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Issue 2: Unsafe use of bed rails
Why should you read this?
When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.
The unsafe use of bed rails can result in serious or fatal injuries.
Bed rails are used a lot in health and social care services to prevent people falling from their beds and being injured. There are risks though. People can become trapped:
- between the rails and the mattress
- between the gaps in the bed rails
Prosecution by CQC
In April 2017, CQC successfully prosecuted a nursing home provider.
The provider pleaded guilty to two offences of failing to provide safe care and treatment, with:
- one offence resulting in avoidable harm to a resident
- a second offence resulting in people using this service being exposed to a significant risk of avoidable harm.
The first offence concerned a 98-year-old man who fractured his hip during a fall at the home in August 2015 but was discharged to the home after treatment in hospital.
There followed four incidents where the man became trapped in a bed rail, or attempted to climb over it. Within four weeks of being discharged, he fell out of bed and re-fractured his hip. He died in hospital.
A safety consultant had previously identified that 14 beds needed bed rail extensions to prevent the occupants falling out of bed. But the provider had not authorised the work until after the resident’s accident.
The provider was ordered to pay:
- a £150,000 fine
- £13,000 prosecution costs
- a £170 victim surcharge
The provider has taken steps to improve
When CQC inspectors visited the care home in November 2015, they found concerns around the use of bed rails used by all 10 people they checked. This suggested that the provider had not taken sufficient action to deal with risks or to keep people safe.
This was a breach of Regulation 12(1) and 12(2) as care and treatment were not provided in a safe way. The service was rated as inadequate against the question, ‘Is the service safe?’.
At a follow-up inspection in March 2016, inspectors found that:
- people's care plans had individual bed rail risk assessments
- care plans contained consent forms for the use of bed rails, and these were signed by a family member where someone was unable to do this themselves
- equipment was assessed for safety and recorded
- care workers understood how to use bed rails to make sure people were safe
These measures helped demonstrate that the provider had carried out sufficient improvements. Therefore, the inspectors rated the ‘safe’ question as good.
What can you do to avoid this happening?
Unfortunately, this sort of incident is not uncommon, but you can do something to reduce the risk.
There have been other serious incidents involving bed rails reported to the Medicines and Healthcare Products Regulatory Agency (MHRA).
Staff should check that the bed rail is the right height for the mattress (for example, when using an overlay mattress) to make sure it protects people from falls. Bed rail extenders may need to be used to achieve this.
A full risk assessment must be carried out before staff decide to use bed rails. Look at the questions in the MHRA guidance on the Safe use of bed rails published in December 2013. This will help to make sure that people are safe and secure.
- Last updated:
- 13 September 2018