Coroner recommendations following mobility hoist death

January 10, 2023 8:35 pm in by

 tas coroner 100123

Aged care and other facilities are being reminded to regularly service their equipment — following the 2019 death of a woman who fell from a mobility hoist.

83 year-old Janet Oates, a resident of Respect Aged Care St Ann’s in Hobart, died in July 2019, the day after she sustained injuries from the fall.

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The hoist had been used on two other patients that day with no issues, however it failed when lifting Mrs Oates, who suffered vertebral fractures.

Paul Coppleman, of Medical and Disability Equipment Services Tasmania examined the equipment and found that the lower nut and bolt on the hoist were worn and in need of replacement. 

Coroner Olivia McTaggart noted in her report that Mr Coppleman beleived the cause of the incident “was the loose nut causing detachment of the spreader bar section which held Mrs Oates in her sling. He was of the view that the nut and bolt under the scale unit had not been checked or properly maintained.”

Upon further investigation, the coroner found that the hoist had last been serviced 13 months before the incident, and has made two recommendations to facilities: that those using mobility hoists review their maintenance schedules to ensure that they are serviced at intervals which are appropriate to detect and prevent failure of the components; and that technicians responsible for servicing mobility hoists use thread locking adhesive (such as Loctite) and/or split pins to provide additional security to critical, load-bearing nuts and bolts.