Inquest opens into death in resthome

Mathew Warren, the grandson of Tauranga woman Lilian Wilson, who died in an accident at a Tauranga rest home, hopes lessons will be learnt through the inquest into her death. Photo/Stephen Parker.

The damage to a hoist which broke, leaving an elderly Tauranga rest home patient with fatal injuries may have been caused by the machine being put in a vice during unauthorised maintenance.

A coronial inquest began yesterday into the 2010 death of 87-year-old Lilian "Lu' Wilson, who died three days after the hoist that was lifting her into a wheelchair at Cedar Manor collapsed, sending her crashing to the ground.

On February 12, 2010 a nurse and caregiver were using a hoist to move her when the whole sling dropped to the floor.

She hit her head as she fell and did not regain consciousness before she died.

A post-mortem examination found she died of pneumonia caused by severe brain injuries, Detective Brian Dudley said.

The court yesterday heard the upper suspension bolt became unscrewed causing the sling carrying Mrs Wilson to drop to the ground.

Mechanical engineer Neil Rogers, an independent expert witness, said the nut used to lock the bolt in place had come loose but a thread-locking adhesive had also been used to keep the bolt in place although this, too, had cracked.

In order for this to happen a significant amount of force would have to be applied and he said it was most likely to have occurred when part of the hoist was put in a vice.

"The upper suspension bolt is not just going to rattle loose. It will have to be undone with considerable, persistent effort," he said.

Evidence also showed a nut, which was most likely intended to be a back-up measure, had been cut down to make it thinner which meant it was no longer strong enough to stop the bolt coming undone, he said.

BV Medical engineer Graham Rusbatch serviced the hoist three months before the accident and noticed the nut had come loose. He tightened it with a pair of pliers and said he felt it was safe but admitted he did not notice a crack in the weld, which could have made it dangerous.

Bill Lawson, the lawyer representing Mrs Wilson's family, questioned how thoroughly the hoist had been serviced when Mr Rusbatch admitted he had serviced 112 devices in less than two-and-a-half days. Mr Lawson and the lawyer for BV Medical both suggested alterations, including cutting down the nut, may have been made by the rest home's maintenance man but they could not be certain as he coincidentally died the same day as Mrs Wilson.

Bupa Care Services managing director Grainne Moss said rest home staff had been told not to undertake any maintenance on equipment, including hoists, but the company policy did not make that clear.

Those policies had since been amended to clearly state maintenance staff should not attempt to fix equipment but rather specialist engineers should be called in, she said.

Mrs Moss said all hoists similar to the one that failed had been withdrawn and stringent testing had been put in place for the purchase of new equipment.

Mrs Wilson's daughter, Janice Warren, said she hoped the inquest would bring closure for the family who had persevered with the case for almost four years to make sure it never happened again.

"I want this to be closure," she told the Bay of Plenty Times. "If we can make it safer and everybody learns by doing this ... we can rest in peace and so can my mother.

"It was horrific. Really horrific."