More seniors have died in Manitoba after becoming trapped in their bed rails, despite years of warnings from U.S. and Canadian health authorities.

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Eileen Stratton died at age 84 at Golden West Centennial Lodge. Bed rails are believed to have played a role in her death. (CBC)

CBC News has learned in the last 2 ½ years, four Winnipeg nursing home residents died following a bed rail entrapment — one in 2011, two in 2012 and one in 2013.

The Winnipeg Regional Health Authority (WRHA), which oversees personal care homes in the city, said in three of the four cases, the residents were found dead in their beds, while one died several days after the incident.

"It's horrifying to think that happened to someone you loved," said Nina Logan, a Winnipeg woman whose mother died in a nursing home in 2004.

Her mother suffocated when she became trapped between the mattress and a bed rail.

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In two of the four recent cases, the WRHA has said it’s not clear to what extent the entrapments contributed to the person’s death because they were very ill and frail at the time.

The health authority wouldn’t reveal any more details about the deaths or the names of those involved.

"People are still having those bed rail entrapments. I’m appalled that it's still going on.  So unnecessary people have to go through that," Logan said.

Province-wide bed assessment ordered

Last fall, prompted by a safety advisory from Health Canada, the Manitoba government asked regional health authorities to carry out a province-wide bed inventory assessment to evaluate the safety of all beds in personal care homes.

"When we look at bed rail entrapment and see the numbers, see the information from across Canada, we obviously take that information very seriously and that is why we started working with regional health authorities around the inventory auditing process," said Lorraine Dacombe Dewar, executive director of Continuing Care at Manitoba Health.

'They’re fighting for their life and there's nothing they can do.'—Nina Logan, daughter of woman who died in bedrail accident

But it wasn’t the first time Health Canada had sounded the alarm. It issued warnings about bed rail hazards in 2008, 2009 and August of 2012, with earlier warnings going back as far as 1995.

U.S. authorities also issued warnings in the same time span.

Manitoba Health said a portion of nursing home beds are assessed for safety every year, but following the latest Health Canada advisory, the assessments were extended to include all beds.

A kit made by Pennsylvania-based National Safety Technologies is used in bed assessments to evaluate the fit of the mattress and the rail.

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This bed testing kit, obtained by CBC News, is used to measure the gap between the rail and the mattress. (Jeff Stapleton/CBC)

Manitoba Health says it takes time to carry out the evaluations because the resident can’t be in the bed.

Both the province and the WRHA said there was a shortage of the testing kits needed to do the job but when CBC News contacted the manufacturer, a company spokesperson said there was no shortage.

CBC News ordered a kit from Pennsylvania for demonstration purposes and received it by courier the following day. The WRHA declined to allow CBC News an opportunity to observe the test kit in use.

Victim’s daughter not happy review took eight years

The province-wide bed assessment comes eight years after the death of Logan’s 84-year-old mother, Eileen Stratton, at Golden West Centennial Lodge.

Logan questions why it has taken that long for a comprehensive review in Manitoba.

"It just seems like people don’t care. I don’t know how you can ignore — you would think that would be something people have to pay attention to," Logan said.

Manitoba Health officials said bed rails are sometimes necessary and has no plan to phase out their use.

But the WRHA said it has been evaluating bed rail safety in recent years and has made progress. 

Lori Lamont, WRHA vice president of long term care, says in the last five years Winnipeg’s 39 personal care homes have replaced one thousand beds — about one fifth of the total.

Lamont says the health region has been encouraging nursing homes to reduce the use of bed rails.  She says it has also been helping families understand the risks associated with rails.

"When I started my career many years ago, the idea that we used restraints to prevent people from falling seemed to be a really good thing," said Lamont. "We now know that using restraints actually increases the risk of something really bad happening to that person."

Health Canada reports more incidents

From 2008 to 2013, Health Canada received reports of 26 Canadian incidents involving hospital bed entrapment.

The federal agency noted in its August 2012 advisory incidents were continuing to be reported despite the warnings it issued in 2008 and 2009.

'I was very upset. Our whole family was upset. It was basically covered up.'—Nina Logan, daughter of woman who died in bedrail accident

In the cases reported to Health Canada since 2009, about two-thirds happened in nursing homes while the remainder happened in hospitals or at home.

Lamont says the WRHA’s incident reporting system doesn’t identify the number of bed rail entrapments that do not result in death. 

However, when the CBC News investigative team reported on WRHA occurrence data in 2008, there were more than 200 bed rail incidents in a four-year period, with either no injury or varying degrees of injury.

Details surrounding death not provided

For Logan, the circumstances of her mother’s death were aggravated by the fact the nursing home did not tell Logan what had happened.  She realized how her mom died only after the CBC I-Team reported on bed rail incidents in 2008. 

A critical incident report about the bed rail entrapment was not shared with Logan when her mom died.

"Even on the report it said they were going to talk to the family about it, which they never did. I was very upset. Our whole family was upset. It was basically covered up," Logan said. "So then you go through the whole grief process again and the horror of knowing my mom didn't die peacefully in her sleep as we thought, but she basically suffocated."

In response to the four most recent cases, Lamont says she hopes deaths related to bed rail entrapments can be eliminated.

"I would hope that in five years we wouldn't be having that conversation," she said.

Logan says she is speaking out because she doesn’t want any other seniors to experience what her mom did.

"I feel really horrible for the families because it's a really terrible thing when your parent dies but even a more horrible thing when you think that they're suffocating to death. They’re fighting for their life and there's nothing they can do," Logan said.