Raised toilet seats are issued daily by occupational therapists. But are they all safe to use with the toilet they are fitted to? The most commonly issued seats are incompatible with some modern toilets, even those in residential and daycare settings, with potentially unsafe results.
When my blind father had a short stay in a care home, the manager told us the care home did not supply equipment for respite clients. If Dad required a raised toilet seat, he would need to provide his own. Social Services had issued a seat for use on his toilet at home, so the manager of the care home advised him to take that with him. I only heard of this conversation afterwards, and I resisted the temptation to try and supervise the fitting, so as not to be accused of interfering.
During my Dad’s stay, we visited him on a rota system. The first family member to visit reported that the raised toilet seat was loose. She showed the staff and they refitted it, explaining that it must have been left unsecured after cleaning. The next visitor found the same thing, reported it, and staff refitted it, blaming the cleaner as before. I was puzzled when I heard this: raised toilet seats are normally cleaned in situ. Were the cleaners really removing it every day to clean it?
When it was my turn to visit, I went into the bathroom and all looked well. However, during my visit, Dad went to the loo and returned complaining that he had felt very unsafe, especially when reaching for the toilet roll. I went in and found the seat lying loose on the toilet. I called the carer, who re-fitted it and pronounced it safe. But then she said that she had already re-attached it twice that morning. That rang alarm bells, so I checked it more thoroughly. I tried to ‘jiggle’ the seat but it didn’t move under my hands. However, in the light of Dad’s comments, I sat on it and leaned towards the toilet roll, whereupon the seat suddenly became completely detached. On closer inspection, I discovered that it was impossible to secure that particular seat to that particular toilet. The profile of the toilet allowed only a tiny area of contact for the fixing screws. Moreover, as the side fixing points on the seat corresponded to the widest point of the toilet, the screws could not possibly make the required three-point attachment with the front fixing. A millimetre of movement in any direction would loosen it completely.
I requested that the seat be replaced with a suitable one urgently, and I was advised to take it up with the manager on Monday. However in my opinion it needed to be made safe in time for Dad’s next trip to the loo. I was prepared to buy a new seat if necessary, but it was Saturday morning and the nearest mobility shop would be closing at midday, so it was urgent. None of the staff knew what to look for, but eventually they agreed to show me to the store cupboard, where I found one that would fit. It was attached, under my supervision, by the chef/handyman. I’m not at all sure about the hygiene implications of that combination of roles, but I’ll leave that for another blogpost…
I then reported the issue to anyone who would listen:
The Senior Carer said casually, ‘Oh that’s OK. It’s quite firm – it only moves when he sits on it.’ I pointed out that ‘when he [sat] on it’ was the very time it needed to be secure, but she did not understand the significance of what I was saying. So I got her to sit on it and then shift her weight to one side, as if to reach for the toilet roll. Then, quite suddenly, she understood completely!
The Care Home Manager showed no interest, but just said that she left ‘all that sort of thing’ to ‘the two occupational therapists who come each week’. They were actually physiotherapists.
The Physiotherapists looked horrified and said ‘Oh no, we don’t do toilets!’ Their remit was to prescribe exercises and walking aids and to supervise their use, but toilets were of no interest to them, even when I indicated the risk of preventable injury in this very vulnerable client group.
The Care Home Owners arranged to check all the raised toilet seats they owned throughout their chain of homes. However, they stressed that they did not undertake to supply equipment for respite clients, and the only safety checks ever carried out on clients’ own equipment were for electrical items.
The Care Quality Commission (CQC) contacted the inspector for that home, but he said that CQC reports don’t cover this issue, so they did not get involved any further.
The Medicines and Healthcare products Regulatory Agency (MHRA) did not understand the compatibility issue and informed the manufacturer that the raised seat was faulty. The manufacturer was not pleased – there was nothing faulty about their equipment or its design, it was just incompatible with the toilet to which it had been fitted. Once I had explained this again to the MHRA, they ordered the manufacturer to amend the instruction leaflet for that specific model of raised toilet seat. But what about other models – or other brands? The same issue will arise whenever a raised toilet seat is fitted without checking compatibility between the toilet and the seat.
The Local Authority reminded us that this particular raised seat had been loaned to my father for use with the toilet to which their staff had fitted it. I asked whether the instructions had included a notice to that effect. If so, it could be shown to care home managers when they instructed clients to take in ‘their own’ equipment that was actually on loan. They replied that they don’t include any written instructions. Even the manufacturer’s carefully amended instructions would not be seen, as ‘Each item of equipment purchased by our service comes with a single instruction leaflet, and it would only get lost if we sent it out to a client’. There was no record of instructions, and the packaging was not kept once an item had been loaned. That meant that only the first staff member to fit a new seat would get to see the manufacturer’s instructions; on subsequent occasions, staff would just rely on their previous experience of fitting toilet seats. The end client would only be shown how to use it and clean it in situ.
The Disabled Living Foundation immediately amended their guide ‘Fitting a Toilet Seat’ (DLF 2012) and sent it back for my comments, before uploading it to their website. I wonder how many people read that page?
The Health & Safety Executive (HSE) stated that their remit is to reduce work-related death and serious injury to employees. In care homes, that would include care workers and other staff, but not residents. They referred me back to the CQC. HSE do get involved whenever a resident dies in such an accident, but it’s a bit late by then.
This problem has wider implications. I subsequently discovered similarly incompatible toilet seats at a day centre and also in the home of a Social Services client. In neither case had anybody reported or apparently even noticed the hazard. However, the day centre manager said ‘I must do something about that immediately – someone could fall and break their hip, and they might not recover!’ At last, someone was taking the problem seriously. I also reported it to Social Services but I was not able to follow up to check whether either seat was ever replaced, because our service was reorganised and I was no longer involved.
I appeal to occupational therapists, assistants, and anyone else who issues and/or fits toileting equipment, to be aware that just because a toilet seat feels secure when tested with the hands, that does not necessarily mean that it is safe for the client to sit on and use.
- Falls from a loose toilet seat can lead to injury and even death. (Daily Mail 2008)
- Feeling insecure on the toilet makes it difficult to relax and can lead to constipation.
- Many care homes ask respite clients to provide their own raised seat, which is then fitted by care staff. Training for care workers does not normally include the fitting of toileting equipment.
- The ‘usual’ way of testing a toilet seat once fitted does not adequately replicate the user shifting their weight.
- The NICE falls prevention guidelines (NICE 2013) do not cover toileting equipment.
- NHS and Social Services do not normally issue written instructions with equipment on loan.
- The only NICE guideline for occupational therapy with older people in residential care (NICE 2008) relates solely to physical activities as interventions for mental health.
- Care homes often have no input from occupational therapists who are trained in this area.
- Apart from occupational therapists, most health and social care professionals, even care home managers, have little or no understanding of the safety implications of this issue – unless they have ever witnessed the problem or dealt with its consequences.
- There is an important role for occupational therapists within care homes, not just for providing organised ‘activities’ but in facilitating ordinary activities of daily living.
Going to the toilet is one of the most basic activities of daily living and we need to ensure that people can sit comfortably and safely while they do it.
Disabled Living Foundation (2018) Fitting a toilet seat. Available at: https://www.livingmadeeasy.org.uk/scenario.php?csid=327 Accessed on 06 July 2019.
Daily Mail (2008) Toilet trouble: six people injured and one dead after falling off faulty raised toilet seats. Available at: https://www.dailymail.co.uk/news/article-1080018/Toilet-trouble-Six-people-injured-dead-falling-faulty-raised-toilet-seats.html Accessed on 06 July 2019.
National Institute for Health and Clinical Excellence (2013) Assessment and prevention of falls in older people. Clinical practice guideline. Available at:https://www.nice.org.uk/guidance/cg161/evidence/falls-full-guidance-190033741 Accessed on 06 July 2019.
National Institute for Health and Clinical Excellence (2008) Mental wellbeing in over 65s: occupational therapy interventions and physical activity interventions. Available at: https://www.nice.org.uk/guidance/ph16/chapter/1-Recommendations#occupational-therapy-interventions Accessed on 06 July 2019.