Includes failures of controls dedicated to the safety of cots and cot sides, including scheduled servicing, maintenance, inspection, fitting, securing, positioning and raising of cot sides or comparable protective components.
What is not included
Excludes general bed, bedrail or patient-moving-and-handling concerns where the assertion does not specifically concern cots or cot sides.
Excludes generic equipment-maintenance failures where no cot or cot-side safety condition is identified.
Excludes failures involving mattresses, bedding or other cot accessories unless they directly affect the safe operation or containment function of the cot or cot sides.
Excludes clinical care, staffing or supervision failures that are not part of the cot or cot-side safety system.
Trends
Reports over time
Reports mentioning this concern, 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.
Department of Health and Social Care2
Anetic Aid Limited1
Care Quality Commission1
Medicines and Healthcare products Regulatory Agency1
NHS England1
NHS South Yorkshire Integrated Care Board1
North Cumbria Integrated Care NHS Foundation Trust1
Rch Care Homes Limited1
Royal Berkshire Hospital1
Tameside and Glossop Integrated Care NHS Foundation Trust1
The Children's Trust1
Ministerial department2
NHS trust2
Private limited company2
Executive non-departmental public body1
Health and social care service regulator1
Healthcare site1
Integrated care board1
Medicines and medical devices regulator1
Registered charity1
Reports and published responses 5 reports
See individual reports that have raised this concern, and the actions taken in response
Cumbria
Concerns raised1
Lack of documentation about the use of cot sides
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North Cumbria Integrated Care NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
North Cumbria Integrated Care NHS Foundation Trust
Explore mandatory electronic fields for bed-rail status and call-bell placement, including with the replacement-record supplier.
North Cumbria Integrated Care NHS Foundation Trust
Revise the Nurse-in-Charge checklist to include bed rails, call bells and environmental safety.
Surrey
Concerns raised2
Lack of guidance on placement of padded cot boards
Failure to provide yearly servicing of allocated cots
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England
The Children's Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
NHS England
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
The Children's Trust
Stop using the cot type allocated to Connor and replace existing beds and cots with models conforming to BS EN 50637:2017.
The Children's Trust
Update the Medical Devices and Equipment Policy and keep it aligned with current regulations and best practice.
The Children's Trust
Provide clinical-assets training through competency assessments, moving-and-handling programmes, therapy training and practice learning, with additional manufacturer training arranged where needed.
The Children's Trust
Maintain contracted inspection, repair and preventive-maintenance arrangements for medical equipment, with monthly KPI monitoring of servicing compliance.
The Children's Trust
Establish clinical-assets governance, appoint a dedicated clinical-assets lead and assign responsibility for safe deployment, registration, servicing and maintenance.
The Children's Trust
Transfer clinical-assets and maintenance records to the centralised CATi system and validate bed condition and service-history data.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
NHS England
Integrated Care Systems are responsible for providers in their areas and can check adherence to guidance intended to prevent future deaths.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
The Children's Trust
Current bed systems, qualified assessment, servicing controls and monitoring arrangements are considered robust responses to sleeping-equipment safety concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Mid Kent and Medway
Concerns raised1
Failure to fully engage cot-side retaining buttons
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Rch Care Homes Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Rch Care Homes Limited
Audit bedrails through maintenance checks and management rechecks to confirm secure locking with an audible click.
Rch Care Homes Limited
Re-educate staff in bedrail use through direct supervision to ensure locking mechanisms are properly engaged.
Rch Care Homes Limited
Provide daily-meeting health and safety briefings reinforcing the risks of unsecured bedrails, recorded in meeting minutes and supervision records.
Manchester South
Concerns raised1
Failure to raise cot sides as required
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Berkshire
Concerns raised1
Failure to highlight the cot-side locking problem in all trolley maintenance schedules
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
AneticAid
Royal Berkshire NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Royal Berkshire NHS Foundation Trust
Contract AA to conduct periodic inspections and required maintenance of QA3 trolleys, documenting faults and remedial actions.
Royal Berkshire NHS Foundation Trust
Update the Clinical Engineering Checklist to specify required checks during every QA3 trolley inspection.
Royal Berkshire NHS Foundation Trust
Correspond with AA to seek amendment of the QA3 trolley servicing schedule.
Royal Berkshire NHS Foundation Trust
Discuss the QA3 trolley servicing-schedule issue with MHRA to support resolution with AA.
Royal Berkshire NHS Foundation Trust
Require AA to inspect and maintain QA3 trolleys in accordance with the updated Clinical Engineering Checklist as an interim measure.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Royal Berkshire NHS Foundation Trust
Responsibility for developing QA3 trolley maintenance schedules lies with the manufacturer, Anetic Aid Limited.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Royal Berkshire NHS Foundation Trust
The Trust considers its Clinical Engineering Checklist, enforced for interim inspections and maintenance, sufficient to address the maintenance-schedule concern in practice.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Royal Berkshire NHS Foundation Trust
The Trust has no control over securing a permanent solution to the QA3 trolley servicing-schedule concern.
Outside remitThe respondent said that this matter was outside its role or authority.
AneticAid
Retrospective changes to QA3 side-rail design, performance or maintenance are not considered necessary because this is the only reported incident and concern is localised.
No action considered necessaryThe respondent said that no further action was needed.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.