Coroner's concern after man died wedged in bed

The man died at The Red House care home in Ashtead

A man who died when he got wedged in a gap created by his care home bed extension called for help for more than an hour, a coroner has said.

Paul Batchelor was found dead at The Red House care home in Ashtead, Surrey, on 27 June 2023, after a mattress extension fell through his bed's extension frame.

The coroner raised concerns about Mr Batchelor’s "numerous cries for help" going unattended and a "lack of awareness" about bed extensions.

A spokesperson for the care home said the circumstances of Mr Batchelor's death were "deeply distressing" and the home fully respected and accepted the remarks.

Susan Ridge, assistant coroner for Surrey, said despite one carer hearing Mr Batchelor's cries for help, she "did not open the door or go into his room as it was said she was frightened of him".

Ms Ridge said Mr Batchelor, "a frail elderly man", was put to bed at about 21:00 BST by care home staff but that his cries for help between 22:05 and 23:15 went unattended.

She also addressed the report to the Care Quality Commission (CQC) and the Medicines and Healthcare Products Regulatory Agency (MHRA) regarding a possible "lack of awareness" of the support needed for a mattress extension or bolster on extended beds.

She said: "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."

'Our highest priority'

A spokesperson for The Red House said the home strived to "provide the highest level of personal care and support" to all residents.

They said issues in relation to equipment and to staff protocols had been addressed "as a matter of priority".

The member of staff no longer worked with the company, the spokesperson said, adding the company had "ensured that the wider team understands how best to manage challenging or stressful situations".

They added: "We have underlined the importance of seeking support from others to sustain responsive and appropriate care, which is our highest priority."

National patient safety alert

Danielle Middleton, deputy director in benefit/risk evaluation at MHRA, said it was reviewing the coroner's report carefully.

She said a national patient safety alert had been issued last year regarding medical beds, trolleys, bed rails, bed grab handles and lateral turning devices, warning of the risk of entrapment.

She said the alert requires staff to receive device training suitable to the roles.

It also requires organisations to have an up-to-date medical device management system in place, including regular servicing and maintenance in line with the manufacturer's instructions.

"It also requires regular risk assessments for patients using bed rails or handles, including entrapment risks," she added.

The CQC has been contacted for comment.