National Patient Safety Alert Supporting Information. Patient hoists and slings: incidents and case examples.
Supporting information to accompany the National Patient Safety Alert on patient hoists and slings NatPSA/2026/005/MHRA.
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This guidance should be read alongside the alert.
This page provides supporting information to accompany the National Patient Safety Alert on patient hoists and slings (NatPSA/2026/005/MHRA). It summarises post-market surveillance data, recurring causes, and case examples which show how serious and fatal incidents may occur.
Overview of incidents reported to the MHRA
The MHRA receives reports of adverse incidents through the Yellow Card scheme and through manufacturer incident reports.
The incidents described occurred in the United Kingdom and include multiple care settings, manufacturers and hoist models.
From 1 January 2015 to 31 December 2025, the MHRA received 22 reports of incidents with a fatal outcome involving patient hoists during routine transfers. Incidents occurred across acute hospitals, care homes, and within patient homes. The incidents occurred across various manufacturers, models or care setting.
These figures are based on Yellow Card reports and are likely to underrepresent the true scale of harm, as not all incidents are reported. The issues described may affect any patient hoist or sling.
Recurring Causes
Investigations consistently identify a small number of recurring causes. They reflect systemic gaps in practice and can occur across different equipment types and care contexts.
1. Detachment at critical load-bearing interfaces
Spreader bar hooks, carabiners, D‑clips and other retaining features can fail when components are missing, worn, damaged or incorrectly assembled. End boom caps or locking mechanisms have, in some instances, been missing, allowing hooks to rotate or disengage when in use. These conditions may not be obvious without a deliberate pre‑use check.
2. Sling loop movement on spreader bar hooks
Loop‑type sling attachments can move out of position on spreader bar hooks before all the patient’s weight is applied. This risk can be increased when slings are new and stiff, as loops may not be fully seated when initially attached. If loop displacement is not identified before the patient’s weight is applied, the sling may fail to retain the patient.
3. Incompatible hoist and sling combinations
Third‑party slings that have not been validated for a specific hoist, or the use of loop‑type slings with spreader bars designed for clip attachments (and vice versa), can result in insecure or incomplete attachment. Compatibility must be confirmed using the manufacturer’s instructions for use and should not be assumed because a sling physically fits.
4. Incorrect sling size or type
Use of an incorrectly sized sling can result in the patient slipping through or falling from the sling. Sling sizes and colour coding vary between manufacturers, which can lead to selection errors where multiple sling brands are used within the same organisation or where staff work across multiple settings. Toileting slings provide minimal support and must only be used for their intended purpose.
5. Inadequate pre‑use checks
Failure to identify unsafe equipment conditions before use is a recurring contributing factor. This includes missing components, worn or damaged retaining features, incorrectly seated sling loops, and incorrect sling attachment. Pre‑use checks should be capable of detecting these conditions and must include a “pause‑and‑check” step after initial load take-up, before the patient is fully lifted (for example, after slack has been removed and the sling attachments are under tension).
6. Maintenance, servicing and LOLER compliance failures
Equipment that is overdue for statutory examination under the Lifting Operations and Lifting Equipment Regulations 1998 (LOLER), or that is in use beyond its indicated service life without appropriate risk assessment and a device replacement plan, has been a factor in fatal incidents. Pre‑use checks are not a substitute for planned maintenance and formal examination programmes. Maintenance and servicing can also introduce faults if equipment is incorrectly reassembled or adjusted. Any hoist or sling that has been serviced or repaired must be functionally checked before being returned to service.
7. Training and competence gaps
Variability in training content and relevance to the specific equipment in use has consistently contributed to harm. Staff must be trained and assessed as competent not only in general moving and handling, but also in the specific hoist and sling combinations they will use. Training may also be relevant for a patient’s family and carers if in a home setting. Training should include correct hoist selection, attachment and fitting, recognition of unsafe conditions, and clear escalation routes.
Case examples
The following cases are from MHRA incident reports. They have been selected to illustrate risk mechanisms addressed in this alert. Identifying information has been removed or anonymised. They do not represent the full range of incidents reported to the MHRA.
Case 1: Fatal injury to a carer during hoist transportation (Residential care)
A care worker was moving a hoist between floors using a passenger lift. The hoist was not in patient use at the time. The care worker was fatally crushed by the hoist inside the lift. This incident highlights that patient hoists present risks beyond patient transfers. The safe handling, positioning and transportation of hoists is particularly important in multistorey settings and must be addressed through training, local procedures and organisational risk assessment.
Case 2: Wrong sling size and colour coding confusion (Care home)
A patient died after carers selected an incorrectly sized sling. The sling appeared visually similar to the correct sling but was a different size. Slings from multiple manufacturers were available on site, each using different colour coding systems to denote size and type. The coroner highlighted the absence of a standardised colour coding scheme across manufacturers as a contributing factor, particularly where multiple sling brands are in use. However, it was confirmed that implementing a universal system is not feasible due to differences in sizing across manufacturers.
Case 3: Incompatible accessory attachment – weighing scale (Acute hospital)
A patient fell from a hoist after a weighing scale accessory was incorrectly attached to the spreader bar. The full weight of the patient and scale assembly was placed onto the sling safety retaining clips, which are intended only to secure the sling and are not designed to bear load, rather than being properly placed onto the sling hook. The clips failed and the patient fell. The accessory had been used in this way for some time without incident. The investigation found that the attachment method was not in accordance with the manufacturer’s instructions for use and had not been validated for that hoist.
Case 4: Post-servicing fault not detected before use (Care home)
An elderly patient died after the legs of a hoist collapsed during a transfer. The investigation identified that a threaded locking knob on the leg mechanism had been overtightened, causing failure under load. This was consistent with incorrect reassembly or adjustment during or following servicing. The fault was not detected before the hoist was returned to use.
Reporting incidents to the MHRA
Healthcare organisations and individuals should report all incidents involving patient hoists and slings to the MHRA through the Yellow Card scheme. Reporting supports the identification of safety signals and enables timely action to reduce harm.