Recurring concern

Unreliable bed-brake safety controls

First to latest report 15 Dec 2014 — 28 Sep 2020

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
4

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.

What is 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 and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    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

  2. Manchester South

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026