£165,000 Fine for Preventable Death of 93 Year Old due to Ill-Fitting Bed Rails


A Huddersfield care home has been fined £165,000 and £18,000 costs after a 93 year old resident died when she became trapped between her mattress and bed rails resulting in her asphyxiation. This brings the total number of RIDDOR reported bed rail related deaths to 25 since 2001 most of which could have been avoided.

Leeds Crown Court heard the case and imposed the fine based on the fact that no formal training had been given to the staff on the safe use/installation of bed rails and also records showed that the resident had previously injured her leg on two occasions when it had become trapped in the rails. The care home group- who own 27 care homes – admitted breaching health and safety regulations.

The Safe Use of Bed Rails

Bed rails also known as bed side rails, cot-sides safety sides and bed guards are used extensively in the care sector to protect vulnerable people from falling out of bed. Analysis of accident data continues to highlight the serious issue of injuries involving bed rails.

There are several causes of injury, the most serious being entrapment of the neck, head or chest. This could lead to death from asphyxiation. Injuries also arise from a person attempting to climb over the rails and falling, entrapping arms legs hands and feet or striking their head or limbs against the rails.

The risks associated with bed rail use include:

  • Poorly fitting rails allowing parts of the body to become trapped, examples include being trapped between the bed rail and the headboard or bottom rail and bed base.
  • Poor rail design for example over-sized spacing between the rails.
  • Poorly fitting mattresses that do not fit snugly between the bed rails leaving gaps between the side of the mattress and the bed rail.
  • Mattresses that are too thin or easily compressible at the edges for certain bed rail types allowing the client to slide under the rail.
  • Loose fitting bed rails allowing movement away from the side of the mattress or up and down the bed exposing dangerous gaps.
  • Use of pressure relieving mattresses which reduce the effective height of the bed rail.
  • Lack of or poor maintenance of a bed rail.
  • Inappropriate assessment of the client regarding bed rail usage.

Most of the fatalities caused by the use of bed rails could have been avoided if a thorough risk assessment of the situation had been undertaken. Effective risk assessment is therefore the key to ensure safe use of bed rails. The assessment should consider the client, the combination of proposed equipment, the bed and the mattress.

Issues to consider will include:

  • If the client is likely to fall from their bed are bed rails an appropriate solution?
  • Does the client’s physical size or behaviour present a risk when using rails?
  • Is the bed rail height and general design appropriate for the bed and the client? Bed rails for adults should not be used for children or vice versa.
  • Could the client’s head neck chest or limbs become trapped between the bars of the bed rail or other spaces that might be created between the bed rail, mattress, and headboard or foot board?
  • Is the bed rail fitted correctly and securely?
  • Is the bed rail in good condition? There should be no parts missing.
  • The rail should be inspected regularly to ensure that it remains in good condition during use.

As a general rule bed rails should be fitted so that the gap between their end and the headboard is less than 60mm. All gaps between rail bars for adults must be 120mm or less and for children 60mm or less

If the bed, mattress, bed rail or condition of the client changes then the risk assessment should be reviewed and documented accordingly.

Kate Lovett

Senior Trainer

Edge ServicesThe Manual Handling Training Company

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