Finding into death of Catherine Mary Reid

80y · Female·multiple injuries in the setting of a fall

Catherine Mary Reid, aged 80, died from multiple fractures sustained in a fall during a mechanical hoist transfer at a disability care facility. While being transferred from wheelchair to bed using an overhead ceiling hoist with a four-point sling, the sling became incorrectly positioned on the spreader bar. When the hoist resumed after freeing the sling from the wheelchair, the worker supporting Mary fell, causing her to sustain fractures to her neck of humerus, femoral neck (bilateral), and sacral insufficiency fractures. She was hospitalised but gradually declined and died 15 days later. The coroner found no breach of occupational health and safety legislation. Key clinical lessons include the importance of rechecking all sling connections after any interruption to transfers, minimising transfer distances, and using equipment with secure locking mechanisms rather than hooks.