As part of its core work to review recorded patient safety events, the National Patient Safety Team carried out a thematic review of incidents where patients were entrapped in beds, bed rails and ancillary devices.

The review identified emerging risks that could lead to these incidents happening, because of issues including changes to ways of working due to COVID-19, patient flow and capacity, and new devices and equipment coming to market.

Incident reports described fatal asphyxiation and other injuries associated with the use of bed rails and the interface between beds (including extra width beds) and:

• trolley frames
• mattresses
• automatic turning devices
• bed levers
• specialist sleep equipment

The Medicines and Healthcare Products Regulatory Agency used our insight from reported cases to update guidance and support a National Patient Safety Alert issued in August 2023. This included giving staff additional guidance on risk assessment, selection and suitability of appropriate equipment and ongoing monitoring. 

Publication reference: PRN01208