BETHESDA, Md., (WUSA) -- "She was a wonderful person, married 62 years with my father," Gloria Black says.
But by November 2006, Clara Marshall was suffering from dementia and her husband could no longer care for her alone.
She was prone to falling, so the assisted living facility in Washington state, where she moved, recommended that her husband purchase a bed rail.
Her daughter says, "I had no idea bed rails were dangerous. I had no idea."
Until Gloria got an early morning phone call about her mother, four months later.
"They said my mother was found dead," she says.
Gloria says she didn't believe the medical examiner's report, which lists her mother's cause of death as "asphyxia due to neck compression." She was essentially strangled by the bed rail that was supposed to protect her.
The pictures Gloria obtained through the Freedom of Information Act show a re-enactment by the caregiver who found her mother's lifeless body.
"If we had any idea that people could die in bed rails, there is no way that my father would have bought that bed rail. And, there is no way that I would have allowed it either," Gloria says.
"These are tragic incidents, but they can be prevented," says, U.S. Consumer Product Safety Commission spokesperson Scott Wolfson.
The CPSC recently took a closer look at deaths and injuries from these kinds of adult portable bed rails used in homes, nursing or assisted living facilities.
CPSC Adult Portable Fed Rail-Related Deaths, Injuries Report
They found from 2003 to 2012, 155 people died as a result in a bed rail related incident. That number is even higher when you include bed rail deaths in hospitals.
The Food and Drug Administration regulates their use and has tracked more than 500 deaths from 1985 to 2013.
FDA MAUDE Database For Medical Device Reports
Wolfson says, "These deaths are happening within people's homes. They're happening with entrapment. We really need parents and caregivers to understand that these older consumers roll into a gap. They cannot free themselves."
The WUSA consumer team traveled to the CPSC's Rockville testing lab to show you just how that can happen, and why it's important the portable bed rails be installed properly.
"This one is installed without the straps, all it is, is placed under the mattress. If you put a little pressure on it, you can see it slides pretty easy. And, if the person laying in the bed would roll over into that, they would eventually get entrapped between the mattress and bed rail and would not be able to get out," says a CPSC engineer.
Cutting a person's air supply and blood to their head. Then the CPSC engineer showed how the bed rail should be installed to keep it in place.
"The straps attach to the opposite side rail and if you try to pull on it, you can see that there's a lot of resistance and there's no gap that opens between the bed rails and the mattress," he says.
But the CPSC says even when installed correctly, caregivers should not be lulled into a false sense of security.
WUSA 9 anchor and consumer correspondent Lesli Foster asks Wolfson, "What do caregivers need to do differently when they're using these adult portable bed rails?"
"It's not the type of product where you can just slide it under the bed and feel like, okay, I'm good now. I just let my loved one use it just days and weeks on end," he says.
Gloria Black says, "I did not realize at all that this was not attached to my mother's bed. I had always assumed that there were nuts and bolts fastening it to her bed."
So, this daughter has made it her mission to keep other families from getting an unexpected, awful call about a loved one lost to a bed rail. She's on a crusade to ensure to spare other families her kind of pain.
"Sometimes there's a need for a reality check. And, the bed rails story is three decades overdue for a reality check. My goal has always been to stop the next death," she says.
Gloria filed a lawsuit against the assisted living facility where her mother died. The case has since been resolved.
Right now, there are no mandatory standards for manufacturers of bed rails.
But the bed rail industry, the CPSC and consumer advocates are working together to form a voluntary standard.
CPSC Peition Requesting A Ban or Standard On Adult Portable Bed Rails
And, the U.S. Consumer Product Safety Commission and the Food and Drug Administration plan to launch an education campaign later this fall.
CFA, Consumer Voice and Consumer Advocates Petition
There are some thins you can do right now.
If your loved one has dementia, experts say a bed rail may not be the safest thing for them. Consider putting the mattress on the floor, and putting a mat below the bed as a cushion.