A lap belt was fitted to her wheelchair and left undone

A 99-year-old resident fell from a stationary wheelchair and died five days later. The coroner's concern was larger than the belt.

What happened

Violet Cloudsdale was 99 and lived at the Lonsdale Nursing Home in Barrow-in-Furness, Cumbria. She fell from a stationary wheelchair while she was unattended. A lap belt was fitted to the chair. It was not fastened.

The fall broke her leg and both arms. She was taken to hospital and died there five days later of bronchopneumonia. The record gives no date for the fall or for the death.

An inquest was held in Cumbria and concluded on 16 September 2015 before Paul O’Donnell, assistant coroner. The conclusion was accidental death.

The outcome

A prevention of future deaths report followed. Report 2015-0387, dated 25 September 2015, was sent to Risedale Estates Limited and to the Care Quality Commission. It required a review of lap belt procedures.

No prosecution, fine or other sanction is recorded.

What went wrong

The coroner’s findings run in two directions at once.

The first is the incident. Cloudsdale would have been less likely to fall had the belt been fastened. A belt was on the chair, a frail woman was in it unattended, and nobody did it up.

The second is the decision that was never made. No risk assessment had been undertaken as to whether a lap belt should be used at all. No attempt had been made to establish her views, or her family’s views, on whether she should be held in her chair. There was concern that using lap belts may be construed as applying unlawful restraint. And the guidance on lap belts was unclear.

So the belt that was there was not done up, and nobody had decided whether it should exist.

What it teaches

A lap belt is restraint, not equipment. It holds a person in place, and it needs the same reasoning as any other hold: a risk assessment, a best interests decision, and a record of what the person wanted.

That reasoning has to happen before the shift, not during it. A belt fitted to a chair with no assessment behind it leaves the staff on the floor with two bad options: tighten it and restrain her without authority, or leave it loose and hope.

Unclear national guidance is a real problem and not an excuse. A home waiting for clarity still has to decide, write down why, and ask the resident.

Questions for the room

The belt was fitted and left undone. Which failure would an inspector have been more likely to notice, and which one contributed to her death?
You are the nurse on that shift. What would a proper best interests decision about the belt have looked like, and who would have signed it?
A resident can tell you she does not want to be held in her chair. What do you do with that answer?

Evidence and limits

Confidence: probable, and the account is thinner than it looks.

The source is the coroner’s own prevention of future deaths report, which is a primary record and a strong one. But the PDF has no text layer and could not be read. Only the judiciary’s index entry was read, which gives the date, the reference, the coroner, the area, the category and the recipients.

Everything substantive above therefore rests on the vault record of that report, not on the report itself. That is why there is no scene here and no sequence of the fall.

No independent news report of the inquest is held. Proceedings concluded on 16 September 2015.

Our restraint reduction training covers mechanical restraint, including belts, and the decisions that have to sit behind one.

Sources

Reviewed 20 October 2026.