Care homes have been ordered to strengthen checks, maintenance and staff training for patient hoists and slings after the medicines’ regulator warned that preventable falls continue to cause deaths and serious injuries across health and social care settings.
The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a National Patient Safety Alert requiring action from care homes, nursing homes, community services and healthcare providers following evidence that patients continue to suffer fatal and serious harm when falling from hoists during transfers and repositioning.
According to the regulator, a review of recent incidents and wider surveillance data found an average of two deaths a year linked to falls from hoists and slings since 2015 - between January 2015 and December 2025, the MHRA received 22 reports of incidents with a fatal outcome during patient transfers in hospitals, care homes and people's own homes.
The alert identifies a series of recurring causes, including incompatible hoist and sling combinations, damaged or incorrectly fitted sling attachments, inadequate pre-use checks, overdue maintenance, incorrect sling selection, insufficient staff training and failures to follow manufacturers' instructions.
New requirements for providers
The MHRA said organisations must complete five actions within the next 12 months, including introducing standardised pre-use checks, reviewing the compatibility of all hoist and sling combinations, maintaining comprehensive equipment inventories, ensuring compliance with servicing and inspection requirements, and providing role-appropriate staff training.
It said a key requirement is a new ‘pause-and-check’ step before a patient is fully lifted, which requires staff to stop once the sling is taut and the person's weight is partially supported to confirm that all attachment points are secure before proceeding with the transfer.
The regulator also said any hoist or sling found to have missing, worn, damaged or incorrectly assembled components should be immediately removed from service and clearly marked ‘Do Not Use’.
Long-standing safety issue
The MHRA said investigations into fatal incidents frequently identified the same contributory factors highlighted in previous national safety warnings issued in 2014 and 2015, suggesting that existing guidance has not been implemented consistently across all settings.
The alert states that implementation should be coordinated by a senior accountable leader, such as a registered manager in care settings without executive boards. It also reminds providers that lifting equipment must be examined at intervals not exceeding six months under the Lifting Operations and Lifting Equipment Regulations.
The safety alert was developed with input from organisations including NHS England, the Care Quality Commission and Care England.
