Coroner's Finding: HUTTON Arthur John

Contributing factors

• bedpole positioned in unorthodox position beneath raised head section of bed
• gap created between vertical bedpole and side of mattress
• resident with known history of frequent falls from bed
• resident with dementia and cognitive impairment
• resident with limited mobility due to amputation
• insufficient gap elimination between bedpole and mattress
• instability of bedpole in unorthodox position allowing lateral movement
• night checks conducted by listening for snoring rather than visual sighting
• lack of formal risk assessment for bedpole use
• no written installation instructions or warnings provided by manufacturer

Coroner's recommendations

1. Anglicare should include specific instruction that gaps between bedpole and side of bed should be eliminated
2. Manufacturers, suppliers and distributors of KA524 bedpole should provide written installation instructions addressing: sufficient weight on apparatus for stability; placement beneath mattress at foot end with U-section pointing toward foot (not beneath raised section); elimination of any gap between bedpole and mattress; frequent checking of position and stability
3. Manufacturers, suppliers and distributors should provide written warnings about dangers including: need for risk assessment in each application; contraindication in persons with history of falling from bed; contraindication in persons with cognitive impairment; contraindication in persons without access to immediate assistance; documented fatality from head and neck entrapment
4. Australian Government Department of Health and Ageing should draw these findings and recommendations to attention of all Australian aged care services and approved providers
5. SafeWork SA should promulgate and distribute a Hazard Alert regarding bedpoles and associated dangers
6. Office of Consumer and Business Affairs should promulgate and distribute a hazard alert or similar publication regarding bedpoles and associated dangers