRACTICE

In February 2000 CO-Gas Safety, along with many survivors and family members, made representations to HSE.

Later in the year, in August, HSE made two recommendations: –

1. Levy on the gas suppliers to pay for awareness and research, and
2. That the gas emergency service carry and use equipment to test gas appliances.

Sadly, these excellent recommendations have been largely ignored. CO-Gas Safety has the original document in which these recommendations were made and can make this available on request.

Colin Breed MP obtained the signatures of 121 MPs for an Early Day Motion for these recommendations in 2007, yet nothing was done.
https://edm.parliament.uk/early-day-motion/32767#tab-supporters

A. Legislation

(i) Impose a duty on the gas emergency service to carry and use equipment to test for CO whenever practicable .

This was recommended by HSC* and HSE in 2000 after an exhaustive gas safety review with the support of the majority of the stakeholders, who were mainly industry.
* Health & Safety Commission – later dissolved, leaving the Health & Safety Executive.

Suggested additions: – The procedure being used by Cadent (and from April 2023 by NGN), is used by all the four companies that make up the GDNs and supply the gas emergency service. The procedure is to reconnect and relight where necessary and undertake a sweep test**. Then, if CO is found, a further investigation is undertaken by a Registered Gas Engineer (RGE) with the qualification CMDDA1. ** https://vimeo.com/727002257/939926c093

That there be a national emergency service also testing for CO where there are carbon-based fuels and investigating for all fuels, not just gas.That all heating and cooking engineers be registered by law as those working on gas are.

That there be a mandatory duty for all engineers to test for CO whenever reasonably practicable.

That the data concerning the CO found is collected, collated and published.

That the gas and any other emergency service continues to be free to the consumer.

That use is made of CO found and downloaded by, for example, CO alarms which have this feature.

That where CO is found, those exposed to CO and their medics are provided with the findings of CO in PPM in writing/digitally and offered further help and support.

That an independent body be set up and funded by a levy on the fuel industry to supply that further help and support. That this body compiles case studies to inform the industry of problems that need addressing. This to include explosions and other gas dangers. That this body lobbies for changes where it finds improvements can be made and is treated as a respected stakeholder. A template can be found in the Advertising Standards Authority. https://www.asa.org.uk/ see under D below.

That the data collected can be made freely and publicly available, with full details to those wishing to undertake research.

(ii) Clean Air Bill should be passed.
See https://bills.parliament.uk/bills/3161 Applies to indoor and outdoor air.

(iii) Reg. 36 of the Gas Safety (Installation and Use) Regulations 1998
https://www.legislation.gov.uk/uksi/1998/2451/contents/made
This should be amended to mandate a specific mandatory duty to test for CO whenever practicable and record parts per million (PPM) found in the flue and in the air in the living space before any further work is done. This should also be carried out after work or servicing as necessary is done. If CO is found, then any persons who could have been exposed to CO (and their medics) must be provided with a copy of the PPM of CO they are likely to have been exposed to.

(iv) Reg. 26 (9) of the Gas Safety (Installation and Use) Regulations1998
https://www.legislation.gov.uk/uksi/1998/2451/contents/made
This should be amended to mandate a specific duty to test for CO as in (iii), above.

B. Funding

(i) Funding for the HSE to employ more of its own gas expert investigators and undertake full investigations where necessary, must be found. This would ensure better safety and impartiality.

(ii) HSE to be funded to supervise the Gas Safe Register more assertively and to remove 8.2 of the consumer policy of the Gas Safe Register. Consumers who fear they have been exposed to CO should have a right to a test by the gas emergency service and a proper investigation by a body independent of the gas industry and, where necessary, by HSE.

(iii) HSE to have funding to take over the work or at least the responsibility for work done now by IGEM in drafting guidance for gas engineers, with IGEM’s help and the help of other bodies.

(iv) Funding for the HSE to pay for investigations and prosecutions, particularly for breach of the landlord’s duties; for failure to provide a gas safety certificate and for failure to supply CO alarms.

In the opinion of CO-Gas Safety, funding must be found or the HSE will continue to have low morale, be ignored and regulations will continue to be flouted.

(v) Funding for work to be done to reduce the levels of CO allowed in CO alarms before alarming, and also allowed for Registered Gas Engineers without breathing apparatus. Care needs to be taken to ensure CO alarms are accurate and are not treated as health monitors, or that they alarm at such a low level they are ignored.

(vi) Funding is needed to raise awareness of the dangers of CO at all levels and directed at members of the fuel industry, the medical profession and the public.

(vii) Funding by the taxpayer, including the wealthy fuel industry, to provide green sustainable fuels and for research to ensure safety. We must also make sure such ‘green fuels’ are indeed green and sustainable.

C. Testing for CO on death

Testing for CO on every death should be undertaken and the results collected, collated and published, having carefully removed suicides and also deaths from smoke inhalation from house fires etc. This was recommended by Baroness Finlay, co-chair of APPCOG, in 2011. We found this easier than expected at the start.

D. Organisation to represent consumers, victims, survivors and families

This could be set up in a similar way to the Advertising Standards Authority (see https://www.asa.org.uk/about-asa-and-cap.html) and funded by the industry. All parts of the industry should contribute, not just the Gas Distribution Networks and RGEs, but also the wealthy manufacturers and gas suppliers.

Data from deaths and from testing by the gas emergency service could be overseen by this body and also by HSE. This body should lobby for CO/fuel safety. Victims, survivors and families should be provided with some free help and advice but not represented in court as individuals. Case studies could be compiled, new dangers reported & awareness raised.

E. Improvement to the Gas Safe Register

Public Liability Insurance should be made a mandatory requirement of the Gas Safe Register. This would probably require legislation.

The Gas Safe Register should concentrate on its job of keeping the register and making sure its registrants are doing a good job.

Some other independent, properly funded body acting for survivors and consumers should be helping with investigations for the sake of the survivors and consumers. This would be far easier if the gas emergency service tested for CO as suggested in A(i), above.

The difficulty of what status the RGE has pending the investigation needs to be considered and dealt with. We suggest suspension, and payment of their normal wage (or average profit over the previous tax year) until the case is determined. This is a problem in many walks of life, e.g. teachers, doctors.

F. APPCOG

It is surely undesirable for a group of Members of Parliament to have the administrative duties of that group paid for by industry, particularly the same industry that gives rise to the reason and need for the group, namely carbon monoxide.

In the opinion of CO-Gas Safety, there are not enough representatives of consumers and/or victims, survivors or family members of victims to provide a truly democratic stakeholder group. There is a democratic deficit. Legislation could ensure representation

G. IGEM

IGEM is an important stakeholder in drafting guidance for RGEs but in the opinion of CO-Gas Safety, it should be HSE that carries the responsibility for the guidance documents because, in the view of CO-Gas Safety, IGEM has a conflict of interest.

H. Practice
(i) Ratio –In the opinion of CO-Gas Safety and many gas experts, the use of the ratio of CO ² and CO is illogical and dangerous. If the ratio was about apples and pears, with pears being dangerous, then if there are enough apples, it would seem that the pears are not at a dangerous level. So surely the ratio is both illogical and wrong? This was also the opinion of the late Harry Rogers, gas expert for over 30 years. Ben Bayliss, RGE Senior Forensic Investigator, and Director of Essex Skills Centre, also agrees www.essexskills.co.uk .

(ii)‘At risk’ should not be used for carbon monoxide risks. The death of Katie Haines from CO in 2010, aged only 31, from mains gas, sadly illustrates this perfectly.

NOTE UPDATE See brief sent to Gaelan Komen of APPCOG at his request 06.07.24 at https://www.co-gassafety.co.uk/information/changes-needed/

 

14. CO-GAS SAFETY’S TEMPLATE FOR LEGISLATION AND PRACTICE IN OTHER COUNTRIES

A. Fuel Supply

Security of fuel supply is crucial, from medical needs to the economy and comfort of citizens. It would be ideal if all fuel were green and was not only renewable but did not emit any toxins in either manufacture or use. But this is a futuristic dream at the moment.

Legislation to ensure safe and secure supply should be put in place with a safety body (in the UK this is HSE) to ensure that the fuel used, especially that in any piped supply, complies to a safe formula.

Legislation needs to make a submission to this safety body mandatory. Lack of approval by the safety body would mean a company is not allowed by law to supply fuel or put fuel into a piped system.

This could be achieved by requiring a licence for any company that supplies any fuel, or for those who insert fuel into pipes. Research would probably be needed.

B. Cost

Ensuring and controlling the reasonably affordable cost of fuel is also important.

This same legislation can provide funds for safety purposes by charging a fee for the aforementioned licence.

C. Funding

The funding from this licence fee could be used for a variety of functions including:-

(i) a body such as Ofgem, the regulator in the UK ( which is funded in this way).

(ii) the safety body, such as HSE in the UK. This would draft regulations that would be secondary legislation.

(iii) a body to deal with emergencies in both fuel manufacture and refinement, pipelines and other supply issues, and also in homes. This body should test for CO whenever practicable and, if found, provide PPM of CO for the person exposed and their medics, either in writing/digitally or both. This body would then be able to provide data which would be able to identify dangers. This should deal with most, ideally all, fuels; not just gas.

(iv) a body to approve appliances and possibly make it mandatory that appliances comply with a standard, such as the CE marking, to be sold legally. Perhaps this body could also deal with recalls of dangerous appliances.

(v) a body to register engineers and chimney sweeps, and to ensure proper training and personal alarm monitors for CO for their own protection. Such personal alarms should be used by all those who enter properties for any purpose, e.g. police officers, nurses, social workers etc. Registered engineers should have a duty to test for CO whenever practicable.

(vi) a body to write guidance documents for engineers. But surely this body should be made up of other experts, members of the public, survivors and ideally also involve a government body such as HSE or its equivalent in other jurisdictions?

(vii) ensuring mandatory public liability insurance in case a trained engineer or sweep injures someone through negligence, yet the engineer concerned has no assets.

(viii) research into many issues including developing greener fuel, safer and more efficient appliances, better medical treatment, collecting and collating data of deaths and injuries, etc.

(ix) the progression and transfer of supply to other fuels that are more eco-friendly.

(x) a body to help those affected by any dangers from the fuels supplied and to ensure the voices of survivors, victims, families of those who have died, and ordinary consumers, are treated as equal stakeholders. This body could provide case studies that would throw up commonly experienced issues that people need to be made more aware of and/or need to be changed to avoid tragedies in the future.

This body should also have the funding to raise awareness of the dangers of certain fuels and appliances, and new dangers.

(xi) a body to fund technological improvements. For example, the filtering of pollutants from gas furnaces. Please see California Statewide Gas Emerging Technologies Program (https://cagastech.com/).

CO alarms should be developed to test accurately at lower levels but must not be used as health monitors or alarm at such a low level that people ignore them. Wearable alarms should be widely available. QR codes could be fitted to boats to warn of CO etc.

(xii) further legislative changes. For example, a Clean Air Act (see https://bills.parliament.uk/bills/3161 ) to apply to indoor as well as outdoor air.

(xiii) giving consideration to making it illegal to supply fuel without a certificate of installation and maintenance, including chimney/flue sweeping and a CO alarm. The poor and vulnerable should be provided with these services free.

(xiv) enforcement. This is vitally important because without it all the most carefully drafted laws will be ignored. Enforcement should principally be by the safety body, which needs powers of prosecution and adequate funding.

How this would be started in a country without legislation on these issues?

If information is put out that this legislation is intended, then invitations could be sent out to fuel suppliers and trade bodies inviting them to consider getting together to form, for example: the emergency body to attend and test for escapes of gas and CO, the body to approve appliances, the register of fuel engineers or the body to ensure help for victims/survivors and their families.

The wealthy fuel suppliers could be charged a licence fee very quickly, which would provide funding for the other bodies to get started and fully funded.

END

 

Stephanie Trotter, OBE was the main author of this document. However, many others helped and contributed. Email office@co-gassafety.co.uk

Questions, comments and criticisms are extremely welcome.

This will be published with a date but may be updated from time to time.

Many members of the gas industry have helped, particularly Ben Kuchta and Ben Bayliss.

All our work group (Jim Lambeth, Paul Overton and Sue Westwood) have helped, as well as other friends such as Frank Brehany, Consumer Champion.

Jennifer Wood, copy editor, has helped with pagination and other editing issues.

Thank you to all the members of all the bodies written about for their kindness in responding to emails and queries.

Thank you also for all the members of the public who have contacted us and helped us to understand the gaps in the system and what needs to be done to improve safety.

---

APPENDIX 1

Brief history of CO-Gas Safety and CV of Stephanie Trotter, OBE,  President & Director of CO-Gas Safety and author of this document

CO-Gas Safety is an independent, registered charity (not for profit) based in England, UK. It is victim based. Charity number 1048370.

It is also a company registered at Companies House. Company number 03084435.

Background

Stephanie became interested in safety when her older son, Alex, then aged 12 suffered a clot on the brain at a children’s activity holiday centre in 1991. Stephanie was extremely concerned about the wrong First Aid and the lack of notification about the injury from the centre involved. This led to a deep concern about the safety of children attending such centres, particularly as her concerns did not appear to be taken seriously.

After brain surgery, Alex recovered; he was lucky. Stephanie’s research found that there were no controls on these centres apart from Health & Safety law.

After a canoe tragedy in March 1993, where four teenagers drowned in Lyme Bay, Stephanie wrote her first legal article advocating licensing of these centres, published in the New Law Journal and read by the judge in the subsequent manslaughter trial. The judge in the trial, Mr. Justice Ognall, publicly urged the government to license these centres and the Activity Centres (Young Persons’ Safety) Act 1995 was enacted. The need to license was supported by the responsible centres.

Through this work Stephanie met Molly Maher (sadly deceased April 2020). She had lost her son Gary to carbon monoxide (CO) in 1985 while they were on holiday in Tenerife. Her daughter Sheree became a wheelchair user as a result of the same incident. Molly helped Stephanie and Stephanie started helping Molly, particularly with an inquest into the death of Janet Smith from CO while on a Thomson’s holiday. Molly had founded Consumer Safety International, a registered charity to help prevent deaths and injuries on holiday, helped by Nigel Griffiths MP and the late David Jenkins of RoSPA.

Molly then founded CO-Gas Safety, again working with David Jenkins, to look exclusively at carbon monoxide and other gas dangers, mainly in the UK. Stephanie agreed to run it.

She has run the independent registered charity CO-Gas Safety since its launch at the House of Commons in January 1995, with help from other voluntary directors (mainly survivors/victims, families and MPs).

Stephanie is a barrister (not practising at the moment). Her husband is John Trotter, who was senior partner and then a consultant in Bates Wells & Braithwaite, a firm that specializes in charity law.

After pupillage and about six months of practice at the bar (mainly crime), Stephanie became a lecturer, then Senior Lecturer, at the Inns of Court School of Law (the final year of the Bar examinations – post graduate students mainly from Oxbridge) for nine years. They have two sons, Alex and Paul, now married with children.

Stephanie has many interests, including house renovating, sailing, swimming, wake boarding, ice skating, gardening and writing. Stephanie has more recently taken up yoga, ballet and Scottish dancing. These are to replace the ice skating because sadly there is no longer an ice rink on the Isle of Wight.

In 2007 Stephanie was awarded an OBE for her work on gas safety.

How CO-Gas Safety is funded

Stephanie is a full-time volunteer and the charity is run almost entirely by volunteers, apart from a small amount of paid assistance to help with compiling case studies (https://www.co-gassafety.co.uk/case-studies/) and the research/collation of our incident data.

The charity was supported by a grant from the Department of Health in the past, matched for 3 years by British Gas. However, for many years now the charity has existed on donations, recently mainly from Kane International (www.kane.co.uk/).

In 2015 the charity received £50,000 from Thomas Cook thanks to the efforts of the parents of the children who died of CO in Corfu in 2006.

The charity has received some generous donations, one of which was £100,000 in late 2020, from a donor who had lost a family member to carbon monoxide; sadly the family wished this gift to remain anonymous, but we know the identity of this donor.

Other contributors to CO-Gas Safety

Stephanie has been greatly assisted by directors, who are mainly victims and MPs. CO-Gas Safety has one industry member, Jim Lambeth, who is retired from the Solid Fuel Association.

CO-Gas Safety’s patron for many years was Lord Hunt of Kings Heath, who had to step down in July 2024 as he was appointed a Minister in the Department of Energy Security and Net Zero.

Paul Overton (father of Katie Overton who died of CO in 2003), Jim Lambeth and Sue Westwood (CO survivor) are key trustees.

CO-Gas Safety has also been greatly helped by gas experts Roland Johns, Ben Kuchta and Ben Bayliss, and by the Guild of Master Chimney Sweeps, which is also deeply concerned about these preventable deaths. Stephanie is also assisted by Frank Brehany (consumer campaigner, solicitor), whom she has known for over 20 years. Jonathan Kane of Kane International has been a supporter of the charity almost since its launch.

The charity is indebted to the many Coroners of the UK, and their officers, for their invaluable help.

The work and achievements of CO-Gas Safety

Stephanie and the charity have helped innumerable victims of CO, gas leaks, explosions and fuel emissions other than CO (we call these CO+), and lobbied ministers, government and industry to make simple and practical changes to save lives and preserve health.

These were, and still are:-

1. To raise awareness of the dangers of CO

2. Testing the air and emissions from appliances for CO whenever practicable, particularly by the gas emergency service.

We are now lobbying for registration by law of all engineers dealing with heating/cooking

appliances powered by carbon-based fuel and for these engineers to have a mandatory

duty to test for CO whenever reasonably practicable. Also to provide PPM of CO when

found in writing/digitally to those exposed and their medics.

The charity has compiled a database of unintentional deaths and injuries from carbon monoxide (CO) since 1995. We use this to learn from its qualitative content but also to extract data and statistics on CO-related deaths that we publish annually. This work is ongoing (see https://www.co-gassafety.co.uk/data/ ).

For a full record of the work that CO-Gas Safety have carried out over many years, please see https://www.co-gassafety.co.uk/information/list-of-work-done/

Landmarks, awards and publications

In 2005 Stephanie and CO-Gas Safety were presented with the CORGI Gas Safety award.

Together with the members of CO+SAVi (victims and victim groups under the All Fuels Action Forum set up by the All Party Parliamentary Carbon Monoxide Group), CO-Gas Safety agreed changes that could become amendments to the Energy Bill. These were professionally drafted in 2013, paid for jointly by CO-Gas Safety and the Katie Haines Memorial Trust (see https://www.co-gassafety.co.uk/our-professionally-drafted-suggestions/ ). Some of these were put down as amendments in the House of Commons but were not successful.

January 2015 marked CO-Gas Safety’s 20 ^th anniversary event at the House of Lords with over 120 guests.

In 2017 CO-Gas Safety won ‘Safety Initiative of the Year’ at the H & V News Awards for our programme of education initiatives.

In March 2018, the New Law Journal published an article written by Stephanie proposing clarification/change in the law regarding landlords and CO alarms. See https://www.newlawjournal.co.uk/content/hidden-killer , or download from https://www.co-gassafety.co.uk/2018/03/ . Despite huge support this legislative change has not been made.

January 2020 saw the charity mark 25 years of activity, publishing 24 years of data of 712 deaths from unintentional CO poisoning that the charity knows about. Our headline was ‘We have the technology to reduce these tragedies’. We check every death with the Coroner concerned, and most are helpful in confirming the facts of the incident and level of toxicity found in the deceased. We know, however, that there are deaths that are never suspected as, or tested for, CO – thus the official figures regarding unintentional CO poisoning are certainly an underestimate, as are ours.

Also in January 2020, the New Law Journal published an article written by Stephanie about how difficult it is for those suffering from carbon monoxide to prove their exposure, even to obtain the correct medical help, let alone make legal claims. See https://www.newlawjournal.co.uk/content/co-the-hidden-dangers , or download from https://www.co-gassafety.co.uk/2020/01/ .

We decided in 2020 that we would no longer publish large press packs but would write an annual report. This is finalised each year around the end of January and published on our website. See https://www.co-gassafety.co.uk/information/

CO-Gas Safety has published two articles in the House (of Commons) Magazine – one published in September 2021 (see https://www.co-gassafety.co.uk/its-time-for-action-against-the-silent-killer-in-our-homes/ ) and another published in January 2022 (see https://www.co-gassafety.co.uk/news220124/ ).

In 2022 we published an animation about CO. Please watch it at https://drive.google.com/file/d/1KA6tdwlDml0-yZtmJm4B8SQR0V_E72jz/view

Please also watch our one-minute film about our Trustee Sue Westwood, who suffered carbon monoxide poisoning and still experiences severe health consequences from it (https://www.co-gassafety.co.uk/one-survivors-story/).

In summer 2022 Stephanie met Charon McNabbs of NCOAA (National Carbon Monoxide Awareness Alliance) from the USA at a talk about CO at CORT (Carbon Monoxide Research Trust). Later that year Charon asked Stephanie to write about the law in the UK on CO for the CPSC (Consumer Product Safety Commission) in the USA. Stephanie considered that she should include the practice and also what was most important to CO-Gas Safety, prevention. Stephanie started to write this as soon as the 2022 report was finished and sent a version to the CPSC in May 2023. Stephanie has been refining this in whatever spare time she’s had to get this ready to publish on the CO-Gas Safety website at https://www.co-gassafety.co.uk/resources/law-practice-prevention/

On 7 ^th February 2023, Kane International won the IGEM Lions Lair (a Dragon’s Den-style contest) in conjunction with CO-Gas Safety. See https://www.co-gassafety.co.uk/news-5/ .

 

Stephanie has also appeared many times on TV (including Newsnight), on radio etc.

CO-Gas Safety continues to lobby industry and government to make improvements to safety with regard to CO and gas and also new fuels such as hydrogen.

CO-Gas Safety continues to press government and industry to set up a body that is properly funded to take over the hard work of the charity CO-Gas Safety.

CO-Gas Safety will mark 30 years of work on the 25 ^th January 2025.

APPENDIX 2

Ofgem

See https://www.legislation.gov.uk/ukpga/1986/44

See also https://www.ofgem.gov.uk/about-us/our-role-and-responsibilities , from which the following is quoted:

‘Who we are

Ofgem is Great Britain’s independent energy regulator.

We work to protect energy consumers, especially vulnerable people, by ensuring they are treated fairly and benefit from a cleaner, greener environment.

We are responsible for:

• working with government, industry and consumer groups to deliver a net-zero economy, at the lowest cost to consumers
• stamping out sharp and bad practice, ensuring fair treatment for all consumers, especially the vulnerable
• enabling competition and innovation, which drives down prices and results in new products and services for consumers.

Our powers and approach to regulation

We operate in a statutory framework set by Parliament. This establishes our duties and gives us powers to achieve our objectives.

The government is responsible for setting the policy for the energy sector and proposing any changes to this statutory framework. We have a clear role to play to support policy issues such as decarbonisation and we need to operate within this framework. We do not direct overall policy in the sector. However, where we think there are important policy gaps that affect consumers, we can call this out.

We continually seek to improve the efficiency and effectiveness of our approach. This includes setting out the costs and benefits, as well as the social and environmental impacts, of all major decisions.

We regulate only where necessary to protect consumers’ interests and we carefully consider whether any regulatory requirement we propose is proportionate. We carry out investigations into company behaviour when we believe they may have breached a condition of their licence, or the requirements of consumer protection, or competition legislation.

We have the power to require disclosure of information, and to impose fines and enforcement orders on companies where we find that a breach has occurred (apart from breaches of consumer law where penalties cannot be imposed).

You can read details of our closed and current investigations, and of enforcement actions we have taken, in our section on Compliance and enforcement .

How we are governed and funded

We are governed by the Gas and Electricity Markets Authority (GEMA) . This consists of non-executive and executive members and a non-executive chair.

GEMA determines strategy, sets policy priorities and makes decisions on a wide range of regulatory matters, including price controls and enforcement. GEMA’s powers are provided for under the following: –

• Gas Act 1986
• Electricity Act 1989
• Utilities Act 2000
• Competition Act 1998
• Enterprise Act 2002
• measures set out in a number of Energy Acts.

You can see more information about GEMA, our senior executive leadership and our organisational structure in Our structure and leadership .

How we are funded

We recover our costs from the licensed companies we regulate. Licensees must pay an annual licence fee, which is set to cover our costs. We are wholly independent of the companies we regulate.’

CO-Gas Safety comment

Ofgem was set up to apparently regulate the gas companies but, in our opinion, it lacks sufficient power although it does mediate between the supply companies.

Ofgem deals with money while HSE’s remit is gas safety.

Ofgem has special duties and powers with regard to ‘customers in vulnerable situations’, who are those eligible for the Priority Service Register (e.g. the old, disabled, sick, poor, young children etc.). Ofgem has provided millions of pounds to the gas distribution networks which run the gas emergency services and we are most grateful to Ofgem.

BUT, all are vulnerable to CO however healthy, wealthy or wise.

 

Both Cadent and Northern Gas Networks, which are two of the four companies that together run the gas emergency service throughout the UK, now relight gas appliances and test for CO in homes of vulnerable customers. SGN does something similar using a third party. Wales & West Utilities is now following. CO-Gas Safety is most grateful to these companies.

We are hoping for vital data from this work. We have offered to help with the data as we have been collecting, compiling and publishing deaths from unintentional CO since 1995.

We are also hoping that this data will convince the gas emergency service, Ofgem, HSE and government that there is a basic need to test for CO at least by the emergency service whenever practicable. In our opinion this has been obviously needed for decades.

 

APPENDIX 3

Enforcement

This section is mainly comment by CO-Gas Safety.

HSE can prosecute Health & Safety offences.

See https://www.hse.gov.uk/foi/internalops/ocs/100-199/130_8.htm

Health & Safety offences and breaches of the gas regulations are most commonly investigated and prosecuted by the Health & Safety Executive (HSE). However, depending on the circumstances, some offences can also be dealt with by other official bodies, such as local authorities or industry-specific organisations, such as the Office of Rail Regulation.

The Gas Safe Register does not have such powers to prosecute.

Before prosecution, the public interest has to be considered.

In the case of manslaughter by gross negligence, only the Crown Prosecution Service can prosecute.

See https://www.cps.gov.uk/legal-guidance/gross-negligence-manslaughter

If a company is to be prosecuted, this is corporate manslaughter, also prosecuted by the Crown Prosecution Service.

See https://www.cps.gov.uk/legal-guidance/corporate-manslaughter

Corporate Manslaughter is an offence created by Section 1 of the Corporate Manslaughter and Corporate Homicide Act 2007 (‘the Act’). It came into force on 6th April 2008.

The effect of the 2007 Act was to widen the scope of the offence so that the focus of the offence is now on the overall management of the organisation’s activities rather than the actions of particular individuals.

Within the framework of the Act, it is possible for the failings of a number of individuals within the organisation to be aggregated. However, it remains the case that the offence applies only in respect of a ‘gross breach’ of a relevant duty of care, reflecting the same standard of culpability as the common law offence (for example, if a company owned a property and was the landlord, and the landlord had failed to keep the gas appliances in a safe condition under Reg. 36 of the Gas Safety (Installation & Use) Regulations 1998 and this failure had resulted in an unintentional death by carbon monoxide poisoning of a tenant of this property company).

 

APPENDIX 4

Numbers affected by CO+ – Impact on UK population in the UK

Written by CO-Gas Safety after studying the small, respected UK university studies.

Because of the lack of monitoring or testing for CO, it is virtually impossible to know how many people are affected in the UK by CO, let alone CO+ (i.e. CO and/or other products of combustion – see https://www.co-gassafety.co.uk/about-co/other-toxins/ ).

It is likely that well over 13 million people in the UK are affected by CO at over 50 parts per million, which is way above WHO guidelines (now approx. 4 PPM for 24 hours).

We summarise two of the university studies below:

1. Research by University College London

Research commissioned from University College London (UCL) and published in an HSE press release dated 02.10.2006 to inform its gas safety review, highlights the dangers of CO poisoning in people’s homes and a lack of public awareness of the risks. See https://www.co-gassafety.co.uk/information/press-release-2006-croxford-ben/

Early findings were:

• 23% of homes had 1 or more defective gas appliance
• 8% of homes were judged to be at risk of dangerous levels of CO
• 45% of homes had received no information on CO dangers, and
• A higher prevalence of problem appliances were in homes of vulnerable people – i.e. the young, old and those in receipt of benefits.

Note: The UK has 28.2 million households, with an average household size of 2.36. This equates to an estimated total of 66,552,000 people. For UK population stats see https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/families/bulletins/familiesandhouseholds/2022

8% of 66,552,000 = 5,324,160. This means that UCL estimated that over 5 million people were judged to be at risk of dangerous levels of CO.

UCL’s report

This report, authored by Dr Ben Croxford, found 50 of 270 homes (18%) had levels of CO exceeding WHO 8-hour average guidelines of 9 PPM.

Of this 50, 26 (9.4%) exceeded WHO 1-hour level (26 PPM) and 10 (3.6%) exceeded WHO 30-minute guideline value of 52 PPM.

In other words, nearly 1 in 5 homes exceeded WHO 8-hour average guideline CO values of 9 PPM, nearly 1 in 10 exceeded WHO 1-hour average guideline CO values of 26 PPM and 1 in 27 exceeded WHO 30-minute guideline CO values of 52 PPM.

2. Research by Liverpool John Moores University

Further research was undertaken by Liverpool John Moores University (LJMU) in 2011. The study involved visiting over 27,000 homes in Coventry and Liverpool (see https://www.ljmu.ac.uk/about-us/news/articles/2015/3/12/life-saving-research-into-carbon-monoxide ). The results of the study were published in an article entitled ‘Investigation of audible carbon monoxide alarm ownership : Case study’ in 2014 (see https://www.emeraldinsight.com/doi/full/10.1108/SASBE-07-2013-0041 . Note: when you click on this link, you will see a small button labelled ‘Permissions’, next to the article date. That takes you to an online form to get a quote for printed copies or permission to reuse).

CO-Gas Safety obtained a copy of the article some years ago due to the kind permission of Emerald Insight. However, the charity has tried for years to obtain and read the original research, and to receive an update on its continued findings.

As part of LJMU’s study in 2011, data loggers were used to measure CO levels in 109 homes in Liverpool over many weeks, which recorded:

· 24 homes with CO levels over 50 PPM – a level where symptoms of poisoning such as headaches, tiredness & drowsiness can be experienced.

· 53 homes with CO levels from 10 to 50 PPM

The following is quoted from the aforementioned article:

‘Stage two fitted 173 homes with Lascar EL-USB data loggers. There were 109 properties in Liverpool with 73 homes in deprived areas and 36 in non-deprived areas. In Coventry 64 homes were targeted but these homes had not had a HFSC (Home and Fire Safety Checks) conducted. 40 were in deprived areas and 24 from non-deprived areas. The monitoring period ran from November 2011 until the following spring.

Homes equipped in Liverpool had been through the HFSC (Home and Fire Safety Check) in stage 1. However, homes that received a data logger in Coventry had not been assessed by a HFSC.

Approximately 29 per cent in Liverpool and 39 per cent of properties in Coventry had readings less than 10 Parts Per Million (PPM). According to WHO guidelines (see more about these further on) residents could stay in the property for eight hours before beginning to feel the effects of CO poisoning. In total 48 and 42 per cent of homes monitored in stage 2 in Liverpool and Coventry respectively had CO readings between 11 and 49 PPM; WHO guidelines recommend that residents would have between 30 and 60 minutes before they begin feeling the effects of CO. Lastly 22 percent and 18 per cent had dangerous readings of over 50 PPM, which would result in the effects of CO poisoning to manifest within 15 minutes of being indoors.’

CO-Gas Safety comment
It seems helpful to average the percentages of Liverpool and Coventry.

We refer to ‘In total 48 and 42 per cent of homes monitored in stage 2 in Liverpool and Coventry respectively had CO readings between 11 and 49 PPM; WHO guidelines recommend residents would have from 30 to 60 minutes before feeling effects of CO.’

The average of 48% and 42% would therefore result in 45% of homes having CO readings from 11 to 49 PPM which, according to WHO guidelines, means residents would experience CO effects from 30 to 60 mins.

We refer to, ‘Lastly 22 percent and 18 per cent had dangerous readings of over 50 PPM, which would result in the effects of CO poisoning to manifest within 15 minutes of being indoors.’

The average of 22% and 18% would therefore result in 20% of homes having CO readings over 50 PPM, which means residents would feel CO effects within 15 minutes of being indoors.

Note: The UK has 28.2 million households, with an average household size of 2.36. This equates to an estimated total of 66,552,000 people. For UK population statistics see https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/families/bulletins/familiesandhouseholds/2022

45% of 66,552,000 equates to 30 million people in the UK exposed to CO from 11 to 49 PPM for 8 hours. 20% of 66,552,000 would equate to over 13 million people.

i.e. over 13 million people in the UK exposed to dangerous readings over 50 PPM, experiencing the effects of CO poisoning manifest within 15 mins.

In total this means over 43 million people in the UK could be exposed to CO in levels far greater than recommended by WHO and significant numbers, running into millions, will eventually suffer chronic ill health from this exposure.

3. Promised further funded research on 75,000 homes in 2015

The research above gave rise to huge concern but looked at relatively small numbers, so a larger study was important. The charity was delighted to read that this was planned. See https://www.ljmu.ac.uk/about-us/news/life-saving-research-into-carbon-monoxide , from which the following is quoted:

‘The Gas Safety Trust (GST) also awarded a grant to LJMU to expand the study from two city centres to five counties by partnering with five Fire and Rescue Services, Merseyside, Cornwall, Bedfordshire, West Midlands and Oxfordshire. The funding is also supported by an in-kind contribution from the Council for Gas Detection and Environmental Monitoring (CoGDEM) whose members have supplied CO alarms and data loggers to undertake a comprehensive CO investigation covering 75,000 households.’

That was years ago in 2015 – where is this research?

Stephanie Trotter brought this up at an APPCOG stakeholder meeting on 10.03.2020. The minutes reported that progress was being made but it was not yet ready for publication. Considering the serious implications of existing small studies, we continued to lobby for this study to be finished and to be published.

CO-Gas Safety has since been told this study was not undertaken due to fire service cut-backs.

We are deeply disturbed this did not seem to be revealed until we questioned and pursued it. We also consider, due to these avoidable delays and the difficulties we experienced, action should be taken now to remedy the continuing trauma suffered by people who continue to be poisoned and cannot prove poisoning.

We are therefore lobbying HSE, Ofgem and government to insist the original recommendation made by HSC/E in 2000 (that the gas emergency service should carry and use equipment to test gas appliances for CO) be implemented.

We are also lobbying for any CO found to be recorded and for the parts per million (PPM) of CO, where found, to be given in writing or digitally to those survivors, their medics and their families.

It seems from the research that high levels of CO are widespread in the UK. Symptoms of CO are similar to those of any virus, including Covid-19. Therefore, the charity considers it imperative that the gas emergency service should action testing of emissions of gas appliances for CO and for the air in the house or workplace as soon as possible, especially as we had hoped this would have been done years ago!

WHO Global Air Quality Guidelines update 22.09.2021

New Air Quality Guidelines were published by WHO in 2021, in response to what they referred to as ‘a much stronger body of evidence to show how air pollution affects different aspects of health at even lower concentrations than previously understood.’ The AQG level for CO is now reduced to 4mg/m ³ over 24 hours (this is approx. 3.5 PPM). See https://www.who.int/publications/i/item/9789240034433 to download the Executive Summary of the new guidelines (see levels on page 4).

History of WHO guidelines from 2010

WHO guidelines for indoor air quality: selected pollutants, 01.01.2010

https://www.who.int/publications/i/item/9789289002134 See page 70, from which the following is quoted:

‘Walker (130) states that the incidence of chronic carbon monoxide exposure in Great Britain is officially 200 per year, while at the same time “250 000 gas appliances are condemned annually”. He speculates that if only 10% of these appliances give off significant amounts of carbon monoxide that reach the breathing space of residents, as many as 25,000 people every year may be exposed to carbon monoxide in their homes. The carbon monoxide support study (89) found that “only one case out of 77 was correctly identified (i.e. diagnosed) on the basis of symptoms alone” and that medical professionals were the least likely group to “discover” the fact of the carbon monoxide poisoning.’

See also page 86, from which the following is quoted:

‘The 24-hour guideline

Chronic carbon monoxide exposure is different from acute exposure in several important respects, as noted above. Thus, a separate guideline is needed to address minimal exposure over 24 hours, rather than the 8-hour period used in the acute guidelines. The latest studies available to us in 2009, especially those epidemiological studies using very large databases and thus producing extremely high-resolution findings, suggest that the appropriate level for carbon monoxide in order to minimize health effects must be positioned below the 8-hour guideline of 10.5 mg/m³, possibly as low as 4.6–5.8 mg/m³. This is also essential since the minimal exposure time for this guideline is three times longer.’

For ref, 10.5 mg/m ³ equals just under 9 parts per million (PPM). 4.6 mg/m ³ is equal to approximately 4 PPM.

WHO guidelines for indoor air quality: household fuel combustion, 21.01.2014

https://www.who.int/publications/i/item/WHO-FWC-IHE-14-01 See page 12, which provides a table of mean concentrations over several time intervals. This was published in 2014 but refers to WHO 2010. For ref, 7mg/m ³ equals just 5.68 PPM

Pollutant	Mean concentration over averaging time
	10 min	15 min	30 min	1 hour	8 hours	24 hours	1 year
CO (mg/m3)	–	100		35	10	7	–

Note:

British Standards Institution BS 40102-1:2023 includes levels for ‘acceptable’ CO:-
15 min: 35 – 100 mg/m ³ versus WHO 100 mg/m ³
1 hour: 10 – 35 mg/m ³ versus WHO 35 mg/m ³
8 hour: 4 – 10 mg/m ³ versus WHO 10 mg/m ³
24 hour: 2.3 – 4 mg/m ³ versus WHO 4 mg/m ³

Conclusion

CO+Savi (group of victims and victim groups) suggests the following statement(s) be used instead of, or with, any existing numbers in presentations, press releases, publications, etc:

Short Version
“There is currently no conclusive and comprehensiveway of accurately establishing actual number of people harmed to whatever level by CO and other toxins (CO+ for short).

It is recognised there are many sources of data collated over the years. However, it is scientifically inconclusive at this point in time.

We know some people suffer temporary illness, irreversible chronic ill health or death as a consequence of exposure to low-level, chronic and high-level, acute CO+ poisoning – Unfortunately, we do not know how many more are affected and have no way of objectively and responsibly estimating true figures.”

There is also a long version, which has not been finalised yet. When finalised, we will put it on the CO-Gas Safety website.

This version has been so far agreed between Roland Wessling and CO-Gas Safety.

We hope others will also support this.

 

APPENDIX 5

Research by Dr Connolly at Liverpool John Moores University , 2019

Coping with Carbon Monoxide (CO) exposure: An Interpretative Phenomenological Analysis http://researchonline.ljmu.ac.uk/id/eprint/11785/

Stephanie Trotter of CO-Gas Safety attended a conference in Lille at which Dr Connolly gave a talk. Stephanie and Dr Connolly corresponded and have come up with the following for inclusion into a submission to Ofgem.

Dr Connolly has explored the lived experience of 11 participants who are coping with unintentional exposure to carbon monoxide (CO) using Interpretative Phenomenological Analysis (IPA). A useful definition of this method can be found at https://delvetool.com/blog/interpretive-phenomenological-analysis

However, this complex methodology seems to amount to exploring the lived experience of people who have been exposed to CO.

Background

There are about 60 deaths a year from preventable CO exposure in England and Wales, and those who survive exposure may be injured and have long lasting burdensome sequelae (effects). Most research is from healthcare professionals and not from the point of view of those who have experienced exposure and those who have been bereaved by exposure. People who don’t die or who are not rendered unconscious have a very difficult time and there’s so little out there about people who have a lower level exposure. Some of those exposed have told Dr Connolly that the fact that medics, and sometimes their own families, do not believe they have been exposed to carbon monoxide is even worse than the life-long injuries they’ve been left with.

The data was analysed using IPA, where four superordinate themes emerged: ‘traumatic experience’, ‘power justice and judgement’, ‘identity and connectedness’ and ‘everybody seems to be in the dark’.

About CO

WHO guidelines: The 24-hour guideline is obviously the most appropriate for people in the home. This is about 4 parts per million (PPM) of CO.

Participants fell into two broad groups – one group was affected by higher levels of CO over a short period and the other was affected by lower levels over a longer period. Of course, few survivors could ‘prove’ exposure to CO at all, despite having symptoms, sequelae, and/or clear environmental signs that CO exposure had occurred. Nor could they provide measurements in parts per million.

Healthcare professionals who suspect that someone has been exposed to CO often rely on an environmental history (clear information about, for example, a faulty appliance or a generator that has been used inappropriately) as well as looking at the condition of that person and taking a blood test to ascertain the levels of carboxyhaemoglobin. These blood tests need to be taken very quickly once the person is away from the source of the exposure, as levels of carboxyhaemoglobin dissipate rapidly.

Another important issue is that CO exposure symptoms can mimic the symptoms of many conditions, including viruses (such as Covid-19), and many healthcare professionals know very little about CO. They will test the blood (or breath) where CO exposure is suspected but they don’t seem to understand the significance of a false negative result in the light of the person’s environmental history and symptoms. Healthcare professionals may not be fully informed and that also applies to members of the public. Nor do healthcare professionals have any recourse to free CO alarms to EN 50291 to give to those who report symptoms similar to CO exposure. Therefore, the only safe step is to obtain a test on both the air in the property and the appliances powered by carbon-based fuels, plus a CO alarm to EN 50291. Such a test is currently almost impossible for an ordinary person to obtain.

‘In interviewing the 11 participants I observed the added distress caused to the participants by the lack of proof of their situation, which could be provided in the form of ambient air testing, or testing suspected appliances for CO. I find the lack of testing for CO, to which so many people may be exposed while cooking meals and heating their homes, is something which should be addressed as a matter of urgency. The lack of proof leads to an assumption that CO is rare, and this contributes to a lack of awareness, knowledge and understanding of this preventable danger.’

CO-Gas Safety comment

The algorithm for GPs (see https://www.gov.uk/government/publications/carbon-monoxide-co-algorithm-to-diagnose-poisoning ) makes it almost impossible for GPs to obtain a test of air and emissions from appliances for CO. We hope this will change very soon.

APPENDIX 6

Our work in Holland and in the EU Parliament and Commission

Work in Holland

Jonathan Kane of Kane International, who helps fund and advise CO-Gas Safety on industry issues, was also Chair of CoGDEM (the trade association of CO alarm manufacturers and manufacturers of analysers testing for CO). Kane made representations to the Dutch Safety Board (DSB) during and after their 2015 investigation and report on CO deaths. Kane highlighted the need to register installers and service technicians, as anyone could become a heating engineer without registration or passing exams.

Following publication, Kane visited the responsible ministry to ensure DSB recommendations were not accidentally neglected or reduced in their importance. As part of that, Kane wanted the ministry to meet Stephanie Trotter of CO-Gas Safety so they could see why it was so important. Kane and Trotter met an MP and a civil servant in 2016. Please see https://www.co-gassafety.co.uk/information/list-of-work-done/ at 508:

‘508. 19.09.16 Stephanie Trotter went to Amsterdam with Jonathan Kane and met Albert de Vries MP of the Dutch Labour party and also Peter van Veen, a civil servant of the Building Minister to urge the Dutch government to register gas engineers in the Netherlands.’

Following this, in December 2016 we heard very good news from Holland regarding, in effect, the mandatory registration of installers and a campaign to highlight the danger of carbon monoxide. This was reported: – http://www.nu.nl/gezondheid/4367965/overheid-scherpt-regels-cv-ketels-vanwege-koolmonoxide.html

Then we saw a media report dated 07.04.2023, which is unfortunately no longer available online. It seemed to state that the consumer can be fined if they do not used a registered installer who can test for CO, which is repeated by the Netherlands Enterprise Agency, RVO here: https://business.gov.nl/regulation/co-certificate-gas-appliances/

Work done at the EU Parliament and Commission

When Stephanie Trotter met Molly Maher in 1994, Maher had various contacts, including Euan Robson who was around this time a Scottish Member of Parliament. Robson had been the Scottish Manager of the Gas Consumers’ Council and had written a first draft of a directive relating to the installation and servicing of appliances burning gaseous fuels. This was a very comprehensive document.

The revised and final drafts were prepared by Robson to incorporate the comments of the members of SECO’s Gas Appliance Working Group following their meetings at COFACE, 17 Rue de Londres, Brussels on 13/11/1991 and 18/03/1992 respectively.

CO-Gas Safety still has a copy of this document.

Maher took Trotter to the European Parliament to lobby for this directive, also for improved safety for tourists in the EU.

 

CoGDEM EU

See http://www.cogdem.org.uk/

The following summary was kindly provided by Kevin Hamon, Senior Analyst at ADS Insight in Brussels. For further information about CoGDEM EU’s past, current and planned activities, please feel free to reach out to him (k.hamon@ads-insight.com).

‘CoGDEM is a British trade association assisting the industry in designing acceptable (British, European and International) codes and standards, and promoting the value of high-quality gas detection equipment and services. Representing over 50 companies, CoGDEM focuses on raising awareness of the dangers of carbon monoxide (CO), carrying out education campaigns, promoting gas safety and the use of CO alarms and portable flue gas analysers compliant with the tough safety standards EN 50291 and EN 50379 respectively. In addition, CoGDEM has now active CO ‘Working Groups’ in France, the Netherlands, Germany and the UK.

Over the past 15 years or so, the CoGDEM EU group, with support from EU Public Affairs consultancy ADS Insight, has been actively raising awareness on CO-related risks and promoting gas and CO safety solutions to prevent intoxications and fatalities. The group did that by organising 10 CO Roundtables, most of them in the European Parliament and with the political sponsorship of former MEPs Linda McAvan (S&D, UK), Marian Harkin (Renew Europe, Ireland) and other key EU policymakers, bringing together relevant EU and national civil servants, stakeholders/industry representatives, victims associations, standardisation bodies and the civil society to discuss and exchange best practices on issues such as national awareness raising campaigns, the safety of tourism accommodations, the health effects of CO poisonings, and the training, competences and certification of heating engineers / installers.

CoGDEM EU also carried out advocacy campaigns on relevant EU legislative proposals, and secured the inclusion of important CO and gas safety references/provisions on key EU laws – such as Regulation (EU) 2016/426 on appliances burning gaseous fuels (Gas Appliances Regulation, GAR) and Directive (EU) 2018/844 on the energy performance of buildings (EPBD) – which is currently being revised again, and on which CoGDEM EU is also currently lobbying for stronger gas/CO safety wording.

Furthermore, CoGDEM EU is continuously monitoring national and regional media in 9 European countries (the UK, Belgium, France, Germany, Poland, the Netherlands, Italy, Spain and Hungary), compiling invaluable data on gas- and co-related incidents (injuries and fatalities), and bringing these figures to the attention of EU and national lawmakers, as relevant.’

CO-Gas Safety comment
At some time, Trotter recalls being asked for the CO-Gas Safety data on deaths from unintentional CO by someone representing the EU. Trotter recalls that this fact-finding mission resulted in the conclusion that countries with gas safety regulations had more deaths from unintentional carbon monoxide poisoning than those countries without good regulation! CO-Gas Safety’s opinion was that without good gas and CO safety regulation, CO was not even suspected as a cause of death.

CO-Gas Safety continued to try to find groups similar to itself in the EU, without success.

Trotter met Frank Brehany through Maher at an Irwin Mitchell meeting. Brehany had worked a great deal in the EU on tourism and cabin air safety. He introduced Trotter to the precautionary principle https://eur-lex.europa.eu/EN/legal-content/glossary/precautionary-principle.html

CO-Gas Safety and Maher’s Consumer Safety International tried to work with Brenda Wall of Holiday Travel Watch and also Holiday Which and Which.

After Brenda died, Frank Brehany took over Holiday Travel Watch.

From about 2008, Trotter related with Linda McAvan, MEP. See https://www.co-gassafety.co.uk/information/list-of-work-done/ 104, 141, 351, 473 and 495.

In June 2009 Trotter was contacted about data for a project Golder Associates were undertaking on behalf of the European Commission. The work was centred around incidents involving tourists at particular accommodation facilities. CO-Gas Safety tried to help but was interested in safety extending to all, not just tourists.

A meeting was organised in Brussels in November 2009 by Linda McAvan MEP about the need for a European Directive on gas, fire and hygiene in tourist accommodation. Attended by Stephanie Trotter and Molly Maher, they lobbied that this directive not be restricted to tourist accommodation. Many useful contacts were made.

Stephanie Trotter met with Frank Brehany in February 2013 to discuss CO-Gas Safety applying for EU funding. The problem was that we needed members from other EU countries and there seemed to be no other similar organisations to CO-Gas Safety. CO-Gas Safety wrote to BEUC in 2013 (consumers@beuc.eu) without success.

In 2014 Trotter was sent some data from the EU on deaths from carbon monoxide with nothing recorded for the UK. She later learned from correspondence from Matthias Brauback (mbr@ecehbonn,euro.who.int, Technical Officer Housing/Urban Planning from the WHO European Centre for Environment and Health, Bonn Office) that only official data from governments can be recorded, not data from NGOs.

In November 2014 CO-Gas Safety responded to an EU consultation about the safety of tourism accommodation, mainly focussing on fire and CO risks. The charity supported the submission by Holiday Travel Watch and also suggested that children’s activity holiday centres should be licensed throughout the EU, as they are in England and Wales.

In 2015 CO-Gas Safety wrote a petition to the European Parliament to ask for changes to reduce deaths and injuries from unintentional poisoning from carbon monoxide (CO) and other products of combustion (CO+). This is copied at the end of this appendix. Notes have been added about the progress of the petition.

CO-Gas Safety tried over many years to contact ANEC (the non-profit, non-governmental organisation that represents the consumer interest in European standards, funded by the European Commission, see https://www.anec.eu/ ). Trotter did meet Stephen Russell at a CoGDEM roundtable event in the EU, hosted by Linda McAvan MEP. CO-Gas Safety received a response on 31/05/2015 and responded on the 20/06/2015 and again on the 31/07/2015. We made the point that all our ideas come from victims and our data, and attached a note showing this. We asked to be included in any work ANEC did with regard to CO.

In November 2015 Stephanie Trotter attended an ABTA meeting held by Linda McAvan MEP in Brussels.

In June 2016 Stephanie attended a CO roundtable event in Brussels organised by CoGDEM and co-hosted by Linda McAvan MEP and Marian Harkin MEP (from Ireland). At this she saw an excellent film warning about carbon monoxide made with funding from the Regulator in Northern Ireland. On 4th June, she wrote to Ofgem asking for a meeting to do the same in England and Wales.

In March 2020 Stephanie Trotter attended a conference about CO in Lille organised by CoGDEM, APRIM (Association Française Professionnelle contre les Risques d’Intoxication au Monoxyde de carbone), ICORN (International CO Research Network), the Gas Safety Trust and CHRU Lille (Lille University Hospital). This was an excellent conference. Many attendees were invited to give talks, including many UK representatives such as Jonathan Kane, Isabella Myers and Hilary Wareing. There were also some survivors of CO in France; their flatmate and the flatmate’s girlfriend had tragically died in the shower from CO. Stephanie Trotter made herself known to these students and exchanged contact details but sadly despite many attempts no responses were received.

Sue Westwood (CO-Gas Safety Director/Trustee and also survivor) would have loved to have attended too but sadly she was too unwell to do so.

Petition to the European Parliament to ask for changes to reduce deaths and injuries from unintentional poisoning from carbon monoxide (CO) and other products of combustion (CO+)

Carbon monoxide (CO) is a deadly gas which can be emitted by faulty cooking and heating appliances powered by any carbon based fuel that burns.

Less than 2% of CO can kill in between one and three minutes (see Para 74 table 23 page 26 http://www.hse.gov.uk/foi/internalops/hid_circs/technical_osd/spc_tech_osd_30/spctecosd30.pdf )

CO cannot be sensed using human senses.

Medics rarely diagnose CO poisoning and it is difficult to diagnose partly because CO mimics viruses and food poisoning and also because different members of the same family can suffer different symptoms.

1. Deaths in the UK are estimated as 50 deaths and 4,000 visits to A & E

https://www.gov.uk/government/news/carbon-monoxide-poisoning-sends-4-000-people-to-a-e-each-year

This estimate was later revised to 40 deaths http://www.nhs.uk/Conditions/Carbon-monoxide-poisoning/Pages/Introduction.aspx

The impact on the population is vast.

The cost is of great concern. Even by Department of Health estimates on England & Wales the cost to the taxpayer is £178 million a year, according to Baroness Finlay co-chair of the All Party Parliamentary Carbon Monoxide Group. CO is therefore a matter of public importance.

CO-Gas Safety has undertaken data collection, collation and publication since 1995 see https://www.co-gassafety.co.uk/data/ and

CO-Gas Safety data:-

1. Has been collected, collated and published since 1995.
2. Collects CO incidents and deaths from ALL Fuels.
3. Has some kind of report, authority (e.g. Solid Fuel Association) or Coroner’s letter to support every entry on our database with regard to the acute deaths from CO.
4. Tries to check every death with the Coroner concerned and most now help (although Scotland lacks a Coronial system).
5. Publishes the names of the dead on the Internet as a memorial so anyone can check.
6. Is the only data to have been validated twice by an independent statistician, Dr Craggs (most recently in summer 2014).
7. Has had over 19 years of input from a victim based organisation that simply seeks the truth. (Note now 20 years).
8. Has a form on our website for the Coroner to fill up after the inquest and which we encourage them to look at before the inquest in order to think about what evidence to call at the inquest (e.g. was there a CO alarm and was it to EN 50291, was it in date and did it work?).

No other UK body does all this.

However, in the opinion of CO-Gas Safety with its 20 years (now 21) of experience, there are many more CO related deaths, injuries and chronic ill health that are not even suspected to be connected to CO. Please note that there are 3,500 unexplained deaths in the UK every year between the ages of 16 and 64, (New Scientist December 2004), and even these are not automatically tested for CO.

2. The UK requires compulsory registration and 5 yearly competency testing of gas appliance installers and maintenance technicians performing work for consumers.

UK Gas Distribution Companies are also obliged to provide a guaranteed 1 hour “Emergency Service Response” to consumer reports of fumes or gas leaks (not CO) but this is not the case in all EU countries.

3.There is a further risk from other products of combustion which we call CO+ (see https://www.co-gassafety.co.uk/about-co/other-toxins/

It is worth noting that while smoking is considered a risk with regard to many diseases (e.g. lung cancer), indoor air pollution from the products of combustion is usually not even considered. Yet the impact from the other products of combustion, especially with regard to indoor air where pollutants are likely to be much more concentrated, is likely to be huge.

4. From talking to victims and their families we quickly came to the conclusion that raising awareness of the dangers of CO and how to avoid being poisoned are the most important issues.

5. From our work with victims and families we also came to the conclusion that a free or reasonably priced test of the emissions from appliances and also indoor air for CO (and ideally CO+) are also very important.

6. At least six people died from carbon monoxide being emitted from a Beko cooker that had a grill door that could be shut. There needs to be a Government backed recall system. Barry Mulcahy set up a website called Total Recall in 2010 but had to stop this in 2014 due to lack of support and funding.

7. From our work we now appreciate that by talking to victims and families, as well as studying individual tragedies and how the fuel industry works, we learn a huge amount of detail about what went wrong and how to prevent future unnecessary deaths and injuries. Deaths and injuries often result in family collapse, loss of work and the need to be cared for, which is not only tragic but is also a drain on the resources of the state.

We petition the EU to consider taking the following action:-

1. To persuade or require EU governments to put out a sustained programme of education and prime time TV public health warnings about the dangers of emission from all fuels, (gas to wood) all appliances (boilers to barbecues) and in all types of accommodation (from bungalows to boats).

   Such warnings should also inform people how to prevent unintentional poisoning by CO+ by using qualified people to install and regularly maintain appliances according to manufacturers’ instructions, to regularly sweep and check chimney and flues, to ensure adequate ventilation and as an extra safeguard, to install a CO alarm to EN 50291.

   Funding for this is lacking but could be provided by the EU or by a levy on the wealthy fuel suppliers.

   A levy on the gas suppliers to raise awareness and for research was recommended by the Health & Safety Commission (now Executive) in 2000 (after an exhaustive gas safety review and with the support of the majority of the stakeholders) but never implemented, in our opinion due to lobbying by the wealthy gas suppliers.

2. To require EU governments to ensure appliance installers and maintenance technicians are well trained and regularly tested to demonstrate their up to date competence and have their competencies publicly available in order to install, maintain and test appliances.

   Such engineers should also be tested on their competence and be required to use EN50379 compliant flue gas analysers to test appliances after installation or maintenance and to test indoor air for CO using EN50543 compliant equipment to ensure sources of CO are found and isolated.

3. To require warnings about CO+ to be clearly marked on fuel (such as bags of charcoal for barbecues) and appliances powered by carbon based fuels.

4. To require CO alarms to EN 50291 to be installed in all property.

5. To set up an EU wide organisation providing services and a website for recalls of dangerous products, ideally supported by funding for prime time TV warnings about them.

6. To require EU governments to provide at least one organisation in each EU country to provide free help and support to victims and their families and ideally free or affordable tests of appliances and indoor air for CO as well as undertake the work of collecting, collating and publishing the deaths and injuries from unintentional CO poisoning.

   From this work the organisations should suggest improvements to governments and to the EU that could be made to reduce these unnecessary tragedies.

© Copyright CO-Gas Safety 2015
Some references updated for the 2016 press pack.

 

Updates on progress of the 2015 petition

Stephanie Trotter received a letter dated 20.11.2015 from the Chair of the Committee on Petitions stating that our petition is admissible. The committee has decided to ask the European Commission to conduct a preliminary investigation of the various aspects of the problem and will continue its examination of our petition as soon as it is in receipt of the necessary information.

Trotter responded to thank the Chair and included the link to the Dutch Safety Board report (https://www.onderzoeksraad.nl/nl/page/3458/koolmonoxide) and film (https://www.youtube.com/watch?v=EgL74t_COV0).

Trotter also referred the Committee to Linda McAvan MEP, who has a special interest in CO and had in November held an event in Brussels about holiday safety which Trotter attended, attached our leaflet about CO and referred to the lack of publicity about the dangers of CO.

Trotter also explained the Catch 22 situation – that to prove CO, you have to prove CO and the difficulty in finding someone qualified under CMDDA1.

On 18 ^th April 2016 Trotter received a letter stating that the petition has now been given a number: 0016/2015.

Frank Brehany, solicitor and consumer champion who ran Holiday Travel Watch for some years, has (17.04.2023) kindly added a commentary on work done in the EU. The case he refers to is the tragic deaths in 2006 of Bobby and Christi Shepherd, aged 6 and 7 respectively, while on holiday in Corfu. They were killed by unintentional CO poisoning from a gas boiler in an outhouse adjacent to their room:

‘I remember most of those meetings in Brussels on touristic safety, mostly organised in response to the Corfu case.

The following commentary is just background.

One of the aspects of the Corfu case was the concern amongst travel companies that the then Package Travel Directive made them the principal source from which a claimant could claim from. They argued that third parties should also be subjected to the provisions of the new directive that was being drafted at the time (this was a big issue in the Corfu case and indeed to the whole debate on CO and other safety). However, in the various stakeholder’s meetings/impact studies etc (which I was heavily involved in), the EU Commission agreed that the travel company should remain the principal focus in any holiday contract with regard to the performance of the holiday contract and any failures (this included safety in a holiday property). However, at preamble 36, the EU Commission acknowledged the role of 3rd parties and included the following statement:

“The organiser’s liability should be without prejudice to the right to seek redress from third parties, including service providers”.

This was confirmed by Article 22.

It was not an ideal solution to the issues of CO or other safety issues, such as swimming pool incidents etc, but it assuaged an industry stung by the Corfu case, raised the debate on safety in holidays (with the Corfu case very fresh in the mind), and potentially would help claimants because they would only have one party to claim from, the responsibility being formally passed to the travel company. This did not however deal with the basics, that there was a need for a directive to deal with safety in holiday properties and as you know, there were multiple debates, discussions, and proposals.

I seem to recall that through Linda McAvan’s work, a directive was advanced, but it came at a time where the effects of the financial crisis was still biting and this was coupled by many countries from the Mediterranean rim objecting to the proposals.

This is the link to the Directive (https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32015L2302&from=EN).

You may also recall that I did propose an initiative which was later presented when we met Thomas Cook, but since I left Holiday Travel Watch, I do not have access to those papers/documentation. For what it’s worth, I do believe that the EU Commission will return to the theme of holiday safety (CO etc), because there is a very interesting directive proposal on short-term rental holiday properties. The impact study outcome reveals a real desire to collect data on many regulatory issues, including compliance on health & safety issues (failure to demonstrate compliance would bring sanctions) – this is akin to my initiative and if followed through, I can foresee that it will be eventually incorporated into the Package Travel Directive as part of the Digital & Consumer Agendas/Workplan of the EU.

Hope my comments and background information helps.’

http://www.frankbrehany.com/