Recurring concern

Unreliable bedrail safety controls

Get email alerts

Request correction

First reported 6 Sep 2013•Latest report 7 Aug 2025

Definition

What this concern includes

Includes failures in controls specifically dedicated to bedrail safety, including person-specific risk assessment, decisions about whether bedrails are required or appropriate, timely provision and repair, fitting and securing, staff training and understanding, compliance with assessments and policy, and referral or review when bedrail risks are uncertain.

Not included

Excludes generic falls prevention, mobility, staffing, documentation or care-planning deficiencies where bedrails are not the material safety control.
Excludes risks from other bed, cot, chair or restraint systems unless the assertion explicitly concerns bedrail safety.
Excludes failures limited to the underlying patient's condition or occurrence of a fall where no bedrail control deficiency is identified.
Excludes unrelated clinical treatment, discharge or transfer failures that do not concern assessment, provision, maintenance or use of bedrails.

Reports: 13
Individual concerns: 24
Date range: 2013–2025
Stated actions: 22

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.

East Kent Hospitals University NHS Foundation Trust2

Manchester University NHS Foundation Trust2

Betsi Cadwaladr University LHB1

Care Inspectorate Wales1

Care Quality Commission1

Care UK1

Caron Group Ltd1

Crosfield House Limited1

Department of Health and Social Care1

Epsom and St Helier University Hospitals NHS Trust1

European Care & Lifestyles (UK) Limited1

Great Western Hospitals NHS Foundation Trust1

NHS England1

NHS Wales1

Nursing and Midwifery Council1

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.

7 Aug2025
Manchester South
Concerns raised2
1. Failure to ensure bed rails are in place when required
2. Failure to conduct timely bed-rail assessments
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.
Actions described in response 6
1. Action
  Revise the admission checklist to specify timely post-admission assessment of bed rails and other fall-prevention equipment, with clearer completion prompts and reasons for omissions.
  Stated by Care UKStated completed
2. Action
  Update Care and Clinical Meeting Notes to require checks against completed risk assessments and timely completion of admission checklists.
  Stated by Care UKStated completed
3. Action
  Update the pre-admission assessment proforma to prompt bed-rail assessment, record relevant falls and equipment history, and require Home Manager completion checks.
  Stated by Care UKStated completed
1. Action
  Publish the updated pre-admission assessment and admission checklist on the intranet and circulate them internally with a link from 7 October 2025.
  Stated by Care UKStated planned
2. Action
  Launch a bed-rails e-learning module covering policies and procedures for colleagues conducting bed-rail assessments.
  Stated by Care UKStated planned
3. Action
  Add an admission-checklist completeness question to monthly Go Audits to enable management auditing against required completion timeframes.
  Stated by Care UKStated in progress
Respondent positions 1
1. Position
  Previous incidents involved crash mats or low-rise beds; there were no reported falls without bed rails or alternative protective measures.
  Stated by Care UKDisputes the concern
AI-generated summary

Marion Jones · 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

Marion Jones, who had stage 4 lung cancer and required assistance with movement, fell from an unrailed bed at Riverside care home on 23 March 2025, sustaining a head injury. The principal concerns were that no bed-rail assessment was recorded or carried out despite family concerns, and that nursing staff lacked a clear understanding of the required assessment process and timing.

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 ensure bed rails are in place when required
Wider context from the report
“1. No pre-admission assessment for bed rails was recorded by the staff member responsible from Riverside, and this does not appear to have taken place. This is in circumstances where bed rails were already in place at Willow Wood and where there were obvious and recorded difficulties with regard to movement in and about bed, in addition to physical activity more generally. Given the circumstances, a pre-admission assessment for bed rails should have taken place and / or been recorded. 2. The inquest heard that family members raised their concerns on admission of Marion Jones to Riverside when they saw there were no bed rails. They were assured that an assessment would take place. This did not happen: it should have done. 3. The manager of the care home agreed that in all the circumstances, including the concerns of the family, such an assessment should have taken place. 4. A registered general nurse involved in care for Marion Jones, and who found her after she had fallen, gave evidence that an assessment for bed rails should have taken place 48-72 hours after admission. The manager of the care home gave evidence that such an assessment should take place as promptly as possible, and that 48-72 hours did not meet this requirement. There is did not appear to appreciate the time within which such an assessment should be conducted. 5. Another registered general nurse involved in the care of Marion Jones gave evidence that she was not sure in what period of time an assessment for bed rails should take place. 6. Therefore, nursing staff responsible for the care of Marion Jones did not know what the appropriate approach was to assessment for bed rails. The awareness of nursing staff at Riverside with regard to assessment for and / or the requirement for bed rails was not apparent 7. The inquest heard that there have been previous incidents where bed rails have not been in place. ”
Source location
Marion Jones · 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 conduct timely bed-rail assessments
Wider context from the report
“1. No pre-admission assessment for bed rails was recorded by the staff member responsible from Riverside, and this does not appear to have taken place. This is in circumstances where bed rails were already in place at Willow Wood and where there were obvious and recorded difficulties with regard to movement in and about bed, in addition to physical activity more generally. Given the circumstances, a pre-admission assessment for bed rails should have taken place and / or been recorded. 2. The inquest heard that family members raised their concerns on admission of Marion Jones to Riverside when they saw there were no bed rails. They were assured that an assessment would take place. This did not happen: it should have done. 3. The manager of the care home agreed that in all the circumstances, including the concerns of the family, such an assessment should have taken place. 4. A registered general nurse involved in care for Marion Jones, and who found her after she had fallen, gave evidence that an assessment for bed rails should have taken place 48-72 hours after admission. The manager of the care home gave evidence that such an assessment should take place as promptly as possible, and that 48-72 hours did not meet this requirement. There is did not appear to appreciate the time within which such an assessment should be conducted. 5. Another registered general nurse involved in the care of Marion Jones gave evidence that she was not sure in what period of time an assessment for bed rails should take place. 6. Therefore, nursing staff responsible for the care of Marion Jones did not know what the appropriate approach was to assessment for bed rails. The awareness of nursing staff at Riverside with regard to assessment for and / or the requirement for bed rails was not apparent 7. The inquest heard that there have been previous incidents where bed rails have not been in place. ”
Source location
Marion Jones · 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
Revise the admission checklist to specify timely post-admission assessment of bed rails and other fall-prevention equipment, with clearer completion prompts and reasons for omissions.

Verbatim wording from the response
“B. Admission check-list form”

Source location
Response from Care UK
Page 2 · response
Published 13 August 2025
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
Update Care and Clinical Meeting Notes to require checks against completed risk assessments and timely completion of admission checklists.

Verbatim wording from the response
“Finally, we have updated our Care & Clinical Meeting Notes form to include that checks should be made as per completed risk assessments, and that the admission checklist should be fully completed within the required timeframes.”

Source location
Response from Care UK
Page 3 · response
Published 13 August 2025
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
Update the pre-admission assessment proforma to prompt bed-rail assessment, record relevant falls and equipment history, and require Home Manager completion checks.

Verbatim wording from the response
“It is Care UK policy where residents are assessed or present as being at risk of falling out of bed, the use of bed rails should be considered. In Marion’s case, the pre-admission assessment did not identify a risk of falling out of bed that would have triggered the bed rails assessment. However, Marion had bed rails in her previous placement and upon admission her family raised concerns regarding bed rails. In those circumstances, Danielle agreed that a bed rail assessment should have taken place. In order to prevent this happening again in the future, we have made the following changes outlined below:”

Source location
Response from Care UK
Page 2 · response
Published 13 August 2025
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
Publish the updated pre-admission assessment and admission checklist on the intranet and circulate them internally with a link from 7 October 2025.

Verbatim wording from the response
“The updated pre-admission assessment and admission checklist will be live on our intranet “mycareuk” from 7 October 2025 and an email from our internal communications platform “iCommunicate” will be circulated with a link to these forms on the same day.”

Source location
Response from Care UK
Page 3 · response
Published 13 August 2025
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
Launch a bed-rails e-learning module covering policies and procedures for colleagues conducting bed-rail assessments.

Verbatim wording from the response
“As previously outlined, we have made changes to our pre-admission pro-forma and admission checklist that will ensure that colleagues consider bed rails assessments before and after admission. In addition to these changes, we are launching a Bed Rails eLearning module which will improve the knowledge of colleagues assessing residents in relation to our policies and procedures regarding bed rails assessments. This eLearning module will be live on our e-learning platform from 13 October 2025.”

Source location
Response from Care UK
Page 3 · response
Published 13 August 2025
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
Add an admission-checklist completeness question to monthly Go Audits to enable management auditing against required completion timeframes.

Verbatim wording from the response
“Also, we have amended our documentation on our “Go Audits” tool. These are audits completed on a monthly basis by our Deputy Home Managers. They look at the individual assessments that form part of a resident’s care plan, for example: MUST Assessment, MFRA Assessment, Choking Risk Assessment, etc. The Audit ensures that all necessary parts of a care plan have been completed, all necessary information has been included, and the information is up-to-date. We have now added an additional question that covers the completeness of the Admission Checklist within the required timeframes. These amendments will go live this month and will allow management to audit compliance with the implemented changes.”

Source location
Response from Care UK
Page 3 · response
Published 13 August 2025
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
Previous incidents involved crash mats or low-rise beds; there were no reported falls without bed rails or alternative protective measures.

Verbatim wording from the response
“Your final concern was regarding evidence given during the inquest that there have been previous incidents where bed rails have not been in place. I discussed this concern with the Home Manager and the Regional Director for Riverside care home. Danielle explained that during the inquest she gave evidence that previous incidents had occurred where bed rails were not in place. However, she explained to me that she was referring to incidents where residents had rolled out of bed without bed rails in place, but a low-rise bed with a crash mat was in place or a resident prevent injury. She has reassured me that she was not referring to any previous incident where a resident with no bed rails had fallen out of bed with no fall out (crash) mat.”

Source location
Response from Care UK
Page 4 · response
Published 13 August 2025
Open published response
3 Jun2025
South London
Concerns raised1
1. Failure to keep the bed rail up when a patient is attended by a lone HCA
This report raised 2 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

Anthony Haydn WOOD · 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

Anthony Haydn WOOD was admitted to St. Helier Hospital and fell from his bed while being prepared to be washed and changed on 22 September 2024. He sustained intracranial injuries and died in hospital on 26 September 2024; concerns included the absence of crash mats, the bed-rail being lowered, and the patient being attended by one staff member despite identified fall risk and a need for two staff members.

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 keep the bed rail up when a patient is attended by a lone HCA
Wider context from the report
“(1) the patient was identified as at high risk of a fall (2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur) (3) there were no crash mats at the side of his bed (4) it was known that the patient had a propensity to push staff when being changed (5) the bed-rail was not up when the patient was attended by a HCA acting alone (6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed (7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed All of these matters are recorded in the Trust's own Datix report. ”
Source location
Anthony Haydn WOOD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Aug2023
North Wales (East and Central)
Concerns raised1
1. Failure to include bed rail assessment in the Welsh Nursing Care Record
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
  Raise the bed-rail assessment issue nationally to expedite standardisation and inclusion in the WNCR.
  Stated by Betsi Cadwaladr University LHBStated completed
2. Action
  Remind ward managers, matrons and heads of nursing about paper-based bed-rail assessments and provide materials for staff safety briefings and ward display.
  Stated by Betsi Cadwaladr University LHBStated completed
3. Action
  Finalise and introduce the updated Bed Rails Procedure.
  Stated by Betsi Cadwaladr University LHBStated in progress
Respondent positions 1
1. Position
  Creation of a standardised bed-rails assessment tool is being led nationally by Cwm Taf Morgannwg University Health Board.
  Stated by Betsi Cadwaladr University LHBRedirects responsibility
AI-generated summary

Malcolm Ralph Unwin · 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

Malcolm Ralph Unwin suffered an unwitnessed fall from his bed while a patient at hospital on 30 December 2022 and died at Wrexham Maelor Hospital on 6 January 2023. The report raised concern that he had not been assessed for bed rails and that the absence of bed-rail assessment from the Welsh Nursing Care Record could result in such assessments being missed in future.

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 include bed rail assessment in the Welsh Nursing Care Record
Wider context from the report
“There was no evidence that the deceased had been assessed for bed rails, whilst in hospital although it is probable that they were in due at the time of his fall. Evidence was given that the bed rail assessment is not currently a part of the Welsh Nursing Care Record which staff access via iPad. In the absence of this being a part of the WNCR I am concerned that this assessment may be missed, and that future death may occur as a result. ”
Source location
Malcolm Ralph Unwin · 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
Raise the bed-rail assessment issue nationally to expedite standardisation and inclusion in the WNCR.

Verbatim wording from the response
“Following your Notice, we raised this issue nationally in order to expedite this process. The issue was discussed at the National Deputy Directors of Nursing Meeting on 07 September 2023, and in response Cwm Taf Morgannwg University Health Board has taken the lead in establishing a national working group to create a standardised bed rails assessment tool across Wales, and to propose this single version for inclusion in the WNCR.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023
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
Remind ward managers, matrons and heads of nursing about paper-based bed-rail assessments and provide materials for staff safety briefings and ward display.

Verbatim wording from the response
“In the interim period, I can confirm we have written to all ward managers, matrons and heads of nursing reminding them of the process for paper based assessment forms. We have provided information which can be used on ward safety briefs with staff and which can also be visibly placed in wards to remind staff.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023
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
Finalise and introduce the updated Bed Rails Procedure.

Verbatim wording from the response
“We are also in the process of finalising our updated Bed Rails Procedure which will be live within the next few weeks.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023
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
Creation of a standardised bed-rails assessment tool is being led nationally by Cwm Taf Morgannwg University Health Board.

Verbatim wording from the response
“Following your Notice, we raised this issue nationally in order to expedite this process. The issue was discussed at the National Deputy Directors of Nursing Meeting on 07 September 2023, and in response Cwm Taf Morgannwg University Health Board has taken the lead in establishing a national working group to create a standardised bed rails assessment tool across Wales, and to propose this single version for inclusion in the WNCR.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 6 September 2023
Open published response
2 Aug2021
West Yorkshire Eastern
Concerns raised1
1. Failure to ensure the bedrails policy is circulated and understood by staff responsible for implementing it
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.
Actions described in response 3
1. Action
  Incorporate learning from bed-rails management into an addendum to the Falls Policy and publish it.
  Stated by Mid Yorkshire Teaching NHS TrustStated completed
2. Action
  Disseminate bed-rails assessment learning through Trust-wide communications, management discussions, and the Gate 43 learning-from-incidents newsletter.
  Stated by Mid Yorkshire Teaching NHS TrustStated completed
3. Action
  Circulate the bed-rails learning through a Trust-wide Patient Safety Bulletin.
  Stated by Mid Yorkshire Teaching NHS TrustStated planned
AI-generated summary

Mary Ann LINCOLN · 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

Mary Ann LINCOLN was admitted to Pinderfields General Hospital on 18 May 2020 and was discovered deceased on the floor of her room on 21 May 2020, with an open fracture of the tibia and fibula. The concerns identified included inadequate overnight checks for vulnerable patients at risk of falls and weaknesses in the circulation and understanding of the bedrails policy.

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 ensure the bedrails policy is circulated and understood by staff responsible for implementing it
Wider context from the report
“(2) There is a bedrails policy in place, the author of the SI report found that it appeared to be comprehensive. During evidence however the staff responsible for implementing its use were either unaware of it (it appears it is not circulated to HCA’s), or find it confusing. There is obviously a void between producing a policy and ensuring it is circulated and understood by all concerned. ”
Source location
Mary Ann LINCOLN · 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
Incorporate learning from bed-rails management into an addendum to the Falls Policy and publish it.

Verbatim wording from the response
“4) Learning from other Trusts in relation to bed rails management (identified through CQC inspections) was circulated by MYHT’s Falls and Quality Practitioner to a number of high level groups including the Patient Safety Improvement Group, Nursing Review Group, Patient Safety Panel and PSCE. The learning was subsequently incorporated into an addendum to the falls policy published in July 2021.”

Source location
2021-0275-Response-from-Mid-Yorkshire-Hospitals_Published-1
Page 4 · response
Published 19 August 2021
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
Disseminate bed-rails assessment learning through Trust-wide communications, management discussions, and the Gate 43 learning-from-incidents newsletter.

Verbatim wording from the response
“████████ including issues raised by the Coroner and/or family and lessons learned, was emailed widely throughout the Trust to senior management ████████ for dissemination to all appropriate staff.”

Source location
2021-0275-Response-from-Mid-Yorkshire-Hospitals_Published-1
Page 4 · response
Published 19 August 2021
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
Circulate the bed-rails learning through a Trust-wide Patient Safety Bulletin.

Verbatim wording from the response
“6) This particular ‘learning from incidents’ will be highlighted again through an upcoming Patient Safety Bulletin which will be circulated trust-wide by end of October 2021.”

Source location
2021-0275-Response-from-Mid-Yorkshire-Hospitals_Published-1
Page 4 · response
Published 19 August 2021
Open published response
28 Sep2020
Manchester South
Concerns raised1
1. Lack of documentation checks confirming bed-rails are in the appropriate position
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
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-rails are in the appropriate position
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
14 Jan2020
London Inner (West)
Concerns raised1
1. Bed rails allowing patients to fall from their beds
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

John David Long · 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

John David Long suffered an unwitnessed fall from his bed in Benjamin Weir Ward at St. George’s Hospital on 4 May 2019, sustaining a head injury that led to his death. The concerns identified relate to the design and suitability of bed rails, the definition and administration of one-to-one care, provision of breaks without leaving the patient alone, and training for one-to-one care.

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
Bed rails allowing patients to fall from their beds
Wider context from the report
“1. The bed rails affixed to patients beds allow a patient to fall easily from the patient’s bed and the make and manufacture of bed rails should be reviewed to ensure they are fit for purpose and act to ensure the patient is secure in their bed and also prevent a patient accidentally falling from their bed. ”
Source location
John David Long · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Jul2019
South Wales Central
Concerns raised4
1. Failure to include willing patient family members in bed rail risk assessments
2. Failure to complete full and frank bed rail risk assessments
3. Lack of an implemented full bed rail policy governing regulatory compliance
1. Failure to review bed rail risk assessments regularly
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 1
1. Action
  Agree and undertake an unannounced joint monitoring visit, including review of Deprivation of Liberty Safeguards and Best Interest decisions.
  Stated by Powys Teaching Local Health BoardStated in progress
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
Failure to include willing patient family members in bed rail risk assessments
Wider context from the report
“3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails. This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly. ”
Source location
Barbara Humphreys · 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 complete full and frank bed rail risk assessments
Wider context from the report
“3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails. This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly. ”
Source location
Barbara Humphreys · 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
Lack of an implemented full bed rail policy governing regulatory compliance
Wider context from the report
“4. The fourth issue is directed to Crosfield house Ltd and Care Inn limited. The company should produce and implement a full bed rail policy which is either group wide or relevant specific only to Crosfield house Ltd. This should detail how the company intends to ensure their employees are following the letter and spirit of the regulations. ”
Source location
Barbara Humphreys · 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 review bed rail risk assessments regularly
Wider context from the report
“3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails. This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly. ”
Source location
Barbara Humphreys · 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
Agree and undertake an unannounced joint monitoring visit, including review of Deprivation of Liberty Safeguards and Best Interest decisions.

Verbatim wording from the response
“reference as part of the wider sharing of lessons. Through our care home governance framework, the health board will continue to monitor the standards of care and treatment provided to Powys residents. A planned date for a joint monitoring visit with Powys County Council was in place but was subsequently postponed whilst the regular visits from the Health and Safety Executive and Care Inspectorate Wales took place. Importantly, a new date is currently being agreed for the visit which will be unannounced. The team that undertakes review visits has also been strengthened with a new addition to the team representing pharmacy and medicines management.”

Source location
2019-0246-Response-by-Powys-Teaching-Health-Board
Page 2 · response
Published 9 September 2019
Open published response
20 Nov2017
Central and South East Kent
Concerns raised1
1. Failure to ensure bed-rail use follows bed-rail risk assessments
This report raised 7 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

Peter Blakeney KING · 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

Peter Blakeney King was admitted to hospital with confusion, headache, fever and limb weakness, and later fell from his bed on 18 March 2017, sustaining fatal head injuries. The concerns included inadequate documentation and implementation of falls precautions, use of bed rails despite an assessment that they were not recommended, failure to provide an observable bed and crash mat, and failure to address falls risk at handover.

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 ensure bed-rail use follows bed-rail risk assessments
Wider context from the report
“(2) In respect of Mr King a falls risk assessment and precautions to minimise the risk of falls was not properly documented; interventions were not recorded and no referrals were made to either the falls team or physiotherapy. A bed rails risk assessment was completed which recorded that bed rails were not recommended but were in use at the time of the fall. ”
Source location
Peter Blakeney KING · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Nov2017
Central and South East Kent
Concerns raised2
1. Unclear bedrail risk assessments
2. Inappropriate use of bed rails
This report raised 2 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

Henry George HONOUR · 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

Henry George Honour suffered an unwitnessed fall in hospital on 4 February 2017, sustaining a left hip fracture that was discovered four days later. He underwent surgery but died on 21 February 2017 from bronchopneumonia associated with immobility and the fracture. Concerns included inadequate falls-risk assessments, inappropriate use of bedrails, and failure to update the assessment or implement protective measures after the fall.

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
Unclear bedrail risk assessments
Wider context from the report
“(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths. (2) In respect of Mr Honour the falls risk assessment completed on admission was at best perfunctory, as were subsequent reviews which did not rectify earlier errors or recognise the need for precautionary measures to be taken when Mr. Honour should have been nursed in an observable bed with a falls alert and hip protectors in light of the risks posed. (3) The bedrail risk assessment was difficult to interpret in light of the falls risk assessment, bed rails were utilised when they should not have been. (4) The falls risk assessment was not updated post fall and no protective measures were put in place. ”
Source location
Henry George HONOUR · 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
Inappropriate use of bed rails
Wider context from the report
“(1) Between January 2017 and April 2017 five deaths occurred on Cambridge Wards at William Harvey Hospital. Common to each was the fact that the death was caused as a result of a fall on the ward in circumstances where falls risk assessments were either inadequate, incomplete, not reviewed or not enforced. Inquests in respect of each the deaths have been held, the last in November 2017. The Trust was given an opportunity following the earlier inquests to provide evidence of changes to practice following the deaths. It is recognised that at the time of hearing the inquests much work has already been done to address these issues but that work is ongoing and parts of that work have not yet been implemented/were in the process of being implemented. It is for this reason that Regulation 28 reports arise from three of the deaths. (2) In respect of Mr Honour the falls risk assessment completed on admission was at best perfunctory, as were subsequent reviews which did not rectify earlier errors or recognise the need for precautionary measures to be taken when Mr. Honour should have been nursed in an observable bed with a falls alert and hip protectors in light of the risks posed. (3) The bedrail risk assessment was difficult to interpret in light of the falls risk assessment, bed rails were utilised when they should not have been. (4) The falls risk assessment was not updated post fall and no protective measures were put in place. ”
Source location
Henry George HONOUR · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Sep2017
Wiltshire and Swindon
Concerns raised3
1. Failure to engage bedrails for patients with immobility, paralysis and involuntary movements despite bed-fall risk
2. Failure to assess bed-fall risk independently of a prior fall from bed
3. Failure of bed-fall risk assessments to provide consistent and coherent answers
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Implement personalised nursing care plan documentation, including bed-rail and falls assessments, across all inpatient areas.
  Stated by Great Western Hospitals NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Automatic bed rails will not be adopted because each patient requires an individual assessment, including paralysis or partial paralysis.
  Stated by Great Western Hospitals NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Francis Mortimer LANGLEY · 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

Francis Mortimer LANGLEY fell from a step ladder in November 2016, sustained thoracic spinal fractures and a thoracic cord injury, and became paralysed from the waist down. He later developed hospital-acquired pneumonia and died on 30 April 2017; the principal concern was the assessment and non-use of bedrails despite identified risks and apparently contradictory assessment responses before a subsequent fall from bed.

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 engage bedrails for patients with immobility, paralysis and involuntary movements despite bed-fall risk
Wider context from the report
“As part of the evidence when there is a fall in hospital (and I understand that SWICC is now part of Great Western Hospital hence I am writing to you). I always look at the risk assessments. For ease of reference I have enclosed with this letter marked A, a copy of the earliest assessment that I can on file dated 14 December 2016 in Great Western Hospital format which as you will see in response to the question as to whether or not the patient was admitted due to the fall or has fallen since admission and is at the risk of falling again the response is "Yes", although the ultimate decision was not to engage bed safety rails. As already stated Francis was transferred to SWICC on 30 January 2017 and I have been supplied with a screen dump image marked B showing the two assessments carried out on 30 January and 12 February 2017. The style is very different to the Great Western Hospital approach and in conjunction with this I have regard to a statement from ████████ who was Forest Ward Manager at the relevant time marked C. You will see at the bottom of his statement that the reason safety bedrails were not engaged is the fact that Francis did not have a history of falls from bed. I have to say that I am somewhat concerned and found the questions raised by the SWICC assessment and responses to be contradictory. By way of example I will refer you to the assessment that was carried out on 12 February a few days before the fall from bed on 17 February 2017. In response to the question as to whether or not Francis was at risk from falls from bed the answer was “Yes and No”. In relation to whether or not the patient could injure themselves against the rails due to spasms or uncontrolled movements, the answer was “Yes” yet in response to Does the patient have any behaviour that may interfere with the correct use of the safety rails the answer was “No”. The latter two responses to me contradict each other. Francis was noted that he would have been compliant with the use of safety rails. I have dealt with many cases whereby patients have fallen from their bed or chairs or simply collapsed whilst on the ward resulting in that patient sustaining a head injury from which they have died. To me given Francis’ immobility and the fact that he was in a condition with lower limb paralysis that was essentially alien to him and which involved involuntary movements I am concerned that when assessing the risk as to why safety rails were not engaged in the absence of any mental disorder. I know this is a concern shared by his widow. To me the risk of knocking a lower limb against one of the rails is outweighed by protecting a patient against the risk from falling from a bed and sustaining in particular a serious head injury. In reading the SWICC approach it is almost as if the fact that Francis had not had a fall from bed already predetermines that he is not at risk which to me seems an odd way of risk assessment. I would be grateful if you could please look at the inconsistency that appears to exist between the approach to the use of bedrails on Forest Ward as compared to the rest of Great Western Hospital as I have said the SWICC assessment concerns me in that it is overly complicated and as I have demonstrated has given rise to conflicting answers as part of the assessment process. I would also be grateful for the Trust's consideration in relation to the policy deployed generally when patients suffer whole or partial paralysis as to whether or not automatically those patients should be subject to bedrails. I appreciate it is not entirely black and white but I do find it surprising and I am concerned that bedrails were not engaged as at the 17 February 2017 although as already stated and I wish to emphasise I did not find that the fall contributed to his death. ”
Source location
Francis Mortimer LANGLEY · 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 assess bed-fall risk independently of a prior fall from bed
Wider context from the report
“As part of the evidence when there is a fall in hospital (and I understand that SWICC is now part of Great Western Hospital hence I am writing to you). I always look at the risk assessments. For ease of reference I have enclosed with this letter marked A, a copy of the earliest assessment that I can on file dated 14 December 2016 in Great Western Hospital format which as you will see in response to the question as to whether or not the patient was admitted due to the fall or has fallen since admission and is at the risk of falling again the response is "Yes", although the ultimate decision was not to engage bed safety rails. As already stated Francis was transferred to SWICC on 30 January 2017 and I have been supplied with a screen dump image marked B showing the two assessments carried out on 30 January and 12 February 2017. The style is very different to the Great Western Hospital approach and in conjunction with this I have regard to a statement from ████████ who was Forest Ward Manager at the relevant time marked C. You will see at the bottom of his statement that the reason safety bedrails were not engaged is the fact that Francis did not have a history of falls from bed. I have to say that I am somewhat concerned and found the questions raised by the SWICC assessment and responses to be contradictory. By way of example I will refer you to the assessment that was carried out on 12 February a few days before the fall from bed on 17 February 2017. In response to the question as to whether or not Francis was at risk from falls from bed the answer was “Yes and No”. In relation to whether or not the patient could injure themselves against the rails due to spasms or uncontrolled movements, the answer was “Yes” yet in response to Does the patient have any behaviour that may interfere with the correct use of the safety rails the answer was “No”. The latter two responses to me contradict each other. Francis was noted that he would have been compliant with the use of safety rails. I have dealt with many cases whereby patients have fallen from their bed or chairs or simply collapsed whilst on the ward resulting in that patient sustaining a head injury from which they have died. To me given Francis’ immobility and the fact that he was in a condition with lower limb paralysis that was essentially alien to him and which involved involuntary movements I am concerned that when assessing the risk as to why safety rails were not engaged in the absence of any mental disorder. I know this is a concern shared by his widow. To me the risk of knocking a lower limb against one of the rails is outweighed by protecting a patient against the risk from falling from a bed and sustaining in particular a serious head injury. In reading the SWICC approach it is almost as if the fact that Francis had not had a fall from bed already predetermines that he is not at risk which to me seems an odd way of risk assessment. I would be grateful if you could please look at the inconsistency that appears to exist between the approach to the use of bedrails on Forest Ward as compared to the rest of Great Western Hospital as I have said the SWICC assessment concerns me in that it is overly complicated and as I have demonstrated has given rise to conflicting answers as part of the assessment process. I would also be grateful for the Trust's consideration in relation to the policy deployed generally when patients suffer whole or partial paralysis as to whether or not automatically those patients should be subject to bedrails. I appreciate it is not entirely black and white but I do find it surprising and I am concerned that bedrails were not engaged as at the 17 February 2017 although as already stated and I wish to emphasise I did not find that the fall contributed to his death. ”
Source location
Francis Mortimer LANGLEY · 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 of bed-fall risk assessments to provide consistent and coherent answers
Wider context from the report
“As part of the evidence when there is a fall in hospital (and I understand that SWICC is now part of Great Western Hospital hence I am writing to you). I always look at the risk assessments. For ease of reference I have enclosed with this letter marked A, a copy of the earliest assessment that I can on file dated 14 December 2016 in Great Western Hospital format which as you will see in response to the question as to whether or not the patient was admitted due to the fall or has fallen since admission and is at the risk of falling again the response is "Yes", although the ultimate decision was not to engage bed safety rails. As already stated Francis was transferred to SWICC on 30 January 2017 and I have been supplied with a screen dump image marked B showing the two assessments carried out on 30 January and 12 February 2017. The style is very different to the Great Western Hospital approach and in conjunction with this I have regard to a statement from ████████ who was Forest Ward Manager at the relevant time marked C. You will see at the bottom of his statement that the reason safety bedrails were not engaged is the fact that Francis did not have a history of falls from bed. I have to say that I am somewhat concerned and found the questions raised by the SWICC assessment and responses to be contradictory. By way of example I will refer you to the assessment that was carried out on 12 February a few days before the fall from bed on 17 February 2017. In response to the question as to whether or not Francis was at risk from falls from bed the answer was “Yes and No”. In relation to whether or not the patient could injure themselves against the rails due to spasms or uncontrolled movements, the answer was “Yes” yet in response to Does the patient have any behaviour that may interfere with the correct use of the safety rails the answer was “No”. The latter two responses to me contradict each other. Francis was noted that he would have been compliant with the use of safety rails. I have dealt with many cases whereby patients have fallen from their bed or chairs or simply collapsed whilst on the ward resulting in that patient sustaining a head injury from which they have died. To me given Francis’ immobility and the fact that he was in a condition with lower limb paralysis that was essentially alien to him and which involved involuntary movements I am concerned that when assessing the risk as to why safety rails were not engaged in the absence of any mental disorder. I know this is a concern shared by his widow. To me the risk of knocking a lower limb against one of the rails is outweighed by protecting a patient against the risk from falling from a bed and sustaining in particular a serious head injury. In reading the SWICC approach it is almost as if the fact that Francis had not had a fall from bed already predetermines that he is not at risk which to me seems an odd way of risk assessment. I would be grateful if you could please look at the inconsistency that appears to exist between the approach to the use of bedrails on Forest Ward as compared to the rest of Great Western Hospital as I have said the SWICC assessment concerns me in that it is overly complicated and as I have demonstrated has given rise to conflicting answers as part of the assessment process. I would also be grateful for the Trust's consideration in relation to the policy deployed generally when patients suffer whole or partial paralysis as to whether or not automatically those patients should be subject to bedrails. I appreciate it is not entirely black and white but I do find it surprising and I am concerned that bedrails were not engaged as at the 17 February 2017 although as already stated and I wish to emphasise I did not find that the fall contributed to his death. ”
Source location
Francis Mortimer LANGLEY · 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
Implement personalised nursing care plan documentation, including bed-rail and falls assessments, across all inpatient areas.

Verbatim wording from the response
“When Great Western Hospitals took over the management of Swindon Community Healthcare Services, each organisation had their own documentation. As with any partnership it takes time to streamline the documentation. I am pleased to update you that from 1 July 2017 the nursing personalised care plan documentation which is used at GWH has been implemented on Forest and Orchard wards (SWICC). The nursing documentation booklet includes bed rails assessment, falls assessment and a care plan. I am sure you are familiar with this document, but I have included a copy of the four day personalised care plan for your perusal. Seven and 14 day versions are available depending on the time the patient is planned to be an inpatient. The assessments and care plans remain the same but there are more pages of the care plan evaluation for the longer admissions.”

Source location
2017-00240-Response-by-Great-Western-Hospital-NHS-Trust
Page 1 · response
Published 2 October 2017
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
Automatic bed rails will not be adopted because each patient requires an individual assessment, including paralysis or partial paralysis.

Verbatim wording from the response
“Consider whether patients who suffer from partial or whole paralysis should automatically have bed rails”

Source location
2017-00240-Response-by-Great-Western-Hospital-NHS-Trust
Page 2 · response
Published 2 October 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to ensure bed rails are in place when required

Failure to conduct timely bed-rail assessments

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.6

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 keep the bed rail up when a patient is attended by a lone HCA

Concerns raised1

Failure to include bed rail assessment in the Welsh Nursing Care Record

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

Failure to ensure the bedrails policy is circulated and understood by staff responsible for implementing it

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

Concerns raised1

Lack of documentation checks confirming bed-rails are in the appropriate position

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

Concerns raised1

Bed rails allowing patients to fall from their beds

Concerns raised4

Failure to include willing patient family members in bed rail risk assessments

Failure to complete full and frank bed rail risk assessments

Lack of an implemented full bed rail policy governing regulatory compliance

Failure to review bed rail risk assessments regularly

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.1

Actions described in response 6

Respondent positions 1

Actions described in response 3

Respondent positions 1

Actions described in response 3

Actions described in response 2

Actions described in response 1