CO: the killer isn’t always only the gas

IT IS estimated that there are 22 million gas users within the UK and it is essential that appliances are installed and maintained correctly.

The current Gas Safety (Installation & Use) Regulations require gas engineers who work on gas to be competent.

Similar competencies are required of the solid fuel and oil industries.

 

The HSE, in its approved code of practice (ACoP), states: “Competence in gas installation requires enough knowledge, practical skill and experience to carry out the job in hand safely, with due regard to good working practice. The installation should also be left in a safe condition for use.

Knowledge must be kept up to date with changes in law, technology and safe working practice.”

The following case studies involved me as a carbon monoxide incident investigator and resulting expert witness in the crown court cases. The first case was for the Dyfed Powys Police Authority and the second for the Health & Safety Executive.

Case study one: manslaughter gross negligence times two

The case involved a selfemployed gas engineer, 62 years of age, who spent all his working life employed in the gas installation and servicing industry. A call to attend to a warm air unit resulted in the appliance being serviced during the end of November/beginning of December 2006. On 17 December 2006 the two occupiers of the property were found deceased, sitting on the sofa in the lounge. The investigation during December 2006 and January 2007 found the appliance discharging very high levels of CO into the property: a failure of the combustion process and blocked flue ways.

The prosecution proved that the work carried out to the warm-air unit amounted to gross negligence, being so far below the required standard of maintenance and repair that the competence level never met the minimum standard. It was also proved and admitted that the gas engineer failed in his duty to comply with the Health & Safety at Work Act 1974 – ‘duty of care’ – and the Gas Safety (Installation and Use) Regulations, by not keeping up to date with the knowledge and practical skill required of him and not being assessed in the category of warm air heaters.

The result was a threeyear custodial sentence for each case, to run consecutively.

Case study two: manslaughter gross negligence

I received a call on Good Friday 2005 to assist the police and Health & Safety Executive in the unexplained death of a 14-year-old girl from suspected carbon monoxide poisoning. No carboxyhaemoglobin (COHb) results had been received from the hospital. Generally the COHb levels are an indication of how much CO the casualty has been exposed to and is reported in percentage terms.

I attended site the following morning and carried out a full carbon monoxide simulation investigation on a flueless gas fire; the investigation was extended to removing the appliance and carrying out further forensic testing procedures.

The installation of the fire was found to have been carried out correctly, but the commissioning had not been done in accordance of the manufacturer’s installation instructions, resulting in the introduction of CO into the lounge and bedroom areas. The post mortem results were conclusive, with some 63% COHb in the blood.

The judge, in his summingup, stated to the defendant:

“You never caused the fault; you simply failed to find it,” referring to the fact that the defendant did not have the competence assessment in the installation, servicing and maintenance of gas fires and owed a duty of care to his client, the mother of the girl. A proven case of manslaughter gross negligence resulted in a twoyear custodial sentence.