Inquest into the death of Melissa STANDEN

Contributing factors

• Failure to develop and implement appropriate risk assessment procedure
• Failure to implement proper risk assessment for transition from cot to bed
• Selection of bed unsuited to patient's needs and size
• Inappropriate bed adaptation with ineffective padding/bumpers for fall prevention
• Loss of critical clinical information about bed configuration from hospital records due to system failures
• Inadequate staff training, particularly for night shift nursing staff
• Lack of involvement of occupational therapists in bed selection
• Poor management practices regarding policies and staff training
• Use of fall risk assessment tool that did not identify risk in children with disabilities
• Bed set at hip height rather than lowest setting for accessibility rather than safety

Coroner's recommendations

1. To the Minister for Health: A group of appropriately qualified experts, in consultation with organisations representing children with physical and neurological disabilities, should develop a standard, guideline or publication improving safety of beds for children with physical/neurological disabilities, including: (1) How to conduct thorough assessment taking into account movement disorders and bed mobility to determine risk of entrapment, entanglement, fall or injury prior to a child being placed in any bed, including assessment of bed accessories/equipment and strategies to minimise risks; (2) Recommended appropriate training in relation to such assessment; (3) Proper review procedures or re-evaluation protocols; (4) Any other matters to ensure bed safety.