Recurring concern

Failure to ensure mattresses are suitable for care recipients and beds

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First reported 29 Nov 2016•Latest report 23 Jul 2019

Definition

What this concern includes

Includes failures to assess, select, match, provide or verify the suitability of mattresses for individual care recipients and the beds on which they are used, including incompatibility, instability, displacement or failure to maintain the recipient safely within the mattress area.

Not included

  • Excludes pressure-relieving mattress inflation, alarm, maintenance or serviceability failures where mattress suitability or bed compatibility is not the deficient control.
  • Excludes general bed safety, bedrail, bed-brake, moving-and-handling or patient-positioning failures unless they directly concern mattress suitability or compatibility.
  • Excludes generic equipment procurement, staffing, training or documentation deficiencies unless they directly cause an unsuitable or incompatible mattress to be provided.
  • Excludes failures involving mattresses in non-care settings unless the assertion concerns the same care-recipient mattress-provision process.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2016–2019

First to latest report issue date

Stated actions
2

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Care Inspectorate Wales1
Caron Group Ltd1
Crosfield House Limited1
Dorset Healthcare University NHS Foundation Trust1
Lambton House1
NHS Wales1

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.

  1. South Wales Central

    AI-generated summary

    Barbara Humphreys · 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

    Barbara Humphreys was admitted to Crosfield House in July 2018 and later experienced repeated entrapment of her leg and foot between bed rails and the mattress. She underwent a right lower-leg amputation and died in hospital on 28 November 2018; the reported medical cause was thrombosis and the inquest conclusion was natural causes. The principal concerns included the lack of a bed-rail risk assessment, unsuitable mattresses, staff training, bed-rail policies, care planning, and communication with family about medical attendance, palliative care and DNAR decisions.

    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

    Use of mattresses unsuitable for particular beds or unable to maintain patient limbs within the mattress area

    Wider context from the report

    “1. The first issue is directed to Crosfield house Ltd and Care Inn limited and Care Inspectorate Wales. It relates to the use of mattresses which are either not designed for use on particular beds or when used on particular beds are not constructed or designed to maintain a level when a patient is placed in the centre of said mattress. Upon placing of a patient in the centre of said mattress certain mattresses can fold at the edge and otherwise become displaced such that a patient’s limbs will not be maintained within the mattress area. The correct mattress for the correct bed is considered de minimus in terms of a standard ”

    Source location

    Barbara Humphreys · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. County Durham and Darlington

    AI-generated summary

    Name not published · 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

    The deceased, who had a history of falls and was assessed as being at risk of falling, was found on the floor after an unwitnessed night and sustained injuries that subsequently led to her death. Concerns included the absence of adequate risk assessments for falls and pressure sores, and the failure to identify that a new mattress was unsuitable for her.

    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 identify unsuitable mattresses for care recipients

    Wider context from the report

    “(2) It became apparent that the new mattress was not suitable for the deceased and that this had not been adequately identified. ”

    Source location

    Name not published · 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

    Install pressure mats whenever a mattress is incompatible with bed sensors.

    Verbatim wording from the response

    “Staff at Lambton House did recognise that a pressure sensor needed to be placed next to the deceased's bed and attempts were made to try to have a floor pressure sensor mat installed next to the deceased's bed. Unfortunately at that time this required a specialist contractor to attend to install the mat and incorporate it into the building's existing alarm system. That change could not take place that day. Unfortunately the deceased suffered a fall later that evening. It is now standard practice for pressure mats to be installed in all cases where a mattress is used that is incompatible with bed sensors.”

    Source location

    2016-0423-Response-by-Lambton-House-Care-Home
    Page 1 · response
    Published 26 February 2017

    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

    Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.

    Verbatim wording from the response

    “Steps are being taken to further minimise the risk that resident's face in situations such as this. Lambton House is currently in the process of phasing in through “Home Loans” the provision of air flow mattresses, where there has been an assessed need to aid pressure relief care. All new air flow mattresses are compatible with bed based pressure sensors. The aim is to eliminate the need for floor based pressure sensors, which in themselves can also create a risk of falls/trips.”

    Source location

    2016-0423-Response-by-Lambton-House-Care-Home
    Page 1 · response
    Published 26 February 2017

    Open published response
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Data last updated 7 September 2026