Recurring concern

Unreliable bed-brake safety controls

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First reported 15 Dec 2014•Latest report 28 Sep 2020

Definition

What this concern includes

Includes failures of controls specifically dedicated to ensuring bed brakes are applied and remain on when required for safe care, including staff application, documentation or checklist checks, verification and related assurance arrangements.

Not included

Excludes bed-rail provision, assessment or positioning failures where the bed-brake control is not the unsafe condition.
Excludes bed alarms, call bells and other alerting systems unless the assertion also identifies a bed-brake safety failure.
Excludes generic clinical-equipment checks, maintenance or staffing deficiencies that are not specifically tied to applying, checking or assuring bed brakes.
Excludes falls or other patient outcomes where no failure of a dedicated bed-brake control is identified.

Reports: 2
Individual concerns: 2
Date range: 2014–2020
Stated actions: 4

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.

Care Quality Commission1

Department of Health and Social Care1

Manchester University NHS Foundation Trust1

NHS England1

Sunrise Senior Living Limited1

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.

28 Sep2020
Manchester South
Concerns raised1
1. Lack of documentation checks confirming bed brakes are on
This report raised 6 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.
Actions described in response 2
1. Action
  Update falls documentation and policy to require immediate scene checks, bed-brake and bed-rail checks, falls-risk review, and appropriate care planning during intentional rounding.
  Stated by Manchester University NHS Foundation TrustStated completed
2. Action
  Review nursing documentation and its effectiveness in supporting individualized care plans through a Trust Task and Finish Group with academic partners.
  Stated by Manchester University NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  The Trust disputes that managers knew the bed brakes were not applied, stating the unwitnessed fall and absent contemporaneous checks prevented that conclusion.
  Stated by Manchester University NHS Foundation TrustDisputes the concern
AI-generated summary

Mr William Ivan McKibbin · 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

Mr William Ivan McKibbin died at Trafford General Hospital on 20 August 2018 following complications of a traumatic brain injury sustained in an unwitnessed fall in hospital. The report raised concerns about bed-rail and bed-brake checks, the culture of openness and candour, communication between specialists and hospital sites, incident investigations, and the process for learning from deaths.

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
Lack of documentation checks confirming bed brakes are on
Wider context from the report
“2. It is a matter of concern that NHS nursing documentation, such as Intentional Rounding Checklists, in use at the Trust and in other hospitals, currently do not include ‘tick-box’ checks to confirm bed-rails are in the appropriate position, and the bed brakes are on. ”
Source location
Mr William Ivan McKibbin · 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
Update falls documentation and policy to require immediate scene checks, bed-brake and bed-rail checks, falls-risk review, and appropriate care planning during intentional rounding.

Verbatim wording from the response
“The intentional rounding core documentation (attached at appendix 4) was adapted alongside the Trust’s Inpatient Falls Management Policy, Falls Care Plan, and Falls Investigation Template, with changes publicised via the Trust’s iNews communication on 9ᵗʰ September 2020 which included a spotlight on falls prevention and management. The updates to documentation were also circulated by the Group Deputy Chief Nurse on 11ᵗʰ September 2020. The changes were also highlighted specifically at Trafford General Hospital via the site Falls Specialist Nurse, with a poster and publicity campaign.”

Source location
2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
Page 6 · response
Published 19 November 2020
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
Review nursing documentation and its effectiveness in supporting individualized care plans through a Trust Task and Finish Group with academic partners.

Verbatim wording from the response
“The Falls Collaborative Research Sub-Group, co-chaired by the Trust’s Group Deputy Chief Nurse and international expert Professor ████████, Director of the National Institute for Health Research’s Older People & Frailty Policy Research Unit, has reviewed and approved the Trust’s Intentional Rounding documentation. The evidence base for rounding was considered at the Falls Collaborative meeting on 21ˢᵗ September 2020. Subsequently, a Task & Finish Group has been established within the Trust with support from academic partners to review the current nursing documentation and its effectiveness in contributing to the delivery of an individualised care plan for patients. A high-level literature review has been conducted on intentional rounding to inform this work programme.”

Source location
2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
Page 7 · response
Published 19 November 2020
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
The Trust disputes that managers knew the bed brakes were not applied, stating the unwitnessed fall and absent contemporaneous checks prevented that conclusion.

Verbatim wording from the response
“I share your concern that the assessment of the brakes was not undertaken immediately post Mr McKibbin’s fall. I also accept in full your findings in relation to the report completed, it was not of the quality I would expect and lacked some key questions and lines of enquiry. Those failings acknowledged; it is not accepted that the Managers from the Trust therefore knew the brakes could not have been on. Sadly, Mr McKibbin’s fall was unwitnessed and, as confirmed, the brakes were not checked at the time. The Trust position on this was that it could not be ascertained as to whether the brakes were on and that the bed rails were applied. I would draw your attention to page 4 of the report where it is noted that “Upon entering the room Mr”

Source location
2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
Page 5 · response
Published 19 November 2020
Open published response
15 Dec2014
Manchester South
Concerns raised1
1. Failure to apply bed brakes when staff are not in the room
This report raised 11 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.
Actions described in response 2
1. Action
  Incorporate bed placement, profiling-bed safety and brake-use training into mandatory manual-handling training for care and nursing staff.
  Stated by Sunrise Senior Living UKStated completed
2. Action
  Monitor mandatory manual-handling training compliance through weekly reports and escalate concerns to the Director of Operations.
  Stated by Sunrise Senior Living UKStated completed
AI-generated summary

RHYS TUDOR WILLIAMS · 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

On 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.

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 apply bed brakes when staff are not in the room
Wider context from the report
“5. The requirement for bed brakes to be properly applied when the staff members are not in the room should be an absolute requirement and this should be reinforced in writing to all staff. ”
Source location
RHYS TUDOR WILLIAMS · Prevention of Future Deaths report
Page 1 · 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
Incorporate bed placement, profiling-bed safety and brake-use training into mandatory manual-handling training for care and nursing staff.

Verbatim wording from the response
“In relation to training on bed placement and safe use of profiling beds (including using brakes on such beds), we now have incorporated this into our manual handling training which is mandatory for all care and nursing staff. Compliance is monitored via manual handling training compliance reports, which are reported weekly to the business. Any concerns on compliance are acted upon by the Director of Operations.”

Source location
2014-0558-Response-by-Sunrise-Senior-Living
Page 1 · response
Published 15 December 2014
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
Monitor mandatory manual-handling training compliance through weekly reports and escalate concerns to the Director of Operations.

Verbatim wording from the response
“In relation to training on bed placement and safe use of profiling beds (including using brakes on such beds), we now have incorporated this into our manual handling training which is mandatory for all care and nursing staff. Compliance is monitored via manual handling training compliance reports, which are reported weekly to the business. Any concerns on compliance are acted upon by the Director of Operations.”

Source location
2014-0558-Response-by-Sunrise-Senior-Living
Page 1 · response
Published 15 December 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of documentation checks confirming bed brakes are on

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.2

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

Concerns raised1

Failure to apply bed brakes when staff are not in the room

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.2

Actions described in response 2

Respondent positions 1

Actions described in response 2