MHRA Issues National Patient Safety Alert on Patient Hoists and Slings: Falls Cause an Average of Two Deaths per Year, Remediation Deadline September 2027

MHRA National Patient Safety Alert: Patient Hoists and Slings (All Types)

Published: 3 October 2026, 09:32 | Category: Recalls and Safety Notices

On 16 September 2026, the UK Medicines and Healthcare products Regulatory Agency (MHRA) issued National Patient Safety Alert NatPSA/2026/005/MHRA concerning the risk of death and serious harm from falls involving patient hoists and slings (all types) during transfer and repositioning. The alert requires all organizations responsible for the use, procurement and maintenance of hoists and slings to complete five remediation actions by 16 September 2027.

Scope

The alert applies specifically to acute and community healthcare providers, nursing homes, care homes, residential care settings, care providers delivering services in patients' homes, and suppliers providing equipment to these organizations. MHRA explicitly states that the issue is not limited to any manufacturer, model or care setting. It therefore should not be understood simply as a defect in a particular batch or brand of device. This is a safety-critical and complex National Patient Safety Alert, and implementation should be led by a senior responsible officer or person with equivalent responsibility within the organization.

Problem Identified by the Authority

The alert states that deaths and serious injuries caused by patients falling from hoists or slings continue to occur. A review of recent fatal incidents and broader surveillance data indicates an average of approximately two deaths per year since 2015. MHRA provides more detailed figures: between 1 January 2015 and 31 December 2025, 22 reports of fatal incidents during patient transfers were received, occurring in acute hospitals, nursing homes and patients' own homes.

Common Causes Listed

The authority lists the following common causes:

• Failure of load-bearing critical interfaces, such as hoist arm hooks, clips, latches or fasteners that are missing, worn, damaged or incorrectly assembled.
• Incompatibility between hoist and sling combinations, including the use of third-party slings not validated for the specific hoist.
• Failure to identify damaged sling loops or sling loops that are not correctly positioned, or incorrect attachment positions.
• Failure to perform effective pre-use checks.
• Inadequate or overdue maintenance, servicing and inspection, including continued use beyond the indicated service life without a risk assessment.
• Incorrect sling size or type.
• Insufficient staff training and competency assessment.
• Failure to follow the manufacturer's instructions for use (IFU).

Five Required Actions

The alert sets out five actions to be completed by 16 September 2027:

• First: Establish and implement standardized pre-use checks consistent with the manufacturer's IFU. For loop sling attachments, require a pause after initial weight bearing and before the patient is fully lifted off the bed to confirm that all attachment points are secure.
• Second: Review and document the compatibility of all hoist and sling combinations used by the organization. Where compatibility cannot be confirmed through the IFU, exceptions must be supported by a risk assessment completed by a qualified person and retained technical evidence. Maintain an accessible list of approved combinations.
• Third: Review the medical device management system or inventory to ensure that all hoists and slings, including those used in community settings, are registered and included in maintenance, LOLER inspection and replacement plans.
• Fourth: Ensure maintenance, servicing and inspection are performed in accordance with LOLER and the manufacturer's IFU. Equipment with overdue inspections or unresolved defects must be taken out of service.
• Fifth: Ensure that personnel receive training appropriate to their role and periodic refresher training.

Inspection Frequency and Inventory Requirements

Regarding inspection frequency, the alert states that LOLER requires thorough examination by a competent person at intervals not exceeding six months. Pre-use checks cannot replace a systematic maintenance program and statutory inspections. If maintenance is outsourced, the organization must still oversee that it is performed according to plan.

The inventory should include, at a minimum: manufacturer, brand and model, batch number, storage location, last servicing date, end-of-service-life date, last LOLER inspection date, and next servicing and inspection due dates.

Training, Reporting and Historical Background

The training section requires coverage of the types of hoists and slings in use, correct attachment and fitting methods, recognition of unsafe conditions, when to stop and escalate, and reporting of incidents and near misses through local reporting pathways and the MHRA Yellow Card system. Training should also address the safe handling and transportation of hoists, particularly in multi-storey buildings.

The alert also refers to Medical Device Alert MDA/2014/054 from 2014 and Patient Safety Alert NHS/PSA/W/2015/010 from 2015, noting that existing guidance has not been reliably implemented. This is one reason why similar incidents continue to recur.

Sources and Applicability

Source: UK Medicines and Healthcare products Regulatory Agency (MHRA), National Patient Safety Alert: Patient hoists and slings (all types): risk of death and serious harm from falls (NatPSA/2026/005/MHRA), published 16 September 2026, https://www.gov.uk/drug-device-alerts/national-patient-safety-alert-patient-hoists-and-slings-all-types-risk-of-death-and-serious-harm-from-falls-natpsa-slash-2026-slash-005-slash-mhra ; supporting information page https://www.gov.uk/government/publications/national-patient-safety-alert-supporting-information-patient-hoists-and-slings-incidents-and-case-examples ; MHRA Managing Medical Devices guidance https://www.gov.uk/government/publications/managing-medical-devices .

Verification scope and access date: This article verified the GOV.UK alert text, supporting information page and related guidance page listed above. Access date: 3 October 2026.

Applicability note: This article is an interpretation of publicly available regulatory information and does not constitute a conclusion or commitment regarding any specific product, company or registration application. The alert is not a recall or a defect determination. Specific requirements are subject to the official original text, and information may change with subsequent official updates.

Information Sources

• Medicines and Healthcare products Regulatory Agency (MHRA) - GOV.UK National Patient Safety Alert, 2026-09-16.
• Medicines and Healthcare products Regulatory Agency (MHRA) - GOV.UK supporting information.
• Medicines and Healthcare products Regulatory Agency (MHRA) - Managing Medical Devices guidance.

AIMEILI Regulatory Interpretation and Business Impact

Regulatory interpretation

NatPSA/2026/005/MHRA is a national patient safety alert rather than a product recall or a finding of non-compliance against a specific manufacturer. Its regulatory significance lies in the system-level expectations it places on healthcare providers and, indirectly, on the supply chain. For manufacturers, the alert reinforces that instructions for use, compatibility information, pre-use check instructions, maintenance intervals, service-life limits and training materials are not merely commercial documents; they are core components of safe device use and post-market risk control. MHRA's statement that the problem is not limited to any manufacturer, model or care setting indicates that the issue is primarily associated with use, compatibility, maintenance and training, while still requiring manufacturers to ensure their technical documentation and labeling support correct use.

For regulatory affairs teams, the alert should be considered in the context of UK medical device vigilance, post-market surveillance, risk management and quality management system obligations. Incidents and near misses reported through the Yellow Card system may feed into broader trend analysis. Manufacturers should be prepared to demonstrate that residual risks from falls during patient transfer have been evaluated, that IFU warnings and cautions are adequate, and that any known compatibility limitations are clearly communicated. Distributors and suppliers should be able to trace affected hoists and slings by manufacturer, model and batch, and should not promote combinations that have not been validated by the manufacturer or supported by a documented risk assessment.

Business impact

• Manufacturers: Expect increased scrutiny of IFU clarity, sling-hoist compatibility matrices, labeling, service-life statements, pre-use check instructions and training content. Post-market surveillance and complaint handling systems should be able to identify fall-related events and near misses by device combination, batch and care setting.
• Distributors and equipment suppliers: Healthcare customers may request documented compatibility evidence, LOLER and maintenance records, traceability data and confirmation that supplied configurations are approved. Sales and technical support teams may need to update product selection tools and training materials.
• CROs and regulatory consultants: UK-focused projects may require updated gap assessments, vigilance reporting procedures, PMS plans and risk management documentation. Supporting clients with UKCA compliance, MHRA registration or post-market obligations should include checking whether hoist and sling combinations are within the intended use and whether IFU content is sufficient.
• Healthcare providers and care homes: The five actions by 16 September 2027 require budget, staff time, inventory review, competency assessment and governance oversight. Providers should prioritize registration of all hoists and slings, compatibility verification, overdue LOLER inspections, removal from service of defective equipment, and documented training.
• Regulatory affairs teams: The alert is a reminder to align technical files, risk files, labeling and post-market documentation with real-world use scenarios. Where a manufacturer identifies a compatibility, maintenance or training gap, corrective and preventive action may be needed even in the absence of a formal recall.

Recommended next steps

• Map all hoist and sling combinations placed on the UK market and confirm that each combination is supported by the manufacturer's IFU or a documented risk assessment.
• Review IFU, labels, quick-start guides and training materials for clear pre-use check and loop-attachment verification instructions.
• Confirm that maintenance, LOLER inspection, service-life and replacement information is available to providers and distributors in accessible formats.
• Check vigilance, complaint and post-market surveillance procedures for capture of fall-related incidents and near misses involving hoists and slings.
• Prepare a documented response for customers and regulators explaining how compatibility, traceability, training and maintenance requirements are addressed.

Return to News

Return to news and regulatory updates.