Author Archives: GambitNash

Large Care Home Group Fined after Death of Elderly Resident Following a Fall

A large UK-based care home group has been fined £57,000 after an elderly resident in their care died when she fractured her neck in a fall during a manual handling transfer. The company pleaded guilty late last year in a Scottish court of breaching section 3 of the Health and Safety at Work etc Act, 1974 which led to the fatal injury of an 88 year old female resident.

On the morning of 22nd October 2008 a carer in the home was in the process of assisting the resident with her undressing as well as transferring her from her bed to her shower chair when the resident fell to the floor. The carer, who had very recently taken up employment within the home, was unaware that a care plan and manual handling assessment stated that two people were required to transfer the resident.

The care home group admitted that they had failed to review and update the risk assessment for the resident and had also failed to provide adequate training and instruction as well as staff supervision for those workers within the home who were expected to undertake people handling activities.

The resident had been at the care home for over ten years when she was taken to the local hospital for emergency treatment following the fall. She died the next day from her injuries.

The Health and Safety Executive (HSE) investigation indicated that the residents care plan and safe system of work assessment had not been updated when there had been changes to her mobility. These documents stated incorrectly that one member of staff was required where other documents pertaining to her care indicated there was a requirement for two staff to assist with manual transfers.

The court heard that staff relied on consulting their colleagues about resident’s manual handling needs rather than reading the care plans and risk assessments. The carer present when the resident fell had not been given sufficient instruction and had not been adequately supervised in relation to manual handling activities.

The HSE Principal Inspector Barry Baker said “Care homes have a responsibility to look after their residents who are often vulnerable and not able to look after themselves. In this case the standard of care provided …fell below acceptable levels with tragic consequences.”

“This is not an isolated incident and every year there are numerous residents who suffer serious injuries as a result of a fall in a care home. To help avoid similar incidents it is crucial that care providers ensure they have thorough care plans for their residents in place and that their staff are properly trained and supported to make these plans work in practice.”

Edge Services

Care Agency Held in Raid Leaving Elderly Lady without Food

Mrs Gloria Foster 81 was left without medication food or water for nine days after the domiciliary care agency who were supposed to be caring for her was closed in a police raid. The agency which was based in Cheam, south London was raided on suspicion of employing illegal immigrants and was raided by both the Metropolitan Police and UK Border Agency officers in January 2013 when they arrested six people.

Mrs Foster lived in Banstead, Surrey and was found by a district nurse who had her admitted as an emergency to her local hospital in Epsom to recover from kidney failure. Unfortunately Mrs Foster died nearly three weeks later.

A full investigation is taking place of Surrey County Council’s Safeguarding procedures as they had commissioned the care package for Mrs Foster from the homecare agency.

Surrey County Council said in a statement: “We are very sad to hear about Mrs Foster’s death and our thoughts are with her family and friends at this difficult time. The safety of vulnerable adults is our top priority, which is why this tragic event is already being urgently looked at by the Surrey Safeguarding Adults Board.”

Edge ServicesThe Manual Handling Training Company

Bed Sore Figures Reveal Pressure on NHS

A recent BBC documentary revealed that 42% of reported ‘Serious Untoward Incidents’ at hospitals throughout England involve bed sores.

The NHS report nearly 12,000 such incidents each year and figures obtained by Freedom of Information requests for the Inside Out programme showed that 4,966 of the last years incidents concerned the presence of severe bed sores. Bed (or pressure) sores are graded by 1 to 4 the most severe are graded at 4 and in some cases can be fatal. The Superman actor Christopher Reeve’s life was claimed by the presence of an infected pressure sore in 2004. According the NHS 95% of bed sores are ‘completely avoidable’ so the programme asked why then are thousands of people suffering unnecessarily? According to a spokesperson from the Royal College of Nursing (RCN) it is because of lack of nursing staff. According to the RCN it can take up to 4 staff to turn a patient and in order to avoid pressure sores patient turning needs to occur very regularly throughout the day and night. If staffing numbers are low then this is less likely to happen.

The programme went on to interview management of the group of hospitals in the West Midlands that were highlighted as being where the number of serious incidents were at their highest.

Edge ServicesThe Manual Handling Training Company

£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