Joseph De Pellergrino-Farrugia

PFD Report Partially Responded Ref: 2017-0430
Date of Report 3 July 2017
Coroner Robert Turnbull
Response Deadline ✓ from report 28 August 2017
1 of 3 responded · Over 2 years old
Response Status
Responses 1 of 3
56-Day Deadline 28 Aug 2017
Over 2 years old — no identified published response
About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner’s Concerns
1. Evidence was heard to the effect that the chair was not fitted with sensors which would have detected the presence of the foot in the mechanism to prevent the crushing injury and to release the foot.
Responses
Response
25 Aug 2017
Response received
View full response
Dear Mr Turnbull Re: Death of Mr. Joseph Francis De Pellegrino-Farrugia.

Further to our communication regarding the death of Mr Joseph Francis De Pellegrino-Farrugia’s death and subsequent Coroner’s investigation, I write to respond to your questions regarding any actions that can be taken to prevent future deaths caused of a similar nature. AJ Ways can and do fit a sensor strips or a protective screen to the underside of the side and back of the chair to avoid accidental trapping. These are not a mandatory attachment and therefore are only added to the chair in response to orders placed by the retailer who sells the chair to a consumer who identifies that there may be a risk of entrapment to small children and animals. To assist in the investigation I have enclosed a copy of the User Instruction booklet which is included with every chair delivered, I think there are several areas of relevance to the suitability and risk analysis for the use of an AJ Way riser recliner that may be important to consider, notably:
1. Section 2 – Essential Information
a. Page 4, gives instruction on the suitability of the user, assessment and the environment it will be used in.
b. Page 5 highlights the potential entrapment risk
2. Section 3 – Recommended Users
a. Page 6, highlights who is/is not suitable to use the chair.
3. Section 5 – General Operation
a. Page 11, gives a warning to check for obstructions during the movement of the chair.
4. Section 9 – Hazard Sensor Device
a. Page 20, highlights the fact that the Hazard Sensor if fitted, does not cover the legrest of scissor action.
b. Points out that care needs to be taken when lowering the legrest to ensure that the user’s legs do not become trapped underneath. Having looked at the evidence presented on how this accident happened I can see that the entrapment occurred at the front of the chair underneath the legrest, the sensors that are used are not suitable for this part of the chair due to the fact that the legrest flexes hence highlighting this in the user instructions.

The sides and back are less visible to the user; this is where a small child or animal could access the underside of the chair without the user noticing when in its raised position therefore this is the area where sensors can be fitted to avoid entrapment. Furthermore we highlight the importance of a risk assessment and care and attention when the chair is being operated to ensure that the user is suitable and there is no risk of entrapment when the chair is being used. I also note that the part that Mr De Pellergrino-Farrugia’s foot was caught in the metal action that raises and reclines the chair, although AJ Way and Co Ltd is the manufacturer of the Riser Recliner chair involved in this accident, it does not manufacture the metal action that provides the lift and recline function, there are many manufacturers of the metal action frames, similarly there are many manufacturers of Rise and Recline chairs. AJ Way and Co Ltd, although a long established UK manufacturer of Rise and Recline chairs, is one of the smaller manufacturers of Rise and Recline chairs producing just 1-2% of the total chairs sold in the UK each year. Many of the other UK manufacturers offer similar sensors to us to reduce the risk however I estimate that up to 50% of the Rise and Recline chairs purchased annually in the UK are imported from low cost countries who do not offer the sensor solution. I hope this assists with your investigation and will be happy to assist further if required.
Action Should Be Taken
In my opinion action should be taken.to prevent future deaths and I believe you have the power to take such action.
Report Sections
Investigation and Inquest
On 28/12/2016 I commenced an investigation into the death of Joseph Francis De Pellegrino
- Farrugia, 92 . The investigation concluded at the end of the inquest on 14 June2017. The conclusion of the inquest was Joseph Francis De Pellegrino-Farrugia died as a result of an accident. On 13th November, 2016, Joseph Francis De Pellegrino-Farrugia suffered a crush injury to his left foot which became trapped in his chair. He was taken to hospital and operated on but thereafter suffered ongoing ulceration and necrosis. He was discharged home but died at 06:55 hours, 20th December, 2016. The injury sustained contributed to the death. Acute Bronchopneumonia Dementia Ulcerated and necrotic great left toe; crush injury of left great toe; (operated 14/11/2016) coronary and hypertensive heart disease.
Circumstances of the Death
1. Joseph Francis De Pellegrino-Farrugia was a 92 year old gentleman with a complex medical history which included dementia. He was very frail and was cared for at home by his wife and professional carers.
2. He spent most of his time in an electric reclining chair and on occasions was transferred from that chair to a commode by his carers.
3. On l4° November, 2016, he was being transferred onto the commode which was placed opposite his chair. Somehow his foot became caught in the mechanism of the footrest of the chair as it was being reclined.
4. It was not possible to free his foot. The Fire Brigade attended and cut him free after two hours. He had sustained crush injuries to his foot which was operated on the same day but he was left with an ulcerated and necrotic great left toe.
5. Joseph died at home on 20th December, 2016. The immediate cause of death was acute bronchopneumonia caused by his dementia. However, evidence was heard that the injury to his foot had made a small but not minimal contribution to his death and the conclusion was that had he not been injured then his health might have been maintained for longer. 21 Grammar School Lane, Northallerton, North Yorkshire, 0L6 IOF Tel 01609 533 805 Fa 01609 780 793
Copies Sent To
1. A. J. Way and CO. LTD 2. CEO National Trading Standards 3. Yorkshire Care Equipment
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.