Recurring concern

Unreliable wheelchair fall-prevention controls

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First reported 25 Sep 2015•Latest report 16 Dec 2021

Definition

What this concern includes

Includes failures of controls specifically intended to prevent falls from wheelchairs, including consistent use or consideration of lap belts and other wheelchair restraints, wheelchair suitability, assessment of wheelchair fall risk, and protective arrangements that do not depend solely on staff intervening during a fall.

Not included

Excludes general falls-prevention failures where wheelchair use or a wheelchair-specific control is not material.
Excludes generic staffing, supervision or training deficiencies unless they directly undermine a wheelchair-specific fall-prevention control.
Excludes post-fall assessment, reporting or treatment failures unless they directly concern preventing a further fall from a wheelchair.
Excludes falls involving beds, toilets, stairs or other settings where no wheelchair fall-prevention control is identified.
Do not duplicate the broader existing concern concerning general control of falls risks when the assertion lacks a wheelchair-specific unsafe condition.

Reports: 4
Individual concerns: 10
Date range: 2015–2021
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission2

Cole Valley Care Limited1

Hc-One Limited1

Risedale Estates Limited1

Springfield Home Care Services Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

16 Dec2021
Newcastle upon Tyne and North Tyneside
Concerns raised1
1. Failure to refer wheelchair fit and seatbelt concerns to the correct specialist service
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  There were no reasonable grounds to suspect an offence under Regulations 12 and 22, so formal criminal investigation was not undertaken.
  Stated by Care Quality CommissionDisputes the concern
AI-generated summary

David Michael O’Brien · 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

David Michael O’Brien died at North Tyneside General Hospital after falling from his wheelchair, sustaining a hip fracture, and developing bronchopneumonia. Concerns included excessive wheelchair use despite advice that it was for mobility only, inadequate communication and record keeping between care providers, failure to undertake a risk assessment, and advice about the wheelchair not being followed.

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
Failure to refer wheelchair fit and seatbelt concerns to the correct specialist service
Wider context from the report
“3. Whilst Springfield Health Care contacted Occupational Therapy to report concerns that the wheelchair appeared too big and his seatbelt too loose, Occupational Therapy was not the correct service to address these issues. ”
Source location
David Michael O’Brien · Prevention of Future Deaths report
Page 2 · concerns
Open source report
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
There were no reasonable grounds to suspect an offence under Regulations 12 and 22, so formal criminal investigation was not undertaken.

Verbatim wording from the response
“The second took place after the inquest and took account of the evidence gathered during the coronial investigation and specifically the concerns raised at points 1-8 of your Regulation 28 report. In both cases the CQC concluded there were no reasonable grounds to suspect an offence under Regulations 12 and 22 RAR 2014 and no formal criminal investigation was undertaken.”

Source location
2022-0068-Response-from-CQC_Published
Page 2 · response
Published 8 March 2022
Open published response
12 Mar2019
East London
Concerns raised3
1. Failure to encourage wheelchair seatbelt use after falls
2. Failure to encourage compliance with wheelchair-fall prevention measures
3. Failure to plan measures to prevent wheelchair falls
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement organisation-wide multifactorial falls risk assessments, including reassessment, care planning, documentation and review requirements.
  Stated by Hc-One LimitedStated completed
Respondent positions 1
1. Position
  Falls among older people cannot always be prevented, although risks can be minimised and staff responses improved.
  Stated by Hc-One LimitedDisputes the concern
AI-generated summary

Mr Frederick Raymond BROOKER · 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

Mr Frederick Raymond Brooker, who used a wheelchair in a residential care home, sustained multiple falls, including a fall on 10 July 2018 that caused a catastrophic traumatic bleed and from which he died on 14 July 2018. The principal concerns were that, despite his recognised high risk of falling, the care home did not put adequate care plans or other measures in place, review the wheelchair or involve relevant services, investigate subsequent falls, or provide evidence of encouragement to use the wheelchair seatbelt.

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
Failure to encourage wheelchair seatbelt use after falls
Wider context from the report
“(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker’s mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt. ”
Source location
Mr Frederick Raymond BROOKER · Prevention of Future Deaths report
Page 2 · concerns
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 encourage compliance with wheelchair-fall prevention measures
Wider context from the report
“(4) There was reliance on the fact that Mr Brooker had mental capacity. This should not override the importance of care planning. Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence of a care plan to reduce the risk of falling from the wheelchair – or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe. The only record of Mr Brooker declining to use the wheelchair seatbelt, was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair. ”
Source location
Mr Frederick Raymond BROOKER · Prevention of Future Deaths report
Page 2 · concerns
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 plan measures to prevent wheelchair falls
Wider context from the report
“(4) There was reliance on the fact that Mr Brooker had mental capacity. This should not override the importance of care planning. Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence of a care plan to reduce the risk of falling from the wheelchair – or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe. The only record of Mr Brooker declining to use the wheelchair seatbelt, was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair. ”
Source location
Mr Frederick Raymond BROOKER · Prevention of Future Deaths report
Page 2 · concerns
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
Implement organisation-wide multifactorial falls risk assessments, including reassessment, care planning, documentation and review requirements.

Verbatim wording from the response
“a. Multi-factorial Risk Assessments”

Source location
2019-0097-Response-by-HC-One
Page 1 · response
Published 14 June 2019
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
Falls among older people cannot always be prevented, although risks can be minimised and staff responses improved.

Verbatim wording from the response
“Regrettably, it is not uncommon for older people to experience a fall, for a variety of reasons. Such falls cannot always be prevented but as an organisation we are committed to supporting people to maintain their safety wherever possible and to ensure that our Colleagues respond appropriately in the event that a fall does occur.”

Source location
2019-0097-Response-by-HC-One
Page 1 · response
Published 14 June 2019
Open published response
8 Feb2019
Birmingham and Solihull
Concerns raised3
1. Inadequate assurance of wheelchair-fall risk management
2. Inconsistent use of wheelchair lap belts across locations
3. Reliance on staff intervention during wheelchair falls
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement wheelchair risk assessments and lap-belt protocols, brief staff, provide care-folder access, and monitor compliance through management oversight.
  Stated by Cole Valley Nursing HomeStated completed
Respondent positions 1
1. Position
  Implemented control measures are considered sufficient to resolve the identified falls, wheelchair restraint and investigation concerns.
  Stated by Cole Valley Nursing HomeExisting arrangements considered sufficient
AI-generated summary

Jean Mary Cutler · 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

Jean Mary Cutler had severe dementia, osteoporosis and no independent mobility, and was at high risk of falling. On 5 October 2018 she fell from her wheelchair at Cole Valley Nursing Home, sustaining a fractured left femur, and died there on 18 October 2018. Concerns included inconsistent use of lap belts, reliance on staff intervention despite understaffing, and inadequate post-incident investigation and falls risk assessment.

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
Inadequate assurance of wheelchair-fall risk management
Wider context from the report
“3. I heard evidence that following the incident the Care Quality Commission and Clinical Commission Group had requested from the nursing home copies of revised risk management documents. In my opinion this has led to the nursing home being given the impression their management of residents from falling out of wheelchairs is adequate. ”
Source location
Jean Mary Cutler · Prevention of Future Deaths report
Page 1 · concerns
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
Inconsistent use of wheelchair lap belts across locations
Wider context from the report
“2. Pre-incident, the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; Outside the nursing home a lap belt would be attached to the wheelchair. Whereas inside the nursing home no lap belt was used. A member of staff was expected to be able to intervene when a resident was in the process of falling. ”
Source location
Jean Mary Cutler · Prevention of Future Deaths report
Page 1 · concerns
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
Reliance on staff intervention during wheelchair falls
Wider context from the report
“2. Pre-incident, the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; Outside the nursing home a lap belt would be attached to the wheelchair. Whereas inside the nursing home no lap belt was used. A member of staff was expected to be able to intervene when a resident was in the process of falling. ”
Source location
Jean Mary Cutler · Prevention of Future Deaths report
Page 1 · concerns
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
Implement wheelchair risk assessments and lap-belt protocols, brief staff, provide care-folder access, and monitor compliance through management oversight.

Verbatim wording from the response
“v) All nursing and care staff working at the Home have been made aware of the new Falls Risk Assessments and Wheelchair Risk Assessments during handover and in staff meetings. The new risk assessments are available within each person’s care folder – which staff have access to throughout the 24-hour period. The protocol for ensuring lap belts are used when people use their wheelchairs (as specified within the new Wheelchair Risk Assessment) has been reiterated to all staff and appropriate use and implementation is monitored by members of the Home’s management team.”

Source location
2019-0040-Response-by-Cole-Valley-Nursing-Home
Page 3 · response
Published 26 May 2019
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
Implemented control measures are considered sufficient to resolve the identified falls, wheelchair restraint and investigation concerns.

Verbatim wording from the response
“Cole Valley Nursing Home and its Directors accept and acknowledge the Coroner’s Concerns and believe that the control measures implemented by the Home serves to demonstrate how the Home and Cole Valley Care Ltd. have resolved said concerns - learning from both the inquest and the concerns detailed within your Regulation 28 report.”

Source location
2019-0040-Response-by-Cole-Valley-Nursing-Home
Page 3 · response
Published 26 May 2019
Open published response
25 Sep2015
Cumbria
Concerns raised3
1. Lack of risk assessment for the general use of wheelchair lap-belts
2. Failure to identify the consent of wheelchair users or their families to lap-belt use
3. Unclear guidance on the lawful use of wheelchair lap-belts
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs Violet Cloudsdale · 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

Mrs Violet Cloudsdale fell unattended from a stationary wheelchair on 11 December 2014, sustaining fractures, and died five days later from bronchopneumonia while being treated in hospital. Concerns included the absence of a risk assessment and consent consideration regarding use of the wheelchair lap-belt, uncertainty about whether lap-belts constituted unlawful restraint, and unclear guidance on their use.

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 risk assessment for the general use of wheelchair lap-belts
Wider context from the report
“(1) It was confirmed in evidence by ████████ that: a) Mrs Cloudsdale would have been less likely 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 would have indeed consented to the lap-belt being fastened to enhance her feeling of safety or security; d) There was a concern that utilising lap-belts may be construed as applying an unlawful restraint; e) Guidance on the use of lap-belts is unclear. A thorough review of your procedures with regard to the use of lap belts fitted to wheel chairs is required. ”
Source location
Mrs Violet Cloudsdale · Prevention of Future Deaths report
Page 1 · concerns
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 identify the consent of wheelchair users or their families to lap-belt use
Wider context from the report
“(1) It was confirmed in evidence by ████████ that: a) Mrs Cloudsdale would have been less likely 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 would have indeed consented to the lap-belt being fastened to enhance her feeling of safety or security; d) There was a concern that utilising lap-belts may be construed as applying an unlawful restraint; e) Guidance on the use of lap-belts is unclear. A thorough review of your procedures with regard to the use of lap belts fitted to wheel chairs is required. ”
Source location
Mrs Violet Cloudsdale · Prevention of Future Deaths report
Page 1 · concerns
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
Unclear guidance on the lawful use of wheelchair lap-belts
Wider context from the report
“(1) It was confirmed in evidence by ████████ that: a) Mrs Cloudsdale would have been less likely 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 would have indeed consented to the lap-belt being fastened to enhance her feeling of safety or security; d) There was a concern that utilising lap-belts may be construed as applying an unlawful restraint; e) Guidance on the use of lap-belts is unclear. A thorough review of your procedures with regard to the use of lap belts fitted to wheel chairs is required. ”
Source location
Mrs Violet Cloudsdale · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to refer wheelchair fit and seatbelt concerns to the correct specialist service

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised3

Failure to encourage wheelchair seatbelt use after falls

Failure to encourage compliance with wheelchair-fall prevention measures

Failure to plan measures to prevent wheelchair falls

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised3

Inadequate assurance of wheelchair-fall risk management

Inconsistent use of wheelchair lap belts across locations

Reliance on staff intervention during wheelchair falls

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised3

Lack of risk assessment for the general use of wheelchair lap-belts

Failure to identify the consent of wheelchair users or their families to lap-belt use

Unclear guidance on the lawful use of wheelchair lap-belts

Respondent positions 1

Actions described in response 1

Respondent positions 1

Actions described in response 1

Respondent positions 1