Contraindication of bed rails in a hospital setting
LD v King’s College Hospital NHS Foundation Trust [30.08.19]
This article was co-authored by Will McGregor, Litigation Executive, London
This case concerned whether the absence of bed rails on an inpatient’s bed amounted to a breach of duty, and whether implementation of bed rails would have prevented a fall being sustained. Following a two day trial in August 2019 the court dismissed the claim. Kennedys acted for the Trust.
The claimant, LD, was admitted to King’s College Hospital on 5 June 2013 having fractured her right wrist and developed respiratory problems. The claimant underwent a bed rail risk assessment following admission and bed rails were not applied. On 15 June 2013, the claimant suffered a fall and sustained an injury to her knees.
The claimant brought a claim against the Trust, advancing a number of allegations including insufficient record keeping, staffing and supervision.
Central to the claimant’s case were the allegations that:
- the Trust was in breach of duty by failing to (i) hold sufficient discussions with the claimant/her family about bed rails on admission (in contravention to the Trust’s bed rails policy requiring such discussions); and in any event (ii) implement bed rails due to the claimant’s history of falls and the fact she had used bed rails at home
- but for this breach, the claimant would not have suffered the fall on 15 June 2013.
The issues were complicated due to a key handwritten entry on the initial risk assessment (as to whether bed rails were recommended by the triage Nurse) being illegible. It could not be confidently determined (even by the author, in his witness statement), whether the entry was a ‘Y’ or ‘N’.
The Trust’s position was that bed rails were contraindicated due to the claimant’s confusion and ability to mobilise, which was clear from the medical records. Further, that in such circumstances, bed rails may pose a danger to patients who are confused and mobile enough to climb over them, potentially falling from a greater height. This was supported by the Trust’s Nursing expert and its own bed rails risk assessment form, which clearly stated ‘bed rails not recommended’ for such patients.
The Trust’s bed rail policy gave significant weight to patient autonomy in relation to decisions regarding their treatment. Nevertheless, the Trust’s witness and expert evidence was that a patient’s best interests, based on professional medical opinion, should outweigh any request to have bed rails.
Quantum was agreed early in the proceedings in the sum of £7,500, subject to liability and no liability offers were made by the Trust.
The claim was dismissed with judgment for the Trust. The trial Judge (HHJ Baucher, sitting at the Central London County Court) found that:
- The key issue to determine was whether or not it was a breach of duty for bed rails not to have been applied on 15 June 2013. The claimant’s own expert had conceded at trial that a responsible body of Nurses would not have applied bed rails, and thus the Trust had not breached its duty in this respect.
- The illegible entry on the risk assessment was ‘No’ for bed rails and the assessment was adequate. Even if the risk assessment indicated ‘Yes’ for bed rails (as submitted by the claimant), later routine assessments would have led to bed rails being removed prior to 15 June 2013 in any event, due to the claimant’s increasingly acute confusion. It would in fact have been a breach of duty for bed rails to have been applied to the claimant’s bed at this time.
Accordingly, HHJ Baucher did not determine causation, but confirmed she “would not have determined that issue in the Claimant’s favour in any event”. The claimant had no recollection of the incident, having said at trial she could only recall being on the floor. HHJ Baucher was not satisfied that the fall was due to an absence of bed rails, “given that the Claimant had a history of waking up confused, having hallucinations, sleep talking, and walking and getting out of bed.”
HHJ Baucher refused permission to appeal at the Judgment Hearing based on her numerous findings of fact. The claimant is seeking permission to appeal in the High Court, which was refused by Mr Justice Stewart on the papers, but is still subject to a permission hearing.
Falls in hospital settings often give rise to claims against NHS Trusts, a number of which relate to bed rails. This decision gives further weight to the contention that in some circumstances there are inherent dangers in using bed rails. As the Judge highlighted, ‘restraining a patient with bed rails is something which no responsible nurse takes lightly’.
It is essential to ensure not only that policies regarding bed rails are consistent, but also for patients and their families to be involved in transparent discussions and for those discussions to be documented.