WARNING letters that could have saved the life of an elderly woman who died after being trapped in her bed's rails never arrived at the nursing home where she died, an inquest heard yesterday.

Esther Boggon, who suffered from senile dementia, died, aged 84, in the Brydan Court nursing home, Galsworthy Road, South Shields, in January last year, after she became trapped between her mattress and the metal bars.

A post mortem examination by Home Office pathologist Dr Peter Cooper gave the medical cause of death as hanging by the neck.

The metal bars, known as cot sides, work in the same way as a baby's cot, with adjustable sets fitted to a normal bed to prevent an elderly person from falling out or from wandering during the night.

South Tyneside Health Authority sent out three separate letters from the Medical Devices Agency (MDA), known as hazard warnings, to the nursing home, listing the dangers of improper use of the bars.

But an inquest held in Gateshead into Mrs Boggon's death heard yesterday that none of the notices had arrived at the home. Nursing staff and carers all said that they had never seen the MDA warnings and had received no formal training in erecting cot sides.

Barbara Dickson, formerly the health authority officer in charge of sending out the hazard warnings, said that between January, 1997 and December, 2000, her office had sent out 156 safety notices on various subjects to the nursing home.

But the coroner, Terence Carney, heard that when police seized the relevant file from the home, it contained only 76 hazard warnings and among those missing were the three leaflets on the dangers of cot sides.

The home's manager, Tony Duggan, earlier told the court that there was a street near to the home, also called Brydan Court, and that mail meant for one often ended up at the other.

* The inquest continues.