Helen Davey: Prevention of Future Deaths Report

Product related deaths

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Date of report: 07/10/2024 

Ref: 2024-0533 

Deceased name: Helen Davey 

Coroners name:  Jeremy Chipperfield

Coroners Area: Durham and Darlington

Category: Product related deaths

This report is being sent to: Office for Product Safety and Standards | Department for Business and Trade  

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:

[REDACTED], Secretary of State for Trade and Business
Office for Product Safety and Standards 
Department for Business and Trade 
1CORONER
I am Jeremy Chipperfield, senior coroner for the coroner area of Durham and Darlington
2CORONER’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. 
3INVESTIGATION and INQUEST
On 10-Jun-24, I commenced an investigation into the death of Helen DAVEY, 39. The investigation concluded at the end of the inquest on 04-Oct-24. The conclusion of the  inquest was that the death was accidental. 
4CIRCUMSTANCES OF THE DEATH
The deceased was leaning over the storage area of an Ottoman-styled “gas-lift bed” when the mattress platform descended unexpectedly, trapping her neck against the upper surface of the side panel of the bed’s base. Unable to free herself, she died of positional asphyxia. One of the two gas-lift pistons was defective. 
5CORONER’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 could occur unless action is taken. In the circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows:

The existence and use of gas piston bed mechanisms whose failure presents risk to life.
6ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.  
7YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by 02-Dec-24. I, the coroner, may extend the period. 
Your response must contain details of action taken or proposed to be taken, setting out thetimetable for action. Otherwise you must explain why no action is proposed.
8COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the family.
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. 
907-Oct-24