Guidance: 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.

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.

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