MHRA: Patient Hoist Sling Safety Alert Addresses Fatal Risks

• The MHRA has issued guidance accompanying a National Patient Safety Alert (NatPSA/2026/005/MHRA) regarding patient hoist and sling safety.
• From January 2015 to December 2025, 22 fatal incidents involving patient hoists during routine transfers were reported in the UK.
• Recurring causes include retaining feature failures, sling loop displacement, equipment incompatibility, and incorrect sling sizing.
• Incidents occurred across acute hospitals, care homes, and patient homes, involving various manufacturers and models.
• The MHRA emphasizes the critical need for thorough pre-use checks, including a 'pause-and-check' step, to identify unsafe conditions before full patient lift.

The MHRA emphasizes the critical need for thorough pre-use checks, including a 'pause-and-check' step, to identify unsafe conditions before full patient lift.

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued comprehensive guidance, accompanying its National Patient Safety Alert (NatPSA/2026/005/MHRA), to address the persistent and often fatal risks associated with patient hoists and slings. This critical medical device safety guidance from the MHRA synthesizes post-market surveillance data, identifies recurring causes of incidents, and provides illustrative case examples to demonstrate how serious and fatal outcomes can arise during routine patient transfers.

Between January 1, 2015, and December 31, 2025, the MHRA received 22 reports detailing fatal incidents involving patient hoists. These tragic events occurred across a range of care settings, including acute hospitals, care homes, and private patient homes, and involved various manufacturers, models, and care contexts within the United Kingdom. The agency underscores that these figures, derived from Yellow Card scheme medical device reports, likely do not represent the full scope of harm, as not all incidents are reported.

Investigations into patient hoist sling incident reports UK consistently reveal a pattern of systemic gaps in practice, which can manifest across diverse equipment types and care environments. A primary concern involves the failure of retaining features such as spreader bar hooks, carabiners, and D-clips. These components can fail due to being missing, worn, damaged, or incorrectly assembled. For instance, the absence of end boom caps or locking mechanisms has, in some cases, allowed hooks to rotate or disengage during use, a condition that may not be immediately apparent without a thorough pre-use check.

Another significant risk factor is the displacement of loop-type sling attachments on spreader bar hooks before the patient's full weight is applied. This risk is heightened when slings are new and stiff, as the loops may not fully seat initially. If this displacement goes unnoticed before the patient's weight is fully transferred, the sling can fail to securely retain the individual. Furthermore, the use of third-party slings that have not been validated for a specific hoist, or the incorrect pairing of loop-type slings with spreader bars designed for clip attachments (and vice versa), frequently leads to insecure or incomplete attachment. Manufacturers' instructions for use must be consulted to confirm compatibility, as physical fit alone is not a reliable indicator.

The MHRA guidance also highlights dangers stemming from incorrectly sized slings, which can result in patients slipping through or falling. Compounding this issue, sling sizes and colour coding vary widely between manufacturers, creating potential for selection errors, particularly in organizations utilizing multiple sling brands or where staff work across different settings. It is also crucial to remember that toileting slings offer minimal support and must be reserved strictly for their intended purpose.

A recurring and critical contributing factor to these incidents is the failure to identify unsafe equipment conditions prior to use. This includes overlooking missing components, worn or damaged retaining features, incorrectly seated sling loops, or improper sling attachment. To mitigate these risks, pre-use checks must be robust enough to detect such conditions. Crucially, these checks should incorporate a 'pause-and-check' step after the initial load take-up – specifically, after slack has been removed and the sling attachments are under tension – before the patient is fully lifted. This emphasis on diligent checks, alongside adherence to statutory examination requirements under the Lifting Operations, is paramount for ensuring patient transfer safety across all care environments.

This MHRA guidance provides critical insights for lawyers advising healthcare providers on potential negligence claims arising from patient hoist and sling incidents, particularly regarding equipment maintenance, staff training, and adherence to pre-use check protocols. Compliance officers must review internal procedures to align with these recommendations, ensuring proper equipment compatibility and staff competency to mitigate legal and safety risks.

Source: Original reporting via GOV.UK