Learning from safety incidents issue 13: Protecting people using wheelchairs (CQC, 24 August 2023)

Summary

This is one of a series of 'Learning from safety incidents' resources published by the Care Quality Commission (CQC). Each one briefly describes a critical issue—what happened, what the CQC and the provider have done about it, and the steps you can take to avoid it happening in your service. This edition is about ensuring the safety of people using wheelchairs in health and social care. The CQC recently prosecuted a care home provider for exposing someone using their service to a significant risk of avoidable harm, which resulted in a life-changing injury.

Content

Incident

Before the incident, the person had been experiencing difficulties with mobility and had sometimes been confused and agitated. They had been provided with an adapted wheelchair with extended footplates for their own use, and staff helped them get around in it. However, staff mainly used a standard wheelchair for communal use within the care home. On several occasions, the person's foot had come away from the footplate when using a standard wheelchair, resulting in a risk of it getting trapped.

On the day of the incident, while pushing the person down a slope in a standard wheelchair, the staff member noticed resistance and found the person's foot caught underneath. The staff member replaced the person's foot on the footplate and continued the journey.

Afterwards, the person complained about pain in the affected leg and was taken to hospital for further assessment.

The person was found to have significant, life-changing fractures to their leg and, at one stage, it was thought it may have to be amputated. The person spent 16 weeks in bed with their leg in a cast, before being discharged from hospital to a different service. Unfortunately, they did not make a full recovery and their physical health was permanently affected by the incident.

The CQC's investigation found that, although the provider knew the risks associated with the use of a communal wheelchair, the care home failed to take adequate steps to assess and mitigate those risks.

Recommendations

To manage the risk of injuries to people from wheelchairs, health and social care providers need to:

• develop and implement adequate moving and handling plans
• develop and implement a risk assessment specific to a person's use of a wheelchair
• have adequate policies and procedures to support staff in managing these risks
• assess a person's mental capacity to decide about using a wheelchair, especially one not provided specifically for them
• provide staff with the training, skills and knowledge required to safely use a wheelchair
• seek the support of other professionals, such as occupational therapists, where required.