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8 December 2009 - South Australia Coroner bedpole advice.

Electronic advice about the use of bedpoles in aged care facilities

Dear Approved Provider

The attached correspondence from the South Australian Coroner’s Court, relates to the preliminary findings of an inquest into the death of a resident at a Residential Aged Care Facility. The cause of death was asphyxiation due to neck entrapment between a vertical bedpole (sometimes referred to as a bedstick) and the side of a bed mattress.

The Deputy State Coroner has indicated that, “…bedpoles should not be used in circumstances where there is a gap between the bedpole vertical component and the mattress, or potential gap if the device or mattress moves, and / or where the intended user has a history of recurrent falls from bed, has a cognitive impairment, with or without limited mobility, or where the intended user’s faculties are compromised by medication. Any person or organisation that utilises bedpoles must ensure that the use of a bedpole is risk assessed in each application.”

Could you please ensure that all relevant personnel are made aware of this information. For more information contact 1800 550 552 (Aged Care Complaints Investigation Scheme).

Thank you for your attention to the above.

Yours sincerely

Authorised for electronic transmission

Darren Clarke
Assistant State Manager
South Australian State Office
Office of Aged Care Quality and Compliance

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PDF printable version of South Australia Coroner's Bedpole advice (PDF 361 KB)

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Inquest

Arthur John Hutton

In this matter the decease, Mr Arthur John Hutton, aged 87 years, died at the St Laurence’s Aged Care Facility at Grange. Mr Hutton occupied a room on his own at the facility. His cause of death was asphyxia due to neck entrapment.

Mr Hutton was an amputee having had a leg amputated many years ago. At the time of his death he also suffered from dementia. He had a known propensity to fall from his bed to the extent that his bed had been lowered and a mattress had been placed on the floor next to his bed in order to lessen the impact of a fall.

Mr Hutton was located deceased on the morning of 16 January 2008. It is evident that he had fallen from his bed at some time during the night. The fall had caused his neck to become entrapped in the space between a vertical bedpole and the side of the bed mattress.

A bedpole, sometimes referred to as a bedstick, is a device utilised to assist a person’s mobility and independence in bed and is widely used in nursing homes and other aged care facilities and in the community generally.

This is not the first occasion in which a bedpole has been identified as having been instrumental in a person’s death. In March 2006 a female resident of a residential hostel in Victoria, whose medication included morphine, died of traumatic asphyxia when she fell from her bed and her neck became trapped between the bedstick and the bed.

Top of pageThese preliminary findings are intended to serve as a warning to those institutions, person and entities who utilise bedpoles that in certain circumstances there is an element of risk involved in their utilisation. In particular, and without intending to limit the circumstance in which a bedpole may place a user at risk, the evidence before me demonstrates that bedpoles should not be used in circumstances where there is a gap between the bedpole vertical component and the mattress, or potential gap if the device or the mattress moves, and / or where the intended user has a history of recurrent falls from bed, has a cognitive impairment, with or without limited mobility, or where the intended user’s faculties are comprised by medication. Any person or organisation that utilised bedpoles must ensure the use of a bedpole is a risk assessed in each application.

I add that Anglicare South Australia, that operates St Laurence’s Aged Care Facility, has commendably implemented certain measure to minimise risk to residents who utilise bedpoles.

I will deliver my formal findings and recommendations on a date to be fixed.

I direct that a copy of these remarks be furnished to all media outlets and to the relevant Commonwealth and State aged care authorities.

Authorised for electronic transmission

Anthony Schapel
Deputy State CoronerTop of page