The Senior Coroner for Surrey, Richard Travers, has delivered his Findings and Conclusions in the Inquest touching the death of Zane Gbangbola, who died at his home in Chertsey, Surrey, during the night of 7th February 2014.
At the time of his death Zane lived with his parents, Nicole Lawler and Kye Gbangbola at no.243 Thameside, a property located adjacent to the River Thames and immediately below a disused landfill site. During the winter of 2013/2014 Chertsey was badly affected by flooding, and in the days prior to Zane’s death his parents hired a petrol driven pump to remove water from their flood basement. The pump was set up in the downstairs utility room, and used by Nicole Lawler at some point on 7th February 2014 (although the extent of use was a heavily disputed issue at the Inquest). During that night both Zane and his father suffered acute illness after exposure to toxic gases, in Zane’s case fatally. Upon investigation by the emergency services all members of the family displayed elevated levels of Carboxyhaemoglobin in their blood, signifying exposure to Carbon Monoxide (CO). However, gas testing carried out by the Fire Brigade at no.243 in the early hours of 8th February 2014 detected a reading for Hydrogen Cyanide (HCN), but not CO.
The Inquest heard from over 70 witnesses in respect of two “competing” theories as to the identity of the toxin that killed Zane.
The first theory, supported by the Family, was that the toxin (most likely HCN) had migrated into no.243 via contaminated floodwater from the ex-landfill site. It was on this basis that the landowner (Brett Aggregates), Spelthorne Borough Council, and the Environment Agency were joined as Interested Persons to the Inquest (the latter two having had a degree of regulatory responsibility for the landfill site since the 1950’s).
The second theory, supported by the remainder of Interested Persons, was that Zane’s death had been caused by exposure to CO gas emitted from the petrol pump whilst it was in use on 7th February 2014. This possibility was strongly denied by the Family, who gave evidence that the petrol pump had never been used other than for several minutes to test that it worked.
In his Findings and Conclusions the Coroner determined that, on balance, Zane had died at approximately 10.30pm as a result of inhaling CO fumes emitted by the petrol pump situated downstairs at no.243. He rejected the evidence of Zane’s parents as to the extent of their use of the pump, which he deemed “improbable”, and found that the pump had been on for 6 hours on 7th February 2014 in an inadequately ventilated location. The Coroner further found that HCN had never in fact been present at no.243, and the sole reading detected by the Fire Brigade was caused as a result of cross-detection from Oxides of Nitrogen.
The Coroner was, however, critical of the company that had hired the pump to Nicole Lawler, as he accepted her evidence that representatives of Surrey Hire and Sales (also an Interested Person at the Inquest) told her it was safe to use indoors. Criticism was also levelled against the HSE and Hire Association Europe; the latter organisation having produced safety instructions (endorsed by the HSE) indicating that the pump could be used indoors if in a ventilated area. This was in direct contradiction to safety instructions issued by the manufacturer of the pump, Honda, and the expert evidence of an HSE representative. A Regulation 28 Report to prevent future deaths has been issued by the Coroner requesting that HAS/HSE review the content of the relevant safety instructions.
Ivor Collet and Nicola Atkins from 1 Chancery Lane appeared at the Inquest on behalf of Spelthorne Borough Council.