Fatal Injury when Patient Falls from Hoist
Monday, 1st December 2008
December 2008 saw an NHS trust fined £20,000 and ordered to pay costs of £17,500 byt the Heath & Safety Executive (HSE) when a ninety year old patient fell from a sling a died at the scene.
The incident occurred in March 2006 at Moseley Hall Hospital which is part of South Birmingham Primary Care Trust. The trust pleaded guilty at Birmingham Crown Court to breaching section 3(1) of the Health & Safety at Work etc Act 1974.
Alice Belle was being trasferred from a commode to her bed using an all purpose hoist and a large sling. The investigation found that neither the hoist or sling were defective, but that Mrs Belle had slipped from the sling becasue it was unsuitable for her. At the time of the accident two nursing assistances were in attendance.
Amanda James, the invesitgating officer from the HSE said "Alice Belle was a frail and vulnerable 90-year-old for whom the sling, used at the tiem of the accident, was unsuitable. The moving and handlign risk assessment in place at the time did not specify which sling should be used for the patient. A suitable risk assessment, carried out by competent staff, would have identified and recorded the appropriate type and size of sling and this should then have been communicated to all staff involved in moving and handling the patient.
"South Birmingham Primary Care Trust failed in its duty, exposing the patient to grave risk. It is essential to ensure that all equipment, inclduing hoists and slings, is appropriate for the individual being moved and handled. It is also vital that professional carers and nursing staff receive adequate information, instruction and training in the correct selection and safe use of that equipment."
Adam Farrer, persecuting, said that no system was in place at the time for allocating slings to patients and it had been left to the nurses in Mrs Belle's case to make their judgement.
Bernard Thorogood, defending, admitted that what had happened had been an 'oversight' and that since this accident, new health and safety structures had been put in place.
In his summing up, Judge William Davis QC, said it had not been possible to establish the exact cause of death, but that the Trust had accepted that grave mistakes had been made. "Those who are most vulnerable, as Alice Belle was, need the most careful care. It is accepted by the Primary Care Trust that they did not give proper care to her and that they did not detail the proper type of sling to be used which allowed inexperienced staff to make a mistake."