A CORONER raised concern following the death of an elderly lady.

An inquest into the death of 92-year-old Dorothy Pegg concluded in October last year and Jonathan Heath, senior coroner for York and North Yorkshire, issued a prevention of future deaths report.

This can be done if it appears there is a risk of other deaths occurring in similar circumstances.

Outlining the circumstances, Mr Heath said Mrs Pegg was a resident at an extra care facility when she was hoisted from her bed into her shower chair.

"The hoist slip was left underneath her," he added. 

"She was wheeled in the shower chair to the living room and prior to being hoisted from the shower chair to her living room chair, slipped to the floor and suffered bilateral leg fractures which contributed to her death."

The coroner said inquest evidence "revealed matters giving rise to concern". 

He said: "In my opinion there is a risk that future deaths could occur unless action is taken.

"There was no system of monitoring the compliance with instructions as to how equipment should be used. There were no instructions as to the circumstances in which it is appropriate that specific prescribed equipment is used."

In its response, Ilkley-based care firm Abbeyfield The Dales set out action taken following Mrs Pegg's death.

This included a new care plan format, as well as the re-introduction of spot check audits which include "ensuring carers comply with instructions as to how/what equipment should be used". 

Abbeyfield said a record of new equipment to support someone's mobility is held in a care plan, which is updated with an image of the equipment. 

The response said "clear instructions" are set out regarding the correct use of equipment.

It added: "We have developed a process to ensure staff are clear of the correct use for and operation of a new piece of equipment that is introduced by an Occupational Therapist or other health professional to support the safe transfer and movement of a resident. 

"This process is intended to ensure there is no ambiguity in how and in what circumstances a piece of equipment is used, and also there is clear accountability and checking that staff are knowledgeable and confident in the use of the equipment to support that resident."

North Yorkshire County Council said it had taken "robust measures".

Among them is a specialist moving and handling training event planned for the coming months.