PFD report

MARJORIE PHILLIPS · Prevention of Future Deaths report

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Issued 18 Sep 2014•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
1

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to ensure staff understand and follow hoist safety training
    Part of recurring concern: Unsafe operation of patient hoists
  2. Tendency of sling material to bag at the sides
    Part of recurring concern: Unsafe use and management of patient slings
  3. Lack of clear guidance on calling emergency services and decision-making authority
    Part of recurring concern: Failure of emergency response leadership and coordination
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Action

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

    Stated by Sunrise Medical LimitedStated completedThe respondent said that this action was complete when they made their response on 18 September 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

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

    Stated by Sunrise Medical LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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) ”

Is this part of a recurring concern?

Yes — Unsafe operation of patient hoists.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

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) ”

Is this part of a recurring concern?

Yes — Unsafe use and management of patient slings.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of clear guidance on calling emergency services and decision-making authority

Wider context from the report

“When a very serious untoward incident had occurred and Mrs Phillips had fallen and was in obvious severe pain, there was no clear guidance as to how the emergency services should be called and by whom that decision could be taken. This resulted in her not being taken to hospital as quickly as should have been the case.(FOR FAVERSHAM NURSING HOME) ”

Is this part of a recurring concern?

Yes — Failure of emergency response leadership and coordination.

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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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026