Mrs Violet Cloudsdale · Prevention of Future Deaths report

On 22nd December 2014 an investigation was commenced into the death of Mrs Violet Cloudsdale, aged 99 years old. The investigation concluded at the end of the inquest on 16th September 2015. The conclusion of the inquest was accidental death. The medical cause of death was:

1. a Bronchopneumonia
2. Fractures of the left tibia, right humerus and left radius.
Cerebrovascular disease, Diabetes mellitus, Hypertension.

Mrs Cloudsdale was a resident at Lonsdale Nursing Home, Barrow-in-Furness. On 11th December 2014, she fell whilst unattended from a seated position in a stationary wheelchair and sustained fractures to the left tibia; right humerus and left radius. She died 5 days later from bronchopneumonia whilst being treated for her injuries at Furness General Hospital, Barrow-in-Furness.

(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.