Risks to Service users known to self-hoist and transfer using ceiling track hoists

Health and Safety Executive - Safety alert

Department Name:
Field Operations Directorate

Bulletin No:
FOD WSW 2-2010

Issue Date:
3rd February 2010

Target Audience:
Services & Health Services (Social Services / Occupational Therapy Departments)

Key Issues:
Potential risks to service users whom are likely to self-hoist and transfer using ceiling track hoists


The purpose of this Safety Notice is to alert health and social care providers to potential risks to service users whom are likely to self-hoist and transfer without the assistance of a carer(s).

It will be of particular relevance to Social Services Departments, Occupational Therapy Departments, and Health Care Providers involved in the provision of and/or maintenance of community care equipment.

The information will aid those organisations undertake suitable and sufficient risk assessments as part of their purchasing, issuing, commissioning, risk assessment, and service user review processes.


An incident involving the death of a service user has highlighted possible risks to individuals known to self-hoist by means of a ceiling track hoist, without the assistance of a carer.

The ceiling track hoist failed whilst the service user was transferring in the equipment. In addition, the emergency lowering device also failed and the individual had no means to summon assistance.

In this particular incident the service user lived alone and had been provided with a make and model of ceiling track hoist intended for use when a carer was present, thereby enabling someone to summon assistance in the event of an emergency. The service user using the hoist did not have a carer or care provision to assist them with transfers in the hoist.

The issues raised by this notice should also be considered where a service user is living in other accommodation types including warden-assisted and/or supported living environments, and other residential health and social care settings (such as in care homes or residential nursing homes). The issues are of particular relevance where care staff and/or support workers are not in attendance when service users are using hoists independently, or where it is likely a service user may try to self hoist when a carer is not present.

Action required:

Where hoisting equipment is provided by a health or social care provider, including any associated equipment such as slings to be used in combination with a hoist, they must ensure so far as is reasonably practicable that:

  1. They have selected the most appropriate equipment available, relevant to the service user's  individual needs (This may require consideration of purchasing or supplying equipment not normally stocked or provided by a health or social care provider);
  2. They have undertaken a risk assessment to identify any risks to the service user from the selection and use of the equipment, having followed the manufacturers' instructions for use and considered the service user's individual needs. This is to ensure any risks to the service user are identified;
  3. They have eliminated and/or controlled any risks identified from the risk assessment process;
  4. They have followed the manufacturers installation instructions and provided the care staff and/or service user with information, instruction and training in how to use the equipment safely;
  5. Where a service user requests or is provided with equipment for self hoisting without the support of a carer, such as to support their independence:
    1. the risk assessment should identify what would happen if any part of the equipment failed to operate correctly and whether the service user would need assistance to safety. If so, the service user should have means to summon assistance which should be accessible to them in the event of an emergency;
    2. the service user is given appropriate information, instruction and training so that they know how to adequately operate and use the equipment safely (including slings and any other associated equipment where relevant)
  6. Responsibilities for maintenance arrangements are agreed when the equipment is provided. This should clarify:
    1. who owns and maintains the equipment;
    2. that the equipment is identifiable for servicing (such as by attaching a unique identification number to the equipment);
    3. any checks that the user should carry out before using the equipment;
    4. how and when equipment should be serviced and maintained;
    5. suitable access arrangements to private properties;
    6. how matters of concern can be raised by the service user;
    7. how and where all records relating the routine maintenance, inspections and repairs of each hoist, sling(s) or other accessories are to be kept.
  7. Regular reviews or assessments are undertaken to ensure that the service users needs have not changed and that the equipment remains appropriate to their needs; and
  8. Periodic monitoring, auditing and reviewing of the servicing arrangements are undertaken to ensure equipment is being maintained appropriately.


British Standard BS 10535 (2006):

Hoists for the transfer of disabled persons - requirements and test methods.


All hoists shall incorporate an emergency lowering device

 'When a hoist is to be used by a disabled person on their own, it is necessary to ensure that in the event of a failure of the hoist, the disabled person is not left in a potentially dangerous situation. NOTE: This may, for example, take the form of a warning in the instructions for use, the fitting of an alarm system or the supply of a conveniently placed telephone, etc'.

Sub-clause 7.6;

'Instructions for Use' specifies an additional requirement for stationary hoists. It states that:

"when a hoist is to be used by a disabled person living on their own, then some form of communication device shall be installed in the area of use of the hoist so that in the event of an emergency the disabled person is able to summon assistance. NOTE: This may, for example, be the fitting of an alarm system or the supply of a conveniently placed telephone, etc."

Permission to reproduce extracts from British Standard BS 10535 (2006) is granted by BSI. British Standards can be obtained in PDF or hard copy formats from the BSI online shop or by contacting BSI Customer Services for hardcopies only: Tel: +44 (0)20 8996 9001, Email: [email protected].

General note:

Please pass this information to anyone you think may need it.

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