May Lewis Cardiff lift death: Unlawful killing verdict
An inquest jury has returned a verdict of unlawful killing on a 96-year-old woman in a wheelchair who died in a lift shaft fall.
May Lewis fell 20ft (6m) and was killed instantly, five days after moving into Pontcanna House, Cardiff.
Mrs Lewis, who had lived at the care home for just five days, broke 52 bones in the fall when her wheelchair was pulled into the empty shaft by a carer.
The inquest had heard that the lift door was faulty.
Staff were routinely using a "dangerous" emergency key to open the locked door.
Dr Nasik Al-Mufti, who was in charge of health and safety at the home, admitted knowing the lift was faulty but said she had only glanced at the safety manual once in four years.
She said: "None of us use a manual to go to Marks and Spencer and use the lifts, you just know how to do it.
"I only looked at the manual once - a quick look - three years before the death."
The hearing was told the manual warned: "Do not use the lifting platform if it is faulty or not behaving properly."
Dr Al-Mufti told the hearing: "If I went through the manual in detail I would have seen it.
"But it's not for me to deal or do anything with the lift. I leave that to the professional contractors who maintain the lift."
Dr Al-Mufti, who has a Phd in biochemistry, added: "I am not a technical person and I am hopeless with machines, so I leave it with my husband.
"I didn't see the yellow sticker of the emergency key which said: 'This key is dangerous'. My concern was to make the key available to the staff."
Dr Al-Mulfti admitted having never carried out a risk assessment on the lift and not being trained in how to use it.
The inquest heard that Mrs Lewis was being reversed into the lift by carer Carole Conway. She failed to notice the lift had not arrived at the top floor when she opened the faulty lift door using an emergency release key.
Mrs Conway, who survived the fall, told the inquest: "I did not look inside before I stepped in, I just assumed it was there.
"The lift was playing up - we always had problems with it. I just remember being on the floor with the wheelchair on top of me."
Mrs Lewis died instantly in the tragedy on March 6 last year.
Lift production specialist Sven Hillman told the inquest the second floor lift door had a faulty locking mechanism.
Mr Hillman said: "When this problem was first discovered the lift should have been turned off and locked up until it was fixed."
He said only trained people should have used the "emergency release key" and not routinely.
Mrs Lewis's daughter, Brenda Jones, told the inquest: "When I last saw my mother, she was enjoying a singalong at the home.
"She was tapping a tambourine and smiling. I had no qualms about the quality of her care."
The inquest jury returned a verdict of unlawful killing.
After the hearing, Care Forum Wales, which represents private healthcare providers provided a statement: "This is an extremely tragic case and our thoughts are with the family of May Lewis at this difficult time.
"Care Forum Wales is committed to ensuring the highest possible standards in social care.
"We will work closely with Pontcanna House and other members and provide support so that nothing like this can happen again. There is nothing more important than the safety and well-being of residents."