Recurring concern

Unsafe use and management of patient slings

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First reported 18 Sep 2014•Latest report 18 Sep 2023

Definition

What this concern includes

Includes failures of controls specifically dedicated to patient-sling safety, including sling selection and suitability, removal of unsafe slings, fitting and application, recognition of sling-related harm, communication with carers, staff instruction and reassessment when concerns arise.

Not included

  • Excludes generic patient moving and handling deficiencies where no patient-sling safety issue is identified.
  • Excludes failures involving hoists, beds or other equipment unless the asserted unsafe condition specifically concerns a patient sling.
  • Excludes generic equipment maintenance, training, communication or documentation deficiencies unless they directly impair safe patient-sling use or management.
  • Excludes injuries or deterioration involving a sling where no failure of a dedicated sling-safety control is identified.
Reports
4

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2014–2023

First to latest report issue date

Stated actions
7

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.

Bluebird Care (Bromsgrove & Redditch)1
Bureau Veritas UK Limited1
Divine Health Services Limited1
Faversham House Nursing Home1
Herefordshire and Worcestershire Health and Care NHS Trust1
London Borough of Southwark1
Medicines and Healthcare products Regulatory Agency1
Prism UK Medical Limited1
R D (Bromsgrove) Limited1
Sunrise Medical Limited1
University Hospitals Sussex NHS Foundation Trust1

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.

  1. Worcestershire

    AI-generated summary

    Anthony John Friend · 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

    Anthony John Friend, who was living with the effects of a brain tumour and required regular personal care, sustained a significant head injury on 17 April 2023 after slipping through a sling while being hoisted from a chair to his bed. He was discharged home for palliative care and died there on 20 April 2023. The principal concern was that an old toileting sling had previously been judged unsuitable and unsafe, but remained at his property and continued to be used, with shortcomings identified in communication, supervision and arrangements for safer alternatives.

    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 remove unsuitable slings from the service user's property

    Wider context from the report

    “In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

    Source location

    Anthony John Friend · Prevention of Future Deaths report
    Page 1 · 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 ensure carers' participation in sling assessments

    Wider context from the report

    “In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

    Source location

    Anthony John Friend · Prevention of Future Deaths report
    Page 2 · 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 discuss sling use with new carers

    Wider context from the report

    “In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

    Source location

    Anthony John Friend · Prevention of Future Deaths report
    Page 2 · 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 demonstrate safer sling use to carers

    Wider context from the report

    “In the course of the inquest, I heard evidence that: 1) As long ago as 28.11.22 (nearly 5 months before the accident which led to Mr. Friend’s death ), ████████, an Occupational Therapist employed by HWHT, had concluded that the sling being used at the time of the accident on 17.4.23 ( the “old toileting sling” ) was no longer suitable for Mr. Friend, ensured that two more suitable slings were provided instead, but did not remove the old toileting sling from Mr. Friend’s property; 2) During a home visit to Mr. Friend’s address on 2.2.23, ████████ noted that the old toileting sling was still being used, and made clear to Mr. Friend’s family and carers that it was “not safe to use”, but again did not remove it from the property; 3) During a home visit to Mr. Friend’s address on 6.3.23, ████████, another Occupational Therapist employed by HWCT, noted that the old toileting sling was still being used by family and carers, and that although the two more suitable slings provided by her colleague ████████ would be difficult to fit, they were nonetheless safer to use. ████████ told the inquest that in hindsight she “should not have allowed [ carers ] to carry on using the unsafe sling” and that she did not know why she had not taken time to show carers how to use the safer slings which had been provided; 4) During a home visit to Mr. Friend’s address on 17.4.23 (just prior to the accident ) in order to assess Mr. Friend for a new sling, ████████ noted that the old toileting sling was still being used. However, she told the inquest that despite her misgivings about it, she did not remove it from the address, and still expected carers to carry on using it for the next two weeks until a new sling arrived. She described this decision as “an oversight” on her part; 5) ████████ also told the inquest that: (a) she should have ensured that Mr. Friend’s carers were present for the home visit and sling assessment on 17.4.23 ( which they were not ); and (b) she should have contacted his new carers ( Divine Health Services Ltd. ) after that visit, to discuss their use of the sling; 6) At no time did either ████████ appear to have communicated their concerns about the continued use of the old toileting sling in writing to either of the agencies which were providing care for Mr. Friend at the relevant times. ”

    Source location

    Anthony John Friend · 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

    Develop and operationalize a policy specifying timely removal of unsafe equipment from patients’ homes, with staff dissemination through team meetings and Trust-wide communications.

    Verbatim wording from the response

    “As a Trust we recognise that at the time of this incident we did not have a robust policy and procedure in place to support our staff in the community with regard to the removal of unsafe equipment. Since the incident we have formulated a working group to design a new policy around equipment provision and this will cover the necessary steps and procedures for our staff, around timely removal of unsafe equipment from a patient’s home. We will have this new policy signed and operational by the 1st April 2024. A key element will be sharing this new policy which will be completed at individual team meetings and via our global all staff communication emails. Whilst we are developing the new policy we have issued more immediate instructions to staff via a focus on card approach.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 2 · response
    Published 18 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

    Implement and disseminate a step-by-step focus card for identifying unsafe equipment, documenting removal warnings, and educating occupational therapy staff on its use.

    Verbatim wording from the response

    “As a Trust we recognise that more timely action was required about removal of older slings so we have in partnership with a range of professionals designed a focus-on-card around a step by step guide for staff when they identify unsafe equipment in a patient’s home. This is a direct impact from this serious incident. This will act as a useful reminder document that staff will have access to when visiting patients in their homes and will be a vital part of new starter’s induction packs.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 2 · response
    Published 18 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

    Create a standardised letter for service leads to send when patients or others resist removal of unsafe equipment, storing copies in electronic patient records.

    Verbatim wording from the response

    “We have also designed a standardised template letter (a copy is attached for your information) for service leads to send to patients if our clinicians experience resistance when removing equipment from a patient’s home and these will be stored on our electronic patient record.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 2 · response
    Published 18 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

    Introduce a countywide communication-focused role supporting joint client visits, delegated tasks, and liaison between HASE and external care agencies.

    Verbatim wording from the response

    “We have also introduced a new role into our countywide service, this role has a significant bias towards improving communication with our external agencies to prevent occurrences like this happening again. They will be involved in joint visits to clients and will have weekly clinical supervision, where tasks will be delegated to them to support improved communication between HASE and other agencies.”

    Source location

    Response from Herefordshire and Worcestershire Health and Care
    Page 3 · response
    Published 18 September 2023

    Open published response

  2. 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 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

  3. Brighton and Hove

    AI-generated summary

    Leslie Isaac LERNER · 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

    Leslie Isaac Lerner died on 3 June 2016 after treatment for a fractured shoulder, including application of an incorrect sling that caused a deep pressure sore and additional pain. The report identified concerns about inadequate senior review, analgesia, communication, handover, continuity of care, recognition of pneumonia and deterioration, and delay in initiating end-of-life care.

    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 competent selection and application of slings

    Wider context from the report

    “13th May 2016 (1) Junior Doctor applied wrong sling with wrong knot for Mr Lerner after she had learned that he had had a fractured shoulder which was to be treated conservatively. I heard that a Nurse should have applied the sling because the chances are that he or she would have known which sling to use and how to apply it. (2) Although the Junior Doctor discussed Mr Lerner with her Senior, the Senior did not actually see him nor specifically state which type of sling (should have been a collar and cuff) should be applied. I was told that the Senior should always see the Patient. ”

    Source location

    Leslie Isaac LERNER · Prevention of Future Deaths report
    Page 2 · 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 recognise harm from an incorrectly applied sling

    Wider context from the report

    “17th May – 22nd May 2016 There is no evidence of any continuity of care. There is good evidence of “hands off” care and nursing. In spite of anxieties expressed by the Manager of Mr Lerner's Rest Home, who came to assess him on the 19th May having been told he was medically fit for discharge (which he was not) and by his nephew Mr Marsh that he seemed ‘chesty’ and so far as the Manager was concerned that she was worried about the sling which did not seem to be supporting his elbow and did not seem to be ‘right’, there was no appreciation of the possibility that the sling was causing half the problems at least that Mr Lerner was suffering. No efforts were made to see whether he was ‘chesty’; a Doctor was not called, another chest x-ray was not ordered and it was not until the next day he was found to have a bilateral pneumonia which needed intravenous antibiotics. In addition he was being nursed at the wrong angle and it seems clear that he couldn’t have been given any personal care such as washing, because if he had been, nursing staff or healthcare assistants would have seen the tightness of the sling and the damage that it was causing. ”

    Source location

    Leslie Isaac LERNER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester South

    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

    Tendency of sling material to bag at the sides

    Wider context from the report

    “During the course of the evidence I heard from an Inspector of the Health and Safety Executive that the sling had a tendency to “bagging” at the sides and if Mrs Phillips had leant her weight over to one side of the sling, this combined with the tendency of the sling material to “bag” might have allowed her to fall from the hoist.(FOR SUNRISE MEDICAL LIMITED) ”

    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

    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

    If the hoist was an Oxford model no longer supplied, no action can be taken by the supplier.

    Verbatim wording from the response

    “The first IFU relates to the Oxford hoist which is no longer supplied by Sunrise Medical Ltd. It is submitted that if the IFU is a comprehensive document which at regular interval refers to safety precautions and bulletins helpful “do’s” and “don’ts”, specific references are made to the sling, maintenance of the same and operation of the hoist only with approved slings. On the basis that these hoists are no longer supplied by Sunrise Medical Ltd, it is submitted that if this was the hoist in question, no action can be taken by our client.”

    Source location

    2014-0413-Response
    Page 2 · response
    Published 18 September 2014

    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 comprehensive instructions address equipment purchase, maintenance and operation, so no further action is proposed.

    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
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Data last updated 7 September 2026