Concerns raised 4 Fitting or adjustment of bed levers in the absence of the patient View source Lack of a policy for reporting bed-lever risk-assessment concerns to the Occupational Therapy Team View source Failure to ensure prescribed bed levers are fitted by trained Occupational Therapy staff View source Failure to ensure bed levers fitted to Divan beds use a strap View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Jean Williams · 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
Jean Williams, aged 80, died at Thornton House Care Home between 6.30 a.m. and 8.27 a.m. on 19 November 2017 after her head became trapped between her bed and a chest of drawers, with her neck resting on a bed lever. The report found that the bed lever’s securing strap had not been used. Concerns included bed levers being fitted or adjusted without the patient present, insufficient reporting and training arrangements, and the possible supply or fitting of bed levers without the required strap.
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. The report was sent to Mobility 2000 Limited; that does not assign responsibility.
PFD Monitor interpretation Fitting or adjustment of bed levers in the absence of the patient
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mobility 2000 Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a policy for reporting bed-lever risk-assessment concerns to the Occupational Therapy Team
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mobility 2000 Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prescribed bed levers are fitted by trained Occupational Therapy staff
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House . Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them .
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Mobility 2000 Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure bed levers fitted to Divan beds use a strap
Wider context from the report “The supplier of the Bed Lever (Mobility 2000), Occupational Therapy staff at the Trust and Lancashire County Council Staff (including Care Assistants) working at Thornton House now fit or adjust Bed Levers if – on assessment – there is identified to be a problem. This raised concerns due to the following:
(a) Mobility 2000 and Lancashire County Council staff are fitting Bed Levers and/or adjusting Bed Levers in the absence of the patient (and therefore not taking into account important individual patient factors such as patient height, when fitting the Lever).
(b) Lancashire County Council do not currently have in place a policy that any concerns/issues raised on their risk assessments of bed levers at the premises should be reported to the Occupational Therapy Team at the Trust.
(c) The Occupational Therapy Team at the Trust, who are now correctly trained to fit and assess a patient for the use of the Bed Lever, are not – at present – routinely fitting the bed levers at Thornton House. In fact, there has been a miscommunication that Bed Levers are no longer to be used at Thornton House. Occupational Therapists prescribe bed levers due to the medical need of the patient and are now trained to fit them properly following full assessment of the patient.
I am concerned that the above raises a risk of future deaths in that bed levers are being fitted in the absence of the patient and not by the fully trained experts who have prescribed them.
In addition, the following matters in respect of Mobility 2000 specifically caused concern:
(a) Mobility 2000 did and do continue to fit bed levers in the absence of the patient at various different locations (not just at Thornton House)
(b) I found that Mobility 2000 did not routinely use the strap when fitting bed levers in 2017 and it is unclear whether staff now have training that they should always use a strap on a Divan bed
(c) The evidence from the Director of Mobility 2000 was that no Bed Levers had been supplied without a strap (to his knowledge). It was clear on the evidence that Mobility 2000 had purchased Bed Levers without a strap from Drive DeVilbiss Healthcare Limited (“Drive”), which should only be used with a specialist bed (and not a Divan bed, which always requires a strap). There is a risk that Mobility 2000 are supplying or fitting these bed levers (Model 130) without a strap to Divan beds.
I have also addressed this report to NHS England, as it was unclear on the evidence whether there may be similar instances of not using straps for Bed Levers (on Divan Beds) by Occupational Therapy Teams at other NHS Trusts.
” Open source report
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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 Supply a hard copy of the manufacturer's instructions with every bed lever.
Verbatim wording from the response “We have recently carried out further training with our staff on how to fit the levers and straps according to the manufacturer's instructions. Further action taken is to make sure a hard copy of the manufacturer's instructions is supplied with every bed lever. We await instructions from LCC with any change of policy regarding the timing of fitting the bed levers, since the incident involving Jean Williams.” Source location 2020-0239-Response-from-Mobility-2000-Ltd.pdf
Open published response
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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 Provide further staff training on fitting bed levers and straps according to manufacturer instructions.
Verbatim wording from the response “We have recently carried out further training with our staff on how to fit the levers and straps according to the manufacturer's instructions. Further action taken is to make sure a hard copy of the manufacturer's instructions is supplied with every bed lever. We await instructions from LCC with any change of policy regarding the timing of fitting the bed levers, since the incident involving Jean Williams.” Source location 2020-0239-Response-from-Mobility-2000-Ltd.pdf
Open published response
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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 Fit the manufacturer-specified strap whenever installing bed levers.
Verbatim wording from the response “Our staff have always fitted the strap when installing the bed levers and they will continue to do so. We do occasionally purchase bed levers without a strap as some of our retail customers prefer them and they are still passed by the medical devices agency; however, these are not, and will not, be supplied via the tces system as the specification does not allow it.” Source location 2020-0239-Response-from-Mobility-2000-Ltd.pdf
Open published response
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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 LCC is responsible for instructing any changes to the policy on when bed levers are fitted.
Verbatim wording from the response “With regard to the fitting of bed levers in the absence of the patient this is likely to be because, on occasion, the equipment needs to be in place prior to the release of a patient from hospital. As the prescriptions are issued by LCC we will await their instruction of any changes to the current system.” Source location 2020-0239-Response-from-Mobility-2000-Ltd.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations