© crown copyright 2005 safeguarding public health a case history of a fatality in a powered...

© Crown copyright 2005

Safeguarding public health

A CASE HISTORY OF A FATALITY IN A

POWERED WHEELCHAIR

Alan Lynch

Date: 2 November 2007 Name: Alan Lynch

Presentation title: Posture Belt Fatality


QUESTION

For a person over 65 who spends most of the daysat in a wheelchair, how long can they sit in oneposition before the potential start towards a pressureulcer? (select one option)

A. Less than 30 mins _____B. 30 mins to 1 hr _____C. 1 hr to 1 hr 30 mins _____D. 1 hr 30 mins to 2 hrs _____E. 2 hrs to 2 hrs 30 mins _____




MHRA informed of the death of an elderly lady who used a powered wheelchair. The lady had been pronounced dead at the scene.

Contact made with:

• Local Police

• Coroners Officer

• Therapist overseeing her wheelchair provision

• Local NHS Wheelchair Service who had supplied the wheelchair




The lady was:

• 83 years old

• Unable to weight bare on lower or upper limbs

• Used the powered wheelchair as her main daily seat

• Left for long periods unattended at home




Photographs of the deceased when found were obtained and examined.

Examination of the photographs showed that the deceased had slid forward out of the wheelchair seat and had been suspended by the waist belt fixed to the wheelchair.

She was completely out of the front of the wheelchair with her knees on the floor and her upper body arched back into the wheelchair.

The waist belt had ridden up her body and had come to rest under her armpits and across the lower portion of her neck.




Simulation using dummy




Using the deceased’s wheelchair and a new waist belt (original removed by Police for forensicexamination) simulations were carried out at theMHRA laboratory at the Centre for AssistiveTechnology in Blackpool.

A volunteer of similar hip size to the deceased wasused to check the effects of an incorrectly adjustedbelt.

Simulation included different belt positions, differentadjustments in length and seating position of theoccupant.




Example of good position




Example of bad position with ‘submarining’




These simulations showed that an overall belt length of 800mm (31.5") was appropriate to give a good posture and belt positioning to avoid forward slip of the pelvis and submarining in the seat.




The belt was extended using its adjustment system built into the clip ends.

At 50mm extension some forward slip of the pelvis occurred.




At 100mm extension considerable posterior rotation and forward slip of the pelvis occurred and the belt started to ride up off the top of the pelvis into the lower torso/soft tissue area as submarining occurred.




At 150mm extension total submarining occurred.




By scaling from the photographs of the deceased as found it was possible to ascertain that the actual belt in use was approx 1100mm (43”) in length from fixing point to fixing point.

This was approx 300mm (12”) too long to offer any assistance in reducing forward slip of the pelvis and submarining in the seat.




With such an extension the deceased waist belt would not have offered anything in the terms of reducing submarining and would only come into effect when the occupant was nearly totally out of the front of the wheelchair as had happened in this case.

By the time this occurred the fastening clips to undo the belt were in a position that the occupant could not have reached or operated due to the force required.




The cause of death was a combination of positional asphyxiation and strangulation probably as the occupant had tried to “limbo” under the belt to exit the wheelchair as she could not weight bare on her lower limbs.

The belt had effectively allowed considerable submarining but had not allowed a full slide to the floor.




- A Coroners report was prepared and the Coronerrequested MHRA attend the actual hearing

- The report was accepted in its entirety and the Court then moved on to examine the actual level of care provided to the deceased in her own home

- A verdict of accidental death was eventually recorded




Following this case and considering other previous reports of ‘near misses’ MHRA produced Medical Device Alert MDA 2005/025 ‘Posture belts fitted to wheelchairs and seating’.

This warned of the need to ensure that all posture belts fitted to wheelchairs were correctly fitted, adjusted and regularly checked.

It also included that the appropriateness of a posture belt should be regularly reviewed for appropriateness especially where a wheelchair occupant or their carer’s capabilities changed.




In 2006 another investigation into a fatality of a child revealed similar problems especially where small children are seated in complex body support and posture control systems.

Subsequently medical Device Alert MDA 2006/059 was issued which reinforced and added to the content of MDA 2005/025 where children are concerned.




LAST QUESTION

Who has not moved since the original request to situp at the start of this presentation? (select oneoption)

A. I have NOT moved or felt discomfort _____

B. I have moved or felt discomfort _____




THANK YOU

For future contact:

Medicines and Healthcare products Regulatory AgencyCentre for Assistive Technology241 Bristol AvenueBisphamBlackpool FY2 0BR

Tel: 01253 596000 or e-mail [email protected]

© crown copyright 2005 safeguarding public health a case history of a fatality in a powered...

Documents

wheelchair slide

submarining slide

home slide

dummy slide

alan lynch presentation

actual belt

belt positioning

adjusted belt