Gloria Linton · Prevention of Future Deaths report

On 30/08/2022 I commenced an investigation into the death of Gloria Linton, aged 77. The investigation concluded at the end of the Inquest on 28/11/2024. The conclusion of the Inquest was a narrative conclusion, recording the cause of death as 1a) Pneumonia 1b) Rib fractures due to entrapment in a commode 2) Covid 19 infection, Cerebrovascular Disease, Ischaemic Heart Disease, Osteoporosis, Oropharyngeal Dysphagia (Clinical Diagnosis), and stating in summary that Gloria Linton died from the effects of medical complications arising from bilateral fractures of the posterior and lateral aspects of her ribs after she had become trapped in the aperture of a commode seat while being tended by carers.

On 06/08/2022 carers had taken Gloria Linton in a wheeled commode into her wet room, where she had toileted and been showered while still seated in the commode. Carers assisted her to stand using manual handling techniques so that she could be dried and have moisturising and barrier creams applied to her. Gloria began to open her bowels again and carers attempted to sit her down on the commode, placing her on the commode seat at an angle such that her left leg passed through the gap at the front of the commode seat and her right leg followed, effectively trapping her in the commode seat's central aperture. She passed further down into the aperture, becoming trapped just below her chest. While trapped she sustained numerous osteoporotic fractures to the back and sides of both her ribcages, through either or both of her own efforts to free herself and the process of being extracted from the commode by the attending emergency services. The rib fractures were found at post mortem to have been a direct contributing cause of the pneumonia that was the immediate cause of Gloria’s death in hospital on 23/08/2022.

(1) The care plan in place for Gloria required her to be transferred between sitting and standing by two carers using a piece of equipment called a Rotanda.
(2) Prior to the events of 06/08/2022 it had been noted and reported that carers were not routinely using the Rotanda, and it had been reiterated to carers by the relevant Community Health Trust that the Rotanda should be used, notwithstanding Gloria’s reluctance.
(3) On 06/08/2022 the carers did not use the Rotanda either to support Gloria to stand so she could be dried and her skin moisturised or to assist her to sit back on the commode when her bowels opened as she was being dried.
(4) Had the Rotanda been used to assist Gloria to sit, it is unlikely that she would have been placed on the commode seat at an angle such that her legs could have passed through the opening at the front of the commode seat.
(5) The carers were employed by Lifeway Care Ltd.