“The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to 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.

— (1) The Mangar Elk inflatable chair was intended to be used to lift Mr Chandler to the ambulance. One section did not inflate and so Mr Chandler was lifted underneath his arms and transferred to a chair borrowed from a local supermarket, no pain relief was given to Mr Chandler before being placed into the ambulance. He was later diagnosed with a pneumothorax. No safety straps were used. (2) Staff are required to ask for assistance when required and are responsible for checking equipment daily. The evidence is that this is not always done. (3) An electronic tablet was used initially to record the incident but this was not sufficiently charged to record all information. Paper records were not adequately completed. (4) The incident occurred in September 2018 and the internal investigation report with recommendations was completed in January 2019. Recommendations within the Report and in particular a clinical debrief had not taken place at the time of inquest (February 2019) -ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe your organisation has the power to take such action.

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, 2019-0060

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