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December 4, 2008

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Elderly patient died in fall from unsuitable hospital sling

South Birmingham Primary Care Trust has been fined £20,000 and told to pay £17,500 in partial costs over the death of an elderly patient who fell while being lifted into bed by a sling that was too big.

Birmingham Crown Court handed down the fine on 1 December after hearing how Alice Belle, 90, died in the city’s Moseley Hall Hospital.

Amanda James, the HSE inspector who investigated the case, described how the vulnerable elderly woman had been in the care of the hospital for some months on a rehabilitation ward, and was totally dependent on the hospital for all her moving and handling needs.

On 25 March 2006, the patient was being hoisted by two carers from a commode to her bed using a large sling and battery-operated lifting hoist, when she slipped through the aperture in the sling. She struck her head on the floor and died at the scene. No system had been in place for the correct choice of sling, which was left to inexperienced nursing staff, the court heard.

The Trust pleaded guilty to contravening s3(1) of HSWA by not ensuring the safety of non-employees. It said in mitigation that it had a good health and safety structure in place, although it agreed it had made an oversight in not having an adequate safe system of work for recording and specifying the size of slings in its moving and handling risk assessments. It has now rectified this shortcoming.

Judge William Davis QC said had the plaintiff been a private company and not a PCT, he would have imposed a higher fine. He added in summing up: “Those who are the most vulnerable need the most careful care.”

In September 2007, the coroner recorded a verdict of ‘accidental death to which neglect contributed’.

Inspector James explained that a suitable risk assessment, carried out by competent staff, would have identified and recorded the appropriate type and size of sling . “This should then have been communicated to all staff involved in moving and handling the patient,” she said.

She concluded: “South Birmingham PCT failed in its duty by exposing the patient to grave risk. It is essential to ensure that all equipment, including hoists and slings, is appropriate for the individual being moved or 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.”

There were 92 incidences of falls to patients or service users involving a hoist or sling in the three years from April 2004 to April 2007.


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In this episode  of the Safety & Health Podcast, ‘Burnout, stress and being human’, Heather Beach is joined by Stacy Thomson to discuss burnout, perfectionism and how to deal with burnout as an individual, as management and as an organisation.

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