Shirley Ashelford
17 Aug 2023 · Coroner Christopher Williams · Inner South London
The coroner's concerns
1. unassisted operation of ceiling hoist by user
“During the inquest I heard evidence of the following matters: · [the deceased] was an unusual local authority OT service user because she operated her hoist and sling mainly without the assistance of a carer because she wanted to maintain her independence and dignity as much as possible. Because she had mental capacity the OT service respected her wishes.”
2. lack of training on asphyxia risk for users and carers
“Users and carers did not appear to have been made aware of the asphyxia risk associated with hoisting. It was not clear whether [the deceased] was trained in the use of the red cord safety feature on the hoist as there was no documentation to confirm this. Her husband and carer had never received training in the use of the red cord for emergency lowering. He was also unaware of the risks of positional asphyxia when [the deceased] was operating the hoist on her own.”
3. information silo between OT and AMT
“I am concerned that two departments in the local authority, the OT department and AMT, did not share information concerning the condition of the hoist, namely, [the deceased]'s reports to OT were not shared with AMT and visit reports from contractors to AMT were not shared with the OT. Likewise, the Bureau Veritas inspection on 30/6/21 appears to have occurred in an information vacuum regarding recent problems with the hoist. Whilst the Veritas inspection report was shared with the AMT it was not share”
4. potential design fault in hoist lowering mechanism
“There was some evidence that another hoist of the same model in the bathroom had a problem with the lowering function and the possibility of a fault in the design of the lowering function. I raise this concern to alert the MHRA and Prism Medical UK Ltd in order to conduct appropriate safety investigations. The hoists are available in situ for a limited period or otherwise will be kept in storage by the Local Authority for inspection purposes.”
5. inspection without background information
“I am concerned that the Bureau Veritas inspection report of 30/6/21 made no reference the report of Higher Elevation and [the deceased]'s complaint on 9/4/21 indicating that the inspector was unaware of recent problems. Had they been aware they might have been able to detect the problem which caused the failure of the hoist to lower on the 20/7/21.”