Concerns raised 11 Failure to follow specialist advice to stop wheelchair use when it was unsafe View source Poor record keeping of safety-relevant care information View source Poor communication of safety-relevant information between staff View source Failure to refer wheelchair fit and seatbelt concerns to the correct specialist service View source Failure to identify which agencies are responsible for client assistance View source Risk of wheelchair toppling for partially sighted and top-heavy users View source Failure to restrict wheelchair use to mobility when no safe alternative seating was available View source Failure to communicate specialist wheelchair assessment and advice to care staff View source Failure to follow mobility-only wheelchair advice and provide safe general seating View source Failure to obtain a risk assessment of wheelchair use View source Failure to document and follow advice from other agencies View source See 8 more concerns
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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. The report was sent to Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to follow specialist advice to stop wheelchair use when it was unsafe
Wider context from the report “4. The evidence from Occupational Therapy contained a clear and contemporaneous note dated 7.11.09 that they informed Springfield Health Care that they were not the correct service and provided contact details for Wheelchair Services. Advice is clearly documented within the evidence from Occupational Therapy that “we cannot assess a wheelchair no matter how urgent and they must contact Wheelchair Services.” The note goes on to state, “[Springfield Health Care] advised client is at severe risk of falling or choking and duty OT advised that client should be maintained in bed if he cannot safely access his wheelchair.” Springfield Health Care “does not recall that advice. Mr O’Brien continued to use the wheelchair every day following this advice , being transferred by hoist into it by his carers.
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Poor record keeping of safety-relevant care information
Wider context from the report “7. The evidence that I heard suggests that Springfield Health Care have poor record keeping and poor communication between staff. It also suggests that as an agency, it is not aware of which agencies are responsible for providing assistance to its clients. Advice given by other agencies appears not to have been documented or followed.
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Poor communication of safety-relevant information between staff
Wider context from the report “7. The evidence that I heard suggests that Springfield Health Care have poor record keeping and poor communication between staff . It also suggests that as an agency, it is not aware of which agencies are responsible for providing assistance to its clients. Advice given by other agencies appears not to have been documented or followed.
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
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 .
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to identify which agencies are responsible for client assistance
Wider context from the report “7. The evidence that I heard suggests that Springfield Health Care have poor record keeping and poor communication between staff. It also suggests that as an agency, it is not aware of which agencies are responsible for providing assistance to its clients . Advice given by other agencies appears not to have been documented or followed.
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Risk of wheelchair toppling for partially sighted and top-heavy users
Wider context from the report “2. Carers from Springfield Health Care gave evidence that Mr O’Brien’s use of the wheelchair was “an accident waiting to happen” as he was partially sighted, “top heavy and could topple over out of his chair” .
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict wheelchair use to mobility when no safe alternative seating was available
Wider context from the report “1. I heard evidence from Springfield Health Care Services that Mr O’Brien was using his wheelchair throughout the day and was either in bed or transferred to his wheelchair with nowhere else for him to safely sit . This excessive use was contrary to advice from Wheelchair Services , who had advised that the wheelchair was only to be used as a mobility aid .
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate specialist wheelchair assessment and advice to care staff
Wider context from the report “6. Springfield Health Care state that they were not aware of the assessment on 20.12.19 by Wheelchair Services or the advice given, despite one of their carers being present during the assessment . On 1.1.2020 Mr O’Brien fell from his wheelchair sustaining injuries which ultimately led to his death.
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to follow mobility-only wheelchair advice and provide safe general seating
Wider context from the report “5. Evidence from Wheelchair Services was that an assessment of the wheelchair took place in Mr O’Brien’s home on 20.12.19. Mr O’Brien and one of his regular carers from Springfield Health Care were present. His seatbelt was tightened and advice was given by Wheelchair Services that the wheelchair was only for use to mobilise and not for general seating . Notwithstanding this advice, Mr O’Brien continued to use the wheelchair throughout the day as his only seating option and was assisted into it by hoist by his carers.
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain a risk assessment of wheelchair use
Wider context from the report “8. Springfield Healthcare accepts that it had not undertaken a risk assessment of Mr O’Brien’s use of the wheelchair , nor had it requested such an assessment be carried out by another agency .
” 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 Springfield Home Care Services Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document and follow advice from other agencies
Wider context from the report “7. The evidence that I heard suggests that Springfield Health Care have poor record keeping and poor communication between staff. It also suggests that as an agency, it is not aware of which agencies are responsible for providing assistance to its clients. Advice given by other agencies appears not to have been documented or followed .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations