A coroner has recommended the Ministry of Health remove all bed levers that carry the risk of head entrapment, following the death of a 74-year-old woman.

Bed leavers are used to assist patients get in and out of bed.

Jane Mansfield Lee was found with her head caught between the metal loop of the bed lever at her home in Thames, in October last year.

In his report, Coroner Michael Robb says this is the third such case he's come across.

He says the bed lever provided to Jane was fundamentally the same design as is provided by other District Heath Boards in New Zealand and through ACC, throughout New Zealand.

'It consists of a long wooden base to which there is attached a metal hoop at one end.

'The long wooden base is positioned under the mattress with the metal hoop then extending up from the bottom of the mattress.

'The metal hoop extends beyond the height of the mattress, providing the patient with the portion of the metal loop as a handle to hold onto and to lever off, in order to steady themselves, in moving in and out of bed.

'The wooden base comes in either a rectangular shape or a wedge shape.

'The space within the metal hoop is approximately 17cm wide in all basic designs.

'That width is sufficient for a head to move within that space and become entrapped.

'Not only has Jane died as a result of an accident when using this particular design of bed lever, but I am aware of two other recent deaths that were the result of the use of this same type of bed lever.

'The circumstances of death were similar in all three deaths.”

The coroner has recommended that no patient, be it through a District Health Board or ACC, be provided with a metal hoop bed lever that carries the risk of head entrapment.

He also wants the DHB's and ACC to replace the bed levers, where the gap between vertical bars of the bed lever handle is less than 85mm but more than 60mm or their equivalent.