Recurring concern

Unreliable bedrail safety controls

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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.

10 Dec2015
Nottinghamshire
Concerns raised2
1. Lack of bed rails assessments
2. Failure to refer bed rails questions to Derbyshire Community Health
This report raised 13 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 3
1. Action
  Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.
  Stated by Your Health LimitedStated completed
2. Action
  Clarify staff responsibility for initial bed-rail assessments and verify completion through care-plan audits.
  Stated by Your Health LimitedStated completed
3. Action
  Improve recording and follow-up of bed-rail referrals so outstanding referrals are flagged.
  Stated by Your Health LimitedStated completed
Respondent positions 1
1. Position
  The local health service was responsible for providing bed rails, with an occupational therapist or district nurse deciding whether they could be used.
  Stated by Your Health LimitedRedirects responsibility
AI-generated summary

Elsie Marjorie Brown · 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

Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.

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 bed rails assessments
Wider context from the report
“1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed. ”
Source location
Elsie Marjorie Brown · Prevention of Future Deaths report
Page 1 · 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 refer bed rails questions to Derbyshire Community Health
Wider context from the report
“3. No referral was made to the Falls Team nor (by Langwith Lodge) to Derbyshire Community Health as regards the question of bed rails. ”
Source location
Elsie Marjorie Brown · 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
Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.

Verbatim wording from the response
“A falls management folder was introduced at Langwith in April 2015, which contains a number of different assessment tools to assist staff in reviewing the safety of a resident who is at risk of falls. This includes a specific bed rail risk assessment and algorithm (attached).”

Source location
Elsie-Brown-Response
Page 2 · response
Published 4 December 2015
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
Clarify staff responsibility for initial bed-rail assessments and verify completion through care-plan audits.

Verbatim wording from the response
“The Company introduced a falls management folder in April 2015, which includes an algorithm and risk assessment for bed rails (See 2 above). Following on from this, if necessary, the care home would make a recommendation for bed rails to the local health service through a referral. An Occupational Therapist or District Nurse then visits the home and makes a decision on whether bed rails can be used to reduce the risk of the resident falling out of bed. Other alternatives are also considered.”

Source location
Elsie-Brown-Response
Page 2 · response
Published 4 December 2015
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
Improve recording and follow-up of bed-rail referrals so outstanding referrals are flagged.

Verbatim wording from the response
“We would have expected a referral to have been responded to within 5-7 days, and at the time of the second incident on 23rd March 2015, no visit had been made. Since the inquest we have improved the system for recording when bed rail referrals have been made and how they are followed up. The new system should ensure that outstanding referrals are flagged up.”

Source location
Elsie-Brown-Response
Page 2 · response
Published 4 December 2015
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 local health service was responsible for providing bed rails, with an occupational therapist or district nurse deciding whether they could be used.

Verbatim wording from the response
“Bed rail referrals have always been made via the nurse practitioner, Claire Byrnes to Derbyshire Community Health. It is the responsibility of the local health service to provide bed rails and we were awaiting an OT visit to the home to make a decision on them being used.”

Source location
Elsie-Brown-Response
Page 2 · response
Published 4 December 2015
Open published response
5 Jun2014
Manchester South
Concerns raised1
1. Failure to update falls risk and bed rails assessments in accordance with policy
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.
Actions described in response 1
1. Action
  Monitor completion and updating of nursing risk assessments through daily matron rounds, ward-manager oversight and out-of-hours compliance reviews.
  Stated by Manchester University NHS Foundation TrustStated completed
AI-generated summary

THOMAS PATRICK MAHER · 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

Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

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 update falls risk and bed rails assessments in accordance with policy
Wider context from the report
“2. On a number of occasions during his stay in the hospital, the falls risk assessment and the bed rails assessment were not updated per policy. ”
Source location
THOMAS PATRICK MAHER · 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
Monitor completion and updating of nursing risk assessments through daily matron rounds, ward-manager oversight and out-of-hours compliance reviews.

Verbatim wording from the response
“The Head of Nursing for Trafford has taken steps to address this issue and has established robust monitoring processes. Matrons undertake daily rounds of the ward areas and review the completion of all nursing documentation; this review focuses specifically on the completion of appropriate risk assessments and helps raise awareness with staff. Ward Managers also have responsibility for ongoing monitoring of compliance in their areas. In addition, the Out of Hours team review compliance with the completion and updating of risk assessments at night and at weekends with any non-compliance being addressed at the time with the individuals concerned and highlighted to the Ward Manager or Matron.”

Source location
2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Page 2 · response
Published 5 June 2014
Open published response
6 Sep2013
Sunderland
Concerns raised4
1. Failure to act on family concerns and requests about bed rails
2. Failure to risk assess family concerns and bed-rail requests
3. Failure to document family concerns and bed-rail requests
1. Delays in repairing 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.
Actions described in response 2
1. Action
  Carry out bed-rail risk assessments within 24 hours of admission and review them monthly or when residents’ needs change.
  Stated by European CareStated completed
2. Action
  Require immediate reporting and repair of bed-rail defects, with staff instructed on reporting routes during and outside office hours.
  Stated by European CareStated completed
AI-generated summary

Peter Pattinson · 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 Pattinson, who had complex medical needs, was readmitted to hospital after falling from his bed at Cedar Court Care Centre and died on 19 March 2013. Concerns included family requests for raised bed rails not being acted on or documented or subject to risk assessment, delayed repair of the bed rails, and missing or non-sequentially paginated daily statements.

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 act on family concerns and requests about bed rails
Wider context from the report
“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”
Source location
Peter Pattinson · Prevention of Future Deaths report
Page 1 · 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 risk assess family concerns and bed-rail requests
Wider context from the report
“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”
Source location
Peter Pattinson · Prevention of Future Deaths report
Page 1 · 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 document family concerns and bed-rail requests
Wider context from the report
“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”
Source location
Peter Pattinson · Prevention of Future Deaths report
Page 1 · 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
Delays in repairing bed rails
Wider context from the report
“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”
Source location
Peter Pattinson · 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
Carry out bed-rail risk assessments within 24 hours of admission and review them monthly or when residents’ needs change.

Verbatim wording from the response
“a. bed rail risk assessments are carried out within 24 hours of admission and are then reviewed monthly or when needs change. Any changes will be discussed with the service user or a family member; and”

Source location
2013-0250-Response-by-European-Care-Group
Page 1 · response
Published 6 September 2013
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
Require immediate reporting and repair of bed-rail defects, with staff instructed on reporting routes during and outside office hours.

Verbatim wording from the response
“b. any defects regarding bed rails are to be reported and repaired immediately. All staff are now aware of how to report defects both within office hours and out of hours; and”

Source location
2013-0250-Response-by-European-Care-Group
Page 2 · response
Published 6 September 2013
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of bed rails assessments

Failure to refer bed rails questions to Derbyshire Community Health

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 update falls risk and bed rails assessments in accordance with policy

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

Concerns raised4

Failure to act on family concerns and requests about bed rails

Failure to risk assess family concerns and bed-rail requests

Failure to document family concerns and bed-rail requests

Delays in repairing bed rails

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 3

Respondent positions 1

Actions described in response 1

Actions described in response 2