National Patient Safety Alert. Patient hoists and slings (all types): risk of death and serious harm from falls (MHRA, 16 September 2026)

Summary

Fatal and serious harm continues to occur when patients fall from hoists or slings during transfers and repositioning. A review of recent incidents with a fatal outcome and wider surveillance data shows an average of two deaths per year since 2015.

Content

This alert is for action by all those responsible for the use, purchase and/or maintenance of patient hoists, working within all acute and community healthcare organisations, care homes, nursing homes and care services supporting people in their own homes, and their equipment providers.

Explanation of identified safety issue

Fatal and serious harm continues to occur when patients fall from hoists or slings during transfers and repositioning. A review of recent incidents with a fatal outcome and wider surveillance data shows an average of two deaths per year since 2015. This is not confined to any manufacturer, model, or care setting. The most common causes of fatal and serious patient falls from hoists include:

• Detachment at critical load-bearing interfaces, including spreader bar hooks, clips, carabiners, fasteners, or other parts that are missing, worn, damaged or incorrectly assembled.

• Incompatible hoist and sling combinations, including use of third-party slings not validated for the specific hoist.

• Failure to identify damaged or incorrectly seated sling loops, or incorrect attachment to spreader bars during fitting and use.

• Failure to conduct effective pre-use checks that would identify unsafe equipment.

• Inadequate or overdue maintenance, servicing and examination under the Lifting Operations and Lifting Equipment Regulations 1998 (LOLER). This included continued use of a hoist or component parts beyond their indicated service life without risk assessment.

• Use of wrong size or type of sling for the patient.

• Insufficient staff training and competence assessment for the relevant hoist and sling types, including failure to follow correct manual handling procedures.

• Non-compliance with manufacturer’s instructions for use (IFU)

All actions to be completed by: 16 September 2027

1. Ensure that standardised pre-use checks are in place and completed for all hoists and slings (aligned with manufacturer’s IFU) to identify unsafe states. Pre-use checks should include a pause-and-check step after initial load take-up but before the patient is entirely lifted to verify that all sling attachment points are securely attached before proceeding.

2. Review and document the compatibility of all hoists and sling combinations in use across your organisation. In exceptional circumstances, where compatibility cannot be confirmed through the manufacturer’s IFU, a risk assessment with supporting technical evidence must be completed by a qualified person. Maintain a local register of approved combinations and ensure this is accessible to all relevant staff.

3. Review the medical device management systems (inventory/database) for your organisation to ensure all patient hoists and slings, including those provided to a community setting, are identified and recorded. These must include maintenance, LOLER examination and device replacement plans.

4. Ensure all hoists are maintained, serviced and examined under LOLER and in accordance with manufacturer’s IFU, with records kept up to date. Remove from service any hoist with overdue examinations or unresolved defects. Slings should be regularly checked in line with manufacturer instructions.

5. Ensure staff receive role-appropriate training with regular updates. Training should cover use in accordance with manufacturer’s IFU, pre-use checks, hoist-sling compatibility, correct fitting and attachment, identification of unsafe states, and how to stop, escalate and report concerns. Training records must be maintained.