Joseph Francis De Pellegrino-Farrugia · Prevention of Future Deaths report

On 28/12/2016 I commenced an investigation into the death of Joseph Francis De Pellegrino - Farrugia, 92 . The investigation concluded at the end of the inquest on 14 June 2017. The conclusion of the inquest was Joseph Francis De Pellegrino-Farrugia died as a result of an accident. On 13th November, 2016, Joseph Francis De Pellegrino-Farrugia suffered a crush injury to his left foot which became trapped in his chair. He was taken to hospital and operated on but thereafter suffered ongoing ulceration and necrosis. He was discharged home but died at 06:55 hours, 20th December, 2016. The injury sustained contributed to the death. Acute Bronchopneumonia Dementia, Ulcerated and necrotic great left toe; crush injury of left great toe; (operated 14/11/2016) coronary and hypertensive heart disease.

1. Joseph Francis De Pellegrino-Farrugia was a 92 year old gentleman with a complex medical history which included dementia. He was very frail and was cared for at home by his wife and professional carers.
2. He spent most of his time in an electric reclining chair and on occasions was transferred from that chair to a commode by his carers.
3. On 14th November, 2016, he was being transferred onto the commode which was placed opposite his chair. Somehow his foot became caught in the mechanism of the footrest of the chair as it was being reclined.
4. It was not possible to free his foot. The Fire Brigade attended and cut him free after two hours. He had sustained crush injuries to his foot which was operated on the same day but he was left with an ulcerated and necrotic great left toe.
5. Joseph died at home on 20th December, 2016. The immediate cause of death was acute bronchopneumonia caused by his dementia. However, evidence was heard that the injury to his foot had made a small but not minimal contribution to his death and the conclusion was that had he not been injured then his health might have been maintained for longer.

1. Evidence was heard to the effect that the chair was not fitted with sensors which would have detected the presence of the foot in the mechanism to prevent the crushing injury and to release the foot.