Recurring concern

Unreliable stability controls for wheeled furniture in patient-care areas

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First reported 5 Nov 2013•Latest report 6 Jun 2023

Definition

What this concern includes

Includes failures of controls dedicated to preventing unintended movement or unsafe access to wheeled chairs, beds and comparable wheeled furniture in patient-care areas, including removal from high-risk areas, securing or locking wheels, checking stability and addressing unsafe placement.

Not included

Excludes general falls-risk assessment, supervision or post-fall response failures where wheeled furniture stability or placement is not the unsafe condition.
Excludes ordinary bed-brake failures limited to bed brakes when no comparable wheeled-furniture condition is identified; those belong to the narrower bed-brake concern.
Excludes wheelchairs, hoists, trolleys and clinical equipment where the assertion concerns their own named equipment-safety system rather than wheeled furniture used in patient-care areas.
Excludes isolated patient falls or unsafe furniture presence where no continuing deficiency in placement, stability or movement controls is asserted.

Reports: 3
Individual concerns: 4
Date range: 2013–2023
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Blackpool Teaching Hospitals NHS Foundation Trust1

Care UK1

George Eliot Hospital NHS Trust1

NHS England1

Welsh Government1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

6 Jun2023
Berkshire
Concerns raised1
1. Failure to position a high-falls-risk resident’s bed appropriately
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Jennifer Evelyn RACKLEY · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jennifer Evelyn Rackley died at Wexham Park Hospital on 15 January 2022 after a fall at her nursing home on 17 December 2021. Concerns included that her bed may have been in the centre of the room with only one sensor mat despite her high falls risk, and that the care home's reported investigation had no written record and could not identify the carers involved.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to position a high-falls-risk resident’s bed appropriately
Wider context from the report
“(1) It seems likely that Jennifer’s bed was in the centre of the room, with one sensor mat only, despite a high falls risk. ”
Source location
Jennifer Evelyn RACKLEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Feb2016
Warwickshire
Concerns raised2
1. Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls
2. Failure to lock the inner wheels of beds
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Discuss the bed-wheel safety risk and identified guidance gaps with the MHRA.
  Stated by NHS EnglandStated planned
2. Action
  Work with occupational therapy and other stakeholders to develop new national resources for assessing and safely using beds.
  Stated by NHS EnglandStated planned
3. Action
  Recreate the incident in laboratory testing to assess brake operation, bed positioning, and movement conditions.
  Stated by ArjoHuntleighStated completed
Respondent positions 1
1. Position
  No further action was considered necessary after post-market surveillance identified no similar incidents globally.
  Stated by ArjoHuntleighNo action considered necessary
AI-generated summary

Eileen Annie Thompson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Eileen Annie Thompson, who had dementia, fell between her bed and a wall after the bed moved and sustained serious head injuries. She died shortly after admission to hospital. The concerns were that the bed’s inner wheels were not locked because their locking mechanisms were inaccessible against the wall, creating a risk of recurrence for other service users.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls
Wider context from the report
“(1) The bed was able to move from the wall because the two inner wheels were not locked. (2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall. (3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall. ”
Source location
Eileen Annie Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to lock the inner wheels of beds
Wider context from the report
“(1) The bed was able to move from the wall because the two inner wheels were not locked. (2) The locking mechanism for the inner wheels was not easily accessible when the bed was placed against a wall. (3) There is risk of recurrence in respect of service users who are provided with this type of bed when the bed is placed against a wall. ”
Source location
Eileen Annie Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss the bed-wheel safety risk and identified guidance gaps with the MHRA.

Verbatim wording from the response
“Our planned action: We will discuss the risk and our findings with the MHRA as we feel that it is within their remit to improve the advice provided in user instructions. We will highlight the fact that some IFUs do not seem to provide enough guidance for staff and that advice is needed on how to safely use a bed with individual wheels, if it is positioned against a wall. Advice is also required on how many wheels need to be locked to hold the bed in position.”

Source location
E-Thompson-Response2
Page 3 · response
Published 15 February 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with occupational therapy and other stakeholders to develop new national resources for assessing and safely using beds.

Verbatim wording from the response
“We feel that staff is aware of the problem but that the solution is not always straight forward. We therefore think that new resources are required for staff to assess the risks more carefully and to be able to make adequate decisions with regards to the safe use of beds.”

Source location
E-Thompson-Response2
Page 4 · response
Published 15 February 2016
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Recreate the incident in laboratory testing to assess brake operation, bed positioning, and movement conditions.

Verbatim wording from the response
“We have recreated a simulation of the incident in a laboratory environment and are able to conclude the following:”

Source location
E-Thompson-Response
Page 1 · response
Published 15 February 2016
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No further action was considered necessary after post-market surveillance identified no similar incidents globally.

Verbatim wording from the response
“In conclusion we believe that the root cause for this event is related to the combination of the use of the device and the patients' health state (including pre-existing conditions). Taking into the consideration that the patient, who was involved in this particular event, was diagnosed with dementia and had no upper body stability, it seems unlikely that a gap between the wall and bed frame could have been created in an immediate manner, without a significant effort from the patient side. We have reviewed the current warnings included with our products, which we feel are clear and fit for purpose and have also undertaken PMS reviews to highlight similar incidents globally (none) and therefore feel that no further action is required in this matter.”

Source location
E-Thompson-Response
Page 5 · response
Published 15 February 2016
Open published response
5 Nov2013
Blackpool and the Fylde
Concerns raised1
1. Presence of wheeled chairs in areas accessible to elderly patients at significant risk of falls
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ethel Cross · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ethel Cross, who had a history of falls, fell on ward 4 at Clifton Hospital when a wheeled chair slipped, suffering a fractured neck of femur, and died the following day. Concerns were raised about wheeled chairs being accessible to elderly patients at risk of falls and the lack of an available alarm to alert staff when a high-risk patient mobilised unsupported.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Presence of wheeled chairs in areas accessible to elderly patients at significant risk of falls
Wider context from the report
“During the Inquiry, I received evidence that chairs utilised by staff which have wheels attached to them had been present on ward 4 and that Ethel Cross had sat on one of these chairs which slipped and she suffered a fracture. I heard evidence that these chairs have been removed from two wards – including ward 4 - on which elderly patients at significant risk of falls may be cared for. I am concerned that such chairs may continue to be present on other wards within the Trust where such patients may have access to them and similar incidents may occur. ”
Source location
Ethel Cross · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to position a high-falls-risk resident’s bed appropriately

Concerns raised2

Inaccessibility of inner-wheel locking mechanisms when beds are placed against walls

Failure to lock the inner wheels of beds

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Presence of wheeled chairs in areas accessible to elderly patients at significant risk of falls

Actions described in response 3

Respondent positions 1