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Accident in hospital - bed rails?

Discussion in 'Legal and financial issues' started by BagLady, Nov 4, 2013.

  1. BagLady

    BagLady Registered User

    May 25, 2011
    Where can I find out about laws, procedures, policies in place that aim to ensure the safety of dementia patients during stays in hospital.

    My mother had an unwitnessed fall in hospital and died several hours later from a bleed to the brain. She was found next to her bed.

    Also, if anyone has advice about where to make a complaint that would be helpful (Hospital, CQC, HSE, NHS England, Ombudsman - it's confusing?).
  2. ITBookworm

    ITBookworm Registered User

    Oct 26, 2011
    Hi Baglady,

    I am so sorry for your loss and that it happened in such a way. I'm afraid I can't help with who you can complain to but I can comment on bed-rails.

    Quite often a person with dementia has no sense of danger and no sense of their reducing abilities. They will try to do things which they are physically no longer capable of - in my FIL's case this was to get out of bed at a point where he could no longer stand unaided never mind walk :( He was in a care home when this happened and ended up on the floor with thankfully only minor damage unlike your poor Mum. We asked about bed rails and were told that, in this sort of case, bed rails were actually a particularly bad idea. FIL would not understand the rails or why they were there and would still try and get out of bed anyway - only this time falling from a greater height. The solution, for him, was to put his bed against the wall leaving only one open side, lower the bed as low as it would go, have a pressure sensor mat on the bed connected to an alarm (so the staff could hopefully stop him if he started to move towards the edge of the bed) and put a 'crash mat' on the open side (in case he did make it out). For him this worked and although I believe he did manage to get out of bed at least once more he wasn't injured at all.

    I don't know what the "rules" are in a hospital situation but I hope this explains a little why bed rails might not have been used.

    Best wishes,
  3. Jessbow

    Jessbow Registered User

    I was told the same about bed rails when my mum was unwell and trying to get out of bed.

    Rails just create more height from which to fall

    My first port of Call would be PALS
  4. nitram

    nitram Registered User

    Apr 6, 2011
    North Manchester
  5. nitram

    nitram Registered User

    Apr 6, 2011
    North Manchester

    Snap - must learn to type faster.
  6. BagLady

    BagLady Registered User

    May 25, 2011
    Sorry - I didn't provide much detail. Bed rails were in use and I don 't believe they should have been.
  7. nitram

    nitram Registered User

    Apr 6, 2011
    North Manchester
    Was a formal risk assessment made and recorded?

    A risk assessment MUST be carried out for each occupant for whom bedside
    rails are being considered. Bedside rails must not be used before a risk
    assessment has been conducted.

    If the answer is yes and there is not another suitable alternative, then you need
    to choose a rail that is suitable for use in combination with……..

  8. BagLady

    BagLady Registered User

    May 25, 2011
    Thanks for that.
    Should I expect that to be included in mum's medical records?
  9. nitram

    nitram Registered User

    Apr 6, 2011
    North Manchester
    Yes - if it isn't they can't prove they did the assessment.
  10. BagLady

    BagLady Registered User

    May 25, 2011
    Thanks, currently trying to decipher the records.
  11. carpe diem

    carpe diem Registered User

    Nov 16, 2011
    Hi I'm sorry to hear what happened.
    Hospitals and dementia don't mix and things do need to change.
    My mum spent a week in hospital and it is the worst place to be when you don't know where the toilet is, where your bed is or who anyone is. My mum was found wandering outside in the carpark from a secure locked ward.
    I complained, I found the complaints form on the Hospitals own web site. Just google the name of the Hospital concerned. The ward sister did phone me the following week and she seemed genuinely interested in making changes.
  12. Saffie

    Saffie Registered User

    Mar 26, 2011
    Near Southampton
    I don't know if a home is different from a hospital but I had to sign an agreement for my husband to have bedrails after a fall.
  13. BagLady

    BagLady Registered User

    May 25, 2011
    Thanks for the feedback. We weren't asked to sign anything like that. Interesting though.

    I've not put much detail on here of what happened. A few things went wrong.

    It's very recent and painful to think about yet. I'm trying to gather together the facts and intend, in the future, to share the experience our family has been through. If anything can be done to help prevent this happening to anybody else I'm all for it.
  14. Long Tom

    Long Tom Registered User

    Nov 7, 2013
    My condolences. You need some answers, clearly. I have some thoughts.

    Firstly, signing things if you do not hold legal authority is meaningless beyond showing you were simply aware, I'm afraid. It might also create a false impression that if something went wrong, it was not the professionals' fault. I will presume you do not hold a registered Lasting Power of Attorney for Health and Welfare.

    On admission, was information given to the hospital that your mother was in any way lacking capacity to maintain her own safety? If so, they should have assessed what supervision she needed. If they were made aware that she may be confused enough to climb out of bed for any reason or none, the rails should not have been used - i.e. if it was to prevent her voluntarily movement that would be restraint - an improper use. A staff member carrying this out or failing to take action in knowledge of this improper use would appear to be a disciplinary offence of the type considered in misconduct and competence hearings. CQC guidance states that equipment must be used safely, so the actions may have been contrary to this guidance. Adherence to the Mental Capacity Act 2005 would also be important. If they thought she needed decisions making for her, what did the staff take in to account? What they ‘usually do’ (wrong) or what was in your mum’s best interests?

    I hope that your mother was discovered very promptly, but if not, there would be further questions about supervision IF they had grounds to think she needed supervision.

    When the bed rails were used, the assessment as mentioned above should have taken place but in my experience, this is rarely a coherent or discrete entry on notes. There should be a policy produced by the NHS trust, and is possibly online. Seek out a copy. Just because the staff 'never' have time because they are so busy, does not mean the responsibility faded away, it just shows a more systemic problem. Same with Mental Capacity Act stuff – ‘too busy’ to make a reasonable judgement is not an excuse.

    The flip side of all this is that if it was reasonable to believe she did not and would not display any confused behaviour, the staff cannot (usually) be expected to predict this. So if she suddenly changed in her manner, or if she is not normally this confused, or there was no information or indication of this, they may not be at serious fault.

    The incident should have been reported to the Adult Protection (AP) team within the local authority. A failure to do so would be grounds for complaint to the Trust. The AP procedure should be available online. Who will be told and who leads the investigation will be detailed within this. The CQC would take some issues up themselves if there was wrongdoing in practice, but this should not stop you doing what you do. The NHS Trust is obliged to notify the Nursing and Midwifery Council about unfit nursing practice.

    When making any complaint, the result is clearly massive and hugely distressing, but try to work out what events would have led up to this and aim your questions there. Did they take the correct steps to understand the care your mother needed? Ask for evidence, find the gaps. You are entitled to ensure the professionals are held to account, and they SHOULD welcome the chance to either explain that they did all they could, or the chance to identify poor practice and address it.

    If you a have not had a response from PALS or find they are in any way inadequate, that would be a terrible shame as many are excellent. I would say the opposite to Nitram - go for the Chief Executive and expect a named senior manager to be in touch, informing you of their policy and in charge of making sure this is followed. Wishing you peace and resolution...
  15. BagLady

    BagLady Registered User

    May 25, 2011
    Thanks very much for the feedback Long Tom.

    LPA for Health and Welfare was in place, with myself named as one of the attorneys.

    The medical records from when my mother was admitted clearly state she was very confused and had been diagnosed with Alzheimers several years ago. There is also a document in there, completed by the hospital, stating she cannot be responsible for her own safety. I don't have the paperwork with me but will post later with what type of document it is - something like an incident form I think.

    I have seen no reference to a risk assessment in the records regarding the use of bed rails, but I am going to ask someone else to check the records for me to make sure I'm not missing something.

    The accident was unwitnessed, records show she was found at 6am. Nothing about how long she might have been there on the floor.

    Your reference to Adult Protection team is a new one to me. I'll have a look on internet.

    Mum's records show nothing at all about any procedures carried out following mum's death - apart from saying it was referred to coroner. The hospital have made no contact with us either to say if they are doing anything about investigating the accident.

    I really appreciate the feedback.

    Sometimes I feel like I'm trying to wade through things that I don't understand, but if I don't do it nobody else is going to do anything about it.
  16. Jessbow

    Jessbow Registered User

    I suppose some weight might be added if the bed rails had been in use for sometime, and you had no objection until the time at which she presumably climbed over them.

    Were they in use on a day to day basis or was it a one off?
  17. BagLady

    BagLady Registered User

    May 25, 2011
    I actually don't know if the bed rails were used every night. I guess that's something else I need to ask.

    (Form I was referring to earlier was a problem sheet, stating patient is confused and unable to maintain own safety. It then lists the Goal and Nursing Actions.)
  18. BagLady

    BagLady Registered User

    May 25, 2011
    Having now received letter back from hospital containing several apologies, where do I go from here - CQC, NHS England, Health Ombudsman, Health and Safety Executive? All of them? Lawyer?
    Several problems - medication prescribed in error, bed rails used despite 2 risk assessments saying not appropriate, should have been nursed in view of nursing station are some examples. Also some questions not answered in response from hospital.
  19. Jaycee23

    Jaycee23 Registered User

    Jan 6, 2011
    My father who had cancer (mum has dementia) came home to die basically and the Marie Currie nurses arranged for him to have a special bed delivered. This had one of those anti pressure sores mattresses and no side rails. Mum and I kept an eye on him by going into the room every ten/fifteen minutes to see him. I went in the room and he was no where to be seen! He had slid down the side of the bed and landed on the radiator pipes which burned his skin off. Mum and I were beside ourselves and managed to get him off the pipes. We phoned the hospital and they came out and put him back in bed and connect his morphine tubes etc. We was told that they are not allowed to put the guards on beds due to health and safety as some fall and strangle themselves. Yes and some fall out and burn their skin on hot pipes!! Luckily mum forgot what happened. Dad passed away two days later.
  20. cragmaid

    cragmaid Registered User

    Oct 18, 2010
    North East England
    I guess where you go, depends on what outcome you are seeking.

    I would certainly recommend professional legal advice, but, and this is a big but, be selective about the type of solicitor you contact. If you want answers first, protocols changed and a proper apology, steer clear of the "Compensation for You" type and speak to a " proper" solicitor. The former will, no doubt get you financial compensation at a cost to the hospital's insurance ( which still comes out of the public purse); the latter might get you a fuller explanation, better consultation and a certainty that this cannot happen again.

    I'm not saying that financial compensation is wrong, but I would want to know the fuller picture regarding re-education and change of practice etc. too.

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