Mystery as woman dies after falling down stairs while strapped to wheelchair at Portsmouth care home
A coroner said it was unlikely the woman could have entered a stairwell by herself
A woman strapped to her wheelchair fell down stairs and died sparking an investigation into the mysterious death at a Portsmouth council care home.
Sandra Moon, 65, fell down nine stairs at Russets Care Home in Gatcombe Drive, Hilsea, on 26 July 2025 before later dying in hospital.
Hampshire coroner Sarah Whitby said it was unlikely the victim could have entered the stairwell on her own - something she had never done in the 11 years she had been at the home.
Portsmouth City Council carried out a review of the unexplained death and said it had now secured the stairwell. Hampshire Police said it did not carry out a criminal investigation.
Ms Whitby, in a Prevention of Future Deaths report, said: “(Ms Moon) accessed a stairwell at the home and fell down a flight of nine steps, whilst still strapped in her wheelchair.
“The reason for her entering the stairwell is unknown, and something she had not done in the previous 11 years of residence. The deceased had some learning difficulties and significant health issues, but was aware of danger.
“Her ability to enter the stairwell of her own accord is in doubt and is not known if another person opened the stairwell door to enable access.”
Ms Moon suffered injuries which made her vulnerable to pneumonia from which she died as a result on 1 August 2025 at Southampton General Hospital.
The coroner added: “During the course of the inquest I heard evidence giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you.
“That a person of impaired cognitive and physical ability was able to access a stairwell in a wheelchair and fall down nine steps, and the reason for her being able to do so is unclear.”
A council spokesperson said: "Following the tragic death of Sandra Moon, Portsmouth City Council carried out a thorough review and took significant action to reduce the risk of a similar incident occurring in the future.
"While it has not been possible to establish definitively how Sandra gained access to the stairwell, a range of improvements have been implemented at Russets Care Home, including enhanced access controls, stairwell door alarms, strengthened risk assessment processes and additional governance oversight.
"We have also reviewed stairwell risks across our other adult social care settings and shared learning more widely through safeguarding and professional networks. Our thoughts remain with Sandra's family, fellow residents and the staff who supported her."