The Inquest touching upon the death of Mrs Gloria Linton concluded last week with the Jury returning a critical narrative conclusion.

Mrs Linton received care at home and on the 6 August 2022 emergency services were called with reports of Mrs Linton being trapped in a commode.

Firefighters cut Mrs Linton free, and she was rushed to hospital but sadly died on the 23 August 2022.

The Jury found that;

Gloria Linton’s cause of death was pneumonia and rib fractures due to entrapment in a commode.  The use of manual handling techniques to assist in sitting and standing as opposed to using the prescribed equipment, i.e. rotunda outlined in the care plan, allowed Gloria to enter the commode at an unnatural angle.  Expert evidence concludes that the combination of the absence of the commode bowl, the unnatural position of the commode seat and the lubrication with creams contributed to Gloria slipping further through the commode opening and becoming entrapped.

The Coroner has invoked his powers pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners’ (Investigations) Regulations 2013 and issued a Prevention of Future Deaths report to Lifeway Care, the company responsible for Mrs Linton’s care at the time of her death.  The Coroner has raised the following concerns;

The MATTERS OF CONCERN are as follows. –

  1. The care plan in place for Gloria required her to be transferred between sitting and standing by two carers using a piece of equipment called a Rotunda.
  2. Prior to the events of 06/08/2022 it had been noted and reported that carers were not routinely using the Rotunda, and it had been reiterated to carers by the relevant Community Health Trust that the Rotunda should be used, notwithstanding Gloria’s reluctance.
  3. On 06/08/2022 the carers did not use the Rotunda either to support Gloria to stand so she could be dried and her skin moisturised or to assist her to sit back on the commode when her bowels opened as she was being dried.
  4. Had the Rotunda been used to assist Gloria to sit, it is unlikely that she would have been placed on the commode seat at an angle such that her legs could have passed through the opening at the front of the commode seat.
  5. The carers were employed by Lifeway Care Ltd.

The family were represented by our Director and Head of Inquests, Gareth Naylor.

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