Susan Toft

I am Andrew Bridgman, Assistant Coroner, for the coroner area of Manchester South

On 17.10.25 an inquest was opened into the death of Susan Toft who died at Stepping Hill Hospital on 28.09.25, aged 77 years. The inquest concluded on 27.03.26. Medical Cause of Death 1a) Myocardial Infarction and Pneumonia (joint causes) 1b) Sepsis of unknown aetiology 1c) Fractures to right femur, tibia and fibula II) Myasthenia Gravis The conclusion was: Accidental Death

In May 2024 ST suffered a traumatic spinal injury rendering her paraplegic.  ST was  discharged from hospital in November 2024.  In December 2024 ST purchased a  converted vehicle to allow rear ramp access for a wheelchair, to be anchored in place of the front passenger seat.  On collecting the vehicle ST’s husband was shown how to secure a ‘demonstration wheelchair’ to the floor of the vehicle.  ST’s wheelchair was not used to demonstrate, nor was ST asked to sit in the wheelchair being used  for the demonstration purposes. In January/February 2025 ST was provided with A Sunrise Q300 wheelchair, later  replaced in May 2025 with an Invacare TDX SP2.  The Vicair cushion provided with  the Sunrise wheelchair was transferred to the Invacare wheelchair. The cushion attached to both wheelchair seat bases with Velcro strips. On 24 September 2025 ST was a front seat passenger, in her wheelchair fixed to the floor of her adapted vehicle, being driven by her husband, which was forced to brake  suddenly and sharply. As the car braked ST slipped from her wheelchair into the  passenger footwell resulting in fractures of her right leg, being taken to hospital the  next day. That ST did not remain restrained in her wheelchair, and submarined beneath the  vehicle seat belt (lap section) was as a result of,

1. the seat cushion (held by Velcro) becoming detached from the wheelchair  base. The adhesive to the wheelchair failed on one side.  It is not clear what happened to the other side, but it was later noted that the Velcro strip  attached to the wheelchair base was missing.
2. The fact that the lap part of the vehicle seat belt did not fit properly across ST’s lap as the seat belt buckle was higher than her lap.

During the course of the course of the inquest reference was made to the   International Best Practice Guidelines BPG1 Transportation of People Seated in Wheelchairs. Throughout that document there is clear reference to the risk of persons submarining because of the risk of failure of the cushion and/or an inadequately fitted vehicle seat belt restraint. Concern One Section 4.5 deals with the seat cushion, and 4.5.1 – cushion attachment. From a seating function perspective, the stability of a cushion is a fundamental  requirement. Therefore, the means of attachment of the cushion to the wheelchair  support surface needs to be capable of repeated fitting and removal without  impairment or deterioration. Cushions may need to be frequently removed for cleaning and maintenance, and an individual user may have a number of cushions for short or long term use. This cushion’s attachment failed after just 9 months of use. The above said Guidelines state that Velcro is strong in shear but less so in tension.   Also that the adhesive must have sufficient shear strength.  It seems that repeated   removal of the cushion for cleaning and maintenance risks exceeding and weakening the relative strengths of the Velcro system itself and the adhesive used to secure the  Velcro strip to the wheelchair base. In the circumstances my concern is that there may be more robust and more reliable  methods of securing the seat cushion to the wheelchair base, that would negate the  risk of detachment, as occurred in this case. Concern Two Section 5 of the above said Guidelines sets out in some detail the importance of  ensuring the adequacy of the fit of the vehicle restraint system to the individual  wheelchair and wheelchair user. It was surprising therefore to learn at the inquest that upon collecting the adapted  vehicle STs husband was only given a demonstration of how to secure the wheelchair to the vehicle.  That there was no assessment of any need to make adjustments to the vehicle occupant restraints to ensure an adequate fit by assessing ST’s position  and safety in the vehicle, using her current wheelchair, and to advise a reassessment  should the wheelchair be changed. As a consequence, the vehicle occupant seat belt did not fit properly across ST’s lap,  contributing to her being thrown into the footwell.

In my opinion action should be taken to prevent the risk of future deaths and I believe  you have the power to take such action.  I have raised this matter with you collectively and as individual organisations.