Inquest touching the death of Zane Gbangbola: Coroner delivers Findings

The Senior Coroner for Surrey, Richard Travers, has delivered his Findings and Conclusions in the Inquest touching the death of Zane Gbangbola, who died in his sleep during the night of 7th February 2014. Zane lived with his parents Nicole Lawler and Kye Gbangbola at no. 243 Thameside, a property located immediately adjacent to the Thames and bordered on the North by 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 the flood basement of no.243. The pump was set up inside in the downstairs utility room, and had been used at some point on 7th February 2014 (although the extent of that use was a heavily disputed issue between the Family and other Interested Persons at the Inquest). During that night both Zane and his father suffered acute illness after exposure to toxic gases, in Zane’s case fatally. Despite all members of the family displaying elevated levels of Carboxyhaemoglobin in their blood, signifying exposure to Carbon Monoxide (“CO”), 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 Person’s 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 IPs, 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 vehemently denied by the Family, who gave evidence that the petrol pump had never been used other than 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 driven pump downstairs at no.243. He did not accept the evidence of Zane’s parents as to their limited use of the pump, which he found “inherently improbable”. In his view the pump had been on for up to 6 hours on 7th February 2014, and had been located in an inadequately ventilated location within the property.

The Coroner was, however, critical of the hire company that had hired the pump to Nicole Lawler, as he accepted her evidence that representatives of Surrey Hire and Sales told her it was safe to use the pump 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 whose specialism was in CO safety prevention. 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 Collett and Nicola Atkins appeared at the Inquest on behalf of Spelthorne Borough Council.