Anderson, Stanley Charles

Contributing factors

• incorrect sling configuration used for patient with catheter
• lack of professional (physiotherapy/occupational therapy) input into sling selection
• inadequate training on sling adjustment and configuration options
• no guidelines for determining appropriate sling configuration based on patient factors
• no systematic review of sling fit as patient became frailer and lost weight
• patient instability in hammock-style sling during transfer
• lack of clear protocols for near-miss reporting and manufacturer feedback

Coroner's recommendations

1. Review and strengthen the training program for use of hoists and slings, with particular emphasis on how incidents such as this can occur
2. Establish clear guidelines on how straps should be adjusted to maximize patient stability, rather than the informal approach of 'we just talk about it'
3. Develop clear guidelines specifying which sling configuration should be used in different patient situations, particularly considering factors such as catheter use, skin integrity, and patient rigidity
4. Ensure professional (physiotherapy or occupational therapy) input is involved in the selection of slings for each patient, rather than selection by unqualified health assistants
5. Implement a system to regularly review sling fit as patients' health deteriorates and weight decreases
6. Establish a system to review incidents and near-misses, and liaise with sling manufacturers regarding possible design improvements
7. Ensure all staff understand the importance of reporting near-misses to enable risk management and manufacturer feedback