An inquest report into the death of a 51-year-old Manitoba woman strangled by a wheelchair seatbelt has been released.

Ann Hickey, a longtime resident at the Manitoba Developmental Centre, a care facility for adults with a mental disability, died in March 2011.

Staff at the Portage la Prairie facility were dealing with other patients when she slid down in the chair and choked.

An autopsy determined her death was accidental, but an inquest was called with the aim of preventing similar deaths from happening in the future.

The inquest heard Hickey had recently moved to the facility and the staff may not have been aware of all her issues. The night she died, staff were not aware there was a plan to have her walking more and that she was not in her own wheelchair, the report states.

The report recommends better communication between staff and a change in policies at the Manitoba Developmental Centre to prevent further tragedies.

The recommendations include training workshops be held more regularly, improvements be made to patient transfer procedures, tags on wheelchairs include info about risk of patient's tendency to shift in chair, and the circumstances be made clear about when a patient needs to be in constant view while walking or using a wheelchair.