Presentation on theme: "A CASE HISTORY OF A FATALITY IN A POWERED WHEELCHAIR Alan Lynch"— Presentation transcript:
1A CASE HISTORY OF A FATALITY IN A POWERED WHEELCHAIR Alan Lynch
2QUESTIONFor 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)Less than 30 mins _____30 mins to 1 hr _____1 hr to 1 hr 30 mins _____1 hr 30 mins to 2 hrs _____2 hrs to 2 hrs 30 mins _____
3MHRA informed of the death of an elderly lady who used a powered wheelchair. The ladyhad been pronounced dead at the scene.Contact made with:Local PoliceCoroners OfficerTherapist overseeing her wheelchair provisionLocal NHS Wheelchair Service who had suppliedthe wheelchair
4The lady was:83 years oldUnable to weight bare on lower or upper limbsUsed the powered wheelchair as her main daily seatLeft for long periods unattended at home
5Photographs 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.
7Using 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.
10These 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.
11The belt was extended using its adjustment system built into the clip ends.At 50mm extension some forward slip of the pelvis occurred.
12At 100mm extension considerable posterior rotation and forward slip of the pelvis occurredand the belt started to ride up off the top of thepelvis into the lower torso/soft tissue area as submarining occurred.
14By 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.
15With such an extension the deceased waist belt would not have offered anything in the termsof reducing submarining and would only come into effect when the occupant was nearly totally out of the front of the wheelchair as had happened inthis 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.
16The 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.
17A Coroners report was prepared and the Coroner requested MHRA attend the actual hearingThe 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 homeA verdict of accidental death was eventually recorded
18Following this case and considering other previous reports of ‘near misses’ MHRAproduced 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.
19In 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.
20LAST QUESTIONWho has not moved since the original request to situp at the start of this presentation? (select oneoption)I have NOT moved or felt discomfort _____I have moved or felt discomfort _____
21THANK YOUFor future contact:Medicines and Healthcare products Regulatory AgencyCentre for Assistive Technology241 Bristol AvenueBisphamBlackpool FY2 0BRTel: or