She fell from her chair because the strap had no buckle

An 84-year-old resident died after a fall from her wheelchair, and the coroner recorded that neglect contributed to her death.

What happened

Shirley Froggett, 84, lived at New Lodge Nursing Home in Mickleover, Derby. Her care plan required a lap strap to secure her in her wheelchair and stop her falling.

On 19 September 2018 the strap was missing its buckle and was not applied. She was found on the floor of the lounge with a fractured left femur.

No medical assistance was requested. Her family was told at 19:00 that she had “shuffled off the chair” and there was “no need for concern”. They found her seriously injured the next day and called an ambulance, more than 24 hours after the fall. The fracture was not noticed at hospital for three days. She developed bronchopneumonia and died on 8 November 2018.

The outcome

At the inquest, Robert Hunter, Senior Coroner for Derby and Derbyshire, concluded she died of bronchopneumonia from a fractured left femur sustained in a fall from a wheelchair, and that the death was an accident contributed to by neglect.

In April 2022 New Lodge Nursing Care Limited was fined £30,000 at Southern Derbyshire Magistrates’ Court, with £7,500 costs and a £170 victim surcharge, for failing to provide safe care and treatment.

In February 2026 the manager, 66, was sentenced to 37 months at Derby Crown Court after pleading guilty to perverting the course of justice. Two care workers received suspended sentences, and a nurse was fined £600 for wilful neglect.

What went wrong

The strap was restraint, and the plan required it. It was not on the chair that morning, and nobody noticed.

The CQC found the fall was reported nine days late, and that the account given, that she removed the lap strap herself, was untrue: no belt had been in place. The nurse did not assess her or call a doctor. After her death, care workers said in statements that she had been restrained in her chair, and the manager repeated that account to the CQC and to a coroner.

The coroner was not satisfied that the home had any reliable system for ensuring care plans and protocols were followed. The judge said that without a whistleblower the case would not have surfaced.

What it teaches

A lap strap is a restraint. Where the plan requires one, its absence is a restraint failure, and the record has to show what was done rather than what should have been.

The second lesson is the first account. The prison sentence went to the manager who repeated it, not to the staff who found her.

A care plan without a system to check it is a document, not a control.

Questions for the room

The strap was missing its buckle. Who should have noticed, and what should have happened to that chair?
You are the nurse on shift when she is found. What do you do in the first hour, and who do you call?
The care plan existed and nothing checked it. What does a manager need to see weekly to know a plan is real?

Evidence and limits

Confidence: confirmed. The coroner’s Regulation 28 report is the primary record for the inquest; two BBC reports carry the prosecution and the Crown Court sentence.

One discrepancy is unresolved: the report gives the place of death as Old Lodge in Etwall, while the record and press give New Lodge in Mickleover, where she lived.

The manager and two care workers were convicted, so naming them would be lawful; this page describes them by role.

Our restraint reduction training covers mechanical restraint and the recording that has to support it.

Sources

Reviewed 20 October 2026.