Morecambe Bay NHS Foundation Trust has been fined £100,000 and ordered to pay costs of £18,465 by Carlisle Crown Court on 29 April 2016 following its conviction for breach of Section 3(1) of the Health and Safety at Work Act 1974.

Summary 

  • This conviction follows an investigation and prosecution by the Health and Safety Executive ("HSE") in relation to inappropriate management of the use of bedrails at the Trust's hospitals.  
  • The HSE told the Court that the University Hospitals of Morecambe Bay NHS Foundation Trust failed to ensure that they managed the risks of bedrails, which is a fundamental element of patient safety for which extensive and comprehensive guidance on risk, management and policies existed.  
  • An initial visit by the HSE to the Trust in February 2012 identified issues with bedrail management, and a second visit in May 2012 resulted in a service of an Improvement Notice on bedrail management and a letter with recommendations.  
  • The HSE stated that the Trust identified actions to improve bedrail management, but failed to implement them. When the Trust was inspected in July 2013, inappropriate bedrails were found to still be in use and management systems were not appropriate to manage the risk.  
  • A further improvement notice on identification and maintenance of third party bedrails was served.  
  • The Court was told that the Trust had a policy on bedrail management but did not have the systems or procedures to underpin the implementation of the policy.  
  • Elements of the failure were lack of the following:  
    • a system to identify and inspect third party bedrails;  
    • planned preventative maintenance on manual beds and bedrails;  
    • an effective system to rectify faults with inappropriate bedrails;  
    • provision of appropriate training;  
    • procedures to audit and monitor the effectiveness of the bedrail management system.

 Learning from this case

This case reiterates the importance of Trust compliance with the expected standards in respect of bedrail management and the importance of ensuring that all action plans are fully implemented. The HSE has indicated that they hope that this case will act as a strong message to others with responsibilities for bedrail management.

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