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recurance

Jean Dye

21 Jul 2025 · Coroner Paul Smith · Greater Lincolnshire

The coroner's concerns

  1. 1. Emergency Power Off circuit activation

    “The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system. The reason for that activation was unclear although a physical activation of any of the three EPO buttons was excluded on the evidence.”
  2. 2. Missing EPO status indicator and reset button

    “There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset.”
  3. 3. Lack of guidance on remote placement of EPO controls

    “I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training.”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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Jean Dye · Recurance