Housing and Health

Accidents at home

Stella Lowry

Every year there are about 5500 fatal accidents inBritish homes (some two fifths of all fatal accidents).A further 2 2 million people have non-fatal accidents athome needing hospital treatment, and another 900 000are dealt with by general practitioners. The cost ofdomestic accidents to the health service in England andWales is about £300 000 a year.'

Statistical information about non-fatal domesticaccidents has been collected since 1976 by the Depart-ment of Trade and Industry, based on attendancerecords at the accident departments of 20 hospitals.Information about fatal accidents is held in thehome accident deaths database, and the Home Officepublishes annual statistics about accidents involvingfire.

British Medical Journal,London WC1H 9JRStella Lowry, MB, assistanteditor

BrMedj 1990;300:104-6

Accidents and childrenAccidents are the commonest cause of death in

children aged over 1 year and account for a third ofall childhood deaths. About three quarters of a millionchildren are injured at home each year, and domesticaccidents account for most of the falls, burns, andpoisonings. Nevertheless, many of these accidents arepreventable.' The accidents that children have oftenreflect their stage ofdevelopment, and this makes themmore predictable by adults. Under the age of 3 monthsone of the commonest accidents is being dropped by anadult; by 10 months children are crawling and startingto walk and risk hurting themselves on the sharp edgesof furniture. Later, increasing independence bringsrisks from any hazard within their reach; falling fromwindows that open too far, swallowing householdchemicals, and playing with matches. By school age,road traffic accidents have become important.From the age of 2 boys are about twice as likely to

have an accident as girls. And childhood accidents alsoshow a definite variation with social class,' this gradientbeing steeper than for any other cause of death inchildren. Thus in Haringey, London, in one yearnearly a fifth of children under 5 attended an accidentand emergency department, three quarters of thembecause of an accident at home (P Constantinides andG Walker, unpublished data). Children from the leastaffluent parts of the borough were four times morelikely to have an accident than those from the mostaffluent parts, and there was a significant associationbetween accident rates and unemployment, over-crowding, rented tenure, poor parental education, andlow social class.

Elderly people are also at risk of accidents at home.As in children, their risk is influenced by what they canor cannot do. Deteriorating sight and poor mobilitymay put them at risk of falls; open or portable firesrather than central heating are a fire hazard; and frailtyor lack of money may prevent them from maintainingequipment properly. In 1987, 18% of people who diedin fires were aged 60-74, and a quarter were over 75.4The guidelines about designing safer houses pro-

duced by the Child Accident Prevention Trust arebased on studies of the type and frequency of accidentsto children at home.6 Many of the guidelines also applyto other groups at risk, including the elderly. Some

Matches

Misuse ofLelectric cookers

Smokers'materials

Othercauses

Faulty appliancesand wirng

Based on Home Office data

Causes of accidental fires in dwellings in 1987 (based Onl Home Officedata)

of the recommendations -L shaped flights of stairsto reduce the distance in a fall, no doors orwindows opening on to stairways, and through routesin kitchens that avoid the cooker-are best introducedduring planning. Others can be incorporated easilyinto existing homes: good lighting of stairwells, hand-rails with an all round grab, no cupboards above thecooker, non-slip floor surfaces in kitchens, safetyglazing for shower screens, and so on. If all of therecommended features were incorporated into thedesign of a new house the trust estimates that the totalcost would be increased by only 5%.

Rules and regulationsBecause the cause of so many domestic accidents is

predictable it is possible to legislate for safety standardsthat reduce the risks-for example, restrictions on theflammability of children's nightwear and on how farwindows in multistorey dwellings may open.6One important problem that has not been properly

dealt with so far is domestic architectural glass, whichwas found to cause no less than half the injuries seen ina group of 80 children with lacerations. Ten years agothe author of this report concluded that safety glassshould be used in all glass doors, French windows,patio doors, and the lower parts of windows -but ourhospitals are still treating over 400 000 such injuriesevery year (R Sinnott, conference of Institutionof Environmental Health Officers, London, 1987).Nearly half involve glass in doors, and two fifths ofthem happen to children under 15.There are regulations covering the use of glass in

buildings. British Standard code of practice BS 6262specifies that safety glass must be used in fully glazeddoors. The code defines a fully glazed door as being onein which the glazed panel is at least 300 mm wide and

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comes within 150 mm of the edges and top of the doorand within 300 mm of the bottom. Any other type ofdoor is not covered by the code. The code also specifiesthat safety glass should be used in windows less than800 mm from the floor in places where many peoplemove about. The concept of "many people" is vague,and would not apply in most homes. Many homescontain large areas of glass that would not be coveredby the code and present a real danger, especially tochildren and elderly people.The regulations covering safety glass are also con-

fusing. British Standard 6206 covers the impact perfor-mance of flat safety glass and safety plastics and dividesthem into three classes: A, B, and C. Class C is theminimum acceptable standard for low level glazing andB that for doors and side panels. Plastics are often saferthan glass, but they tend to bow and discolour withtime and are easily scratched. "Wired glass" is notnecessarily safe. The mesh holds the shattered pieces ofglass together, but does not increase the strength of theglass under impact. "Laminated glass" consists of twolayers ofannealed glass with an interleaved and bondedlayer of plastic. It is just as likely to crack as any otherannealed glass, but the plastic layer holds the piecestogether. Laminated glass may be of safety class A, butthis should not be assumed. People wanting safe glassfor domestic use should use "toughened glass." Thishas a high compressive strength, and because it tendsto break into small cuboid pieces it is always of safetyclass A, regardless of its thickness.The restricted applications of regulations about

domestic glass and the confusing range of productsavailable make it hard for householders to knowwhether their homes are safe or not, and perhaps itwould be better to stipulate that the highest grade ofsafety glass should be used for all domestic glazing.

Limitations of legislationLaws to improve home safety have drawbacks as

well as advantages. The standards may not be hard andfast enough-indeed, the present standards for safetyglass are under review after recent publicity about thedeath of a boy whose heart was punctured by a spear ofglass from a conservatory fitted with toughened glassthat met current standards. Other factors may need to

/10 People dzed and 9480 were injured in housefires in 1987

Safe as houses? How safe is safety glass?

be considered- for example, is the best safety glasseasy to break if it is necessary to escape from a fire?There is also the question of personal freedom, giventhat most people regard their homes as places wherethey can do as they like. Many home safety featuresare, therefore, couched as recommendations ratherthan laws.Laws and recommendations may be combined, as in

the case of domestic wiring. For new houses the localelectricity board must be satisfied with the standard ofwiring before connecting the supply; thereafter thingsare left to the owner's discretion. Fixed wiring shouldlast for 20 to 30 years if properly used, although ofcourse systems installed 20 years ago were not designedto cope with the proliferation of electrical domesticequipment that has occurred since. Sockets, switches,and circuit breakers are subject to mechanical wear andhave a shorter life.

Ideally, domestic wiring should be checked everyfive years. In 1986 a total of 47 electrocutions occurredin the home (J Stockting, conference of Institutionof Environmental Health Officers, London, 1987),and faulty electrical equipment and wiring are alsocommon causes ofdomestic fires (figure). In 1987 therewere 63000 domestic fires in the United Kingdom,4and though they accounted for less than a fifth of allfires they accounted for no less than three quarters ofall deaths and non-fatal injuries from this cause. Deathoccurs most commonly through the effects of gas andsmoke; hence the installation ofsmoke detectors mighthave an important preventive role.The incidence of domestic fires is significantly

associated with unemployment, low socioeconomicstatus, and inversely with owner occupation.8 Veryovercrowded conditions increase the risk of fire andthe difficulties of escaping from it. The Institutionof Environmental Health Officers is particularlyconcerned about the risks in houses in multipleoccupation.9 Because of the shortage of environmentalhealth officers, they are confined to reacting to com-plaints rather than able to inspect regularly. Until theservice is adequately funded the poorest and mostdisadvantaged members of our society will not be

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adequately protected from the dangers of badly main-tained properties.

Prevention by educationClearly, voluntary compliance with advice must

remain the principal means of preventing accidentsat home. Reinforcing such advice is, nevertheless,crucial. A study in Newcastle on the effects of anational television campaign about childhood acci-dents found that over half of families with youngchildren had seen none of the programmes, and only atenth of those specifically encouraged to watch hadtaken any action as a result.' But almost two thirds ofthose families who had received specific advice at ahome visit had taken action to improve domesticsafety.Hence people respond best to simple, specific advice

directly relevant to their own homes when it is givenseparately from other information. It may not bepossible to make special visits to all patients to adviseon home safety, but doctors are well placed to giveopportunistic advice during home visits or when apatient presents as the result of an accident.

ConclusionAccidents at home place a heavy strain on health

service resources, yet many domestic accidents arepredictable and potentially preventable. Safetyfeatures can be incorporated into most houses rela-

tively cheaply. Doctors are often ideally placed to offeradvice not only about home safety, but also about whathelp is available from social security offices to providefamilies on low incomes with safety features likefireguards and stair gates. Legislation is no guaranteeof domestic safety, but it at least provides someprotection for the most vulnerable members of society.This protection is lost if the regulations cannot beenforced, and the present shortage of environmentalhealth officers adds to the dangers.

1 I)epartment ofTrade and Industry. Home and leisure acctident research. Elezventhannual report home accident surveillance system: 1987 data. London: DTI,1989.

2 Child Accident Prevention Trust. Basic principles of-child accident prevention. Aguide to action. London: CAPT, 1989.

3 Constantinides P. Safe at home? Children's accidents and inequalice. RadicalCtommunitv Medicine 1988 Spring: 31-4.

4 Home Office. Fire statistics United Kingdom 1987. London: GovernmentStatistical Service, 1989.

5 Page AM. Child safety and housing. Practical design guidelitnes for commissioningagencies, architects, designers, and builders. London: Child Accident Preven-tion Trust, 1986.

6 Gloag D. Colloquium on strategies for accident prevention. A review of the presentposition. London: Medical Commission on Accident Prevention, 1987.

7 Jackson RH. Lacerations from glass in childhood. BrMedJ 1981;283:1310-2.8 Chandler SE, Chapman A, Hollington SJ. Fire incidence, housing and social

conditions-the urban situation in Britain. Fire Prevention 1984;172: 15-20.9 Institution of Environmental Health Officers. Houses in multiple occupation.

London: IEHO, 1984.10 Colver AF, Hutchinson PJ, Judson EC. Promoting children's home safety.

BrMedj 1982;285:1177-80.

In the article on electromagnetic radiation in homes (16 December,p 1517) Mr Brian Maddock of the Central Electricity ResearchLaboratories was wrongly referred to as Brian Maddox. Weapologise to Mr Maddock.

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Acquired immune deficiencysyndrome

A Colour Atlas ofAIDS in the Tropics.M A Ansary, S K Hira, A C Bayley,etal. (Pp 126; figs; colour plates; £35.)London: Wolfe Medical, 1989. ISBN0-7234-1567-6.HIV Infection: Teaching Slides. WHolmes, F Savage. In sets of 24 colourslides, with literature: HIVc-clinicalmanifestations; HIVe-preventionand counselling; HIVv-virology andtransmission. Cost ofeach set inclusiveof surface postage to any destination:self mounting £3.50+VAT; mounted£4.90+VAT; mounted in plastic file orfile-bar £9.80+VAT. Airmail postageplus 60p per set of 24 slides. Availablefrom Teaching Aids at Low Cost, POBox 49, St Albans, Herts AL l 4AX.Matters of Life and Death: WomenSpeak About AIDS. Ed I Rieder, PRuppelt. (Pp xii+234; £6.50 paper-back.) London: Virago, 1989. ISBN1-85381-103-3.TIakhing Liberties: AIDS and CulturalPolitics. [Based on a conference,London, March 1988.] E Carter, SWatney. (Pp 240; £8.95 paperback.)London: Serpent's Tail, 1989, in asso-ciation with the ICA. ISBN 1-85242-147-9.

PsychiatryPreventing Mental Illness. J Newton.(Pp xi+275; £9.95 paperback.)London: Routledge, 1989. ISBN0-415-03902-9.Progress in Psychiatry. "EatingBehavior in Eating Disorders." Ed B TWalsh. Series editor D Spiegel. (Ppxsii+232; figs; £22.50.) Washington:American Psychiatric Press, 1989.Distributed by Cambridge UniversityPress. ISBN 0-88048-163-3.

PsychologyCllntncal Pracstic. No 4. "Anxietv andDepressive Disorders its the MedicalPatient." LR Derogatis. TN Wise.

Series editor J H Gold. (Pp xi+v 260;£20.) Washington: American Psychi-atric Press, 1989. Distributed byCambridge University Press. ISBN0-88048-159-5.Clinical Practice. No 5. "Anxiety: NewFindings for the Clinician." Ed P PRoy-Byrne. Series editor J H Gold.(Pp xiv+204; £20. Washington:American Psychiatric Press, 1989.Distributed by Cambridge UniversitVPress. ISBN 0-88048-177-3.Psychological Management of thePhysically Ill. Ed J H Lacey, F Burns.(Pp x+349; £29.50.) Edinburgh:Churchill Livingstone, 1989. ISBN0-443-03601-2.

z'ilev Sent'es in Clinical Approachesto Cri'minal Behaviour. "ClinicalApproaches to Violence." Ed KHowells, CR Hollin. Series editorsCR Hollin, K Howells. (Pp xis4- 344;£35.95.) Chichester: Wilev, 1989.ISBN 0-471-92214-5.

Radiology

-AFIP Atlas oJ Radiologic-PathologicCorrelations, Fascicle L. "Renal CysticDisease." D S Hartman. Series editorA J Davidson. (Plp xiv + 160; figs andcolour plates; £34 paperback.; Phila-delphia: Saunders, 1989. DistribuLtcdby Harcourt Brace Jovanovich. ISBN0-7216-2343-3.

Clinical Radiology of the Small Intes-tine. H Herlinger, I) Maglinte. (PIpxviiiv+605; figs; £93.,) Ihiladelphia:Saunders, 1989. DistribuLted byHarcourt Brace Jovanovich. ISBN0-7216-4608-5.Fundamentals sf Skeleial Radiology.CA Helms. (Pp xii-+209; figs; £25paperback.) Philadelphia: Saunders,1989. Distributed by Harcourt BraceJovanovich. ISBN 0-7216-2346-8.Outpatient Invasive Radl'ologic Pro-cedures: Diagnostic and Therapeutic.AB Dublin. (Pp xii+ 154; figs; £30.Philadelphia: Saunders, 1989. Dis-tributed by Harcourt Bracc Joevano-vich. ISBN 0-7216-1532-5.

Principles of Biliarv' Lithotripss. Ed A SCass, L H Stahlgren. (Pp vii- 104;figs; $25.) New York: Futura, 1989.ISBN 0-87993-349-6.Radiology of the Esophagus. M SLevine. (Pp xi%,+ 373; figs; 8£64.v Phila-delphia: Saunders, 1989. Distributedby Harcourt Brace Jovanovich. ISBN0-7216-2906-7.

Rehabilitation

Health Services Research Reports."Outcomes of Artificial Lower LimbFitting in Scotland." P Knight, JUrquhart. (Pp ii 111 +appendixes;figs; £3.95 paperback.) 1989. Obtain-able from the Common ServicesAgency for the Scottish HealthService, ISD Publications, TrinityPark House, South Trinity Road,Edinburgh EH5 3SQ.

Respiratory medicine

Surfaciani Replacement Therapy. EdD L Shapiro, R H Notter. (Pp ix+ 321;figs; $69.50.) New York: Liss, 1989.Distributed by John Wiley and Sons.ISBN 0-8451-4281-X.

Social services

Assessing Elderly People for ResidentialCare: a Practical Guide. J Neill. (Pp57; £4 paperback.) London: NationalInstitute for Social Work, 1989. ISBN0-902789-59-7.

Sociology

Growing Old in the Twentieth Centur'.Ed M Jeffervs. (Pp xiv+256; figs;£35.) London: Routledge, 1989. ISBN1)-415-03103-6.

Statistics

Monographs on Statiisttcs and AppliedProhabilitv. No 34. "Design andAnalysis of Cross-Over Trials." BJones, MG Kenward. (Pp xii+340;figs; £27.50.) London: Chapman andHall, 1989. ISBN 0-412-30000-1.

Surgery

DasY Care: Surgeryj, Anaesthesia andManagement. Ed EG Bradshaw, H 1Davenport. Pp xv+ 191; £25.)London: Arnold, 1989. ISBN 0-7131-4560-9.Progress in Surgerv Vol 3. Ed I Taylor.Pp x+227; figs; £17.50 paperback.)Edinburgh: Churchill Livingston,c1989. ISBN 0-443-03959-3.Reoperative Gastrointestinal Surgerv.Ed T T White, i W Mulholland, R CHarrison. lPp xii+299; figs; £50.:Connecticut: Appleton and Lange,1989. D)istributed by Prentice-HallInternational. ISBN 0-8385-8390-3.

Third world

Rheumattc Fever and Rheumatic HeartDisease in Developing Countries. B LAgarwal. (Pp 144; figs; Rs75.) Banga-lore: Arnold Publishers, 1988. ISBN81-7031-155-1.Urbanization and Its Implications forChild Health: Potential Jor Action.World Health Organisation. (Pp vi-80; figs; $12.80 paperback.) Geneva:W'orld Health Organisation, 1989.ISBN 92-4-156123-8.

Toxicology

The Toxicology ofChemicals. "Carcino-genicity: Summary Reviews of theScientific Evidence. Vol 1." Commis-sion of the European Communities:Industrial Health and Safety. (Pp vi+184; ECU 15.) 1989. Office for OfficialPublications of the European Com-munities, Jean Monnet Building-C4/73, L-2920 Luxembourg. ISBN92-825-9381-9.

Ultrasound

Clinics in Diagnostic Ultrasound. Vol25. "Diagnosis and Therapy of FetalAnomalies." Ed J C Hobbins, B RBenacerraf. (Pp xiii+324; figs; £35.)New York: Churchill Lis-ingstone,1989. ISBN 0-443-08609-5.

Urology

Essential Urology. N Bullock, GSibley, R Whitaker. (Pp viii+ 342; figs;£9.95 paperback.) Edinburgh: Churc-hill Livingstone, 1989. ISBN 0-443-0384 1-4.Urinarv Calculi: ESWI., E'ndourologv,and Medical Therap,. J E Lingeman,L H Smith, J R Woods, et al. (Pp xvi+460; figs; £36.3).) Philadelphia: Leaand Febiger, 1989. ISBN 0-8121-1187-7.L'rological Pathology. W M Murphy.(Pp x+603; figs; colour plates; £78.)Philadelphia: Saunders, 1989. Dis-tributed by Harcourt Brace Jovano--ich. ISBN 0-7216-2417-0.

MiscellaneousGlossar- of Medical Ternminology tor theHealth Professions. Ed J Willey. Ppix+302; £18.25 paperback.) NewJersey: SLACK, 1988. Distributed byJohn Wiley and Sons. ISBN 1-55642-056-0.I'hc God Squad. P Doyle. (Pp 204;£3.99 paperback.) London: Corgi,1989. ISBN 0-552-13582-8.Li/fe in Research. D Richter. (Pp s-ii+170; £3.95 paperback.) Sutton: StuartPhillips Publications, 1989. ISBN1-869808-01-0.Loss of the Good Authoritt: the Cause ofDelinquency. TI'litt-Aitkens, A T Ellis.(Pp x+264; £14.95.) London: Viking,1989. ISBN 0-670-82493-3.On Art and Therapy: An Explsration.M Thomson. (Pp x + 118; £6.99 paper-back.) London: Virago, 1989. ISBN 1-85381-045-2.Positive Health Guides. "The BreastBook." j Cochrane, A Szarewski. (Ppsiii+ 135; figs; £5.99 paperback.)London: Optima, 1989. ISBN 0-356-15416-5.Tradition and the Biological Revolution:the Application of Je-awish Lazo to theTreatment of the Criticall-Y 111. D BSinclair. (IPp x+I18; £19.95.) Edin-burgh: Edinburgh University Press,1989. ISBN 0-85224-636-6.

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