Kent and Ascot baths with transfer seats and shepherd's crook/ shower pole fitted - risk of serious injury

(Care in Bathing Ltd) Seat may detach from bath causing occupant to fall and be seriously injured (MDA/2015/023)


  • Identify affected devices.
  • Inspect the shepherd’s crook / shower pole following the instructions in the field safety notice (FSN).
  • Ask the manufacturer for lock nuts and get these fitted by a suitably trained person.
  • Review and implement the regular inspection sheet.
  • Return the email / faxback form in the FSN to the manufacturer.

Action by

All involved in the provision, prescription, use and maintenance of this equipment.

Deadlines for action

Actions underway: 7 July 2015, actions complete: 4 August 2015

Problem/ background

If the shepherd’s crook / shower pole becomes loose, its lower part can get caught in the frame of the bath. This stops the bath descending to its lowest position, can break the lifting mechanism and can stop the safety features of the bath working. This means that when the transfer seat turns it hits the edge of the bath and can become detached.

Manufacturer contacts

Care in Bathing Ltd.
Telephone: 01527 594 224



If you are responsible for cascading these alerts in your organisation, these are our suggested distribution lists.

Trusts (NHS boards in Scotland)

CAS and SABS (NI) liaison officers for onward distribution to all relevant staff including:

  • all wards
  • clinical governance leads
  • community hospitals
  • EBME departments
  • equipment libraries and stores
  • equipment stores
  • health and safety managers
  • in-house maintenance staff
  • medical directors
  • nursing executive directors
  • occupational therapists
  • purchasing managers
  • risk managers
  • supplies managers

Social services

Liaison officers for onward distribution to all relevant staff including:

  • disability equipment stores
  • education departments for equipment held in schools
  • equipment stores
  • equipment supplies managers
  • in-house residential care homes
  • loaned equipment store managers
  • occupational therapists

Independent distribution

Establishments registered with the Care Quality Commission (CQC) (England only):

  • care homes providing nursing care (adults)
  • care homes providing personal care (adults)
  • domiciliary care providers
  • further education colleges registered as care homes
  • hospices
  • hospitals in the independent sector
  • independent treatment centres

Establishments registered with OFSTED:

  • children’s services
  • educational establishments with beds for children
  • residential special schools

Please note: CQC and OFSTED do not distribute these alerts. Independent healthcare providers and social care providers can sign up to receive MDAs directly from the Department of Health’s Central Alerting System (CAS) by sending an email to: and requesting this facility.



Send enquiries about this notice to MHRA, quoting reference number MDA/2015/023 or 2015/003/010/601/006.

Technical aspects

Claire Dunne and Sara Vincent
Telephone: 020 3080 7162 / 7169

Email: or

Clinical aspects

Mark Grumbridge
Telephone: 020 3080 7128


Reporting adverse incidents in England

Through the Yellow Card website.

Northern Ireland

Alerts in Northern Ireland are distributed via the NI SABS system.

Enquiries and adverse incident reports in Northern Ireland should be addressed to:

Northern Ireland Adverse Incident Centre
CMO Group
Department of Health, Social Services and Public Safety
Telephone: 028 9052 3868
Fax: 028 9052 3900


Northern Ireland Adverse Incident Centre (NIAIC)

Reporting adverse incidents in Northern Ireland

Report directly to NIAIC using the forms on the website.


Enquiries and adverse incident reports in Scotland should be addressed to:

Incident Reporting and Investigation Centre
Health Facilities Scotland
NHS National Services Scotland
Telephone: 0131 275 7575
Fax: 0131 314 0722


Reporting adverse incidents in Scotland

NHS boards and local authorities in Scotland should report to Health Facilities Scotland.

Contractors such as private hospitals carrying out NHS work and private care homes that accept social work funded clients should report to Health Facilities Scotland.

Private facilities providing care to private clients should report to the Care Inspectorate and MHRA.


Enquiries in Wales should be addressed to:

Healthcare Quality Division
Welsh Government
Telephone: 1267 225 278 / 02920 825 510


Reporting adverse incidents in Wales

Report to MHRA through Yellow Card and follow specific advice for reporting in Wales in MDA/2004/054 (Wales).

Download documents

Kent and Ascot baths with transfer seats and shepherd’s crook/ shower pole fitted

Published 23 June 2015