Bed Rails is the most common term, but other names include; bed side rails, side rails, cot sides, and safety sides.
Bed rails are used extensively in hospitals, care homes and people’s own homes to reduce the risk of bed occupants falling out of bed. However, The MHRA (Medicines and Healthcare Products Regulatory Agency) continue to receive reports of adverse incidents involving these devices. The most serious of these have led to injury due to falls and death by asphyxiation as a result of entrapment of the head, neck or chest.
From the 1st of January 2018 to the 31st of December 2022, they received 18 reports of deaths related to bed rails and associated equipment, and 54 reports of serious injuries. Most incidents occurred in nursing homes or the patient’s own home.
In August 2023 the MHRA issued a National Patient Safety Alert which highlighted the need for providers to carry out adequate and appropriate risk management to prevent the occurrence of such incidents.
- Click here for the National Safety Alert on Bed Rails from August 2023
- Click here to view full Bed Rails Guidance
New Bed Rail Risk Management Guide
We are pleased to inform you that a new Bed Rail Risk Management Guide is now available to support all care providers in responding to the National Patient Safety Alert regarding the safe use of bed rails. This guidance should be helpful to any provider that supports individuals with Bed Rails, and will be particularly important for all Care Homes who are responsible for ordering bed rails and completing the associated risk assessments.
This guidance has been developed to help providers confidently and safely navigate decisions around the use of bed rails and bed levers. It aligns with the latest MHRA guidance and draws upon best practice principles to ensure that equipment is used only when necessary, and always in a safe, person-centred manner.
While this guide has been developed primarily with Care Homes in mind, it can also be used as a reference in community settings. Although there is currently no expectation for community providers to order equipment, we strongly encourage providers to familiarise themselves with the guidance so they can identify risks and raise appropriate referrals for community-based reviews where necessary.
What the Guide Includes:
- Key points from the National Patient Safety Alert and MHRA’s Bed Rails: Management and Safe Use
- A structured approach to completing risk assessments
- Guidance for applying the Mental Capacity Act (2005), including best interest decision-making
- Practical considerations and prompts to support person-centred conversations with individuals, relatives, and carers
- A QR code linking directly to the Patient Safety Alert leaflet for sharing with individuals or family members
- Clear advice for professionals reviewing equipment they did not originally prescribe
We understand this may be a new process for some providers, especially where changes to an individual’s current arrangements may cause distress. The guide offers language and strategies to approach these conversations sensitively, supporting engagement, shared decision-making, and documentation.
This tool is intended to be used and reviewed as needed, and we recommend referring to the National Patient Safety Alert and MHRA guidance regularly to remain up to date with your roles and responsibilities.
We encourage you to share this guidance with relevant staff, including those involved in risk management, equipment provision, review, or direct care. This tool is part of our ongoing commitment to supporting safe, responsive care across our provider community.
Click here to access the guide
Webinar – National Safety Alert – Actions for Hertfordshire Care Providers
HCPA, together with Hertfordshire County Council and Hertfordshire Equipment service, hosted this 1 hour webinar to support providers to meet the actions set out within the guidance.
Investigations into incidents involving falls often found the likely cause to be worn or broken parts, which should have been replaced during regular maintenance and servicing, but which were either not carried out or were carried out improperly.
This webinar is for Managers, Moving and Assisting leads, clinical leads and organisation’s so you are clear on the guidance and expectations to ensure you have everything in place to prevent the risk of death from entrapment or falls.