Briefing Subject: Medical and Healthcare Regulatory Agency (MHRA):National Patient Safety Alert Briefing Date: 29 February 2024

Briefing Detail:
The Medical and Healthcare Regulatory Agency issued a National Patient Safety Alert
for medical beds, trolleys, bed rails, bed grab handles and lateral turning devices on
the 30th August 2023 (Reference No: NatPSA/2023/010/MHRA).

The alert identifies safety issues around the use of the equipment as mentioned
above and the reports of deaths and serious injuries from entrapment or falls relating
to medical beds, bed rails (also known as bed safety rails), trolleys, bariatric beds,
lateral turning devices and bed grab handles (also known as bed levers or bed sticks).
The alert is requiring the following action to be taken by the deadline of 1 st March
2024 by:

All those responsible for the use, purchase, prescription and maintenance of
medical beds, trolleys, bed rails, bed grab handles and lateral turning devices
including all Acute and Community healthcare organisations, care homes,
equipment providers, Occupational Therapists and early intervention teams to:

1. Update your organisation’s policies and procedures on procurement,
   provision, prescribing, servicing and maintenance of these devices in line
   with the MHRA’s updated guidance on the management and safe use of
   bed rails.
2. Develop a plan for all applicable staff to have training relevant to their role
   within the next 12 months with regular updates. All training should be
   recorded.
3. Review the medical device management system (inventory/database) for
   your organisation or third-party provider for devices within your
   organisation, including those which have been provided to a community
   setting (for example, the patient’s own home). Keep this system up to date.
4. Implement maintenance and servicing schedules for the devices in the
   inventory/database, in line with the manufacturer’s instructions for use
   and/or service manual. Prioritise devices which have not had regular
   maintenance and servicing. If this is outsourced, compliance with the
   schedule should be monitored.
5. Review patients who are children or adults with atypical anatomy as a
   priority. Ensure the equipment they have been provided with is compliant
   with BS EN 50637:2017 unless there is a reason for using a non-compliant
   bed. Record this on the risk assessment and put in place measures to
   reduce entrapment risks as far as possible.
6. Review all patients who are currently provided with bed rails or bed grab
   handles to ensure there is a documented up-to-date risk assessment.
   Complete risk assessments for patients where this has not already been
   done and for each patient who is provided with bed rails or bed grab
   handles.
7. Implement systems to update risk assessments where the equipment or the
   patient’s clinical condition has changed (for example,
   reduction/improvement in weight or mobility), and also at regular intervals.

The London Borough of Sutton is working with Partners within the Local Authority
area and wider to ensure the required action is taken by all relevant organisations and
agencies to ensure the safety of Sutton residents.
See below link for full details of the alert:

https://www.gov.uk/drug-device-alerts/national-patient-safety-alert-medical-beds-
trolleys-bed-rails-bed-grab-handles-and-lateral-turning-devices-risk-of-death-from-
entrapment-or-falls-natpsa-slash-2023-slash-010-slash-mhra

Please see attached template risk assessment that you may find helpful:
BEDRAILSRISKASSESSMENTTOOL_TCESupload_20122023_CKS_V1 (2).docx

For further information and advice or queries please contact:
[email protected]