MHRA: NatPSA/2026/005/MHRA Patient Hoists Alert Mandates Safety Actions

• The MHRA issued National Patient Safety Alert NatPSA/2026/005/MHRA on September 16, 2026, addressing fatal and serious harm from patient falls during hoist and sling transfers.
• An average of two patient deaths per year since 2015, with 22 fatal incidents reported between 2015 and 2025, are linked to these falls across various care settings.
• The alert mandates five key actions, including standardized pre-use checks, documented hoist-sling compatibility, updated medical device management systems, rigorous maintenance and LOLER examinations, and comprehensive staff training.
• These issues are not confined to specific equipment or settings, indicating systemic failures in implementing existing safety guidance.
• Implementation of the alert requires coordination by an executive leader or senior accountable person, highlighting the critical need for organizational oversight and compliance.

The continued occurrence of fatal and serious harm underscores a critical failure in the systematic implementation of existing safety guidance, necessitating immediate and comprehensive action across all care settings.

The Medicines Healthcare products Regulatory Agency (MHRA) has issued a critical National Patient Safety Alert, NatPSA/2026/005/MHRA, on September 16, 2026, addressing the persistent risk of death and serious harm from patient falls involving hoists and slings. This alert highlights an ongoing pattern of incidents occurring during patient transfers and repositioning, which has led to tragic outcomes.

This comprehensive GB patient hoist safety alert targets all entities responsible for the use, procurement, and maintenance of patient hoists. This includes acute and community healthcare organizations, care homes, nursing homes, and services supporting individuals in their own homes, as well as their equipment providers. The MHRA emphasizes that the issues identified are not confined to any specific manufacturer, model, or care setting, indicating a systemic problem across the healthcare landscape.

A review of recent incidents with fatal outcomes, coupled with broader surveillance data, reveals a disturbing trend: an average of two deaths per year since 2015 linked to patient falls from hoists or slings. Between January 1, 2015, and December 31, 2025, the MHRA received 22 reports of fatal incidents during patient transfers. These incidents occurred in diverse environments, including acute hospitals, care homes, and within patients' own homes.

Investigations into these incidents frequently uncover similar contributing factors, which are consistent with themes raised in previous alerts such as Medical Device Alert MDA/2014/054 and Patient Safety Alert NHS/PSA/W/2015/010. This continuity suggests that existing guidance has not been reliably and systematically implemented, underscoring the urgent need for renewed focus on patient transfer equipment risk management.

To mitigate these significant risks, the MHRA NatPSA/2026/005/MHRA patient hoists alert mandates five critical actions. Firstly, organizations must implement and complete standardized pre-use checks for all hoists and slings, aligning with manufacturer's instructions for use (IFU). A crucial component of these checks is a 'pause-and-check' step after initial load take-up but before full patient lift, to verify secure sling attachment points.

Secondly, a thorough review and documentation of the compatibility of all hoist and sling combinations in use is required. Where manufacturer's IFU does not confirm compatibility, a qualified person must complete a risk assessment with supporting technical evidence. A local register of approved combinations must be maintained and accessible to all relevant staff. Thirdly, medical device management systems UK (inventory/database) must be updated to identify and record all patient hoists and slings, including those in community settings, ensuring they include maintenance, LOLER patient lifting equipment compliance examination, and device replacement plans.

Fourthly, all hoists must be maintained, serviced, and examined under LOLER (Lifting Operations and Lifting Equipment Regulations) and in accordance with manufacturer’s IFU, with up-to-date records. Any hoist with overdue examinations or unresolved defects must be immediately removed from service. Slings also require regular checks per manufacturer instructions. Finally, staff must receive role-appropriate, regularly updated training covering IFU use, pre-use checks, hoist-sling compatibility, correct fitting and attachment, identification of unsafe states, and proper procedures for stopping, escalating, and reporting concerns. Comprehensive training records must be maintained to ensure UK care home hoist sling regulations and broader safety standards are met.

The MHRA has designated this alert as safety-critical and complex, requiring implementation to be coordinated by an executive leader or an equivalent senior accountable person, such as a registered manager or responsible individual in organizations without executive boards. This directive underscores the high level of organizational responsibility and oversight demanded.

Legal and compliance teams in UK healthcare and care homes must urgently review and update patient hoist and sling safety protocols, including pre-use checks, compatibility documentation, and LOLER compliance, to mitigate significant regulatory and litigation risks highlighted by MHRA's NatPSA/2026/005/MHRA. The continued occurrence of fatal and serious harm underscores a critical failure in the systematic implementation of existing safety guidance, necessitating immediate and comprehensive action across all care settings.

Legal and compliance teams in UK healthcare and care homes must urgently review and update patient hoist and sling safety protocols, including pre-use checks, compatibility documentation, and LOLER compliance, to mitigate significant regulatory and litigation risks highlighted by MHRA's NatPSA/2026/005/MHRA.

Source: Original reporting via GOV.UK