IN THE WAKEFIELD CORONER’S COURT

 

3144/2006 – 3145/2006

 

INQUESTS TOUCHING THE DEATHS OF CHRISTIANNE SHEPHERD AND ROBERT SHEPHERD (DECEASED)

 

HELD FROM 27^TH APRIL 2015 CONCLUDING ON 13^TH MAY 2015

 

Before Senior Coroner, David Hinchliff

A Jury was duly sworn

 

REGULATION 28: REPORT TO PREVENT FUTURE DEATHS

 

This report is being sent to:

 

• Thomas Cook Group c/o Fieldfisher LLP Solicitors, Riverbank House, 2 Swan Lane, London, EC4R 3TT

 

• Louis Group including the Louis Corcyra Beach Hotel c/o of Hill Dickinson LLP Solicitors, The Broadgate Tower, 20 Primrose Street, London, EC2A 2EW

 

• The Secretary of State for the Department for Culture, Media and Sport, 100 Parliament Street, London, SW1A 2BQ

 

• The Secretary of State for the Foreign and Commonwealth Office, King Charles Street, London, SW1A 2AH

 

• The Federation of Tour Operators, Graphic House, 14-16 Sussex Road, Haywards Heath, RH16 4EA

 

• The Secretary of State for the Department of Trade and Industry, 1 Victoria Street, London, SW1H 0ET

 

• ABTA – The Travel Association, 30 Park Street, London, SE1 9EQ

 

 

Coroner

 

I am David Hinchliff, Senior Coroner for the Eastern Area of West Yorkshire.

 

Coroner’s Legal Powers

 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

 

INVESTIGATION and INQUEST

 

On 3^rd November 2006 I opened Inquests touching the deaths of Christianne Shepherd, aged 7 and Robert Shepherd aged 6. The Inquest concluded on 13^th May 2015. The Conclusion of the Inquest was in Narrative form as follows. The medical cause of death was 1(a) Carbon monoxide poisoning

 

The Conclusion was in Narrative form, namely:-

 

1. Incorrectly installed and badly maintained boiler
2. Fuel protection device disconnected deliberately
3. Air conditioning pipes badly fitted
4. Hotel misled/lied to the Tour Operator about gas supplied to the hotel bungalows
5. Resort Audit carried out in 2004 by the Tour Operator was inadequate
6. Monthly Health and Safety Audit form inadequate, did not reflect the Tour Operator’s Health and Safety Policy/Guidelines
7. Resort Staff not given enough Health and Safety information regarding how to identify the presence of gas/electric water heaters
8. Resort Audit in 2004 was incomplete, checks not carried out vigilantly as stated in the Tour Operator’s Training Manual (Boiler room not identified)
9. The Tour Operator breached their duty of care

 

CIRCUMSTANCES OF THE DEATH

 

Christianne and Robert Shepherd were taken on a half-term holiday from 22^nd to 30^th October 2006 by their father and his then partner, to the Greek island of Corfu. The Tour Operator was Thomas Cook. The family stayed at the Louis Corcyra Beach Hotel in Gouvia. The allocated accommodation was a semi-detached bungalow situated in the grounds of the hotel. Water heating and air conditioning was from an LPG water heater located in a separate annex, which was attached to the bungalow. The water heater was badly installed and defective, and dangerous in that in-built safety devices had been deliberately disconnected. The water heater had not been serviced or maintained, causing carbon monoxide fumes to escape into the bungalow through defective building and piping. Whilst occupying the bungalow all the occupants were victims of carbon monoxide poisoning causing the deaths of the children and the near deaths of the adults.

 

CORONER’S CONCERNS

 

During the course of the Inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you.

 

The MATTERS OF CONCERN are as follows:-

 

1. An on-line and publically accessible Central Register should be introduced to compel all Tour Operators to record and maintain up-to-date information relating to energy sources and the annual service history for all hotels, apartments and holiday premises used by Tour Operators. This information and the entries recorded on the Central Register should be taken from a form completed by the Tour Operator at the time of contracting with the hotelier or other holiday premises provider. The Tour Operator must carry out an audit at least once in a 12 month period.

 

2. In most situations a hotel, apartment or other holiday premises will be used by more than one Tour Operator. In this event a system should be devised for Tour Operators to work in collaboration with communicate and actively share information pertaining to Health and Safety issues.

 

3. There should be awareness raising and Health and Safety promotion activities undertaken to make travellers aware of the dangers of carbon monoxide poisoning and to promote the benefits of travelling with a portable carbon monoxide detection device. This could effectively be achieved by being linked to promotion of the E111 European Health Insurance Card Scheme.

 

4. The responsibility for Health and Safety checks should not be delegated to Tour Representatives who are often inexperienced and over worked and will lack the time, knowledge and commitment to carry out this task. The responsibility for this should be by suitably qualified specialists in Health and Safety. Furthermore, and where appropriate, this should include suitably qualified and experienced specialists, in particular experts of Health and Safety, e.g. gas safety.   Such specialists should visit the relevant accommodation and carry out full and detailed Health and Safety checks, the reports from which should be publically accessible. In organisations that do not have suitable in-house personnel for this purpose then suitably qualified and experienced Consultants should be instructed.

 

5. Arising from recommendation (4) above, Tour Operators and the owners and controllers of hotels, apartments and holiday premises should devise and/or subscribe to suitable Health and Safety accreditation ratings.

 

6. Within the structure and hierarchy of every provider of hotels, apartments and holiday premises there should be a robust internal structure for a system of management, supervision support and training in respect of Health and Safety issues.

 

7. All holiday brochures and travel promotional literate and Health and Safety information should be written in clear, easy to understand language and should make specific reference to the dangers of carbon monoxide poisoning, and make reference to safeguards that travellers should adopt.

 

8. That the relevant UK Government department should consult, draft, instigate and implement EU legislation on gas installations and carbon monoxide safety, and introduce common minimal standards for all hotels, apartments and other holiday premises.

 

That the Government should do its utmost to encourage and promote through legislation and improvement of safety standards across Europe, which would require hotel owners and other holiday accommodation providers to install carbon monoxide detectors in accommodation, which has individual gas appliances, whether or not the said appliances are inside guests’ sleeping accommodation or immediately adjacent thereto.

 

I am aware that recent attempts to introduce such legislation has not progressed. It is my desire that this recommendation should produce a renewed initiative for EU legislation requiring the installation of carbon monoxide detectors by Tour Operators and holiday accommodation providers.

 

9. I acknowledge that to introduce legislation as recommended herein may be a slow and tedious procedure, which may, as has previously happened, fail. I therefore recommend that the travel industry, although supporting and providing their own initiative to relevant government departments. The industry should, nevertheless, endeavour to regulate itself by introducing industry wide initiatives and improvements in the Health and Safety of holiday makers, particularly with regard to carbon monoxide poisoning issues. Thomas Cook, one of the largest providers of holiday accommodation in the world should be at the forefront of such initiatives to create industry wide protocols and initiatives on the lines that legislation would introduce, should that ever occur.

 

10. It is my understanding that ABTA, The Travel Association, to whom this report is being sent, produces the ABTA Technical Guide for Accommodation Suppliers, which has a section dedicated for fuel management, and is reviewed every five years. This will next be reviewed in 2016. These recommendations, where relevant to ABTA’s review, are timely and I recommend that where relevant my concerns listed at (1) to (9) herein, should be considered and incorporated in the next edition.

 

ACTION SHOULD BE TAKEN

 

In my opinion action should be taken to prevent future deaths and I believe your organisation have the power to take such action.

 

YOUR RESPONSE

 

You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 16^th November 2015. I, the Coroner, may extend the period.

 

Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed.

 

COPIES and PUBLICATION

 

I have sent a copy of my report to the Chief Coroner and to the following interested persons:

 

• Stephanie Trotter, OBE, President and Director of CO-Gas Safety, Priory Cottage South, Priory Road, Seaview, Isle of Wight, PO34 5BU

 

• Mary Creagh MP, Member of Parliament for Wakefield, 20-22 Cheapside, Wakefield, WF1 2TF

 

• David Weston, Chief Executive of The Bed and Breakfast Organisation, Belfry House, Batts Field, Bruton, BA10 0DX

 

• Linda McAvan MEP, 79 High Street, Wath-upon-Dearne, Rotherham, South Yorkshire, S63 7QB

 

• Professor the Baroness Finlay of Llandaff, Co-Chair of the All-Party Parliamentary Carbon Monoxide Group, House of Lords, London, SW1A 0PN

 

I am also under a duty to send the Chief Coroner a copy of your response.

 

The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner.

 

 

18 September 2015  

 

……………………………………………. Senior Coroner, West Yorkshire (Eastern Area)

Death and CO

Upstairs, a family of four lay in their beds. Quiet filled the house.

For a long time the killer had patiently waited. Now, downstairs in their kitchen- silent murder was food for thought. He was sure to be never caught.

Like a vapour he slid under the kitchen doorway. Running cold dirty fingers against the walls always. His trade mark black marks. In the darkness of the hallway- he encountered red blinking eyes. Restless and alert -it was the smoke detector ready set to scream, protecting sleeping families.

The pair of eyes could only watch Paralysed, as the killer creeps up the stairs. He was in his element here.

Blink twice and he’s missed. The invisible criminal.

Often socially mistaken he’s tasteless.

Normally exhausted- fatigue always reported.

NHS caution: nausea, dizziness, distortion.

 

Like a sarcophagus mummys coughing in her sleep

Daddy is lethargic, can hardly move his feet

Children choke, like respiratory disease

Boiler’s yellow flame means combustion incomplete

Something must be wrong when the canary doesn’t tweet.

 

Carbon monoxide concentration is sending you to sleep.

 

By Samuel Spence

About the author

My name is Samuel Spence and I attend Dartford grammar sixth form. I enjoy short stories, spoken word and rap. I was emotionally moved when I heard about the carbon monoxide poisoning that occurred at Thomas Cooke earlier this year (note by Stephanie – deaths occured in 2006 but the inquest was in 2015), and I felt a compulsion to respond in a creative manner that could help raise awareness. The piece of work that I have attached is the result. I have tried my best to convey a sense of peril and a chilling reminder about the ‘silent killer’.

Thank you Samuel.

 

Please see https://www.youtube.com/watch?v=zHp4nMZKub8 and please let Stephanie know what you think about this by email office@co-gassafety.co.uk

The Smoke and Carbon Monoxide Alarm Regulations 2015 are through and came into force on the 1^st October 2015. Please see Hansard http://www.publications.parliament.uk/pa/ld201516/ldhansrd/lhan43.pdf from page 1720 to the end.

We supported these regulations (because we support anything that will save lives) but they will only affect  ‘354,000 Private Rented properties with solid fuel, or 8.6% of the total.’. However, we think the comments by the Lords, particularly those by Lord Hunt and Lord McKenzie are helpful as was the personal experience of one the friends of Earl Cathcart.

As was reported on Sky by Neil Shepherd, father of Christi and Bobby, the children who died of CO in 2006 in Corfu, there were substantial donations made to several charities including independent registered charity CO-Gas Safety.
CO-Gas Safety is extremely grateful for this valuable donation to assist the charity to continue its work of preventing deaths and injuries from unintentional CO poisoning.
However, the amount of the donation although extremely welcome is not life changing for the charity, which will continue to do its work in a similar way. CO-Gas Safety still has no assured, continuous funding to collect, collate and publish data and provide victim support which it has done since 1995. Therefore all the work, apart from a small amount of paid work by our database officer, will still be done by volunteers. The charity’s directors are still considering the best use for these funds but the initial decision is to simply continue to do what the charity has always done.

I’ve heard that nearly 50,000 people are searching for the term Carbon Monoxide Poisoning every month. This came from Google so is all over the world. However, CO-Gas Safety doesn’t come up when you type Carbon Monoxide Poisoning in to Google. The trick apparently is to keep repeating Carbon Monoxide Poisoning on the website so please forgive me for repeating this on different parts of our website! CO victim Sue Westwood-Ruttledge kindly told me about this and another victim told me she had taken ages finding our website because it didn’t come up under carbon monoxide poisoning so I’m trying to add lots of references to carbon monoxide poisoning.

I’ve heard that nearly 50,000 people are searching for the term Carbon Monoxide Poisoning every month. This came from Google so is all over the world. However, CO-Gas Safety doesn’t come up when you type Carbon Monoxide Poisoning in to Google. The trick apparently is to keep repeating Carbon Monoxide Poisoning on the website so please forgive me for repeating this!

We’ve pledged the support of CO-Gas Safety to Gas Safety Week.

We would like support for our call for prime time TV warnings of the dangers of carbon monoxide poisoning from all fuels, (gas to wood), all appliances (boilers to barbecues) and all types of accommodation (bungalows to boats).

If you agree please write to Stephanie office@co-gassafety.co.uk Thank you.

A major change to the Gas Industry Unsafe Situations Procedure (GIUSP) came into effect in July. A single message of “Danger Do Not Use”, irrespective of either an “At Risk” (AR) or “Immediately Dangerous” (ID) classification being applied, is aimed at helping customers understand when appliances must not be used. Version 7 of GIUSP became current on 1 July 2015, but Gas Safe Register recognises that registered businesses/engineers will need time to revise their processes, procedures and documentation and carry out necessary internal update training. Therefore, Gas Safe Register will inspect to this version of the Procedure from 1 July 2016, so providing a 12-month lead-in period (businesses are encouraged to adopt the revised procedure as soon as possible).  The full text of the revised procedure can be downloaded from Gas Safe Register’s website.

My choices would be as follows:

1. The egg – I could relate to this one and it spoke to me in many ways – for me the message was that the acute poisoning leaves you brain dead/mindless and incapable of thinking at all (before it kills you) or in the case of chronic exposure that doesn’t kill you, you are left confused, dazed etc etc (I cant quite find the right word/s to aptly describe the process of spiralling down to near nothingness ). After constant exposure and post exposure (when your mind slowly starts to return) you are left with a single track mind at best ,where dual-tasking is something you have to relearn – for me, with the way things are at the moment, I cant imagine ever being able to multitask as I used to.

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