Lower Hutt rest home failed to prevent elderly woman’s death after she became trapped against wall: Coroner

The woman died after becoming trapped between her bed and the wall. Photo / Getty Images

Warning: This story contains details which may distress some people

A coroner has found Lower Hutt’s Worburn Rest Home failed to keep an elderly resident safe and should have done more to ensure her safety before she became trapped between her bed and a wall heater.

Daphne Louise Hedges, 89, was found stuck between her bed and the wall, with part of her body pressed against a wall heater which was switched to its maximum temperature.

She had superficial burns to her body, but forensic pathologist Dr Amy Spark found her cause of death to be cardiac amyloidosis – where protein deposits in the heart lead to abnormalities in the normal electrical conduction of the heart resulting in a fatal arrhythmia.

Coroner Heidi Wrigley said the cardiac issue may have been brought on by the stress of Hedges finding herself trapped in the middle of the night.

On the night she died, Hedges was sleeping on a pressure-relieving mattress after having suffered injuries in multiple previous falls. One of the nurses who cared for her during the night told police that “quite often” during her night-time checks on Hedges she would find her off to the side of her bed, against the wall. The nurse would reposition her.

Hedges was very frail, weighing just 44.6kg. The mattress was supposed to relieve the pressure of her injuries, having been on bed rest for some time.

However, it was not secured to her normal mattress as it should have been – which, the coroner noted, had caused issues previously, when Hedges had fallen off the bed but been helped back up by staff.

The mattress should have been secured either by a fitted bottom sheet or by straps – neither of which were visible on Hedges’ bed.

Coroner Wrigley found Hedges slipped off her mattress, which had happened before with little movement from her, and become trapped between the bed and wall, touching the heater.

To free herself, Hedges likely tried to use the heater wall switch to pull herself up but was unsuccessful, turning the heater to the maximum setting in the process. The coroner found it likely that the stress of her predicament caused Hedges’ heart issue, and ultimately her death.

The coroner ruled Hedges’ death may have been preventable had the rest home secured her mattress to the bed, or ensured it was the right size for the bed. She also found that the rest home did not appreciate the seriousness of the risk, despite having found Hedges trapped in similar situations on multiple occasions.

“I find that one reason why no such steps were not taken is because the responsible healthcare assistants did not appreciate, and therefore did not notify, the trapping hazard indicated by the multiple occasions on which Mrs Hedges was seen positioned between the side of her bed and wall.”

Wrigley said it was important to educate staff on the risks.

“The training of healthcare assistants should will teach the identification and mitigation of trapping hazards, including those arising from the use of pressure-relieving mattresses.”

Coroner Wrigley also extended her sympathies to Hedges’ family in her findings.

”I hope that it is of some comfort to them that lessons may now be learned from her death.”