Source · Prevention of Future Deaths
Violet Cloudsdale
Ref: 2015-0387
Date: 25 Sep 2015
Coroner: Paul O’Donnell
Area: Cumbria
Responses identified: 0 / 2
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The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.
Date
25 Sep 2015
56-day deadline
20 Nov 2015 est.
Responses identified
0 of 2
Coroner's concerns
The care home lacked risk assessments and consent for wheelchair lap-belt use, and unclear guidance on their application raised concerns about unlawful restraint, contributing to a fall.
View full coroner's concerns
(1) It was confirmed in evidence by (that: a) Mrs Cloudsdale would have been less to have fallen if the lap-belt which was fitted to the wheelchair had been fastened; b) No risk assessment had been undertaken as to whether the lap-belt should generally have been utilised; c) No attempt had been made to identify whether Mrs Cloudsdale or her family have indeed consented to the lap-belt being fastened to enhance her feeling of safety or security; There was a concern that utilising lap-belts may be construed as applying an unlawful restraint; Guidance on the use of lap-belts is unclear. Care likely would
A thorough review of your procedures with regard to the use of lap belts fitted to wheel chairs is required.
A thorough review of your procedures with regard to the use of lap belts fitted to wheel chairs is required.
Report sections
Investigation and inquest
On 22nd December 2014 an investigation was commenced into the death of Mrs Violet Cloudsdale, aged 99 years old The investigation concluded at the end of the inquest on 16"h September 2015. The conclusion of the inquest was accidental death. The medical cause of death was: a Bronchopneumonia
2. Fractures of the left tibia, right humerus and left radius. Cerebrovascular disease_ Diabetes mellitus Hypertension_
2. Fractures of the left tibia, right humerus and left radius. Cerebrovascular disease_ Diabetes mellitus Hypertension_
Circumstances of the death
Mrs Cloudsdale was a resident at Lonsdale Nursing Home, Barrow-in-Furness On 11t December 2014, she fell whilst unattended from a seated position in a stationary wheelchair and sustained fractures to the left tibia; right humerus and left radius_ She died 5 days later from bronchopneumonia whilst being treated for her injuries at Furness General Hospital, Barrow-in-Furness_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
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Report details
- Reference
- 2015-0387
- Date of report
- 25 September 2015
- Coroner
- Paul O’Donnell
- Coroner area
- Cumbria
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 20 Nov 2015 (estimated).
Sent to
- Care Quality Commission
- Risedale Estates Limited