14 Apr 2026 Susan Toft · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Failure to assess and maintain adequate vehicle occupant-restraint fit for the wheelchair and wheelchair user View source Failure to provide reliable seat-cushion attachment during repeated fitting and removal View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Susan Toft · 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
Susan Toft, a wheelchair user, was injured when her adapted vehicle braked suddenly and she slipped from her wheelchair into the passenger footwell. She later died in hospital from myocardial infarction and pneumonia, with sepsis and fractures also recorded in the medical cause of death. Concerns included failure of the wheelchair cushion attachment and inadequate fitting of the vehicle seat belt to her wheelchair and position.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Healthcare Trades Association; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and maintain adequate vehicle occupant-restraint fit for the wheelchair and wheelchair user
Wider context from the report “Concern Two
Section 5 of the above said Guidelines sets out in some detail the importance of ensuring the adequacy of the fit of the vehicle restraint system to the individual wheelchair and wheelchair user .
It was surprising therefore to learn at the inquest that upon collecting the adapted vehicle STs husband was only given a demonstration of how to secure the wheelchair to the vehicle. That there was no assessment of any need to make adjustments to the vehicle occupant restraints to ensure an adequate fit by assessing ST’s position and safety in the vehicle, using her current wheelchair, and to advise a reassessment should the wheelchair be changed .
As a consequence, the vehicle occupant seat belt did not fit properly across ST’s lap , contributing to her being thrown into the footwell.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Healthcare Trades Association; that does not assign responsibility.
PFD Monitor interpretation Failure to provide reliable seat-cushion attachment during repeated fitting and removal
Wider context from the report “Concern One
Section 4.5 deals with the seat cushion, and 4.5.1 – cushion attachment.
From a seating function perspective, the stability of a cushion is a fundamental requirement. Therefore, the means of attachment of the cushion to the wheelchair support surface needs to be capable of repeated fitting and removal without impairment or deterioration . Cushions may need to be frequently removed for cleaning and maintenance, and an individual user may have a number of cushions for short or long term use.
This cushion’s attachment failed after just 9 months of use.
The above said Guidelines state that Velcro is strong in shear but less so in tension.
Also that the adhesive must have sufficient shear strength. It seems that repeated removal of the cushion for cleaning and maintenance risks exceeding and weakening the relative strengths of the Velcro system itself and the adhesive used to secure the Velcro strip to the wheelchair base .
In the circumstances my concern is that there may be more robust and more reliable methods of securing the seat cushion to the wheelchair base, that would negate the risk of detachment , as occurred in this case.
” Open source report
23 Mar 2015 Joseph Allison · Prevention of Future Deaths report London (East)
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Concerns raised 5 Failure to train in-house service engineers to recognise the Minivator 2000 defect View source Unavailability of feeler gauges for the appropriate Minivator 2000 safety check View source Failure to adequately advise the stairlift industry of risks in unimproved Minivator 2000 stairlifts View source Exposure of service engineers to Minivator 2000 stairlift risks during test rides View source Failure to undertake a nationally publicised safety recall campaign for end-users View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Remind manufacturing members to continue providing field-safety training until affected products are traced and necessary action is taken.
View source
Action
Reiterate to manufacturers the need for written dealer agreements covering recalls and field-safety work, and for using industry channels to raise awareness.
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AI-generated summary
Joseph Allison · 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 Allison died after the upper trunnion assembly of his Minivator 2000 stairlift failed, throwing him down the stairs and causing cervical vertebrae and head injuries. He subsequently died from bronchopneumonia. Concerns included inadequate training and equipment for service engineers, the absence of a nationally publicised safety recall, and insufficient communication to the stairlift industry about the risks of unimproved stairlifts.
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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. The report was sent to British Healthcare Trades Association; that does not assign responsibility.
PFD Monitor interpretation Failure to train in-house service engineers to recognise the Minivator 2000 defect
Wider context from the report “(1) In-house service engineers have not been specifically trained to be aware of the defect in the Minivator 2000 , nor issued with feeler gauges to implement the appropriate safety check
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Healthcare Trades Association; that does not assign responsibility.
PFD Monitor interpretation Unavailability of feeler gauges for the appropriate Minivator 2000 safety check
Wider context from the report “(1) In-house service engineers have not been specifically trained to be aware of the defect in the Minivator 2000, nor issued with feeler gauges to implement the appropriate safety check
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Healthcare Trades Association; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately advise the stairlift industry of risks in unimproved Minivator 2000 stairlifts
Wider context from the report “(4) No or no adequate initiative has been taken to advise the stairlift industry generally of the risks inherent in unimproved Minivator 2000 stairlifts
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Healthcare Trades Association; that does not assign responsibility.
PFD Monitor interpretation Exposure of service engineers to Minivator 2000 stairlift risks during test rides
Wider context from the report “(2) In-house and third party service engineers are thereby exposed to the same risks which end-users face if they test-ride the serviced stairlifts themselves
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to British Healthcare Trades Association; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake a nationally publicised safety recall campaign for end-users
Wider context from the report “(3) No nationally publicised safety recall campaign has been undertaken to alert end-users to the danger, or request that such users contact the manufacturer for access to the remedial programme
” 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 Remind manufacturing members to continue providing field-safety training until affected products are traced and necessary action is taken.
Verbatim wording from the response “1 and 2 - we are satisfied that Handicare has adjusted internal process and training to ensure that appropriate training is provided to the in-house engineers on an ongoing basis. BHTA will remind all its manufacturing members that if training is necessary to address a field safety issue the training must continue to be provided until such time as all the products have been traced and the necessary action taken.” Source location 2015-0103-Response-by-BHTA
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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 Reiterate to manufacturers the need for written dealer agreements covering recalls and field-safety work, and for using industry channels to raise awareness.
Verbatim wording from the response “4 The business did raise the matter at one of our meetings (minutes of which are distributed to all relevant members) and we have discussed how to improve notifications and co-operation throughout the supply chain. We will reiterate to manufacturers the need to have written agreement with their dealers setting out what will be expected of them in the event of a recall or the need for field safety work; and that they should make full use of ourselves and the publications read by businesses in the sector to raise awareness.” Source location 2015-0103-Response-by-BHTA
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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 Handicare's adjusted internal processes and ongoing engineer training are considered sufficient to ensure appropriate training.
Verbatim wording from the response “1 and 2 - we are satisfied that Handicare has adjusted internal process and training to ensure that appropriate training is provided to the in-house engineers on an ongoing basis. BHTA will remind all its manufacturing members that if training is necessary to address a field safety issue the training must continue to be provided until such time as all the products have been traced and the necessary action taken.” Source location 2015-0103-Response-by-BHTA
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations