Source · Prevention of Future Deaths
William Rice
Ref: 2026-0405
Date: 10 Aug 2026
Coroner: Guy Davies
Area: Cornwall & the Isles of Scilly
0 responses identified · 2 indexed addressees
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Response deadline: 5 October 2026 (stated in the report).
Date
10 Aug 2026
56-day deadline
5 Oct 2026
stated in the report
Responses identified
0 of 2
Coroner's concerns
William lived in a property owned by Cornwall Council. The decision whether to approve or refuse an adaptation such as a stairlift to Cornwall Council owned property is a matter for Cornwall Housing Ltd (CHL) under its adaptations policy.
View full coroner's concerns
William lived in a property owned by Cornwall Council. The decision whether to approve or refuse an adaptation such as a stairlift to Cornwall Council owned property is a matter for Cornwall Housing Ltd (CHL) under its adaptations policy. CHL is a company set up by Cornwall Council to manage and maintain its housing stock.
Adult Social Care (ASC) Therapy assessed William’s functional needs on 7 August 2025 and recommended the adaptation as being urgently required. ASC drafted and submitted the application for a stairlift on William’s behalf.
The application to CHL noted that there was a serious risk of William falling down the stairs due to significant issues of mobility and balance together with the fact that William needed to be able to safely access the staircase to fulfil caring responsibilities as sole carer for his wife who has dementia. The application also referred to the fact that William and his wife had lived at the property for 50 years and there was a support network in the locality. In addition to the risk to life there is also an indication that social services would incur significant costs as a result of any refusal of the application due to the need to provide additional social care in the absence of necessary adaptations.
The terms of the current adaptations policy do not take account of any of these factors. There are criteria which require applications for adaptations to be refused in all circumstances in which there is under or over occupancy. Williiam lived in a 3-bedroom property occupied by he and his wife. This was deemed to be under occupancy and the application was initially refused on that basis. At Inquest CHL witnesses mainatained that this was the correct decision under current policy. Therapists within ASC do not consider the CHL policy adequately addresses risk and wider circumstances. There are practitioners within CHL who consider the adaptations policy to be flawed. The court found that on two occasions the stairlift for Williiam’s property had been authorised as an exception to the policy. The evidence from CHL is that these decisions (exceptions being made to policy) were erroneous because there are no exceptions under the terms of the policy.
The court found that there has been no formal multi agency review of potential risks to life from strict application of current policy. ASC and CHL have conducted separate reviews leading to learnings which appear focused on communication rather than policy. These reviews and learnings have not addressed the concern of a risk of future deaths from the application by CHL of policy to future cases with similar facts to William’s.
Adult Social Care (ASC) Therapy assessed William’s functional needs on 7 August 2025 and recommended the adaptation as being urgently required. ASC drafted and submitted the application for a stairlift on William’s behalf.
The application to CHL noted that there was a serious risk of William falling down the stairs due to significant issues of mobility and balance together with the fact that William needed to be able to safely access the staircase to fulfil caring responsibilities as sole carer for his wife who has dementia. The application also referred to the fact that William and his wife had lived at the property for 50 years and there was a support network in the locality. In addition to the risk to life there is also an indication that social services would incur significant costs as a result of any refusal of the application due to the need to provide additional social care in the absence of necessary adaptations.
The terms of the current adaptations policy do not take account of any of these factors. There are criteria which require applications for adaptations to be refused in all circumstances in which there is under or over occupancy. Williiam lived in a 3-bedroom property occupied by he and his wife. This was deemed to be under occupancy and the application was initially refused on that basis. At Inquest CHL witnesses mainatained that this was the correct decision under current policy. Therapists within ASC do not consider the CHL policy adequately addresses risk and wider circumstances. There are practitioners within CHL who consider the adaptations policy to be flawed. The court found that on two occasions the stairlift for Williiam’s property had been authorised as an exception to the policy. The evidence from CHL is that these decisions (exceptions being made to policy) were erroneous because there are no exceptions under the terms of the policy.
The court found that there has been no formal multi agency review of potential risks to life from strict application of current policy. ASC and CHL have conducted separate reviews leading to learnings which appear focused on communication rather than policy. These reviews and learnings have not addressed the concern of a risk of future deaths from the application by CHL of policy to future cases with similar facts to William’s.
Report sections
Investigation and inquest
On 31 October 2025 the coroner service commenced an investigation into the death of 91-year-old William. The investigation concluded at the end of the inquest on 15 July 2026.
The medical cause of death was established on the evidence as follows:
1a Right Subdural, Subarachnoid, Right Rib Fractures 5-9, Large Right Pleural Effusion, Left Cerebellar Contusion
1b Fall
II Frailty
The four questions – who, when, where and how – were answered as follows:
William George RICE died on 22 October 2025 at Royal Cornwall Hospital Treliske Truro from trauma consistent with a fall downstairs on 20 October 2025 at his home address.
An assessment by adult social services (ASC) led to an urgent request on 13 August 2025 for Cornwall Housing Ltd (CHL) to install a stairlift at William’s home address. The urgent request was based upon a serious risk of William falling down the stairs due to significant issues of mobility and balance together with the fact that William needed to be able to safely access the staircase to fulfil caring responsibilities as sole carer for his wife who has dementia.
The request for a stairlift was refused on 3 September 2025 by CHL applying the terms of company policy. ASC were not notified of the refusal and only became aware of the fact of the refusal on 16 October 2025 on which date an immediate appeal was lodged. A decision by CHL to authorize the stairlift following the appeal was made on 23 October 2025 as an exception to the policy and unbeknown to the fact that William had fallen downstairs on 20 October 2025 and died on 22 October 2025.
The conclusion as to the death was as follows:
William died from catastrophic injuries sustained after falling down the stairs at his home whilst awaiting the outcome of an application process for the installation of a stairlift by Cornwall Housing Limited, this adaptation having been urgently requested by social services over two months before the fatal fall.
The medical cause of death was established on the evidence as follows:
1a Right Subdural, Subarachnoid, Right Rib Fractures 5-9, Large Right Pleural Effusion, Left Cerebellar Contusion
1b Fall
II Frailty
The four questions – who, when, where and how – were answered as follows:
William George RICE died on 22 October 2025 at Royal Cornwall Hospital Treliske Truro from trauma consistent with a fall downstairs on 20 October 2025 at his home address.
An assessment by adult social services (ASC) led to an urgent request on 13 August 2025 for Cornwall Housing Ltd (CHL) to install a stairlift at William’s home address. The urgent request was based upon a serious risk of William falling down the stairs due to significant issues of mobility and balance together with the fact that William needed to be able to safely access the staircase to fulfil caring responsibilities as sole carer for his wife who has dementia.
The request for a stairlift was refused on 3 September 2025 by CHL applying the terms of company policy. ASC were not notified of the refusal and only became aware of the fact of the refusal on 16 October 2025 on which date an immediate appeal was lodged. A decision by CHL to authorize the stairlift following the appeal was made on 23 October 2025 as an exception to the policy and unbeknown to the fact that William had fallen downstairs on 20 October 2025 and died on 22 October 2025.
The conclusion as to the death was as follows:
William died from catastrophic injuries sustained after falling down the stairs at his home whilst awaiting the outcome of an application process for the installation of a stairlift by Cornwall Housing Limited, this adaptation having been urgently requested by social services over two months before the fatal fall.
Circumstances of the death
The circumstances of William’s death are set out in the above answers to the four statutory questions (who, when, where and how).
I can add that it was found that if a more flexible policy had been applied (in the initial response to the application for a stairlift) taking account of wider circumstances, the outcome could possibly have been different.
I can add that it was found that if a more flexible policy had been applied (in the initial response to the application for a stairlift) taking account of wider circumstances, the outcome could possibly have been different.
Copies sent to
I can confirm I have sent the report to2. The Service Director for Adult Social Care, Cornwall CouncilSIGNATURE [REDACTED] HMC Guy DaviesWilliam RicePrevention of future deaths report20260405_PublishedDownload
Inquest conclusion
William died from catastrophic injuries sustained after falling down the stairs at his home whilst awaiting the outcome of an application process for the installation of a stairlift by Cornwall Housing Limited, this adaptation having been urgently requested by social services over two months before the fatal fall.
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Report details
- Reference
- 2026-0405
- Date of report
- 10 August 2026
- Coroner
- Guy Davies
- Coroner area
- Cornwall & the Isles of Scilly
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: 5 Oct 2026 (stated in the report).
Sent to
- Cornwall Council
- Cornwall Housing Limited