Recurring concern

Inadequate controls for positional asphyxia during patient handling and care

First to latest report 4 Mar 2021 — 17 Aug 2023

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
3

What this concern includes

Includes failures of controls specifically intended to prevent, detect or respond to positional asphyxia during patient handling and care, including hoisting with harnesses or slings, patient positioning, supervision, staff guidance and escalation when the hazard is identified.

What is not included
  • Excludes generic moving-and-handling, staffing, training or documentation deficiencies where positional asphyxia is not the identified hazard.
  • Excludes ordinary respiratory, airway or resuscitation failures unrelated to positional asphyxia during patient handling or care.
  • Excludes restraint-specific assertions that concern restraint application or training rather than the broader patient-handling and care context; those belong to the existing restraint-related asphyxia concern.
  • Excludes failures occurring after positional asphyxia has been reliably recognised and appropriate emergency treatment has begun.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner South London

    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 service-provider awareness of positional asphyxia risks during hoisting

    Wider context from the report

    “1) The risk of fatal positional asphyxia associated with the use of harnesses/slings when hoisting was not appreciated by the OT services and AMT concerned with the provision, use and maintenance of the hoist. This indicates that training may be required to raise awareness of the risk of positional asphyxia in order to reduce the risk of future deaths. I consider it important to highlight to service providers the dangers associated with unassisted use of ceiling hoists and sling harnesses. ”

    Source location

    Shirley Frances Ashelford · Prevention of Future Deaths report
    Page 4 · 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

    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 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

    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

    Place the self-hoisting policy on the case-management system, share it with relevant staff and include it in new-starter induction.

    Verbatim wording from the response

    “10. This new policy (which contains a checklist) will be placed on Adult Social Care’s internal case management system and the information will shared by the Occupational Therapy Team Manager and Principal Occupational Therapist with all relevant staff. It will also be included in the new starter induction to advise new starters within the service. LBS also proposes to have a training session on the new policy. This training will be provided to the approximately 23 OTs who are currently employed by LBS’ Social Care. It will also include OT apprentices and students, team managers and health colleagues (that is, OTs, sitting within Health e.g. the reablement team that will be invited).”

    Source location

    Response from Southwark Council
    Page 3 · response
    Published 6 September 2023

    Open published response

  2. Inner North London

    AI-generated summary

    Paula Anne SPEIRS · 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

    Paula Anne Speirs died following the ingestion of non-prescribed benzodiazepines before a planned procedure at Weymouth Street Hospital. The procedure was cancelled because staff considered her intoxicated, but she was allowed to sleep in a room without formal observations or specific monitoring instructions. The concerns included inadequate monitoring of an intoxicated patient and a lack of instructions to nursing staff on avoiding positional asphyxia.

    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 provide nurses with instructions on avoiding positional asphyxia

    Wider context from the report

    “1. However, in spite of her intoxication at 7am (from what was at the time an unknown substance, initially presumed to be alcohol), no formal observations were ordered or undertaken. Her room was easily accessible, but nobody was specifically tasked with monitoring her. No instructions were given as to how frequently she should be checked, or what that checking should involve. 2. The nurses looking after Ms Speirs were not given any instructions on how to avoid positional asphyxia. When I asked them about this at inquest, they explained that they had not previously heard of positional asphyxia. I have encountered positional asphyxia most frequently in a custodial setting. Detainees in police cells are now subject to very clearly laid down procedures that attempt to reduce the risk of positional asphyxia and to reduce drink and drug related deaths. It seems to me an omission that there is not a similar regime in a hospital, where one would expect the medical care to be of a higher standard. ”

    Source location

    Paula Anne SPEIRS · Prevention of Future Deaths report
    Page 2 · 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

    Disseminate learning about positional asphyxia from the investigation to all clinical staff.

    Verbatim wording from the response

    “To acknowledge our newly acquired knowledge regarding ‘positional asphyxia’, the learnings from this investigation have been disseminated with all clinical staff.”

    Source location

    2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
    Page 6 · response
    Published 8 March 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Unfamiliarity with positional asphyxia was neither unusual nor criticism-worthy because the hospital does not use restraint, restrictive interventions or rapid tranquilisation.

    Verbatim wording from the response

    “Despite comprehensive investigation we have failed to identify that this term is used or taught in training or clinical practice in healthcare in the UK, with the exception of environments where physical restraint or rapid tranquilisation are employed e.g. in police custody/ cells or in a mental health facility. It is true the four witnesses were unaware of the term, but that is neither unusual nor a matter for criticism.”

    Source location

    2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
    Page 5 · response
    Published 8 March 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Training specifically on positional asphyxia was considered inappropriate because restrictive interventions are not used and the subject is outside accredited ILS training.

    Verbatim wording from the response

    “The Weymouth is not a setting where restrictive interventions are used, nor are there any clinicians who deliver restrictive interventions so Weymouth staff, like other hospitals, do not actively train for it and it would be inappropriate to do so. All clinical staff are trained and attend annual refresher courses in ILS (Resus Council accredited) at Middlesex University covering all relevant aspects as determined by the professional trainers and the approved curriculum. Positional asphyxia is not included in any Resus Council accredited ILS training.”

    Source location

    2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
    Page 6 · response
    Published 8 March 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing airway-management training and recovery-position skills were considered sufficient to address airway obstruction and patient positioning risks.

    Verbatim wording from the response

    “Positional asphyxia is simply not taught in the UK in an acute hospital setting. However, the knowledge and skills for management of the airway is taught, which includes appropriate use of the recovery position. It is important to note that Ms Speirs was placed in this position in line with Resuscitation Council guidelines. The knowledge and skills for management of the airway and positioning of a patient, is embedded in clinical care delivered at the Weymouth and throughout Phoenix Hospital Group.”

    Source location

    2021-0064-Response-from-Phoenix-Hospital-Group-Redacted
    Page 6 · response
    Published 8 March 2021

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026