Jacqueline Mary LANGWORTHY · Prevention of Future Deaths report

On 24 October 2024 I commenced an investigation into the death of Jacqueline Mary LANGWORTHY, 61. The investigation concluded at the end of the inquest, heard before a jury,

from 7 July 2025 to 10 July 2025.

The conclusion of the inquest was:

Accident

The cause of death was:
1a

Asphyxiation

1b.

1c .

II .

Miss Langworthy was an experienced care assistant who had recently begun employment at a care home, where she was shadowing more senior members of staff. The home was equipped with a platform lift, intended for transporting wheelchair users accompanied by a carer. It was also used to move bulky equipment, although care home policy prohibited staff from travelling in the lift with equipment.

For reasons that remain unclear, Miss Langworthy entered the lift with stand aid. As the lift descended, the wheels of the stand aid caught on the edge of the lift platform, causing it to become wedged and pin Miss Langworthy against the wall of the lift shaft. Although she was able to call for help, Miss Langworthy could not reach the controls. The platform continued to descend, suspending her mid-air.
By the time she was freed, she was unresponsive, and resuscitation was unsuccessful.

An experienced HSE engineer examined the lift and confirmed there were no mechanical defects in either the lift or the stand aid. The engineer found that, once the downward toggle switch had been activated, the platform continued to move under latch control, placing the controls out of Miss Langworthy’s reach, as she remained trapped above the platform. The platform could not be stopped via the control wall pressure switch while descending.

The engineer noted that such risks were known within the industry, with a history of wheelchair users being injured in similar circumstances. She explained that “hold-to-run” controls—now a requirement under current standards (BS EN 81-41:2010)—would likely have prevented the incident, as the passenger would be expected to release the control in the event of danger. However, the lift pre-dated this requirement (BS 6440:1999), and such standards are not applied retrospectively.

(1) Many platform lifts still in use in care settings and other premises do not have hold-to-run controls.

(2) Evidence was received indicating that such controls can be retrofitted at relatively low cost.

(3) There is limited awareness of both the risks posed by the absence of hold-to-run devices and the feasibility of fitting such devices to existing platform lifts.