Man died when lift plunged to ground less than an hour after ‘routine service’
A pensioner with dementia died when a lift – which had had a routine service less than an hour before, plunged to the ground, an inquest heard.
Kenneth Roy Bardsle asked ‘what’s going on?’ moments before the broken lift fell and he suffered ‘catastrophic injuries’.
Wheelchair-user Mr Bardsley, 88, had been a resident at Serendipity Care Home in Urmston, Trafford, for two years when he died in January last year.
A jury found Mr Bardsley’s death to have been accidental, caused by multiple injuries, including a fractured pelvis and ribs after the lift – which was more than 20 years old – malfunctioned due to a faulty door mechanism, reports the Manchester Evening News.
The inquest had heard lift engineers had twice visited the home in the week of his death – with the latest service taking place less than an hour before the crash.
There had also been more thorough twice-yearly inspections required by law.
Reports from these, the jury heard, had repeatedly found there to be ‘category B’ (less serious) faults with the lift, but the care home boss and manager admitted they had not read them and the works were not done.
It’s not known if the door fault found by an expert to have caused the accident was present at the checks carried out before Mr Bardsley, from Manchester, was fatally injured.
Back-up safety gear also failed to do its job, but this fault had never been identified during inspections.
Coroner Alison Mutch OBE will now write a report to prevent future deaths.
She said the Care Quality Commission (CQC) had not picked up in 2014 that faults identified with the lift had not been acted upon.
After the hearing at Stockport Coroner’s Court, Mr Bardsley’s daughter Carol said: “We never anticipated anything like this would ever happen.
“In the latter part of his life he had a stroke and my brother could no longer look after him as he needed professional help. We had every faith that the care home would help us.
“We can’t understand why it happened. It’s been extremely difficult for us to understand why the lift was being used if it wasn’t safe."
On January 30 2017, Mr Bardsley, a retired export packer and widower, was wheeled from his room by care worker Sharon Cover to travel from the first to the ground floor for lunch.
Ms Cover had noticed earlier that morning that the lift was out of order, but said a Lancs and Cumbria Lifts engineer gave her the all-clear.
But shortly after loading Mr Bardsley’s wheelchair into the lift, which had an outer door and an inner bi-folding metal door, the car came to a halt.
Ms Cover sounded the lift alarm and shouted out to colleagues that she was stuck and could see a door ‘hanging off its hinge’ and Mr Bardsley was asking ‘what’s going on?", when they suddenly plummeted to the basement.
She said: “He was shouting, I was screaming. When we hit the ground the panel from the top of the lift hit his head, I heard him say ‘Oh My God’. The walls of the lift came in.”
The carer hit her head on the handle of the wheelchair and injured her jaw.
Colleagues arrived at the basement to find the lift had dropped below the basement floor and the doors had caved in on them.
Described as ‘covered in blood’, Ms Cover had to be pulled from the lift while Mr Bardsley, described as ‘grey and groaning’ was taken out in his wheelchair and taken up to the ground floor.
Paramedics were called but during assessment, Mr Bardsley deteriorated and went into cardiac arrest. Taken by ambulance to Salford Royal Hospital, he later died.
Det Insp Thomas Gilbert, who investigated the death on behalf of GMP, said they had considered two possible offences – gross negligence causing manslaughter and corporate manslaughter, but that the case had not passed the ‘high threshold’ to bring these charges.
Dr Lumb, Home Office pathologist, told the court the cause of death was multiple injuries, including fractures to Mr Bardsley’s ribs and a fractured pelvis, consistent with a ‘fall from a height’, which caused extensive blood loss.
Contributory factors, he said, were osteoporosis and heart disease.
Josmy Anish, care home manager, said the lift had issues ‘every now and then’ and the problems were ‘mainly the doors’. At these times, Lancs and Cumbria Lifts, which carried out four service checks a year, would be called out to fix it.
After the hearing, Mr Bardsley’s daughter Carol added: “The past two years have been tough for the whole family. It’s been a very long wait and we’ve finally had some of the answers that we have been searching for. We wouldn’t want any other family to have to go through what we have.
“My father was a hardworking, family man and there will always be a big gap in our lives that will now never be filled. He will be greatly missed by all who knew him.”
Daniel Denton, lawyer at Slater and Gordon, said: “Kenneth Bardsley was a frail and very vulnerable gentleman who had suffered from worsening dementia for several years.
"We hope that lessons will be learned from this unnecessary death and changes will be implemented to make sure this never happens to anyone else."
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