First reported 5 Jan 2015•Latest report 26 May 2025
Definition
What this concern includes
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.
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.
Reports
5
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
17
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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
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.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Explore mandatory electronic fields for bed-rail status and call-bell placement, including with the replacement-record supplier.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
Action
Revise the Nurse-in-Charge checklist to include bed rails, call bells and environmental safety.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.7
Action
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Stop using the cot type allocated to Connor and replace existing beds and cots with models conforming to BS EN 50637:2017.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Update the Medical Devices and Equipment Policy and keep it aligned with current regulations and best practice.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022.
Action
Provide clinical-assets training through competency assessments, moving-and-handling programmes, therapy training and practice learning, with additional manufacturer training arranged where needed.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Maintain contracted inspection, repair and preventive-maintenance arrangements for medical equipment, with monthly KPI monitoring of servicing compliance.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Establish clinical-assets governance, appoint a dedicated clinical-assets lead and assign responsibility for safe deployment, registration, servicing and maintenance.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Transfer clinical-assets and maintenance records to the centralised CATi system and validate bed condition and service-history data.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Integrated Care Systems are responsible for providers in their areas and can check adherence to guidance intended to prevent future deaths.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Current bed systems, qualified assessment, servicing controls and monitoring arrangements are considered robust responses to sleeping-equipment safety concerns.
Stated by The Children's TrustExisting 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Action
Audit bedrails through maintenance checks and management rechecks to confirm secure locking with an audible click.
Stated by Rch Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 1 April 2016.
Action
Re-educate staff in bedrail use through direct supervision to ensure locking mechanisms are properly engaged.
Stated by Rch Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 1 April 2016.
Action
Provide daily-meeting health and safety briefings reinforcing the risks of unsecured bedrails, recorded in meeting minutes and supervision records.
Stated by Rch Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 1 April 2016.
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.
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.
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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.5
Action
Contract AA to conduct periodic inspections and required maintenance of QA3 trolleys, documenting faults and remedial actions.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 January 2015.
Action
Update the Clinical Engineering Checklist to specify required checks during every QA3 trolley inspection.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 January 2015.
Action
Correspond with AA to seek amendment of the QA3 trolley servicing schedule.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 January 2015.
Action
Discuss the QA3 trolley servicing-schedule issue with MHRA to support resolution with AA.
Stated by Royal Berkshire NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 January 2015.
Action
Require AA to inspect and maintain QA3 trolleys in accordance with the updated Clinical Engineering Checklist as an interim measure.
Stated by Royal Berkshire NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 January 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Responsibility for developing QA3 trolley maintenance schedules lies with the manufacturer, Anetic Aid Limited.
Stated by Royal Berkshire NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Trust considers its Clinical Engineering Checklist, enforced for interim inspections and maintenance, sufficient to address the maintenance-schedule concern in practice.
Stated by Royal Berkshire NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Trust has no control over securing a permanent solution to the QA3 trolley servicing-schedule concern.
Stated by Royal Berkshire NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
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.
Stated by AneticAidNo action considered necessaryThe respondent said that no further action was needed.
Pin
Get email alerts
Request correction
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.
