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Bed Rail Management Safety
CASE: Death Due to Poor Bed Rail Management
A leading health care organisation has been fined over the inappropriate management of bedrails at one of its care homes, a vulnerable adult died at the home where the bed rail was used. The home admitted breaching Section 3 (1) of the Health & Safety at Work etc. Act 1974; Regulation 9 of the Provision and Use of Work Equipment Regulations 1998, and was fined £400,000 with £15,206 costs.
According to the HSE, the Specialist Nursing Home failed to ensure it managed the risk of bedrails through appropriate assessment and review of bedrail arrangements, and failed to train staff in the assessment of and safe use of bedrails.
The risk to vulnerable adults from poor bed rail management leading to injuries are known. In addition, death can occur where vulnerable adults fall through gaps or get caught through gaps between a mattress and a bed rail.
Recommendation for Bed Rail Management
- Ensure there is a bed rail management policy in place which is reviewed and updated as necessary
- Ensure that the bed rail policy is communicated to all staff including agency workers
- Ensure that a suitable and sufficient risk assessment is developed to assess the risk of using a bed rail for each user
- The risk assessment should be reviewed at intervals and always after a change in the health and condition of the vulnerable adult
- The risk assessor carrying out the risk assessment should be trained in how to carry out appropriate risk assessments to ensure all hazards are identified, controls are put in place and actions taken
- Ensure staff are given information, instruction and training in the use of bed rails with regular refreshers
- Ensure a monitoring schedule is in place for staff to check the bed rail at planned regular intervals during the day and night. This is to ensure any defects or movement in position is identified and actioned
- Ensure that sensor pads are switched on as this will alert staff
- Ensure bed rails are maintained in accordance with the manufacturer’s recommendations and follow safe operating instructions for use
- Ensure all the bed rail equipment is compatible with the bed and mattress and is designed to be used together