Terrence Taylor
21 Jun 2024 · Coroner Keith Morton · Cambridgeshire and Peterborough
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. window restrictors ineffective against deliberate defeat
“The current standards have been developed to prevent accidental falling from windows. They do not deal with deliberate attempts to defeat the restrictor, which may well be the situation encountered residential care homes, as in fact occurred in this case. This limitation is not known or understood by operators of residential care homes.”
2. window restrictors ineffective against deliberate defeat
“window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm”
3. window restrictors insufficient strength
“it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N”
4. misunderstanding of standard adequacy
“Operators of care homes are likely to consider they are taking reasonable steps to secure windows by fitting restrictors that meet the British Standards, whereas the 2013 Department of Health Guidance and the 2019 Health and Safety Executive research indicates that is not so”
5. lack of updated guidance
“Action is required to ensure operators of care homes are provided with reliable, up to date guidance and to ensure that the limitations of the British Standard are widely known and understood by operators of residential care homes”
6. need for standard revision
“Action is required to review the British Standard relating to window restrictors to consider whether some different standard or qualification to the existing standard is required in respect of residential care homes and/or deliberate acts to disable window restrictors”
Linked reports
Identical hazardConfidence 0.90 · high
Earlier report
“window restrictors may be inadequate in preventing a determined effort to force a window open beyond the 100mm restriction”
This report
“window restrictors tested to current British Standards may be inadequate in preventing a determined effort to force a window open beyond 100mm”
Closely relatedConfidence 0.80 · moderate
Earlier report
“I was informed that CQC did not routinely check window restrictors on inspections.”
This report
“it is suggested that window restrictors (and their fixings) are capable of withstanding push forces of at least 850N”