Prevention of Future Deaths reports · 2017
Regulation 28 report to prevent future deaths, reference 2017-0430, written 3 Jul 2017. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 3 Jul 2017 |
|---|---|
| Reference | 2017-0430 |
| Deceased | Joseph De Pellergrino-Farrugia |
| Coroner | Robert Turnbull |
| Coroner area | North Yorkshire (West) |
| Category | Other related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Robert Turnbull Senior Coroner for Western Area of North Yorkshire REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. A. J. Way and CO. LTD. 2. CEO National Trading Standards 3. Yorkshire Care Equipment 4. 5. The Chief Coroner CORONER I am Robert Turnbull, Senior Coroner for Western Area of North Yorkshire 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2011 httQ :llwww. leQislation . pov. u k/ukpga/2009/25/sched ule/5/paragra ph/7 http://www.legislation.pov.uk/uksi/201 3/1 629/parU7/made 3 INVESTIGATION and INQUEST 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 June2017. 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. 4 CIRCUMSTANCES OF THE DEATH 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. 4. 3. On l4° 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. 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. 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. 5. 21 Grammar School Lane, Northallerton, North Yorkshire, 0L6 IOF Tel 01609 533 805 Fa 01609 780 793 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — 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. ACTION SHOULD BE TAKEN In my opinion action should be taken.to prevent future deaths and I believe you have the power to take such action. YOUR RESPONSE 6 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by 28 August 2017. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons 1. A. J. Way and CO. LTD. 2. CEO National Trading Standards 3. Yorkshire Care Equipment 4. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated 03 July2017 Signature__________________________ Senior Coroner for Western Area of North Yorkshire 21 Grammar School Lane, Nortliallerton, North Yorkshire, DL6 IDF I Tel 01609 533 805 Fax (116(19 780 793
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Mr. Robert Turnbull Senior Coroner 21 Grammar School Lane Northallerton DL6 1DF 25th August 2017 Dear Mr Turnbull Re: Death of Mr. Joseph Francis De Pellegrino-Farrugia. Further to our communication regarding the death of Mr Joseph Francis De Pellegrino-Farrugia’s death and subsequent Coroner’s investigation, I write to respond to your questions regarding any actions that can be taken to prevent future deaths caused of a similar nature. AJ Ways can and do fit a sensor strips or a protective screen to the underside of the side and back of the chair to avoid accidental trapping. These are not a mandatory attachment and therefore are only added to the chair in response to orders placed by the retailer who sells the chair to a consumer who identifies that there may be a risk of entrapment to small children and animals. To assist in the investigation I have enclosed a copy of the User Instruction booklet which is included with every chair delivered, I think there are several areas of relevance to the suitability and risk analysis for the use of an AJ Way riser recliner that may be important to consider, notably: 1. Section 2 – Essential Information a. Page 4, gives instruction on the suitability of the user, assessment and the environment it will be used in. b. Page 5 highlights the potential entrapment risk 2. Section 3 – Recommended Users a. Page 6, highlights who is/is not suitable to use the chair. 3. Section 5 – General Operation a. Page 11, gives a warning to check for obstructions during the movement of the chair. 4. Section 9 – Hazard Sensor Device a. Page 20, highlights the fact that the Hazard Sensor if fitted, does not cover the legrest of scissor action. b. Points out that care needs to be taken when lowering the legrest to ensure that the user’s legs do not become trapped underneath. Having looked at the evidence presented on how this accident happened I can see that the entrapment occurred at the front of the chair underneath the legrest, the sensors that are used are not suitable for this part of the chair due to the fact that the legrest flexes hence highlighting this in the user instructions. The sides and back are less visible to the user; this is where a small child or animal could access the underside of the chair without the user noticing when in its raised position therefore this is the area where sensors can be fitted to avoid entrapment. Furthermore we highlight the importance of a risk assessment and care and attention when the chair is being operated to ensure that the user is suitable and there is no risk of entrapment when the chair is being used. I also note that the part that Mr De Pellergrino-Farrugia’s foot was caught in the metal action that raises and reclines the chair, although AJ Way and Co Ltd is the manufacturer of the Riser Recliner chair involved in this accident, it does not manufacture the metal action that provides the lift and recline function, there are many manufacturers of the metal action frames, similarly there are many manufacturers of Rise and Recline chairs. AJ Way and Co Ltd, although a long established UK manufacturer of Rise and Recline chairs, is one of the smaller manufacturers of Rise and Recline chairs producing just 1-2% of the total chairs sold in the UK each year. Many of the other UK manufacturers offer similar sensors to us to reduce the risk however I estimate that up to 50% of the Rise and Recline chairs purchased annually in the UK are imported from low cost countries who do not offer the sensor solution. I hope this assists with your investigation and will be happy to assist further if required. Yours faithfully Managing Director AJ Way Co Ltd
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