Recurring concern

Unsafe operation of patient hoists

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First reported 18 Sep 2014•Latest report 17 Aug 2023

Definition

What this concern includes

Includes failures in the dedicated patient-hoist operation process, including staff or carer competence, adherence to required staffing and lifting procedures, user and carer awareness of hoist risks, emergency-lowering arrangements, relevant safety guidance and escalation of unsafe hoist practices.

Not included

Excludes generic moving-and-handling, staffing, training or documentation deficiencies where patient-hoist operation is not the material safety condition.
Excludes failures involving beds, slings, wheelchairs or other equipment unless the assertion explicitly concerns safe operation of a patient hoist.
Excludes hoist design, inspection, maintenance or component defects where no failure in operating or managing the hoist is identified.
Excludes pressure-relief practices, falls or other clinical-care concerns where patient-hoist operation is not the deficient control.

Reports: 3
Individual concerns: 4
Date range: 2014–2023
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Alexandra Grange Care Home1

Bureau Veritas UK Limited1

Faversham House Nursing Home1

London Borough of Southwark1

Medicines and Healthcare products Regulatory Agency1

Prism UK Medical Limited1

Sunrise Medical Limited1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

17 Aug2023
Inner South London
Concerns raised2
1. Lack of user and carer awareness of positional asphyxia risks during hoisting
2. Failure to train carers in emergency lowering using the hoist red cord
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop and establish a self-hoisting policy and checklist covering risk warnings, equipment checks, emergency plans, fault reporting and competency confirmation.
  Stated by London Borough of SouthwarkStated completed
AI-generated summary

Shirley Frances Ashelford · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Shirley Frances Ashelford died after the lowering mechanism of a ceiling hoist failed while she was transferring from her bed to a mobility scooter, leaving her suspended in a chest harness. The harness tightened and, in combination with respiratory weakness caused by multiple sclerosis, led to fatal asphyxia. Concerns included inadequate awareness and training about positional asphyxia and emergency lowering, failures to share information about reported hoist problems, and a possible design fault in the hoist's lowering function.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of user and carer awareness of positional asphyxia risks during hoisting
Wider context from the report
“2) Users and carers did not appear to have been made aware of the asphyxia risk associated with hoisting. It was not clear whether Shirley was trained in the use of the red cord safety feature on the hoist as there was no documentation to confirm this. Her husband and carer had never received training in the use of the red cord for emergency lowering. He was also unaware of the risks of positional asphyxia when Shirley was operating the hoist on her own. My concern is that there may be a general a lack of training of users and carers in the operation of this type of hoist and the risk of positional asphyxia. ”
Source location
Shirley Frances Ashelford · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to train carers in emergency lowering using the hoist red cord
Wider context from the report
“2) Users and carers did not appear to have been made aware of the asphyxia risk associated with hoisting. It was not clear whether Shirley was trained in the use of the red cord safety feature on the hoist as there was no documentation to confirm this. Her husband and carer had never received training in the use of the red cord for emergency lowering. He was also unaware of the risks of positional asphyxia when Shirley was operating the hoist on her own. My concern is that there may be a general a lack of training of users and carers in the operation of this type of hoist and the risk of positional asphyxia. ”
Source location
Shirley Frances Ashelford · Prevention of Future Deaths report
Page 5 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and establish a self-hoisting policy and checklist covering risk warnings, equipment checks, emergency plans, fault reporting and competency confirmation.

Verbatim wording from the response
“8. Whilst it was accepted during the inquest that LBS had taken steps to protect Ms Ashelford by offering a care package, a pendant alarm and a micro environment in a room downstairs when she started reporting concerns with her hoist, LBS has reflected upon matters that arose in the inquest. As part of this LBS has now developed a policy and checklist, titled “Self Hoisting Policy London Borough of Southwark”, which is to be followed in the event LBS is working with a service user who expresses the motivation and demonstrates both the mental and physical capacity to use a hoist independently. As set out above, there are no current service users who fit this categorisation. However, the policy is now in place in the event that such occurs in the future.”

Source location
Response from Southwark Council
Page 2 · response
Published 6 September 2023
Open published response
18 Oct2017
Manchester West
Concerns raised1
1. Inadequate staff training on hoist use
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Wycliffe Ashton Matthews · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Wycliffe Ashton Matthews sustained traumatic spinal cord injuries after letting go of a standing hoist during a third hoisting at Alexander Grange Care Home on 11 December 2016, and this led to his death and pneumonia. Concerns included apparently untrained or inadequately trained staff in the use of the hoist and failures to keep proper notes of the events leading to the death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate staff training on hoist use
Wider context from the report
“1. During the Inquest evidence was heard that:- i. The staff at the home seemed untrained or at least inadequately trained on the use of the hoist. ii. The staff failed to keep any, or any proper, note of the events which led to the death. ”
Source location
Wycliffe Ashton Matthews · Prevention of Future Deaths report
Page 1 · concerns
Open source report
18 Sep2014
Manchester South
Concerns raised1
1. Failure to ensure staff understand and follow hoist safety training
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Publish a model-specific Sunrise hoist instruction manual containing sling safety, maintenance and operation guidance.
  Stated by Sunrise Medical LimitedStated completed
AI-generated summary

MARJORIE PHILLIPS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Marjorie Phillips, aged 82, fell from a hoist while being transferred from her bed to a wheelchair and landed on its metal supporting legs. She died several days later from resultant pneumonia. Concerns included possible sling design issues, lifting her with only one staff member present, inadequate adherence to hoist training, and unclear arrangements for calling emergency services, which delayed her transfer to hospital.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure staff understand and follow hoist safety training
Wider context from the report
“In-house training is given to the staff at Faversham Nursing Home in connection with matters relating to Health and Safety. It was apparent that the staff had not heeded the training or had not fully understood its to the use of hoists. The training was said to include the fact that no-one should be lifted in a hoist when only one staff member was present. This was clearly not the case when Mrs Phillips was lifted.(FOR FAVERSHAM NURSING HOME) ”
Source location
MARJORIE PHILLIPS · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Publish a model-specific Sunrise hoist instruction manual containing sling safety, maintenance and operation guidance.

Verbatim wording from the response
“The second IFU is the document in relation to Sunrise hoists. On the rear cover of the document you can see that the document was published as recently as July 2014. Page 1 starts with a clear advice that the equipment is not operated until the instruction manual has been read and understood. On the same page the reader / operator / customer is assured that Sunrise hold the CE mark and that the hoists meet a total of four CE directives. At the bottom of the same page specific reference is made to the Lifting Operations and Lifting Equipment Regulations 1998 (LOLER). Safety instructions are clearly set out in easy to understand language at paragraph 3, page 3 with further guidance and illustrations at paragraph 9, page 7.”

Source location
2014-0413-Response
Page 2 · response
Published 18 September 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of user and carer awareness of positional asphyxia risks during hoisting

Failure to train carers in emergency lowering using the hoist red cord

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Inadequate staff training on hoist use

Concerns raised1

Failure to ensure staff understand and follow hoist safety training

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 1

Actions described in response 1