Concerns raised 5 Lack of safety information for users of nursing care beds with extensions View source Failure to formalise resident room checks in care home policy and procedures View source Failure to check residents who may be in distress View source Failure to ensure adequate support and retention of mattress extensions or bolsters on nursing care beds View source Lack of procedures for staff frightened or concerned about entering a resident’s room alone View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Paul Rodney Batchelor · 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
Paul Rodney Batchelor, a frail elderly man in a care home for respite care, became wedged after a mattress extension fell through the frame of his extended nursing bed and died of positional asphyxia and bronchopneumonia. His cries for help went unattended for over an hour. The concerns were inadequate support for mattress extensions on extended beds and the lack of formalised procedures for staff responding to distressed residents at night, including when staff are frightened or concerned about entering a room alone.
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 The Red House (Ashtead) Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of safety information for users of nursing care beds with extensions
Wider context from the report “First Concern: There may be a lack of awareness of the need to ensure adequate support for the mattress extension or bolster when using nursing care beds with an extension frame fitted.
And that without adequate support there is a risk of death in that the mattress extension can fall through the bed frame creating a sufficient gap for a person to become wedged or stuck.
The lack of awareness of the risk may be compounded because when the mattress extension is fitted into the gap between the standard mattress and the footboard it may appear as though the bolster is adequately supported. Further that over time and use mattress deck extensions or other supporting framework can become detached or lost from the bed
Since this incident the court heard evidence that the care home and its sister care home have checked all existing extended profile beds and taken steps to ensure that they are fitted with the correct support.
However, the coroner is concerned that users of nursing care beds with extensions may need to be made aware of the circumstances of this death to prevent other deaths in similar circumstances .
” 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 The Red House (Ashtead) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to formalise resident room checks in care home policy and procedures
Wider context from the report “Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures . Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own. There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be in distress.
” 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 The Red House (Ashtead) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to check residents who may be in distress
Wider context from the report “Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures. Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own. There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be in distress .
” 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 The Red House (Ashtead) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure adequate support and retention of mattress extensions or bolsters on nursing care beds
Wider context from the report “First Concern: There may be a lack of awareness of the need to ensure adequate support for the mattress extension or bolster when using nursing care beds with an extension frame fitted .
And that without adequate support there is a risk of death in that the mattress extension can fall through the bed frame creating a sufficient gap for a person to become wedged or stuck .
The lack of awareness of the risk may be compounded because when the mattress extension is fitted into the gap between the standard mattress and the footboard it may appear as though the bolster is adequately supported. Further that over time and use mattress deck extensions or other supporting framework can become detached or lost from the bed
Since this incident the court heard evidence that the care home and its sister care home have checked all existing extended profile beds and taken steps to ensure that they are fitted with the correct support.
However, the coroner is concerned that users of nursing care beds with extensions may need to be made aware of the circumstances of this death to prevent other deaths in similar circumstances.
” 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 The Red House (Ashtead) Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for staff frightened or concerned about entering a resident’s room alone
Wider context from the report “Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures. Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own . There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be in distress.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations