Kenneth Bardsley
27 Dec 2018 · Coroner Alison Mutch · Manchester (South)
The coroner's concerns
1. lack of formal requirements for lift engineer qualifications
“there is a risk that future deaths will occur”
2. regulatory lift examinations not read or acted upon
“there was a gap in the system which meant that regulatory lift examinations could take place but not be read or acted upon, with no escalation process”
3. lack of clarity in follow up requirements
“lack of clarity as to how engineers should be made aware and follow up requirements made by engineers carrying out the regulatory lift examinations”
4. CQC missed faults in regulatory examinations
“CQC did not pick up that there were faults identified in the regulatory examination that had not been acted upon”
5. no system to ensure details from lift examinations are read and passed on
“Serendipity Care Home did not have a system in place to ensure details from the lift examinations were read; considered and passed on to the lift servicing company”
6. engineers not expected to review regulatory examination reports
“the lift company Lancs and Cumbria engineers carrying out serving/repairs were not expected to ask to see the regulatory examination reports”
Responses
No published response was found on judiciary.uk.