Hoisting incidents happen rarely and are very sad when they do happen. We do have to learn from them. A narrative around lessons learned surrounding a hoist fatality and several hoisting incidents at one hospital trust. Trust in the UK. Highlighting the consequences of when stop pause and a check has not been carried out as part of the standard hoisting procedure. Thank you to Mandy Giblin for sharing to highlight the risks for everyone.

1. Steven’s Story
Who he was and how he died
Incident details and Findings
Relatives and Staff Experience
Outcome from Inquest
Update on actions
Lessons Learned

2. Steven was….
• 85 year old man
• Father
• Husband
• Wife who was his full time carer
• Quality of life maintained by his wife and
family
• After 12 days in hospital considered fit for
discharge back to his home

3. What happened?
• Required weighing as per the Trust policy
• Whilst Steven was hoisted back to bed he fell from
the sling and hit his shoulder and head on the floor.
• Head injury and a fractured shoulder
• Marked deterioration in condition two days after the
fall
• Not be suitable for interventional treatment.
Steven died 5 days after falling from the hoist
Steven died due to sustaining an intracerebral
haematoma as a result of the fall and subsequent
bronchopneumonia.

4. As well as a Trust HLI investigation…..
• Police
– Quarantined the hoist
– Requested service histories and witness statements
– Interviewed the two staff and interviewed Senior Managers from the
Division
– Involved in the re enactment of the incident.
• Health and Safety Executive
– Requested service histories of the hoist and those across the Trust
– Interviewed all staff involved in the incident
– Involved in re-enactment scenario to determine root causes
– Requested training records for all staff
– Charged the Trust for time spent on site for contravention of LOLER
regulations
• Coroner
– Requested police involvement
– Liaison with Trust, Police and HSE
– Leading the Inquest

5. What was found….
• No fault found with the hoist,
spreader bar and sling
• Hoist 3 weeks overdue 6 monthly
LOLER inspection but still safe to
use
• Hoist registered to a different ward
and could not be located
• Staff Nurse had not received
practical element of MH training but
CSW had undertaken both practical
and theory
• The root cause was human error and
incorrect attachment of the sling
straps to the hoist spreader bar

7. Outcomes and actions…
• Training – monitoring, practical, theory
• Hoist checklist on all wards
• Equipment checking – escalation of missing
items to Senior Management Teams
• Sling to be date marked on opening
• Review of training programme and paperwork
• Ceiling hoist checking system
Key lesson – Check all attachments
before use of a hoist!

8. Staff experience……
• Staff were supported and continued to work on the ward
• Staff were assessed for competence as part of support
• Interviewed by the Police and the HSE
• Participated in the re-enactment of the scenario to try to
understand what happened
• Statements were given to the investigating team and they
met with Clinical Head of Division
• Staff continued to see patient and family on the ward
Staff involved and those who were witnesses were all required to
attend the coroners court and provide evidence in front of a jury
Never came to work with the intention to cause harm but this will
stay with them forever

9. Steven’s family experience….
• Were assigned a critical friend from Corporate Services
• Wrote a letter of complaint regarding the incident and the lack of
communication following the incident
• Liaised with the matron for the area
• Met with the senior team to discuss incident
• Raised questions regarding care and treatment
• Concerns focused on the small detail of the report
• Family continued to see nursing staff involved whilst on ward and
whilst Steven was dying – unintended negative impact
Steven’s daughter was required to provide evidence at
Coroner’s Court in front of a jury, the organisation and the staff
involved
Have expressed their desire for this to never to happen to
anyone else

10. Trustwide Lessons Learned
• Monitoring of training compliance to be
monitored locally and Trust Wide reports
circulated
• Hoist checklist developed and implemented
across all Divisions
• Ceiling hoists check to be implemented across
the Trust
• Patient Safety Alert sent out across the Trust
• Medical Engineering escalation process to be
implemented across the Trust
• Training programme update applicable across all
Trust staff

11. Inquest
• Held over 2 days in December 2013
• Led by Greater Manchester Coroner
• Jury deliberation
• All staff were asked to provide evidence
throughout the inquest
• Family members had the opportunity to ask
questions of the staff
• Demonstration of incident during inquest.
Verdict: Accidental Death

12. External Agencies
• Police
- Concluded no criminal case to answer
- Handed investigation over to the Health and Safety Executive
• Health and Safety Executive
- Investigation lead gave statements / evidence at inquest
- Asked questions of staff involved
- No formal report received as yet
- Conclusion acknowledged to be the same as the Trust
investigation
• Coroner
- Identified no requirement for reporting individuals to
professional bodies
- Acknowledged human error as root cause
- Acknowledged actions of the Trust were adequate
- Considered to be a ‘one-off’ event………………. However

13. Two further incidents occurred in January 2014
No actual harm to patients
•Root cause = same as first incident
• Sling hooks not correctly attached to the
spreader bar
•Joint Divisional investigation undertaken
•Action plan to be Trust wide…. Key
Stakeholder meeting has taken place
This happened again….

14. Trustwide Action Plan
• Manual Handling and Hoist Training program to
be reviewed and redeveloped
• Ceiling hoists to be marked with date labels
• Roll out of checklist and alert signs for all mobile
hoists and ceiling hoists undertaken
• Review of design features of the current hoists,
liaising with MHRA and manufacturers
• Sharing of the findings from three incidents
• Included in face to face Clinical Mandatory,
medical device session
• Lessons learned to be shared across all the
Divisions and nationally.

17. Thank you
Any Questions