During a HSE visit to the Trust in February 2012 issues were identified with the Trust’s management of bedrails. On a subsequent visit in May 2012 the Trust was served with an Improvement Notice in relation to bedrail management with various recommendations made, which the Trust failed to implement.

The Trust was inspected on a third occasion in July 2013, but inappropriate bedrails were still found to be in place along with inadequate management systems. A further Improvement Notice was served.

The particular issues were the lack of a system to identify and inspect third party bedrails; the lack of planned preventative maintenance on manual beds and bedrails; a lack of an effective system to rectify faults with inappropriate bedrails; lack of provision of appropriate training, and a lack of procedures to audit and monitor the effectiveness of the bedrail management system.

The Trust was eventually prosecuted for breaching Section 3 (1) HSWA 1974. They pleaded guilty at the Carlisle Magistrates’ Court, but the case was referred to Carlisle Crown Court for sentencing. The Trust was fined £100,000 and ordered to pay costs of £18,465.