A jury has returned a verdict of accidental death after a man with severe learning difficulties hit his head when his wheelchair overturned on a steep slope.
Jurors at the inquest of James Barrie Moor, who died aged 76 at his home in Kernick Road, Penryn in July 2012, said there was nothing that carers could have done differently which would have prevented his death.
Assistant coroner Barrie van den Berg heard that on July 21 Mr Moor was returning from a trip with a carer in his bespoke mobility vehicle and had just been removed from the vehicle when accident happened. The carer who was pushing him into his home, Nicholas Brown, tripped, and Mr Moor started to roll down the steep driveway towards the road.
Mr Brown said Mr Moor was a man who “had a zest for life, and he also loved going out in his own car”. On the afternoon in question he had been out on a trip with one of his carers, who had taken him to Helston to buy fish and chips for the other residents at the home.
On his return he had been taken from the vehicle and was being pushed to the home.
Mr Brown said: “I don’t know how it happened but my foot went away from me. I went falling to the ground and by the time I got up the wheelchair started going down the drive. It’s quite steep. I made a dive for his wheelchair. The chair spun at the bottom of the drive and he came up and landed on his side.”
Mr Brown told a colleague who had come out, to call for an ambulance.
They righted Mr Moor and took him to the top of the drive, where they were met by paramedics who took him to the Royal Cornwall Hospital in Truro.
Mr Brown stayed with Mr Moor at the hospital throughout the evening and into the next day.
Mr Moor was admitted to the Wheal Coates ward of the hospital, and died on July 25 from a cerebral oedema (swelling of the brain).
A statement by Mr Jonathan Wyatt, a consultant at the accident and emergency department in Truro, said that after being admitted it was initially very difficult to give Mr Brown a CT scan as he was “not cooperative” although he was able to be treated for a wound on the side of his face.
Mr Wyatt said the results of a scan the next day “didn’t demonstrate a fracture”.
Consultant pathologist Dr H Jones read notes from an autopsy of Mr Moor, which found that he had died of brain swelling due to cerebral contusions, and that he had a small fracture to the base of his skull, but said that it was a small linear fracture of a type that would not always be picked up on a CT scan.
Emma O’Hara, an inspector with the Health and Safety Executive, investigated the incident to see if there had been any issues with training or with the practical management of risks at the home.
She said: “At the time of the accident Mr Brown was following practices as he should have been.
“The conclusion is that this was an unfortunate accident and nothing could have been done to prevent it in these circumstances.”
The coroner returned a verdict of accidental death.