Coroner recommended healthcare assistants receive training in identifying and mitigating trapping hazards, particularly when using ill-fitted mattresses. Photo: 123RF
The coroner has recommended more training for healthcare staff on the dangers of trapping caused by mattresses.
Daphne Louise Hedges, aged 89, was found dead in her room at Woburn Rest Home in Lower Hutt, run by Enliven and part of the not-for profit organisation Presbyterian Support Central, in 2016.
Staff found her in the early hours of 19 December, wedged between her bed and the wall, with burns where she rested against a wall heater.
It was turned to maximum, despite it being summer.
Her son reported no issue was raised by staff regarding the positioning of the bed beside the wall heater, and they were told the previous occupant of the room had the bed in the same place.
Coroner Heidi Wrigley found the most likely scenario was that Hedges accidentally turned up the temperature while trying to extricate herself.
A doctor determined the cause of death to be a fatal arrhythmia of the heart, which the coroner found was likely caused by the stress of being stuck.
The coroner's report found an ill-fitting pressure-relieving mattress was likely to blame, and recommended the size of the mattress should always match the base.
In her report, Coroner Heidi Wrigley recommended healthcare assistants receive training in identifying and mitigating trapping hazards, particularly when using these mattresses.
This death "may have been prevented had Woburn Rest Home staff taken better action to protect her from becoming trapped, the associated stress of which precipitated her death," the report said.
"The pressure relieving mattress used should be matched in size to the base mattress and securely fitted to the base mattress through the use of a closely fitted sheet, straps and/or other mechanisms to avoid the risk of movement".
In a statement, the rest home said it accepted the recommendations "with regret".
"We have taken responsibility and accountability as detailed by Coroner Wrigley. We have adopted the recommendations as outlined, including offering an apology to the family."
The provisional report was sent to them in June 2022, by which time Enliven said it had already begun a review of pressure injury equipment, and training on its use.
"Regarding the trapping hazard, this was added to the health and safety mandatory training for staff that has been released and is available on our intranet in 2023."