Safety alert issued to care homes over residents falling from hoists

All care homes and hospitals that provide NHS funded care have been issued with a Patient Safety Alert over people being put at risk of death or serious harm from hoists.

The alert has been issued following patient safety incident reports that suggest existing Health and Safety Executive (HSE) advice on safely using hoists and providing training has not always been reliably and systematically implemented.

The Medicines and Healthcare Products Regulatory Agency (MHRA) received 78 reports of falls from hoists between 2011 and 2014 which included three deaths and nine incidents resulting in severe injury.

Data from a National Reporting and Learning System (NRLS) search also revealed 15 occurrences in a recent four year period where a person has come to harm through falls from hoists, including one death and three severe injuries. Injuries included hip, leg and ankle fractures, head injuries, lacerations and haematomas.

The incidents occurred in acute hospitals, care homes and people's own homes.

Dr Mike Durkin, NHS England director of patient safety, said: “All patients expect and deserve only the best possible care and each of these incidents is unacceptable. It is thanks to the staff that have brought this issue to our attention by reporting incidents to national reporting systems that we have been able to raise awareness of this risk through a Patient Safety Alert.

“It is vital that all national advice around operating hoists is adhered to and that only staff and carers with training appropriate to the type of hoist and condition of the person being lifted are permitted to operate them. By issuing this alert we are asking local organisations to ensure steps are taken to further prevent these kinds of incidents from occurring.”

Care homes and hospitals now have until 9 December to take action and identify if any falls from hoists have occurred or could occur in the organisation. They also have to come up with an action plan to lessen the risk of falls from hoists and share any good practice.

NHS England analysed the MHRA and NRLS data and found there had been a failure to follow correct manual handling procedures including instructions on the number of care workers required to perform manoeuvres and an inadequate assessment of people's abilities or disabilities and selection of equipment.

Sling straps had been incorrectly fitted to the hoist or the person being lifted and in some cases the wrong size or type of sling was used. There was also unclear responsibility for equipment maintenance.

For more information on the patient safety alert go to https://www.england.nhs.uk/patientsafety/wp-content/uploads/sites/32/2015/10/psa-falling-from-hoists-1015.pdf