A lap belt outside the door, and nothing inside

A nursing home resident at high risk of falling was held in her wheelchair with a belt outdoors and with nothing indoors.

What happened

Jean Mary Cutler had severe dementia and was bed and chair bound, with no independent mobility. In July 2018 she fell out of bed at her care home and needed surgical repair of a fractured left femur. She was also diagnosed with osteoporosis.

Her needs and the risk of falling led to a recommendation that she move to a nursing home. In August 2018 she was accepted at Cole Valley Nursing Home in Birmingham, and assessed on arrival as at high risk of falling.

The risk of falling from a wheelchair was recognised. The home’s practice was a lap belt outside the building and none inside, where a member of staff was expected to intervene if someone began to fall. The home was understaffed.

On 5 October 2018 one member of staff was in the communal dining area but could not prevent her falling from her wheelchair. An x-ray on 14 October showed a fractured left femur, treated conservatively. She died at the home on 18 October 2018.

The outcome

James Bennett, HM Assistant Coroner for Birmingham and Solihull, began an investigation on 26 November 2018. The inquest concluded on 25 January 2019. Mrs Cutler died from a combination of natural causes, namely osteoporosis, and an accidental fall.

No prosecution or civil claim is recorded. On 8 February 2019 the coroner sent a Regulation 28 report to prevent future deaths, reference 2019-0040, to the directors of Cole Valley Care Limited. One response was published.

What went wrong

The coroner found an inconsistent approach to a risk the home had already identified: a lap belt outside, none inside, and reliance on staff intervening in time. That reliance continued after 5 October 2018, which he said had revealed the inadequacy of the measure.

The home had not investigated the restraint devices it used inside. Its internal investigation named a lack of internal knowledge and guidance, care plans that did not guide staff correctly, and unstable management. The only action it took was an incident debrief.

The manager accepted that the plan would have been stronger with a review of the falls risk assessment, of restraint devices inside and outside, and of staffing numbers. Revised falls documents requested by the Care Quality Commission and the clinical commissioning group were undated and unsigned.

What it teaches

A restraint decision that changes at the front door is not a decision. The home identified the risk, then answered it with a rule that depended on where she sat, and an assumption that someone would be close enough to catch her.

Record the decision once, apply it wherever the person is, and treat staff intervention as a control only when the staffing that makes it true is written down.

Questions for the room

The home used a lap belt outside and nothing inside. What did staff think the difference protected against?
You are the nurse in charge on 5 October 2018 with one colleague in a dining area. What do you change before the next meal?
The action plan listed only an incident debrief. What must a manager’s review contain to count as learning?

Evidence and limits

Confidence: probable. There is a single primary source, the coroner’s Regulation 28 report, which carries the inquest conclusion and the matters of concern. The provider’s response forms part of the same record. Both were read, and no independent report of the inquest was found.

Proceedings are concluded: the inquest ended on 25 January 2019 and the establishing record is Regulation 28 report 2019-0040, so the page may be cited outward.

Our vulnerable and volatile persons training covers work with vulnerable adults, including restraint decisions and the planning that has to sit behind them.

Sources

Reviewed 20 October 2026.