SINGAPORE - Coroner Marvin Bay has urged residents to be "precise, prompt and thorough" in reporting lift faults following an incident in which an elderly man died while riding a mobility scooter out of a lift.

Mr Lim Hang Chiang, 77, did not realise that Lift A of Block 247, Pasir Ris Street 21, had "mislevelled" and was about 13cm higher than the floor landing when he reversed his scooter out of it on May 15 last year.

He hit his head when he fell backwards and died of a head injury the next day.

Coroner Bay, who found Mr Lim's death to be a "tragic misadventure" on Friday (Dec 29), said estate management and lift repair personnel should also play their part in presuming that the calls they get about lift faults are genuine and deserving of further investigation, even if the fault is not immediately evident when the lift is inspected.

He added: "It would also be ideal for estate management agencies to create protocols allowing for a reasonable period of post-repair surveillance and inspections, of repairs done on potentially hazardous lift faults, to ensure that these faults have been effectively and comprehensively addressed."

In his findings, he said the Building and Construction Authority (BCA) had uncovered six mislevelling incidents involving the lift between December 2015 and March last year.

No one was injured in these earlier incidents. The problem was either corrected with built-in recovery mechanisms or rectified after a technical repair.

Coroner Bay said this mislevelling phenomenon was seemingly random and intermittent in nature. This was why the problem was not replicated when repair personnel inspected the lift.

"When the repair personnel did not find a mislevelling fault, the incident would then be dismissed as a prank call or repairs would be effected on other parts of the lift. The mislevelling would therefore not be addressed," he said.

Mr Lim had taken Lift A from the 10th storey of the block on the day of the incident and was reversing out at the ground floor when he fell backwards.

Two of his neighbours who were in the lift immediately went forward to help.

Mr Lim's daughter-in-law later arrived at the scene and he was still fully conscious when she took him to Changi General Hospital.

A CT scan revealed that he was bleeding inside his skull and his condition became worse while awaiting transfer to the Surgical High Dependency Unit. He died the following day.

Responding to queries from The Straits Times, BCA said it takes a serious view on safety. It would also like to send a strong message to all lift owners and contractors to exercise due diligence in maintaining their lifts and taking feedback seriously.

It added: "The BMSM (Lift, Escalator and Building Maintenance) Regulations 2016 were implemented in July 2016 to enhance lift reliability and safety. Under the enhanced regulations, registered lift contractors are required to achieve specific maintenance standards tied to key outcomes."

Mr Lim's family members were in court on Friday but they declined to comment when approached by The Straits Times.