Nursing home resident had leg amputated following bedrail failures

February 5, 2021

A Welsh nursing home has been fined after a resident’s leg was repeatedly trapped in a bed rail.

In November 2018, a resident at Crosfield House Limited in Rhayader was admitted to hospital when her leg, which had repeatedly been trapped between her mattress and the bed rail, became discoloured and cold to the touch. She had to have her leg amputated.

The HSE found that there was a lack of training and guidance on how to complete a bed rail assessment. Employees at the home had not received any training on the safe use of bed rails and were unaware of the risks from bed rail entrapment. It also found that, despite the resident’s leg becoming repeatedly trapped between September and November 2018, no review on the use of bed rails was carried out.

Crosfield House Limited of Dark Lane, Rhayader, Wales pleaded guilty to breaching Section 3 (1) of the Health and Safety at work etc Act 1974 was fined £25,000 and ordered to pay costs of £11,747.

Speaking after the case HSE inspector Sarah Baldwin-Jones said: “The incident could so easily have been avoided by simply conducting a detailed bed rail risk assessment.

“Those who manage bedding equipment, should ensure that there are no gaps between the mattress and bed rail, where someone could get trapped.

“Employees involved in the provision and use of bed rails need to be aware of the key risks and know what to do if they suspect someone may be at risk of entrapment. In this case none of the employees recognised the risks and despite repeated entrapments, nothing was done to prevent recurrence.”

 

This is valid as of 5th February 2021.

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