Form for Coroners

ACCIDENTAL DEATH FROM CARBON MONOXIDE POISONING OR OTHER FUEL RELATED TOXINS (e.g. heavy metals, Nox, Benzene)
(not suicide or CO poisoning during accidental fire, e.g. burning furniture)

* indicates required field

Name:*

Email:*

1. Surname of Deceased:

2. Forename/s of Deceased:

3. Age:

4. Date of Incident:

5. Date of Death, if different:

6. Address or location where incident occurred:

7. Property type and tenure:

e.g. house/owner occupied, flat/council or Housing Association, bedsit/private rental, workplace, etc.

8. Fuel concerned:

e.g. mains gas, bottled propane gas, solid fuel, petrol etc.

9. Appliance concerned:

e.g. central heating boiler, water heater only, fire/room heater, cooker (oven, grill or hob), kiln, generator, engine etc. Ideally provide manufacturer and serial number. If boiler, condensing or non condensing.

10. Had the appliance been serviced within a year before the incident?

Please select... Yes No

11. Date of last service, if known:

12. CORGI OR Gas Safe Registration No, if relevant:

Please select... Yes No Don't know

From 01.04.09 Gas Safe Registration No. only:

CORGI/Gas Safe Reg. No.:

13. Cause of accident, if known:

e.g. blocked flue, faulty or clogged up appliance, lack of ventilation, combination of some/all of these etc.

14. Was anyone else killed or injured in the same incident?

Please select... Yes No

(If so and if their medical details were relevant could you please give us some details below).

Other death or injury details:

15. Illness before death?

Please select... Yes No Don't know

Illness details:

16. Blood CO level %:

17. Were other products of combustion tested for?

Yes No Don't know

e.g. NOX, Benzene, heavy metals etc. See www.epa.gov/ttn/chief/ap42/ch01/final/c01s04.pdf and our website www.co-gassafety.co.uk/other_toxins.html.

Other products testing details:

18. Was a CO alarm (as opposed to a detector) present?

Yes No Don't know

If Yes, was it to EN 50291?

Yes No Don't know

Was a CO detector present?

Yes No Don't know

19. Other further information:

Information such as manufacturer of alarm or detector, standard, (e.g. UL or BS), age, battery or mains operated, whether it has been tested or not since the death etc.

20. Had there been a recent exchange of the meter?

Yes No Don't know

If Yes, when was this done?

Who was it done by?

21. Verdict and Date of Inquest, if already held

Verdict:

Verdict date:

Name and address of Coroner:

Email address of Coroner:

H.M. Coroner, please enter your initials to confirm that the information you have entered is accurate:

Today's date:

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