17 Aug 2023 Shirley Frances Ashelford · Prevention of Future Deaths report Inner South London
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Concerns raised 6 Failure to provide inspectors with information about recent hoist problems View source Lack of service-provider awareness of positional asphyxia risks during hoisting View source Lack of user and carer awareness of positional asphyxia risks during hoisting View source Failure to train carers in emergency lowering using the hoist red cord View source Possible design fault in hoist lowering function View source Failure of OT and AMT to share information about hoist condition View source See 3 more concerns
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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.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bureau Veritas UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide inspectors with information about recent hoist problems
Wider context from the report “5) I am concerned that the Bureau Veritas inspection report of 30/6/21 made no reference to the report of Higher Elevation and Shirley’s complaint on 9/4/21 indicating that the inspector was unaware of recent problems . Had they been aware they might have been able to detect the problem which caused the failure of the hoist to lower on the 20/7/21.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bureau Veritas UK Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bureau Veritas UK Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bureau Veritas UK Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bureau Veritas UK Limited; that does not assign responsibility.
PFD Monitor interpretation Possible design fault in hoist lowering function
Wider context from the report “4) There was some evidence that another hoist of the same model in the bathroom had a problem with the lowering function and the possibility of a fault in the design of the lowering function . I raise this concern to alert the MHRA and Prism Medical UK Ltd in order to conduct appropriate safety investigations. The hoists are available in situ for a limited period or otherwise will be kept in storage by the Local Authority for inspection purposes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Bureau Veritas UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of OT and AMT to share information about hoist condition
Wider context from the report “3) I am concerned that two departments in the local authority, the OT department and AMT, did not share information concerning the condition of the hoist , namely, Shirley’s reports to OT were not shared with AMT and visit reports from contractors to AMT were not shared with the OT . Likewise, the Bureau Veritas inspection on 30/6/21 appears to have occurred in an information vacuum regarding recent problems with the hoist. Whilst the Veritas inspection report was shared with the AMT it was not shared with the OT department.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations