A nursing home has been fined after a resident’s leg was repeatedly trapped in a bed rail.
An 88-year-old care home resident was admitted to hospital when her leg, which had repeatedly been trapped between her mattress and the bed rail, became discoloured and cold to the touch. She had to have her leg amputated.
Barbara Humphreys died in hospital in November 2018 following the incident at the care home.
The care home’s operators admitted a health and safety offence before magistrates and the home’s operators pleaded guilty to breaching Section 3 of the Health and Safety at Work Act. And have been fined £25,000 and ordered to pay costs of £11,747.
An investigation by the Health and Safety Executive (HSE) into the incident found that there was a lack of training and guidance on how to complete a bed rail assessment. Employees at the home had not received any training on the safe use of bed rails and were unaware of the risks from bed rail entrapment. It also found that, despite the resident’s leg becoming repeatedly trapped between September and November 2018, no review on the use of bed rails was carried out.
The prosecutor said a decision was made to fit a rail to the residents bed in August 2018, despite information they “can create a risk of entrapment”.
The resident was involved in “six separate bed rail incidents”.
The court heard her foot became “trapped” and she was taken to hospital where it was decided that her leg should be amputated. She later died in hospital.
However, the prosecutor said it was the “medical evidence” that the “bed rail entrapment is not thought to have caused her death”.
A subsequent Health and Safety Executive investigation found “fundamental failings” in the management of the bed railings, including in risk assessments and staff training.
She said this demonstrated “systemic failings” on behalf of the defendants to manage the bed railings.
HSE inspector said: “The incident could so easily have been avoided by simply conducting a detailed bed rail risk assessment. “Those who manage bedding equipment, should ensure that there are no gaps between the mattress and bed rail, where someone could get trapped “Employees involved in the provision and use of bed rails need to be aware of the key risks and know what to do if they suspect someone may be at risk of entrapment. In this case none of the employees recognised the risks and despite repeated entrapments, nothing was done to prevent recurrence.
If you use bedrails in your work environment and would like advice please feel free to give one of our team a ring on 01691 688723.
Information provided by:
https://press.hse.gov.uk/2021/01/20/nursing-home-fined-following-breaches-of-bedrail-safety/
https://www.bbc.co.uk/news/uk-wales-54989764