Belinda Jane Wise · Prevention of Future Deaths report

On 27th March 2015 I commenced an investigation into the death of Belinda Jane Wise.

At inquest the determinations were that;
On the 6th March 2015 at Sainsbury's, Glen Road, Oadby, Belinda entered the lift. Belinda leant against the rear doors and subsequently fell backwards when the doors opened hitting her head. There were no sign or auditory warnings within the lift to indicate the rear doors would open. Belinda died on the 11th March 2015 at University Hospital, Clifford Bridge Road, Coventry and Warwickshire of a left-sided subdural haemorrhage.

Conclusion – Accidental death

Cause of death
1a Left sided subdural haemorrhage
1b Fall

Mrs Wise was taking warfarin for a diagnosed cardiac condition.

She arranged to meet a friend for lunch at a Sainsbury's café and entered the lift to take her to the mezzanine level within the store. She recollected leaning on the lift side, and being surprised when rear doors opened, opposite to where she had entered the lift. There was no sign or auditory warning to alert the passengers of this. She stumbled and fell to the floor, banging her head.

Initially she was attended by the store's First Aid responder, but appeared to be uninjured.

However, a short time later she became unwell and an ambulance was summoned. She was taken to the local neurosurgical centre for suspected brain injury, and on arrival was deeply unconscious and CT scanning revealed a large subdural haemorrhage with mid line shift. Her condition was thought to be unsurvivable; she was palliated and died 5 days later.

It was a finding of the jury that there were no signs or auditory warnings within the lift to indicate that the rear doors would open. Evidence taken from the Sainsbury's store and from the Borough Council investigation confirmed that such warnings are not standard or mandatory. In this instance, it was clear from the evidence that the deceased did not appreciate that the part of the lift that she was leaning was actually the rear doors, as they were not marked in any way.

Further consideration should be given to the possibility of making the doors more apparent and distinguishable from the rest of the interior, and also to the sounding of a warning message (that may assist visually impaired passengers).