A frail gran living in sheltered accommodation choked to death after getting her head stuck in a poorly-fitted bedside support handle, a report has revealed.
Horrified carers discovered the widow, who was in her 80s and suffered from Parkinson’s disease, with her head wedged between the £20 rail and her bed.
Despite efforts to revive the stricken mum-of-five, she was pronounced dead at the scene when paramedics arrived last year.
A serious case review by Coventry Safeguarding Adults Board revealed today that the death of the woman – known only as ‘Mrs C’ – could have been avoided.
An inquest held earlier this year into her death found that the cause was “positional asphyxiation”.
The case review concluded that care workers and therapists failed to check whether the device was properly fitted.
And the review found that the handle – used to help the elderly climb out of bed – was not recommended for use with Mrs C’s electric bed as it was more likely to cause slippage.
Despite this, the handle was not attached to the bed frame in accordance with safety guidelines.
The review concluded the metal grab handle became an “invisible” part of Mrs C’s furniture and was never inspected by care workers.
It also discovered that Mrs C and her family had complained after she was left in bed with her head on the grab handle, with her body not straight.
The report read: “This complaint may be considered an early indicator of the risks that could be associated with the bed grab handle.
“While it is disappointing that Mrs C felt the need to complain, it also demonstrates that she was able to use the complaints system to register her dissatisfaction, and her needs were promoted by her family and as far as possible a resolution was found.
“The frequency of complaints is not necessarily indicative of a poor standard of care but it does suggest that concerns were being raised about the suitability of the flat as accommodation for Mrs C up to two years before she died.”
The review also found that the grab handle was old enough that staff attending to Mrs C should have been able to see that it was not fit for purpose.
It read: “The simple fact is that the bed grab handle was a piece of old equipment which had been provided ten years earlier, and had not been systematically reviewed or managed in that time.
“The bed grab handle effectively became ‘invisible’ to those who were working with Mrs C and providing her care.
“It seems reasonable to suggest that it would have been apparent to those staff in daily contact with Mrs C that the bed grab handle was not fit for purpose because anyone making her bed could have seen that it was not properly secured.”
Mrs C spent the last years of her life in a one-bedroom in a “housing with care” complex run by Anchor Trust in Coventry, West Mids.
The site has staff on-duty 24 hours a day but the review said that staffing levels were reduced overnight due to most residents being asleep.
Coventry City Council, which published the serious case review, recommended 12 improvements.
Brian Walsh, chair of Coventry’s safeguarding adults board, said there was no evidence that any organisation directly caused Mrs C’s death, but it was clear lessons could be learned to better protect people.
Simon Brake, assistant director of policy and performance at the council, admitted the death was entirely avoidable.
He said: “This is a piece of equipment that, if fitted and used correctly, can be of great benefit.”
Mr Brake said he did not want anyone to fall and hurt themselves because they were too scared to use equipment they had been issued.
He said the family recognised the equipment was important, but wanted to ensure lessons were learned to try to prevent a similar tragedy.
Linda Watson, district manager for Anchor, said: “This was a tragic but isolated accident and we pass on our condolences to the lady’s family.”
Mrs Watson said in future Anchor care staff would risk-assess all equipment residents brought with them.
Grab handles can be bought in supermarkets for as little as #20 but can be dangerous if not fitted properly.