Kenneth Roy Bardsley · Prevention of Future Deaths report

On 1st February 2017 I commenced an investigation into the death of Kenneth Roy Bardsley. The jury inquest concluded on the 26th November 2018 and the conclusion of the jury was one of Accidental death contributed to by failure of interior door mechanism.
The medical cause of death was 1a) Multiple injuries; 2) Osteoporosis; Ischaemic heart disease; Valvular heart disease

Mr Kenneth Roy Bardsley died on the 30th January 2017, at Salford Royal Hospital due to multiple injuries, received as a passenger in a lift, which malfunctioned at Serendipity Care Home.

1. The inquest heard that there are no formal requirements for a minimum standard of qualification for people to be lift engineers. In effect, anyone can advertise themselves as a lift engineer/maintenance company;
2. The evidence given to the inquest was that there was a gap in the system which meant that regulatory lift examinations could take place but not be read or acted upon, with no escalation process;
3. During the inquest evidence was given that within the specific lift company in this case and more widely, there was a lack of clarity as to how engineers should be made aware and follow up requirements made by engineers carrying out the regulatory lift examinations;
4. In inspections of the home, the CQC did not pick up that there were faults identified in the regulatory examination that had not been acted upon;
5. That Serendipity Care Home did not have a system in place to ensure details from the lift examinations were read; considered and passed on to the lift servicing company;
6. That the lift company Lancs and Cumbria engineers carrying out serving/repairs were not expected to ask to see the regulatory examination reports;
7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist. One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift service.