At least three people across New Zealand have suffocated to death from a bed lever given to them by health professionals prompting calls for them to not be used anymore.
Coronial findings released today into the deaths of Colin Lee and Jane Lee found the unrelated pair died in the same manner - asphyxiation by bed lever.
Colin Lee from Paengaroa, 84, had been given a bed lever to help with his independence due to health issues and issues caused by long-term diabetes.
Colin Lee was insulin dependent, blind in one eye, and struggled with his balance due to his diabetes.
He was given a bed lever two years ago after he fractured his upper arm and needed help getting out of bed, and two months later, his wife Hermione found him unresponsive on the floor.
Coroner Michael Robb reported Colin Lee's diabetes played a role in his fall but found that his cause of death was suffocation after his head got trapped in the bed lever.
The lever used was a metal U-shaped loop attached to a wooden plank. The plank wedged between the bed base and mattress so the loop was on the outer edge and rose above the mattress to provide support when getting in and out of bed.
Jane Lee, unrelated to Colin Lee, was found by her husband Robert in October last year in their Thames home with her neck pressed firmly to the metal bar of a bed lever she had been given.
The 74-year-old suffered an array of health issues including heart disease, diabetes and neuromuscular disorder, had limited sight and also struggled with balance.
The hoop was 17cm wide, which was big enough for a person's head to become trapped within it, the coroner said.
The first death reported to be as a result of the bed levers was of Harold Leslie Carter in 2016.
A coroner found that he had died of asphyxia after falling from his bed during a sudden deterioration of his heart disease.
Now, Robb has said there was overwhelming evidence that the lever presented a risk of suffocation. This was previously acknowledged by one of the manufacturers, Enable, after the first death in 2016.
At the time, the Canterbury DHB dismissed the lever as unsafe and stated Carter's death was from his health issues and age.
Robb said he believed the risks of the lever were unrecognised in many regions of New Zealand.
"The reality is that at least three patients to my knowledge have died from asphyxiation through their use of these metal hoop levers.
"The circumstances of death were similar in all three deaths."
The coroner recommended no patients were given the hoop lever, and instead it was replaced with a three-bar bed lever, a similar hoop with a safe rail divider.
All three of the people who died as a result of the lever were retired with health issues and given the lever to help them get in and out of bed.
Enable New Zealand, Accessable and the Ministry of Health stopped buying and routinely issuing bed levers with hoops from December 2018, after the Coroner informed them of his concerns.
The Bay of Plenty District Health Board has acknowledged the "inherent risk" of the bed lever.