“are: First Concern: There may be a lack of awareness of the need to ensure adequate…”

The coroner’s concerns

are: First Concern: There may be a lack of awareness of the need to ensure adequate support for the mattress extension or bolster when using nursing care beds with an extension frame fitted. And that without adequate support there is a risk of death in that the mattress extension can fall through the bed frame creating a sufficient gap for a person to become wedged or stuck. The lack of awareness of the risk may be compounded because when the mattress extension is fitted into the gap between the standard mattress and the footboard it may appear as though the bolster is adequately supported. Further that over time and use mattress deck extensions or other supporting framework can become detached or lost from the bed Since this incident the court heard evidence that the care home and its sister care home have checked all existing extended profile beds and taken steps to ensure that they are fitted with the correct support. However, the coroner is concerned that users of nursing care beds with extensions may need to be made aware of the circumstances of this death to prevent other deaths in similar circumstances. Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures. Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own. There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be in distress.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0494

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0