HM Coroner for Pembrokeshire, Mr. Michael Howells, stressed the importance of having gas boilers regularly serviced after a Cresselly couple died from carbon monoxide poisoning while taking a shower.

An inquest in Milford Haven recorded verdicts of death by misadventure on 31-year-old Karl Hone Bissett and his partner 21-year-old Rosalyn Harris, who were found unconscious on the floor of a shower room at Schwandi, Cresselly, on September 15 last year.

WPC Sharron Gibby, of Tenby police station, told the inquest that the emergency services had been called to Schwandi at 1.43 pm on the afternoon in question, after the couple had been discovered by Miss Harris's father, Mr. John Harris.

Miss Harris and Mr. Bissett had returned to stay with Miss Harris's parents at the family home the week before after previously living with Mr. Bissett's mother in Plymouth.

The couple had met in April of 2001 and that morning had taken Miss Harris's three-year-old son by a previous relationship to visit his father in Pembroke Dock.

WPC Gibby explained that the Harris family had lived at Schwandi for some 15 years, with Mrs. Brenda Harris's mother living with them in a granny annex which had been converted from an integral garage before the family had acquired the property.

The gas cooker in the annex was supplied by bottled gas located outside. This gas also supplied a shower in the downstairs bathroom.

WPC Gibby explained that Mr. John Harris and his son Matthew had both used the shower earlier that morning.

Mrs. Harris and Matthew had then gone off to an antiques fayre in Carmarthen.

When Miss Harris and Mr. Bissett returned from Pembroke Dock at around 12.25 pm, Miss Harris had indicated that she was going to have a shower.

Mr. Harris had gone out to pick some blackberries and, on his return, prepared some lunch for his mother-in-law, who was feeling unwell and had stayed in bed.

At around 1.15 pm he became concerned as to where his daughter and Mr. Bissett were.

He went to the shower room and knocked on the door. He could hear the shower going, but had no answer.

He felt that the couple may not have answered as they were embarrassed over the fact that they were showering together, so he went back outside.

On his return 10 minutes later he again knocked on the door, becoming increasingly concerned when they again failed to answer.

Mr. Harris went to see his neighbour, Mrs. Rosemary Griffiths, of Avondale, and they managed to gain access to the bathroom to find Mr. Bissett and Miss Harris lying together on the floor.

The shower curtain was wrapped around Miss Harris's face, giving the impression that the couple had collapsed and fallen out of the shower.

Mr. Harris and Mrs. Griffiths managed to get the couple out of the shower room and began mouth-to-mouth resuscitation, Mrs. Griffiths's husband, Trevor, coming in and taking over while Mrs. Griffiths contacted the emergency services.

An ambulance from Tenby, crewed by Mike Tebbutt and Adrian Aldman, arrived and took over CPR. A second ambulance arrived from Haverfordwest and the couple were conveyed to Withybush Hospital, but were declared dead on arrival.

Mr. Harris told the inquest that, while he had lived at Schwandi for over 15 years, the gas boiler heating the shower had never been serviced to his knowledge.

He used the shower at least once every day, sometimes twice, and his son and wife also used it quite regularly.

Mr. Harris said that he usually showered with the window open, although this was not always the case for his wife and son. There was also an extractor fan in the room to counteract condensation.

He admitted that he never realised that the boiler should have been serviced regularly, but added that it had never gone wrong in the time the family had been there.

He could not recall any unusual smell in the shower room when he and Mrs. Griffiths gained access.

Mr. Griffiths said that he had been watching television when he noticed Mr. Harris speaking to his wife, who was in the garden.

A short while later she came back to say that Miss Harris and Mr. Bissett appeared to be trapped in the shower room, but she and Mr. Harris could not open the door.

"I went next door to help while Rosemary used our portable telephone to call the emergency services," Mr. Griffiths explained.

On entering Schwandi, Mr. Griffiths saw that Mr. Harris had managed to get the shower room door ajar and together they managed to open the door fully.

Mr. Griffiths said that he could not smell anything in the room, but suggested that Mr. Harris open the window and turn the shower off to get some ventilation in.

Mrs. Griffiths had been cut off, as she was out of range for her 'phone, so Mr. Griffiths had used the 'phone at Schwandi to call 999. Mrs. Griffiths had then tried mouth-to-mouth on Miss Harris.

Mr. Griffiths then took over from his wife, while she relayed instructions received from over the 'phone.

Mr. Griffiths said he could feel no pulse and did not notice Miss Harris breathing.

Local plumbing and heating engineer, Mr. Gerald Hicks, of 2 Pisgah Cottages, told the inquest that he had extended the pipe outside, to move the gas bottles further away from their original location, but had not carried out any work on the boiler.

He said that he had had experience of gas heating installations as an apprentice and later in his career, but had not worked on them for some years as he was not Corgi registered.

He had never been asked to look at the boiler or service it because the family had never had any problem with it.

"They never asked my opinion on it, and I never ventured one," he said. "If I had been asked to look at it, I would have said if I felt it was inadequate."

Tests on the boiler were carried out on behalf of the Health and Safety Executive by Mr. Howard Reed.

He said that the heater was installed in approximately 1983 or '84 and there had been no indications that it had been serviced since then.

Mr. Reed told the inquest that the flue installation did not comply with either the manufacturers instruction or British safety standards, as it was bent at almost 90 degrees straight from the appliance and was not discharging exhaust gases safely.

"By today's standards, such a shower would not be allowed in such a location," he said.

He said that without the window being open, the extractor fan was pulling flue gases back into the shower room to replace the air it was removing.

The heat exchanger fins in the boiler were also "quite blocked."

"It was not burning efficiently and producing quite high levels of carbon monoxide," he said.

He added that carbon monoxide was odourless and colourless and was not usually detected by the general public.

Wind could also have an effect by blowing exhaust gases back down the flue and two tests on levels of carbon monoxide in the room on the Monday and Tuesday after the incident had produced higher readings in windier conditions.

However, he could not comment on how windy it had been on the Saturday and whether this had been a contributory factor.

A post mortem undertaken by Dr. Meville Jones at Withybush Hospital gave the cause of death in both cases as carbon monoxide poisoning.

Mr. Howells said that from evidence it was clear that the flue for the boiler had not been properly constructed and was not in accordance with British standards or manufacturers instructions.

"Normally the window in the room was left open when people showered, which alleviated the problem somewhat," said Mr. Howells. "If the window was shut, the only way for the fan to draw air in to replace air extracted was through the flue, drawing the gases back into the shower room.

"In recording a verdict, an accident is something which happens when people do not have control over events.

"In my opinion, the appropriate verdict is one of misadventure, as something that was controllable went wrong.

"No-one intended it to go wrong, but there was clearly something not right with the shower room."

Extending his sympathy to the family, Mr. Howells added that this tragedy showed the importance of having gas appliances serviced regularly.

He also praised neighbours Mr. and Mrs. Griffiths for the assistance they gave.

"I commend you for your attempts to resuscitate the couple in such circumstances," he said

"This went beyond the bounds of good neighbourliness and the assistance you gave was tremendous."