Recurring concern
Inadequate controls for positional asphyxia during patient handling and care
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Request correctionFirst reported 4 Mar 2021•Latest report 17 Aug 2023
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.
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
- 2
- Individual concerns
- 3
- Date range
- 2021–2023
- Stated actions
- 3
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
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.
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Concerns raised2
Lack of service-provider awareness of positional asphyxia risks during hoisting
Lack of user and carer awareness of positional asphyxia risks during hoisting
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 concernsEach statement is shown once, even when linked to more than one concern.
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.2
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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 Southwark -
Action
Place the self-hoisting policy on the case-management system, share it with relevant staff and include it in new-starter induction.
Stated by London Borough of Southwark
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Concerns raised1
Failure to provide nurses with instructions on avoiding positional asphyxia
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Disseminate learning about positional asphyxia from the investigation to all clinical staff.
Stated by Phoenix Hospital Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Unfamiliarity with positional asphyxia was neither unusual nor criticism-worthy because the hospital does not use restraint, restrictive interventions or rapid tranquilisation.
Stated by Phoenix Hospital Group
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Position
Training specifically on positional asphyxia was considered inappropriate because restrictive interventions are not used and the subject is outside accredited ILS training.
Stated by Phoenix Hospital Group -
Position
Existing airway-management training and recovery-position skills were considered sufficient to address airway obstruction and patient positioning risks.
Stated by Phoenix Hospital Group
Data last updated 7 September 2026