“At the inquest the evidence showed that the electric armchair had been ordered by the…”

The coroner’s concerns

This report was published as a scan, so its text was read automatically. Check the wording against the original before you quote it.

— At the inquest the evidence showed that the electric armchair had been ordered by the Occupational Therapist and delivered by Tremorvah Industries (Mobility) at short/no notice to Mrs Parr’s address on 21 March 2016. No notification was given to the son — who had requested to be present when it was delivered nor to the Occupational Therapist or Kerrier Home Care Ltd who provided the carers who would assist Mrs Parr in using the new chair. This meant there was limited or no opportunity for the family and carers or district nurses to be trained or for appropriate risk assessments to be carried out prior to the use of the new equipment or at the time of the first use. Mrs Parr was at high risk of falling. She was very frail and dependant on the carers for all her needs. She was not able to mobilise alone and required at least one carer to transfer. She would sit in the chair until the carers assisted her. The electric chair was provided on the day before she was found fallen. It appeared that Mrs Parr managed to use the controls to place the electric chair into the standing position while she was sitting in the chair resulting in her falling to the floor. In the days prior to the fall she had become more confused. The District Nurse Manger explained that it was the role of the District Nurses to carry out the Falls Risk Assessment for clients living in the Community at risk of falling. The District Nurses were very dependent on other agencies to inform them of falls or changes to the risk of falls e.g. the delivery of the electric chair or changes in presentation which increase the risk of falls e.g. confusion. In this case the District nurses were not informed of the fall on 21° March from the new electric chair and no requirement for this to be done and so there was a lost opportunity to provide input — which in this case could have been to deactivate the electric armchair while the carers were not present. Although there were informal procedures in place for district nurse notification, there were no formal protocols or procedures in place. There is a high mortality rate of elderly patients who fall and fracture their femur

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2016-0466

Added to Minute Book

8 Oct 2026

Reuse

We show short extracts and link to the original. We don’t host the full report.

Something wrong, such as a date or who it was sent to? Report a mistake

Is this report about someone close to you? You can ask us to remove names from our pages.

Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0