A WOMAN in a nursing home died of strangulation after her neck became caught in the safety belt of her HSE-supplied, purpose-built wheelchair, an inquest heard yesterday.
Pauline Kerr (61), care of Kiltipper Woods Care Centre, Kiltipper Road, Dublin, was discovered sitting on the floor with her back against the bottom of the wheelchair, her head tilted backwards and her safety belt "tight against the front of her neck" by a staff member on September 16th, 2007.
"Pauline was really pale. I ran over to her and opened up the belt - the belt had been strangling her," staff nurse Liji Joseph told Dublin County Coroner's Court yesterday. The discovery was made at 12.20pm and Ms Joseph sought immediate assistance, but all efforts to resuscitate Mrs Kerr failed and she was pronounced dead at 1.50pm.
Mrs Kerr, who suffered from dementia and who had been a patient at the facility since 2005, was in her own room with the door open at the time of the incident and was being checked by a staff member every 10 to 15 minutes.
The chair was specially made for Mrs Kerr and was supplied by the HSE, following assessment by an occupational therapist, with a belt around the waist to prevent her from falling out of the chair, the inquest heard.
Mrs Kerr was last checked by a carer at the facility, Anne Cunningham, 10 minutes before the tragic discovery.
Mrs Kerr had a tendency to wiggle down in her chair and on one occasion had been found with the strap at her chest, Ms Cunningham told the court.
A postmortem found that Mrs Kerr died of asphyxia due to mechanical obstruction of the upper airways, due to a restraining belt on a wheelchair.
A majority jury returned a verdict of accidental death under the direction of the coroner Dr Kieran Geraghty. Asked by Dr Geraghty what could prevent a similar incident happening again, manager and owner of the facility Mary McDermott said close observation, or one-to-one care.
She had never used such a chair at the facility before, she said.
Mrs Kerr had been moved into a common room on a previous occasion, but she would get very agitated with so many people there.
Assistant director of Public Health Nursing with the HSE, Barbara Goldsmith, told the inquest that the HSE-employed occupational therapist had visited the home and there had been an inquiry regarding the chair, but she did not have the report with her, she said.
She assured the coroner that the HSE would bring in recommendations arising from the inquiry into all nursing homes. The nursing home was inspected in July 2007 and the nursing care at the facility was excellent, she said.