(APG0029)
Written evidence submitted by the CO-Gas Safety, The Carbon Monoxide & Gas Safety Society
Terms of Reference
CO-Gas Safety experience of All Party Groups, is largely confined to the All Party Parliamentary Gas Safety Group, now named the All Party Parliamentary Carbon Monoxide Group (APPCOG). The charity considers it’s experience has provided material for comment on the following:-
Summary of submission
The charity, CO-Gas Safety, thanks the Committee on Standards for this opportunity and has the following suggestions to improve All Party Groups.
A proper grievance procedure should be published and followed.
It would be helpful if an independent overseeing body could be created and put on all the All Party websites. Hopefully, any suggestion or complaint could be resolved informally. A possible sanction could be either making any transgression public or revoking, in effect, a licence to be an All Party Group.
It may be that our recommendations are too radical and would make the APGs too similar to Select Committees. However, with regard to APPCOG in our opinion, the difficulty with guidelines is that there is a lack of equality of arms between survivors, families and the vast wealth and influence of the fuel industry.
Note It was by chance CO-Gas Safety learned of this inquiry, yet this charity is a stakeholder in the stakeholder forum advising the All Party Parliamentary Carbon Monoxide Group.
It would be helpful if the All Party Groups were required to alert all stakeholders to this inquiry ideally by email to those companies and individual who are stakeholders or on the All Party’s mailing list as well as in any general newsletters etc.
There is the concept of justice not only being done but being seen to be done.
Our experience is that industry has too much influence on the Government generally.
David Cameron, MP, when seeking election, assured anyone who would listen that he would reform the “far-too-cosy relationship between politics, government, business and money”.
Separately, Frank Brehany & Jonathan Kane submitted separate papers which CO-Gas Safety support. Frank has collaborated with CO-Gas Safety on matters of mutual interest for over twenty years. Jonathan Kane is on the board of reference of CO-Gas Safety and Kane International is a private company that makes flue gas analysers and has supported CO-Gas Safety for many years as a donor & a supporter. Both Frank and Jonathan have attended many APPCOG meetings along with Stephanie and other directors of CO-Gas Safety. Frank & Jonathan have both read and support this submission as we support theirs.
The Terms of Reference
It is obviously valuable for All Party Groups to listen to people outside Parliament whether they are business or ordinary people or those particularly affected by the issue that has led to the creation of the All Party Group. For example, with APPCOG, those who have lost loved ones to CO or who have survived CO and those bodies or people who represent them, as well as the fuel industry.
The problem is how to balance the interests of small charities, ordinary people, survivors and families with those of industry - because there is an obvious conflict and a vast difference in their powers and resources. Industry attendees are paid to attend APPCOG events; survivors cannot due to illness or funding.
The charity will now explain the dangers of carbon monoxide as well as provide some examples of its work with APPCOG, to provide context to CO-Gas Safety’s suggestions.
About the charity – summary
CO-Gas Safety is a victim based, independent, registered charity that works to prevent deaths and injuries from unintentional carbon monoxide (CO) poisoning and other gas dangers.
CO-Gas Safety was launched at the House of Commons on 25th January 1995.
The charity also collects, collates & publishes data of deaths & injuries from CO from all fuels since 01.09.1995 and ongoing and seems to be the only body to do this.
CO-Gas Safety seems to be the only body to offer free, confidential and specific advice and support to victims/survivors & their families.
All CO-Gas Safety’s ideas to change law and practice have come from data, Coroners, survivors & families.
About Carbon Monoxide (CO)
CO is a deadly gas that can be emitted from faulty cooking or heating appliances or any appliance (boiler, fire, cooker, generator, gas lamp, barbecue etc.) powered by any carbon based fuel (gas, coal, oil, wood, petrol, diesel etc.) that burns.
CO is produced as a product of combustion when insufficient oxygen is available during combustion to produce CO2.
CO cannot be sensed by any of the human senses of smell, taste, sight, touch or hearing.
Less than 2% of CO in the air can kill in between one and three minutes. about:blank http://www.hse.gov.uk/foi/internalops/hid_circs/technical_osd/spc_tech_osd_30/spctecosd30.pdf see Para 74 table 23 page 26.
Fire fighters, talking about CO in smoke, which you can smell, say it takes only three breaths; the first breath you don’t think there is anything wrong, at the second breath you suspect there is something wrong but by the third breath you are incapable of taking any action.
Known deaths and injuries cost taxpayers £178 million a year* and CO-Gas Safety is sure from nearly 26 years of experience of talking to survivors/victims, families and gas engineers, that these are the tip of an iceberg. *https://www.publications.parliament.uk/pa/cm201314/cmselect/cmcomloc/50/50iii132.htm
Prevention
CO-Gas Safety’s data and over 25 years of experience have given the charity all its ideas about how to prevent deaths and injuries from unintentional CO:
To summarise, prevention from death or injury from CO isn’t rocket science but depends on consumer knowledge, proper training of engineers and sweeps, ensuring ventilation and installing a CO alarm independently tested to EN 50291 bought from a recognised supplier.
Consumer knowledge must be backed up by a diligent and decent system.
Awareness would be increased by testing gas appliances for CO and publishing the results. If CO is/has been present it is surely obvious to ensure safety that the source of the CO should be found and the amount of CO in parts per million measured and provided to those who have been exposed to it in writing or digitally and their medics.
More about the charity’s history, objectives, work achievements and funding.
Stephanie Trotter, OBE has written this submission, approved by directors from the work group. She has run the charity since its launch in 1995 helped by voluntary directors/trustees, mainly survivors/victims with some MPs (now sadly only one Conservative MP – the charity is looking for a Labour & Lib Dem MP) and one industry member (now retired from industry).
Background about Stephanie Trotter, OBE who runs the charity with the help of other voluntary directors, mainly survivors.
Stephanie’s CV can be found on https://www.co-gassafety.co.uk/. She is a barrister, not practising at the moment. Stephanie became concerned about safety issues after her son, Alex was injured at a children’s activity centre in 1991 when aged 12, which resulted in a clot on the brain. After the canoe tragedy, (four teenagers drowned in Lyme Bay in 1993) Stephanie wrote a legal article advocating licensing of these centres. Ultimately thanks to the MP for the canoe parents’ private members’ bill, David Jamieson, the law was changed by the Activity Centres (Young Persons’ Safety) Act 1995 and licensing for children’s activity centres introduced. This Act didn’t cover scouts/guides or university students but protected many young people. This campaign took less than three years.
As part of her campaigning for children’s activity centres to be licensed Stephanie met the now late Molly Maher, whose son Gary had died of CO poisoning in Tenerife and whose daughter, Sheree was severely injured in the same incident in 1985. Molly had set up a charity Consumer Safety International (CSI) which campaigned for safer holidays (CO, balconies, pools etc.). Molly helped Stephanie with her campaign; Stephanie helped Molly with CSI. Molly set up a separate charity to look exclusively at CO and other gas dangers in the UK, Stephanie agreed to run it and CO-Gas Safety launched at the House of Commons on the 25th January 1995.
Stephanie has written many legal articles published in the New Law Journal on corporate manslaughter, damages for personal injuries and on carbon monoxide poisoning.
Stephanie has written a submission to the DWP Select Committee on the HSE in 2004 which can be found on:
https://publications.parliament.uk/pa/cm200304/cmselect/cmworpen/456/456iii.pdf She has also made submissions to the HSE, given evidence to APGSG and also made submissions to APGSG/APPCOG.
Stephanie and CO-Gas Safety received a CORGI Gas Safety award in 2005.
In 2007 Stephanie received an OBE for her work on gas safety.
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. CO-Gas Safety, proactively contacted the parents to suggest a gas expert, the now late Harry Rogers to go out to Corfu to investigate and write a report at the parents’ expense as sadly CO-Gas Safety lacked the funds to pay for this. Without Harry’s report the true facts would not have seen the light of day. Stephanie also recommended a barrister for the parents at the inquest, Leslie Thomas, now QC. The verdict was unlawful killing due to a breach of Thomas Cook’s duty of care.
In 2017 the charity and retired British Gas investigator and trainer, Roland Johns won H & V News, ‘Safety Initiative of the Year’ with regard to a training course for engineers.
Stephanie operates a helpline for survivors/victims and their families and has done so since 1995 and ongoing. This seems to be the only specific help and advice for victims/survivors.
This is largely confined to providing advice and gas experts. As it is almost impossible for a survivor to prove exposure to CO, it is rare for the charity to recommend lawyers. Neither Stephanie nor anyone connected to the charity, nor the charity receive payments for such help or recommendations.
Stephanie also started collecting, collating and publishing data of deaths and injuries from unintentional CO from 01.09.1995 to the present day and ongoing. The purpose was and is to find common denominators to prevent future deaths and injuries. The charity considers that many deaths and injuries from CO are not recorded as CO because, for example, there is no automatic test on death for CO and it is almost impossible for a survivor to obtain a test on the appliances for CO.
The charity also collects and publishes (with permission) case studies https://www.co-gassafety.co.uk/case-studies/
The charity also lobbies industry and government for changes to reduce deaths & injuries and/or help victims/survivors.
CO-Gas Safety has talked to innumerable people over the years. Survivors, victims and
families are a valuable research resource but are sadly largely ignored by industry and
government.
The issues
When CO-Gas Safety started in 1995 it found that basically only families and survivors would talk to the charity.
Three basic problems:-
25 years on:
There is no automatic test for CO on dead bodies although co-chair Baroness Finlay recommended this in 2011 and the test could be done relatively easily due to technology and because CO stays in a dead body, which can be tested a long time after death.
The gas emergency service does not test gas appliances for CO, which you can’t sense using human senses but only tests for natural gas leaks which can be smelt (due to an additive).
The gas emergency service does not use equipment to test emissions from gas appliances for products of combustion, including CO, even though the gas emergency personnel are equipped with Personal Alarm Monitors for CO (PAM) or equivalent.
However, consumers calling the gas emergency service 0800 111 999 are told to turn everything off, open windows & doors and get out. Therefore, by the time of arrival, CO has usually disappeared.
If the Gas emergency service suspect CO from talking to the occupiers, they will turn the gas off and leave.
However, the occupier may have been brain damaged from CO, yet appear fit and left to handle a dangerous situation. The occupier may or may not be encouraged to seek medical help. The effects of CO can become worse with time, namely days or weeks.
The occupier or landlord is encouraged to find a Registered Gas Engineer (RGE) to service the appliances. In the charity’s experience of over 25 years, most medics fail to test blood or breath for CO and, even if done, usually fail to do this in time, because once a survivor is in fresh air or given oxygen, CO quickly leaves the blood or breath of a survivor.
Therefore, even when survivors are tested, often the result is a dangerous false negative.
That’s why it’s essential and reliable to test appliances and air survivors were exposed to.
If a person exposed to CO obtains the services of a Registered Gas Engineer (RGE) to service a gas appliance, that servicing destroys any evidence of CO - a Catch 22 situation: that to prove CO, you have to prove CO.
The article can be found on the following website:
https://www.co-gassafety.co.uk/wp-content/uploads/2021/01/profession_co_hidden-dangers_stephanie-trotter-obe.pdf
Evidence of CO needed to convince medics
Evidence of CO is needed to persuade medics to take poisoning seriously. Please watch CO-Gas Safety’s one minute film http://www.co-gassafety.co.uk/one-survivors-story/ about Sue whose doctors assumed she was taking cocaine, not poisoned by CO.
We also have other case studies to show this - see https://www.co-gassafety.co.uk/case-studies/non-fatal/ Gill Wing and Rebecca Scarlett.
Proof of CO
If a person wishes to prove CO, they can instruct a RGE, qualified under CMDDA1, to test a gas appliance, provided:-
Therefore this is rarely undertaken.
Even this is usually not good enough for a court case because an independent court expert witness would need to investigate and test, for a typical cost of £3,000.
However, an RGE qualified under CMDDA1 would probably be good enough for a medic to treat a person correctly.
Lack of victim support
There is still no victim support other than what CO-Gas Safety, a tiny charity (with no guaranteed funding and almost entirely run by volunteers), provides.
Otherwise Stephanie Trotter tries to ensure she is available to answer her mobile 07803 088688 seven days a week, 365 days a year but Stephanie is well past retirement age.
CO-Gas Safety’s funding
The charity was funded for many years by the DoH’s S. 64 grants programme and for three years Centrica matched that grant, but austerity seemed to end these DoH grants.
CO-Gas Safety kept going somehow; it received £50,000 from Thomas Cook (see p. 5). However, it costs around £25,000 per year to run CO-Gas Safety.
Kane International, a private company making portable flue gas analysers used by RGEs, also funds CO-Gas Safety. There is no conflict of interest with Kane because CO-Gas Safety has always been in favour of raising awareness and testing for the source of any CO.
The charity pays one person, hourly very part time to prepare CO-Gas Safety’s database & case studies and helps from time to time with press packs etc.
The All Party Parliamentary Group on Carbon Monoxide – APPCOG
Background to CO-Gas Safety’s involvement with APGs
The charity is most familiar with this All Party Group. Stephanie Trotter has also, along with Frank Brehany, given evidence to the All Party Group on Deaths Abroad.
The charity has worked since 1995 to lobby for changes to reduce deaths and injuries from unintentional CO. A list of work done since can be found at https://www.co-gassafety.co.uk/information/list-of-work-done/ The charity started keeping a more detailed list of work done since about 2000.
APPCOG was the All Party Parliamentary Gas Safety Group but changed its name in 2012 to reflect that CO could be emitted by any carbon based fuel, not just gas. CO-Gas Safety supported this thinking but expressed the view other products of combustion are also present in emissions from cooking and heating appliances, not just CO.
These other products of combustion include tiny amounts of metal and aromatic hydrocarbons, which the charity and Roland Wessling of Cranfield university collectively called ‘CO+’. Please see https://www.co-gassafety.co.uk/about-co/other-toxins/
The charity wanted recognition of these other toxins due to injuries they can cause, especially over time.
The charity was also concerned that death from explosions of gas and, eventually, the risks of hydrogen, would otherwise not be within this All Party Group’s remit.
In 1999 the charity probably first contacted the All Party Gas Safety Group because Fraser Kemp MP, the charity thinks was a co-chair of APGSG and he had had several deaths in his constituency from CO.
One was the tragic death of Anne Brennan, who died of CO aged 19 in 1999. Anne was hoping to become an MP. CO-Gas Safety gave her family support and urged them to employ a lawyer for the inquest, for which the charity was thanked by Mrs Brennan at the inquest.
Mr and Mrs Brennan have been helpful ever since and, with their permission, the charity recently published Anne’s case study in CO-Gas Safety’s 25th anniversary press pack 2020 and website https://www.co-gassafety.co.uk/case-studies/fatal/
Fraser Kemp MP tabled a private member’s bill in 1999 https://hansard.parliament.uk/commons/1999-02-23/debates/e5b7c51a-72f4-4ac2-9b7a-ab7eeaed0195/FuelSafety
‘The Bill is in three sections. The first would provide, initially, for the installation of carbon monoxide detectors in houses in multiple occupation. The second part would place a duty on the Government to raise public and professional awareness of the dangers, and the third would make new provision for the maintenance of heating equipment and introduce tougher penalties for those who abuse it.’
The charity fully supported Fraser Kemp MP’s bill but sadly Government failed to support the bill.
In 2000 the charity persuaded victims, survivors and family and others interested, particularly a chimney expert Jim Kinnibrugh, who is still active, to make presentations to officials from the HSE which was undertaking a fundamental review into gas safety.
The charity did this and made a big impression. Stephanie could send a booklet including these presentations if requested. The directors/trustees considered officials were very moved by the presentations by victims and survivors etc. and in the charity’s opinion, as a result, recommendations were made in August 2000 by the HSC/E:-
This would obviously help a survivor to find out if there had been an emission of CO, the source of the CO as well as the parts per million of CO the person had been exposed to. If this was provided to the survivor/victim and their medics in writing or digitally, CO-Gas Safety considers that the correct medical treatment would be provided. Proof of CO would also assist with raising awareness and prevention.
Stephanie has the original HSC/E document, ‘Proposals for change’ and could send if requested.
The charity has tried to find numerous other ways of improving gas safety and of course technology is improving all the time. However, sadly the charity has concluded that research, awareness and testing are still absolutely vital.
Sadly, these excellent recommendations were not implemented. CO-Gas Safety heard that the Chair of HSC/E Bill Callaghan had a breakfast meeting with the gas suppliers in 2003 and was persuaded recommendations would be brought in voluntarily. The charity was not invited to this meeting nor, as far as is known, were any other victim groups or charities.
Deaths have appeared to have greatly reduced since 1995. However, as there is no automatic test on dead bodies it is difficult to be sure of this.
Although some progress is being made on raising awareness, so far there is little progress on testing and it is still the case many people do not know what CO is, nor how to prevent it.
It is also the case many people exposed to CO and possibly brain damaged either do not even know they’ve been poisoned by CO or cannot prove their exposure to medics or members of their own family. Some are told they are suffering from an overdose or imagination, causing even more distress to people already suffering neurological injury. Some survivors have been offered inappropriate operations or treatments.
Several survivors have told the charity that the fact that they are not believed is even worse than the injuries they live with.
In 2006 Barry Sheerman MP, co-chair of APPCOG, started an inquiry which he likened to a Select Committee, asking many to give evidence including Stephanie Trotter. He seemed keen to shame the industry into action, but no action was forthcoming. Perhaps he was unable to achieve the action he sought. Please find attached evidence submitted.
Baroness Finlay undertook inquiries and made some very good recommendations in 2011. Sadly again, despite her recommendations, little action followed. Again, perhaps she was unable to achieve the action the charity sought, and that HSC/E had recommended in 2000.
In 2012 Baroness Finlay asked all victims and victim groups to get together to decide what needed to be done. All agreed. The sub-group named itself ‘CO+SAVI’, a name suggested by John Arnold who was Policy Connect’s APPCOG manager at the time (see below) and agreed by everyone in the group.
CO+SAVI did agree what was most wanted (see attached) and this was put this forward for inclusion in the Energy Bill 2013. However, these suggestions were barely discussed by the stakeholder group, the All Fuels Action Forum, almost entirely industry.
The charity has attended numerous meetings organised by APPCOG over the years which help raise awareness amongst MPs and industry members. This work needs doing and APPCOG has been successful amongst the industry and MPs. However, surely the most important people to hear about CO and how to prevent it are members of the public? A levy for publicity and research would have achieved much more and faster. The charity’s impression is the group seems serious and represents itself as having much power or influence with the use of the Portcullis logo greatly impressing people.
However, in CO-Gas Safety’s view, there is little or no parliamentary action. CO-Gas Safety understands and accepts that the group cannot achieve legislative changes itself. However, members of APPCOG can table EDMs, ask PQs and table private members’ bills, ask to see CEOs of gas suppliers, providers of other fuel such as coal or wood, manufacturers of boilers and other appliances, ask to see ministers, use their influence to persuade industry & Government to bring in safer laws and practices and use its funds to promote safety issues via publicity etc. It is entirely possible APPCOG asks to see ministers etc. but is refused.
APPCOG’s administration is provided by Policy Connect, a not for profit group providing
administrative help for other All Party Groups, This service is funded by industry – It is transparent but everybody knowing funding is from industry, doesn’t help nor does it remove industry’s influence. https://www.policyconnect.org.uk/appcog/home
It seems industry runs the system which means people who are poisoned cannot prove this to their medics who therefore, along with Government, think CO is rare.
However, extrapolating from the small studies, CO is widespread - https://www.co-gassafety.co.uk/about-co/numbers-affected-by-co/
CO-Gas Safety does understand extrapolating from small studies can be dangerous and was delighted a large study of 75,000 homes would be undertaken, apparently fully funded by the Gas Safety Trust starting in 2015 - https://www.ljmu.ac.uk/about-us/news/life-saving-research-into-carbon-monoxide. CO-Gas Safety cannot understand why more has not been done to complete this research or raise funds to do this.
Deaths and injuries from CO are easy to prevent and, if a person was poisoned, it seems obvious to find the source of poisoning and parts per million of CO occupiers are exposed to.
With regard to Covid-19, (or indeed HIV, pesticides etc.) awareness and testing are crucial - The charity considers this is true of CO.
Symptoms of CO are similar to Covid-19, so the charity made yet more determined efforts since March 2020 to highlight this, partly inspired by the case of Ms Katie Reid, a Council tenant with pneumonia and a five year old at home, in Scotland in March 2020.
Ms Reid’s gas was cut off due to her CO alarm alarming, leaving her with no central heating. However, she could not find a Registered Gas Engineer (RGE) to service her boiler, because RGEs were afraid she had Covid-19. Finally, her local paper helped her find a RGE to service her boiler. https://www.eveningtelegraph.co.uk/fp/mum-recovering-from-pneumonia-claimed-angus-council-initially-refused-to-fix-gas-because-they-believed-she-had-coronavirus/ The charity has the full article if needed, as it’s difficult to download in full.
Due to Covid and possible confusion with CO, and because much funding is being provided by Ofgem to the Gas Distribution Networks who run the gas emergency service for vulnerable consumers and innovation projects in RIO – 2, CO-Gas Safety was determined to get through to APPCOG or a Government Minister but has not been successful.
The charity once could meet Ministers and government department heads but now it seems impossible to raise vital issues with those with the power to change things.
There are two relatively simple uncontroversial issues that could have been resolved but need legislation.
https://www.co-gassafety.co.uk/wp-content/uploads/2021/01/A-hidden-killer-New-Law-Journal-23.03.18-022_NLJ_7786_BackPage_Trotter.pdf
Both 1 & 2 above could be relatively easily fixed yet it seems no real attempt has been made to do so. Maybe we expect too much but we hoped for more Parliamentary action.
To conclude:
Our over 25 years of experience suggests groups such as APPCOG are unable to make positive claims for change, can suppress individual activity through false expectations & assumptions and typically receive funding from 3rd parties wishing to maintain the “status quo”, preventing essential and obvious consumer safety and protection.
This is why in our opinion:
A proper grievance procedure should be published and followed.
It would be helpful if an independent overseeing body could be created and put on all the All Party websites. Hopefully, any complaint could be resolved informally.
A possible sanction could be either making any transgression public or revoking, in effect, a licence to be an All Party Group.
28 January 2020