| Originator: |
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National Patient Safety Alert - MHRA
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- Care Trusts
- Mental Health Trusts
- Specialists Trusts
- Learning Disabilities Trusts
- Mental Health & Social Care Trusts
- Ambulance Trusts
- Mental Health & Learning Disabilities Trusts
- Acute Trusts
- Community Trusts
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- Other contacts
- Independent Healthcare Providers (registered with CAS)
- Clinical Commissioning Groups
- Social Care Providers (registered with CAS)
- Special Health Authorities
- Territorial CMOs in Northern Ireland, Scotland & Wales
- Integrated Care Boards
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| Title: |
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Patient hoists and slings (all types): risk of death and serious harm from falls
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| Broadcast content: |
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Fatal and serious harm continues to occur when
patients fall from hoists or slings during transfers
and repositioning. A review of recent incidents with
a fatal outcome and wider surveillance data shows
an average of two deaths per year since 2015. This
is not confined to any manufacturer, model, or care
setting. The most common causes of fatal and
serious patient falls from hoists include:
• Detachment at critical load-bearing
interfaces, including spreader bar hooks,
clips, carabiners, fasteners, or other parts
that are missing, worn, damaged or
incorrectly assembled.
• Incompatible hoist and sling combinations,
including use of third-party slings not
validated for the specific hoist.
• Failure to identify damaged or incorrectly
seated sling loops, or incorrect attachment
to spreader bars during fitting and use.
• Failure to conduct effective pre-use checks
that would identify unsafe equipment.
• Inadequate or overdue maintenance,
servicing and examination under the Lifting
Operations and Lifting Equipment
Regulations 1998 (LOLER). This included
continued use of a hoist or component parts
beyond their indicated service life without
risk assessment.
• Use of wrong size or type of sling for the
patient.
• Insufficient staff training and competence
assessment for the relevant hoist and sling
types, including failure to follow correct
manual handling procedures.
• Non-compliance with manufacturer’s
instructions for use (IFU) This National Patient Safety Alert provides further background, clinical information and actions for providers.
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| Additional information: |
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This Alert is not relevant to Primary Care
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| Action underway deadline: |
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18-Sep-2026
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| Action complete deadline: |
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16-Sep-2027
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