Care home sentenced after resident's bed rail death

Date:

23 May 2011

A Llangollen nursing home has been fined following the suffocation of an elderly woman after she become trapped between her mattress and bed rails intended to stop her falling.

Elizabeth Roberts, 89, was found suffocated in her room at the Headlands Nursing Home on 30 August 2008. Her upper body had slid down to the floor between the bed mattresses and bed rails where she had become trapped.

Mold Crown Court heard Mrs Roberts had suffered from a previous entrapment incident three weeks before but no alternative bedding arrangements had been made.

A Health and Safety Executive (HSE) investigation revealed care staff at the home engaged bedside rails after Mrs Roberts repeatedly fell from her bed, however employees had not been provided with up-to-date training on the safe use of bed rails, in particular the risk of entrapment created.

HSE found the home also failed to complete a suitable and sufficient risk assessment on the use of bed rails for Mrs Roberts, which should have identified that they may have been unsuitable in her case. There was no company policy on the safe use of bed rails and no system for routine inspection, monitoring and maintenance.

Deevale Homecare and Services Ltd of Grosvenor Road, Wrexham, who own and operate the Headlands Nursing Home in Llangollen, pleaded guilty to breaching Section 3(1) of the Health & Safety at Work etc. Act 1974, and Regulation 3 (1) Management of Health & Safety at Work Regulations 1999. They were sentenced at Mold Crown Court today and fined £70,000, with £21,818.56p in costs.

HSE inspector Sarah Baldwin-Jones said:

"This is a terrible incident and one that could have been easily avoided.

"It is essential that home owners and care staff consider whether bed rails are the most appropriate method of preventing a patient falling from bed.

"There are many alternative options such as the use of low profile beds, which should be considered. When using bed rails, homes should take adequate steps to assess the potential risks created. This should consider the bed occupant as well as the set up of the bedding arrangements.

"To assist home owners, free guidance on the safe use of bed rails has been made widely available for a number of years. This home could have taken the simple steps provided in the guidance to train care staff and implement a safe system of routine inspection and maintenance at their home. Had this occurred at the Headland Nursing Home, Mrs Roberts' death could have been prevented."

Notes to editors

1. The Health and Safety Executive is Britain's national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice; promoting training; new or revised regulations and codes of practice; and working with local authority partners by inspection, investigation and enforcement.
2. Section 3 (1) of the Health and Safety at Work etc. Act 1974, states that: "it shall be the duty of every employer to conduct its undertaking in such a way as to ensure so far as is reasonably practicable that persons not in its employment who may be affected thereby are not thereby exposed to risks to their health or safety."
3. Regulation 3 (1) Management of Health & Safety at Work Regulations 1999 states that: 'Every employer shall make a suitable and sufficient assessment of the risks to the health and safety of persons not in his employment arising out of or in connection with the conduct by him of his undertaking, for the purpose of identifying the measures he needs to take to comply with the requirements and prohibitions imposed upon him by or under the relevant statutory provisions.
4. The risk of entrapment created by bedding arrangements and bedrails is detailed in the Medical and Healthcare products Regulatory Agency (MHRA) Device Bulletin DB2006 (06) Safe use of Bed Rails.
5. Further information on risk assessment can be found on the HSE website at http://www.hse.gov.uk/contact/faqs/riskassess.htm

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Issued on behalf of the Health and Safety Executive by COI News and PR Wales