MHRA Issues National Patient Safety Alert on Patient Hoist Fall Risks

We use some essential cookies to make this website work. We’d like to set additional cookies to understand how you use GOV.UK, remember your settings and improve government services. We also use cookies set by other sites to help us deliver content from their services. You have accepted additional cookies. You can change your cookie settings at any time. You have rejected additional cookies. You can change your cookie settings at any time. 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. Date of Issue: 16 September 2026 Reference No: NatPSA/2026/005/MHRA​ 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. This is a safety critical and complex National Patient Safety Alert. Implementation should be coordinated by an executive leader (or equivalent senior accountable person, such as a registered manager or responsible induvial, in organisations without executive boards). 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: 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. Between 1 January 2015 to 31 December 2025, the MHRA received 22 reports of incidents with a fatal outcome during patient transfers. The incidents occurred in acute hospitals, care homes and in patient’s own homes. The problems described may affect all hoists and slings. Investigations into incidents often found similar contributing factors, which are consistent with the themes raised in Medical Device Alert MDA/2014/054 and Patient Safety Alert NHS/PSA/W/2015/010, indicating that existing guidance has not been reliably and systematically implemented. For further information on incidents