Bed rails: management and safe use

Guidance on managing and using bed rails safely.

This web page features the most up-to-date guidance. It replaces previous guidance on the same topic.

You can download a PDF version of Safe use of bed rails (PDF, 962 KB, 33 pages).

Part of the MHRA's role is the regulation of medical devices, including overseeing investigations into adverse events and promoting the safe use of devices in the UK.

The MHRA continues to receive reports of incidents relating to bed rails and associated equipment. These incidents are concerning as some have led to patient harm or death, primarily from entrapment.

This publication has been updated to reflect changes in devices and practices, as well as information gained from the investigation of adverse incidents.

The government intends to extend acceptance of CE marked devices in Great Britain beyond 30 June 2023. For more detail on this see the implementation update on work towards a strengthened future medical devices regime.

This document is aimed at all users, carers and staff with responsibility for the provision, prescription, use, maintenance and fitting of bed rails. This includes:

This document identifies areas for safe practices, so that policies and procedures can be reviewed and put in place. This includes:

It also identifies areas of good practice, such as:

This document is not intended to replace clinical decision making.

Bed rails are used extensively in acute, community and home care environments to reduce the risk of bed occupants falling out of bed and injuring themselves.

However, the MHRA continues to receive reports of adverse incidents involving these devices. The most serious of these have led to injury and death by asphyxiation after entrapment of the head, neck or chest.

Most incidents occurred in community care settings, particularly in nursing homes. These could have been prevented if adequate risk assessments and appropriate risk management had been carried out. Clinicians should carefully consider the benefits and risks of bed rails before they are used for an individual bed user.

NHS ‘Never events’ are defined as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers. NHS ‘Never events’ number 11 (1) covers chest or neck entrapment in bed rails.

For the purpose of this document the term bed rail will be adopted, although other names are often used, e.g. bed side rails, side rails, cot sides, and safety sides.

In general, manufacturers intend their bed rails to be used to prevent or reduce the risk of bed occupants from falling and sustaining injury. They are not designed or intended to limit the freedom of people by preventing them from intentionally leaving their beds; nor are they intended to restrain people whose condition disposes them to erratic, repetitive or violent movement.

They may be UKCA, CE or CE UKNI marked as medical devices to show they meet the requirements of the UK Medical Devices Regulations 2002 (as amended) (2), in combination with, or as an accessory to, the bed if their intended use meets the definition of a medical device.

Rigid bed rails can be classified into two basic types:

Figure 1 - Example of an integral bed rail

Figure 2 - Example of a 3rd-party bed rail

The integral type is involved in far fewer adverse incidents than the third-party type, usually because risks associated with installation and compatibility are reduced. Bed rails should meet recognised product standards that include acceptable gaps and dimensions when fitted to the bed (See Legislation and Standards).

Figure 3 - Example of a community-style bed with full-length integrated bed rails.

Bed rails, which fit under the mattress or clamp to the bed frame should not be confused with bed grab handles (also known as bed sticks or bed levers) which are designed to aid mobility in bed and whilst transferring to and from bed.

Bed grab handles can pose the same hazards to users as bed rails, and their use should be carefully considered, risk assessed and documented.

Bed grab handles are not designed to prevent patients falling from their bed. Bed grab handles come in a variety of sizes and designs (Figure 4). They should not be used as, or instead of, bed rails.

Figure 4 - Example of a bed grab handle

Bed rails are often used at the same time as medical devices or equipment. This would naturally include a bed frame and a mattress. Other bed equipment could include pressure-relieving surfaces either passive or active, or other systems such as monitoring equipment depending on the bed occupant's needs.

The decision to use bed rails should always consider the bed occupant's care needs, the environment it is used in and what other equipment is or may be present.

The use of bed rails is associated with a number of direct and indirect risks to bed occupants, as well as the possible benefits from reducing the risk of falls. Direct hazards include entrapment and entanglement either within gaps in the rails themselves, between the rails and the mattress or between the rails and the bed frame. In the most serious cases, this has led to asphyxiation and death of bed users if they have trapped their head between rails or been unable to free themselves from a position and suffered postural asphyxiation. Severe limb damage has also been reported in cases where someone has become entangled in bed rails. Figure 5 shows the main areas of the bed-bed rail system where entrapment may occur.

Figure 5 - Bed rail entrapment areas. Split rails have additional entrapment risk areas

Indirect hazards are also present: cases have been reported where bed users have been confused or disoriented and have tried to get out of the bed by climbing over the bed rails. Users have then fallen from a greater height than would otherwise be the case, increasing the severity of injury.

When medical devices are prescribed, issued or used, it is essential that any risks are balanced against the anticipated benefits to the user. The process of understanding, evaluating, addressing and recording these risks is known as risk management.

Where manufacturers cannot remove or reduce risks during the design and manufacturing processes, subsequent warnings of any remaining risk should be clearly displayed in the user instructions and product markings. These risks must constitute acceptable risks when weighed against the benefits to the bed user. Any such warnings or limitations to use, including the necessary maintenance schedules throughout its intended life, should be considered both during procurement and by prescribers, passed on to all users and carers of the equipment and steps taken to ensure that they are understood and complied with.

Users, carers and prescribers need to follow the manufacturer's instructions for use and any warnings about associated risks. The equipment should only be used and maintained in line with the manufacturer's instructions for use.

There are many bed rails on the market, having a variety of fitting and operation methods.

The possible combinations of bed rails, beds and mattresses (and other equipment in the environment), together with the differences between bed occupants, means that a careful, thorough and individual risk assessment is necessary if serious incidents are to be avoided.

Risk assessments should be carried out before the initial prescription of bed rails and then reviewed and recorded after each significant change in the bed occupant's condition, replacement of any part of the equipment combination and regularly during its period of use, according to local policy.

It is unlikely that one type of bed and bed rail will be suitable for a wide range of users with different physical sizes and needs.

The points to consider during a risk assessment include:

Our adverse incident investigations have shown that the physical or clinical condition of bed occupants means that some are at greater risk of entrapment in bed rails. Those at greater risk could include older people, adults or children with:

Risk assessments should account for any characteristics which might put the bed user at greater risk from use of bed rails.

The decision to use bed rails should be made with the consent of the bed user whenever possible. The reasoning for the decision to issue bed rails should be effectively communicated and recorded, including to the carers or family members when this is appropriate.

A bed occupant died after climbing over the bed rails and falling. The user touched the bed position control and raised the bed to its maximum height. They then tried to get out of the bed by climbing over the rail, only to fall and suffer a broken neck. The additional height of the bed rail likely increased the severity of the injury.

Advice – If bed users are known to be in a confused state, then bed rails may serve to increase the overall risk of injury. A risk assessment should have identified the hazard of leaving bed controls accessible and the potential for an increased fall height.

We provide an example of a risk assessment checklist, produced using feedback from prescribers of bed rails and the findings of adverse incident investigations in Appendix 1 – Example adult entrapment risk assessment checklist.

Please note that the example checklist should not be adopted or used without adequate consideration of a specific bed occupant's needs and local policies.

The checklist should be used in conjunction with the guidance in this document, together with the judgement of the nurse, therapist, bed user and carer involved.

Alternatives to bed rails may be considered, such as:

Each of these options may act to introduce different hazards even as they reduce the risk of bed fall injury or the risk from bed rails, and so should be managed appropriately.

Adjustable or profiling beds usually have compatible integral type bed rails available from the manufacturer; these are preferable to other systems that may not fit as well. In all cases it is essential that the selection process follows a risk assessment considering the needs of the bed occupant and the use environment.

Third party bed rails require particularly careful selection.

If bed rails are being purchased for stock, general factors can be considered at the purchase stage:

Risk assessments should be carried out before use and then reviewed and recorded after each significant change in the bed occupant's condition, replacement of any part of the equipment combination and regularly during its period of use, according to local policy. An example of a risk assessment checklist is included in Appendix 1.

The manufacturer's instructions for use should contain information on the selection of the mattress, including dimensions and other characteristics, to reduce the risk of entrapment. They should also contain information on compatibility with other equipment and whether they are suitable for children or small adults.

For more information on gaps permitted by device standards, please see Appendix 2 – Bed rail dimensions in BS EN 60601-2-52 and Appendix 3 – Bed rail dimensions in BS EN 50637. Note that the values expressed in standards are primarily intended for the manufacturers of medical devices.

In all cases it is essential that the selection process follows a risk assessment considering the needs of the bed occupant.

In community care environments it is common for beds and bed rails to have been acquired from different sources. Often bed rails from unknown sources are found to be in use and in many cases they have been found to be unsuitable or unfit for purpose.

Bed rails for divan beds (domestic) are mainly of the third-party type, not tailored for one specific bed or mattress length and width, or a specific mattress density.

A bed rail intended for use on a domestic divan bed was used on a hospital type bed. This produced a large gap between the bottom of the bed rail and the bed when the mattress was compressed.

A child slipped feet first between the bed rail and the bed. The gap was not large enough for the child to pass completely through and the child was trapped at chest level and died from postural asphyxiation.

Image illustrating case study.

Advice – When supplied, the suitability of the installation should be checked including following the manufacturer's instructions for use regarding compatibility with other devices.

It is essential that all bed rails can be fitted correctly to an appropriate bed base allowing safe use. Aspects to consider at the start of the fitting process will include points such as:

Entrapment can happen between the end of the bed rail and the headboard if the gap is inappropriate. Avoid gaps over 60 mm which could be enough to cause neck entrapment.

Entrapment can also occur in the space between a poorly fitting mattress and side of the bed rail or bed rail that does not fit the bed base snugly enough.

The compressible nature of the edge of most mattresses can contribute towards the entrapment risk.

Image illustrating case study.

Advice – Assess the possible gaps between rails and other equipment, particularly in the high-risk areas shown in Figure 5 during the rail fitting process.

From our investigations, the MHRA has identified a number of issues that, if they had been avoided during the selection process, may have reduced the likelihood of adverse incidents occurring. For example, avoid:

The length, width and height of the mattress should be checked to ensure that these dimensions are within the limits specified by the bed manufacturer and do not introduce gaps that could increase the risk of entrapment. If the mattress is not the right size, the bed rails may not fit properly and create entrapment gaps. Some manufacturers may also specify the density of static mattresses.

Suitable evaluation of a patient before providing a bed rail is a skill. Organisations responsible for the provision, installation and maintenance of rails should ensure that those carrying out these tasks are appropriately trained in the competent use of these devices, in the skills needed to properly conduct a risk assessment in accordance with local policy and that they understand the risks posed by this equipment.

Organisations should develop processes to ensure that staff are appropriately trained and that risk assessments are carried out and recorded to a suitable standard.

Those responsible should be aware of how and when to arrange for maintenance and to report faults. Depending on the environment, this could include care staff, family members or the bed user themselves.

Most reported injuries relating to bed rails are now from incidents that take place in community settings.

Use of bed rails in the community comes with additional challenges. There may be greater variability in available equipment, and it can be more difficult to maintain equipment appropriately than in hospitals. Those responsible for day to day care may be less aware of the serious risk that can be present with improper use of bed rails. Any subsequent changes in the patient situation and the associated risks may mean greater chance of inappropriate bed rail use.

Wherever bed rails are used to reduce fall risk, a risk assessment should be made, and the rails should be regularly assessed for suitability and for correct function. Carers should be aware of the risks, should have access to the instructions for use supplied with devices and should know when to carry out or request reassessment of the needs of the bed user.

Some designs rely on the weight of the divan or standard mattress to keep the bed rails in position. A lighter mattress can allow the rails to move away from the side of the bed, creating an entrapment gap, or can allow the rails to fall off the bed completely.

Image illustrating case study.

Advice – Check the compatibility of any installed equipment, the suitability of this for the bed user and that all these devices are fitted correctly.

The majority of bed rails on the market are designed to be used only with individuals over 1.46 m in height (4’ 9"), which is also the height of an average 12-year-old child. A risk assessment should always be carried out on the suitability of the bed rail for the individual child or small adult, as bar spacing and other gaps will need to be reduced.

When purchasing or making assessments of bed rails for children, seek guidance on suitable rails from the manufacturers and assess their compatibility with the size of the individual and the specific circumstances of use. A new standard for medical beds for use with children has been published: it is not yet clear how many products are available that comply with the standard (See section Standards).

It is recommended that all gaps between the rail bars should be a maximum of 60 mm.

A bed rail was supplied to the parents of a child being cared for in the community. No assessment of the child's physical size was carried out to determine if an entrapment hazard existed: in this case the gap between the horizontal bars of the bed rail was too large. The child slipped between the bars and asphyxiated as a result of head entrapment.

Image illustrating case study.

Advice – Risk assessments should include an evaluation of the suitability of the equipment for the physical characteristics of the intended user.

Most adjustable and profiling beds feature integral bed rails that are incorporated into the bed design or are offered as an optional accessory by the bed manufacturer. We have found they are involved in far fewer adverse incidents than the third-party type.

The bed rails will be UKCA, CE or CE UKNI marked to show they meet the requirements of the Medical Devices Regulations 2002 (2) in combination with, or as an accessory to, the bed.

Some beds have a single-piece bed rail along each side of the bed; these require care in use because when the bed profile is adjusted entrapment hazards can be created. These are not always obvious when the bed is in the horizontal position.

Split bed rails (one pair at the head end and one pair at the foot end) also require care in use because the space between the head and foot end rails may vary according to the bed profile adjustment. Therefore, on some designs, entrapment hazards may be created when the bed is adjusted to profiles other than flat.

Use the rails as instructed by the bed manufacturer.

Active, dynamic or hybrid mattresses or mattress overlays may be prescribed in order to reduce the risk of pressure injury. As these will raise the resting level of the user relative to the top of the bed rail, the effective height of the rail will be reduced. In turn this may increase the risk of the bed user falling from bed. Highly compressible surfaces may also create additional entrapment hazards.

The bed, mattress and rail system should be assessed in all configurations as these risks may not be obvious in a single arrangement. The risk assessment should consider the ‘worst case’ condition in particular: for example, the effective height of the top of the bed rail with the bed plus a fully inflated active mattress, or the highest point reached when an alternating cell mattress is used.

Before and during use of specialist mattresses with bed rails, consider:

A pressure ulcer reduction overlay was added to a bed that already had a bed rail fitted. The additional height of the combined mattress/overlay reduced the height of the bed rail. The bed occupant fell over the rail, sustaining a serious head injury.

Image illustrating case study.

Advice – Risk assessments should be revised when substantial changes to the bed system are made. Particular attention should be given when the effective height of the bed rail may be compromised.

Likewise, the use of patient turning systems for pressure relief carries similar risks of compatibility with other equipment in use and the patient themselves.

The risk assessment should consider the whole patient environment and possible interactions between any equipment that is in that environment.

Inflatable or padded bed sides are not generally adjustable and may need to be used with a mattress and bed rails of particular dimensions. It is therefore important not to change the mattress or bed rails from the size or specification recommended by the manufacturer, to avoid creating entrapment gaps and instability. Inflatable rails may change shape when the bed occupant leans against them and this should be taken into account when carrying out the assessment of the risk of entrapment.

Some inflatable or padded bed sides house the mattress in its own ‘pocket’ or compartment, a feature which greatly reduces entrapment risks between the mattress and the side walls.

Inflatable bed sides need to be fully inflated to be effective. They may deflate over time so regular checks should be made to ensure this has not happened.

Care should be taken to use inflatable and padded bed sides correctly, as specified in the manufacturer's instructions for use.

Bed rail bumpers, padded accessories or enveloping covers are primarily used to prevent impact injuries, but they can also reduce the potential for limb entrapment when securely affixed to the bed or rail, according to the instructions for use. However, bumpers that can move or compress may themselves introduce entrapment risks.

Bed and bed rail devices may have a useful lifetime measured in years and might be used in various locations with many different patients. Manufacturers should specify how devices should be used, cleaned and maintained so that they remain in good working order and continue to be safe to use.

MHRA adverse incident investigations have revealed that some incidents with bed rails have been caused by inadequate maintenance. Bed rails should be included in planned preventative maintenance schemes.

Bed rails should be maintained in accordance with the manufacturer's recommendations in the instructions for use. Examples of common types of damage include:

Bed rail assemblies should be traceable, for example by using the manufacturers serial number, the Unique Device Identification number (when available) or labelling with an in-house number. This will assist in ensuring that every device is regularly inspected and maintained in a satisfactory condition. Traceability also allows devices to be suitably identified should a safety issue arise, such as a manufacturer recall due to a fault. Records should be kept of inspections, repairs and maintenance completed on bed rails. Suppliers of the bed rails should be contacted for advice and replacement parts.

Bed rails found to be unsuitable or in poor condition should be withdrawn from use and appropriately destroyed. If they are kept or stored, MHRA has received incident reports of them finding their way back into use. Manufacturers should be able to advise on the expected working life of their products.

When not in use, bed rails should be stored in matched pairs in a suitable area where they will not get damaged.

A care home had fitted third-party bed rails to a resident's divan bed. One of the bed rails moved away from the side of the bed, creating a gap in which the resident became trapped and died as a result.

Bed rails in poor condition from lack of maintenance (Side of bed)

On inspection, the locking mechanism to secure the bed rails against the sides of the bed (under the mattress) was missing.

Bed rails in poor condition from lack of maintenance (Under mattress)

Advice – This incident could have been prevented if appropriate installation and maintenance checks had been in place, and if users were more aware of the correct configuration of the device.

Follow the instructions for use supplied by the manufacturer. Typical aspects to check during planned maintenance include:

The frequency of inspection should be addressed by local policy, specific to the conditions of use and the recommendations in the manufacturer's instructions for use. Defective devices should be withdrawn and replaced, if appropriate, quickly.

For more information on this topic, refer to our publication ‘Managing Medical Devices’ (34).

People responsible for making decisions on the provision of bed rails and the care of people for whom they have been provided need to be aware of their duties under relevant health and safety legislation.

The Health and Safety at Work Act (4) places duties on:

Employers and self-employed persons – to avoid exposing those not in their employment (e.g. members of the public and patients) to health and safety risks.

Employees – to take reasonable care for the health and safety of themselves and others affected by their acts, and to co-operate with their employer on health and safety obligations.

The Management of Health and Safety at Work Regulations (5) require that employers and the self-employed should make a suitable and sufficient assessment of the risks to the health and safety of persons not in their employment which arise out of or in connection with their undertaking.

Employers also need to ensure that all employees who are responsible for selecting, fitting, maintaining and checking bed rails have received appropriate training.

The Mental Capacity Act (6) protects those who may not be able to make decisions about their own care and treatment. Those that lack capacity may or may not benefit from the use of bed rails. Whenever possible, the views of the patient should be accounted for when considering the use of bed rails.

All care professionals should understand their obligations under this act, and organisations should ensure that these requirements can be implemented effectively.

All products classed as medical devices in Great Britain (England, Wales and Scotland) are currently subject to the UK Medical Devices Regulations 2002 (SI 2002 No 618, as amended) (UK MDR 2002) (2). This will include many beds and bed rail systems intended for use with patients. The UK MDR 2002 details the requirements for manufacturers to meet before applying a UKCA mark on their device and placing it on the market. To do this, they must comply with the essential requirements for general medical devices (Part II of the UK MDR 2002, Annex I [as modified by Part II of Schedule 2A to the UK MDR 2002]). This includes requirements such as making sure that the design of equipment is suitable for the products intended purpose, that the device is labelled appropriately and is supplied with instructions for use (where these are necessary for the sage use of the device). The UK MDR 2002 also contains requirements for manufacturers to implement a quality management system, and maintain suitable post-market surveillance of devices. Devices which have been CE marked in accordance with applicable EU legislation will also be recognised on the Great Britain market until 30 June 2023 (7).

In Northern Ireland the requirements for medical devices are subject to the EU MDD (8) and a CE mark or CE UKNI mark must appear on the device. The EU Medical Device Regulations (2017/745) (9) will fully apply in Northern Ireland from 26 May 2021. In a similar process to the UK MDR 2002, manufacturers will have to comply with the General Safety and Performance Requirements listed in Annex I of the EU Medical Devices Regulations (2017/745).

Not all beds or fall protection equipment will be classed as medical devices. This will depend on the intended use described by the manufacturer and without a clear medical purpose the definition of a medical device may not be met. In these cases, the product should still meet the requirements imposed by general consumer protection legislation.

Manufacturers may opt to demonstrate compliance with aspects of the UK Medical Devices Regulations 2002 by making sure their products meet agreed standards. When purchasing or specifying equipment, it may be desirable to confirm what technical standards are met by the device. This should be available either in the device instructions for use or from the manufacturer themselves.

The current designated medical bed standard is:

BS EN 60601-2-52: 2010+A1:2015 "Particular requirements for the basic safety and essential performance of medical beds".

This standard contains requirements for the dimensions and function of medical beds intended for adults and includes information on the permissible gaps between rails and the rails and the bed frame.

A separate standard has now been published that covers beds intended for use with children (and others of small stature):

BS EN 50637:2017 "Medical electrical equipment. Particular requirements for the basic safety and essential performance of medical beds for children".

As this is a recent document, it may be some time before manufacturers market beds which meet this standard.

Standards such as these are primarily intended for manufacturers to demonstrate that the products they supply are suitable to be UKCA, CE or CE UKNI marked and placed on the market. The dimensions and measurements that they specify may not be appropriate to conduct in a clinical environment (for example requiring the use of tools with precise dimensions and mass) and may not assure safety if they are uncritically applied to all bed users.

Previous medical bed standards were largely replaced by BS EN 60601-2-52, but older beds may have been assessed against these earlier standards. Previous standards include:

BS EN 1970:2000 "Adjustable beds for disabled persons".

BS EN 60601-2-38:1997 Revision 1 "Medical Electrical Equipment – Part 2. Particular requirements for the safety of electrically operated hospital beds".

An adverse incident is an event that causes, or has the potential to cause, unexpected or unwanted effects involving the safety of device users (including patients) or other persons.

Adverse incidents can be caused by:

We strongly encourage everybody (patients/users/carers) to report all adverse incidents to us. By reporting to us we can:

Haugh J, O Flatharta T, Griffin TP, O’Keeffe ST. High frequency of potential entrapment gaps in beds in an acute hospital. Age Ageing. 2014;43(6):862–5.

Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev. 2012;(1).

Healey FM, Cronberg A, Oliver D. Bedrail use in English and Welsh hospitals. J Am Geriatr Soc. 2009;57(10):1887–91.

Healey FM, Oliver D, Milne A, Connelly JB. The effect of bedrails on falls and injury: A systematic review of clinical studies. Age Ageing. 2008;37(4):368–78.

NPSA. Bedrails; reviewing the evidence; a systematic literature review. 2007;

Example adult entrapment risk assessment checklist.

Note that compliance to this standard requires the use of specific measurement tools, rather than basic distance measurements alone. It is intended to be used by manufacturers. For this reason, it is recommended that end users do not use solely these measurements as the sole basis for evaluating suitability of a bed rail installation.

BS EN 60601-2-52 BS EN 60601-2-52 Full length rails gaps side view, split rails gaps side view and gaps top-down view

Note that 50637:2017 defines different sized beds: cots, oversized cots, cribs and junior beds. Please see the text of the standard for full definitions or contact the manufacturer of a particular bed in your control that complies with this standard.

Compliance to this standard requires the use of specific measurement tools, rather than basic distance measurements alone. It is intended to be used by manufacturers. For this reason, it is recommended that end users do not use solely these measurements as the sole basis for evaluating suitability of a bed rail installation.

BS EN 50637 rail gaps

Paragraph added to the summary section which explains that the government intends to extend acceptance of CE marked devices in Great Britain beyond 30 June 2023.

New version of the 'Safe use of bed rails' PDF attached

This has been updated due to the end of the Brexit transition period.

First published.