1. [REDACTED] 
Chief Executive Officer 
Office for Product Safety and Standards Cannon House 
18 The Priory 
Birmingham 
B4 6BS 

2. [REDACTED]                                                     
Secretary of State for Health and Social Care 39 Victoria Street 
London 
SW1H 0EU 

3. [REDACTED] 
Director General 
UK Cleaning Product Industry Association

I am Ian Potter, assistant coroner, for the coroner area of Inner North London.

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. 

On 21 March 2024, an investigation was commenced into the death of ELIZABETH VAN DER-DRIFT, then aged 93 years. The investigation  concluded at the end of inquest heard by me on 1 August 2024. 

The inquest concluded with a short-form conclusion of accidental death. The medical cause of death was: 

1a aspiration pneumonia 
1b ingestion of toxic substance (laundry detergent)
1c dementia 

Ms Van Der-Drift had lived with dementia for a number of years. Her  condition was such that she often could not recall when she last consumed food and she would often go in search of something to eat.  

Sometime on the night of 13/14 March 2024, she gained access to laundry  detergent tablets/pods that were brightly coloured. Given the nature of the  packaging and the tablets/pods, I determined that, given her cognitive  impairment as a result of the dementia, Ms Van Der-Drift likely believed that  they were some form of sweet or confectionary. Having gained access to the  tablets/pods, she bit into at least one of them. Shortly thereafter, Ms Van Der- Drift was found complaining of stomach pain and shortness of breath. 

An ambulance conveyed Ms Van Der-Drift to hospital where, despite  treatment, her condition deteriorated, and she died in hospital on 19 March 2024. 

The MATTERS OF CONCERN are as follows:

(1) During the course of hearing the evidence I was shown a picture of the
packaging for the laundry tablets/pods in question. The packaging, in  this instance, was predominantly bright pink and white, with orange,  yellow and green also present. One witness (a carer experienced in  caring for those living with dementia) gave me her view that the  packaging bore more than a passing resemblance to a bag of sweets,  and she considered that this was more likely to be the case when  viewed from the point of view of a person living with dementia or some  other cognitive impairment.  

In my view, the packaging of this particular product is not alone among similar products, that also opt for bright, eye-catching colours. It was  for this reason that I formed the view that sending this report to the  individual manufacturer/retailer (under whose brand the product was  labelled) would be short-sighted. The employment of eye-catching and bright colours appears to be an industry-wide phenomenon. 

It has long been acknowledged that products of this nature can pose  risks to children; however, there appears to be less acknowledgement of the risks posed to those living with dementia or other forms of  cognitive impairment.  

In terms of the laundry tablets/pods themselves, I note that these have a jelly-like appearance and again I regard them as being colourful and potentially sweet-like in their appearance. This again has the serious  potential to render a highly toxic/hazardous product as appealing to  those with dementia or other cognitive impairment (as well as  children). There is a wealth of material available (media reports,  scientific studies and research etc.) to document the relatively  frequency that products of this nature are accidentally or inadvertently ingested. 

I am well aware of The Food Imitations (Safety) Regulations 1989,  UKSI 1989 No. 1291 and note Regulation 4, in particular. However, it  seems to me either that the regulations themselves have insufficient  regard to those living with dementia or other cognitive impairment or  that the application of the regulations is not approached with sufficient rigour.  

The overarching concern here is that laundry tablets/pods and their  packaging are being produced in a way that, by virtue of their bright  colouring, appearance, and packaging, are being confused with food by people living with dementia or other cognitive impairment. The  issue is, in my opinion, compounded when one considers that the  products themselves are far from innocuous in the event of their  accidental ingestion. 

(2) In this case, I also noted that there was no obvious design feature, in  terms of the packaging, that makes accessing the content particularly difficult for someone with even the most basic of manual dexterity. In  my view, this only adds to the risks. 

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

You are under a duty to respond to this report within 56 days of the date of  the report, namely by 8 October 2024. 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. 

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

[REDACTED] – daughter of Elizabeth Van Der-Drift.
 
The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person she  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  publication of your response by the Chief Coroner.