31 Oct 2023 Evelyn Ann Burcham · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 4
Unavailability of riser-recliner chairs with controls that limit unauthorised use View source Failure to assess and mitigate the risk of cognitively impaired residents accessing riser-recliner chair controls View source Health and safety risk from disabling riser-recliner chair controls at the mains View source
Risk of death to other residents from cognitively impaired residents operating riser-recliner chair controls View source See 1 more concern
Linked responses
Aria Care Group Department of Health and Social Care Health and Safety Executive
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Aria Care Group
Process all future riser/recliner chair orders through Shackleton’s and fit supplied chairs with lockable handsets.
View source
Aria Care Group
Work with residents and families to replace privately owned riser/recliner chairs lacking lockable handsets.
View source
Aria Care Group
Explore and develop a potentially universal lockable cover to restrict access to riser/recliner handset controls.
View source
Aria Care Group
Use compatible Shackleton’s controls to reduce unauthorised access while universal covers are developed.
View source
Aria Care Group
Use generic and resident-specific risk assessments requiring safe chair positioning and electrical isolation where residents cannot independently control chairs.
View source
Aria Care Group
Reduce riser/recliner chair use through a phased approach and purchase assessed-need furniture solely from Shackleton’s with lockable handsets.
View source
Health and Safety Executive
Notify the Office for Product Safety and Standards about the incident for consumer-product safety consideration.
View source See 4 more actions
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AI-generated summary
Evelyn Ann Burcham · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Evelyn Ann Burcham, who had dementia and required full care, was tipped from a riser-recliner chair after another resident accessed and operated its remote control while it was unattended. She sustained a severe brain bleed and died ten days later. The principal concern was that the risk of cognitively impaired residents accessing and operating chair controls had not been foreseen, and that the chairs lacked a suitable safety feature to restrict access to the controls.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of riser-recliner chairs with controls that limit unauthorised use
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” Source location Evelyn Ann Burcham · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess and mitigate the risk of cognitively impaired residents accessing riser-recliner chair controls
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” Source location Evelyn Ann Burcham · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Health and safety risk from disabling riser-recliner chair controls at the mains
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” Source location Evelyn Ann Burcham · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Risk of death to other residents from cognitively impaired residents operating riser-recliner chair controls
Wider context from the report “I am concerned that these chairs are common place in care home settings where residents suffer from cognitive impairment. The risks of another resident with dementia accessing the controls of the riser-recliner chair(s) was not foreseen by the Home and so was not factored into any operative risk assessment at the time; hence no measures were in place to minimise the risk. There remains a real and immediate risk that those with a cognitive impairment that manifests itself in a compulsion to fiddle and/or press buttons, can create a risk of death to other residents in the same care facility or setting. If this particular care home group did not foresee the risk then it is likely that others have not foreseen it either.
I was told at the Home had made enquiries with manufacturers of these standard riser-recliner chairs about the ability to ‘lock’ the remote control and/or find a safe was of storing it so that it is not accessible to anyone who does not have the authority, training or appropriate cognitive function to be able to use it safely. It would appear that a chair with a ‘safe’ remote cannot be purchased by the Home and there do not appear to be any regulatory or manufacturing standards (over and above manufacturing standards for consumers) that require these types of chairs to have this, or some alternative, safety feature that limits the use of the controls. I was told that the only way to render the remote ‘safe’ was to turn the power off at the mains, which in itself could create health and safety issues if the chair needed to be operated quickly.
” Source location Evelyn Ann Burcham · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Process all future riser/recliner chair orders through Shackleton’s and fit supplied chairs with lockable handsets.
Verbatim wording from the response “Following receipt of the request, Aria Care reached out to Shackleton’s, our furniture supply partner seeking advice and guidance on riser/recliner chairs and the potential for purchase and supply of handsets that could be locked in a secure position and avoid unauthorised access and repositioning.” Source location Response from Aria Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with residents and families to replace privately owned riser/recliner chairs lacking lockable handsets.
Verbatim wording from the response “Where residents are currently living in our care homes and have purchased privately their riser/recliner chair, and this device is not fitted with a lockable handset, we will work with that resident and/or their family to seek a solution and ensure the riser/recliner is replaced by a chair that has a lockable handset. We anticipate this may take the first quarter of 2024 to fully resolve, where the equipment supplied is privately owned and already in use.” Source location Response from Aria Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Explore and develop a potentially universal lockable cover to restrict access to riser/recliner handset controls.
Verbatim wording from the response “In the meantime, our property services department are working with NH Maintenance (NHM), to explore other options, including the development of a cover that could potentially be used universally, to restrict access to the handset controls, this device would be lockable.” Source location Response from Aria Care
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use compatible Shackleton’s controls to reduce unauthorised access while universal covers are developed.
Verbatim wording from the response “Whilst waiting on the development by NHM, we will look to use the controls provided by Shackleton’s to reduce unauthorised access to riser/recliner chair controls, where they are compatible. For chairs where we cannot control access via the introduction of the covers, we have introduced generic and individualised risk assessments which include the requirement to:” Source location Response from Aria Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use generic and resident-specific risk assessments requiring safe chair positioning and electrical isolation where residents cannot independently control chairs.
Verbatim wording from the response “Whilst waiting on the development by NHM, we will look to use the controls provided by Shackleton’s to reduce unauthorised access to riser/recliner chair controls, where they are compatible. For chairs where we cannot control access via the introduction of the covers, we have introduced generic and individualised risk assessments which include the requirement to:” Source location Response from Aria Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reduce riser/recliner chair use through a phased approach and purchase assessed-need furniture solely from Shackleton’s with lockable handsets.
Verbatim wording from the response “5) Agreement that via a phased approach Aria Care will reduce the use of riser/recliner chairs across the organisation and where an assessed need exists, riser/recliner furniture will be purchased solely from Shackleton’s, as our furniture partner, with lockable handsets.” Source location Response from Aria Care
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify the Office for Product Safety and Standards about the incident for consumer-product safety consideration.
Verbatim wording from the response “After receiving your report, HSE contacted the other regulatory bodies who may have an interest or potential regulatory role in respect of this incident. We have written to CQC (who are already in receipt of your report) on the patient safety aspects. HSE has also notified the Office for Product Safety and Standards (OPSS) who are the national regulator for consumer products and who work with the local authority Trading Standards services that undertake most enforcement activity.” Source location Response from Health and Safety Executives
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A universal lockable handset cannot be supplied because riser/recliner chairs use different manufacturers, and some chairs are incompatible with available handsets.
Verbatim wording from the response “Following receipt of the request, Aria Care reached out to Shackleton’s, our furniture supply partner seeking advice and guidance on riser/recliner chairs and the potential for purchase and supply of handsets that could be locked in a secure position and avoid unauthorised access and repositioning.” Source location Response from Aria Care
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A universal lockable handset cover cannot provide an immediate short-term solution because development and trial may take two to three months.
Verbatim wording from the response “In the meantime, our property services department are working with NH Maintenance (NHM), to explore other options, including the development of a cover that could potentially be used universally, to restrict access to the handset controls, this device would be lockable.” Source location Response from Aria Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consumer-product safety enforcement for chairs purchasable for domestic use normally falls to local-authority Trading Standards, not HSE.
Verbatim wording from the response “With regard to product safety matters, the chair involved in this tragic incident would appear to meet the definition of a ‘machine’, and therefore the relevant supply legislation would be the Supply of Machinery (Safety) Regulations 2008, which implemented the EU Machinery Directive 2006/42/EC in GB.” Source location Response from Health and Safety Executives
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC cannot take further enforcement action because there is insufficient evidence linking the incident directly to a registered person.
Verbatim wording from the response “investigator from CQC’s national enforcement team; investigations are now complete, and it has been adjudged that CQC has no basis to take further action as there is insufficient evidence linking this directly to a registered person. The family were made aware of the outcome of CQC’s decision and CQC will continue to monitor the provider.” Source location Response from Department of Health and Social Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Service-user safety enforcement in registered care homes is outside HSE’s remit.
Verbatim wording from the response “In England, the Care Quality Commission (CQC) is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC. The Memorandum of Understanding between CQC and HSE explains the respective roles and responsibilities of each organisation with regard to health and safety incidents in the health and adult social care sectors.” Source location Response from Health and Safety Executives
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation CQC is responsible for regulating safety, treatment and care matters involving service users in registered care homes.
Verbatim wording from the response “In England, the Care Quality Commission (CQC) is the lead inspection and enforcement body for safety and quality of treatment and care matters involving patients and service users in receipt of a health or adult social care service from a provider registered with CQC. The Memorandum of Understanding between CQC and HSE explains the respective roles and responsibilities of each organisation with regard to health and safety incidents in the health and adult social care sectors.” Source location Response from Health and Safety Executives
Open published response
3 Jul 2017 Joseph Francis De Pellegrino-Farrugia · Prevention of Future Deaths report North Yorkshire (West)
View report summary
Concerns raised 1
Lack of chair sensors to detect a foot in the mechanism View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 1
AJ Way Co Ltd
Fit sensor strips or protective screens beneath chair sides and backs where entrapment risk is identified.
View source
×
AI-generated summary
Joseph Francis De Pellegrino-Farrugia · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Joseph Francis De Pellegrino-Farrugia, a 92-year-old man with dementia, was injured when his foot became trapped in the mechanism of his electric reclining chair during a transfer to a commode. He sustained crush injuries and ongoing ulceration and necrosis of his left great toe, and died at home on 20 December 2016; the injury contributed to his death. Evidence raised concern that the chair lacked sensors to detect and release a trapped foot.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of chair sensors to detect a foot in the mechanism
Wider context from the report “Evidence was heard to the effect that the chair was not fitted with sensors which would have detected the presence of the foot in the mechanism to prevent the crushing injury and to release the foot.
” Source location Joseph Francis De Pellegrino-Farrugia · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fit sensor strips or protective screens beneath chair sides and backs where entrapment risk is identified.
Verbatim wording from the response “AJ Ways can and do fit a sensor strips or a protective screen to the underside of the side and back of the chair to avoid accidental trapping. These are not a mandatory attachment and therefore are only added to the chair in response to orders placed by the retailer who sells the chair to a consumer who identifies that there may be a risk of entrapment to small children and animals.” Source location 2017-0430-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Sensors are unsuitable for front legrest entrapment because the legrest flexes, so they cannot address the accident mechanism.
Verbatim wording from the response “Having looked at the evidence presented on how this accident happened I can see that the entrapment occurred at the front of the chair underneath the legrest, the sensors that are used are not suitable for this part of the chair due to the fact that the legrest flexes hence highlighting this in the user instructions.” Source location 2017-0430-Response
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Protective sensors are added only when retailers order them after identifying an entrapment risk.
Verbatim wording from the response “AJ Ways can and do fit a sensor strips or a protective screen to the underside of the side and back of the chair to avoid accidental trapping. These are not a mandatory attachment and therefore are only added to the chair in response to orders placed by the retailer who sells the chair to a consumer who identifies that there may be a risk of entrapment to small children and animals.” Source location 2017-0430-Response
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.