A string of failures, including a lack of training with the equipment, not reviewing the patient’s care plan and staff having an ‘inconsistent understanding’ of how to work the seat belt on the hoist, were laid out by Health and Safety inspector Kirstyne O’Brien at an inquest on Wednesday.
The woman suffered serious injuries after falling out of the hoist and died four days later in March 2016.
Earlier this year, the States Employment Board, which is responsible for employing all States staff, pleaded guilty to one count of contravening the health and safety law and was fined £50,000 and ordered to pay £10,000 in prosecution costs.
During the inquest, the woman’s daughters praised the treatment their mother received while at St Saviour’s Hospital, adding they did not wish to blame the two healthcare assistants.
In a statement the daughters said: ‘We are relieved to have finally arrived at an inquest of our mother’s tragic accident. We wish to state that throughout the time, we have maintained our support for the staff at Oak Ward. We view the accident as exactly that.’
However, the statement added that the family had been left frustrated by the lack of information and support they received from the Health Department during the 20-month process and that their primary concern was to ensure that similar incidents would not happen again.
The inquest heard that the woman was being helped out of the bath by two experienced healthcare assistants when her entire body suddenly became entirely ‘rigid’ and ‘stiff’ and she became unresponsive.
One of the healthcare assistants attempted to lower the hoist and apply the brakes as quickly as possible while holding the woman in place, as the seat belt had not been properly fastened. However, the patient ‘dived’ out of the hoist, hitting her head on the bathroom floor.
Statements from both healthcare assistants were also read out. They said they could not have predicted that the woman would suddenly become stiff and that they had ‘never seen anything like that before’.
Rachel McBride, acting head of Older People’s Services in the Health Department, confirmed that as part of the improved safety measures all Ambulift hoists had been replaced and that additional training had taken place.
Relief Coroner Advocate Cyril Whelan said the woman had died of bronchopneumonia due to immobility caused by her head injuries four days after falling from the bath hoist.
Speaking after the inquest Susan Devlin, managing director for Community and Social Services, said: ‘On behalf of the Health Department, I would like to say how deeply sorry we are for the failings in the care of the woman, and to express our sincere condolences to her family for their loss, and the distress that will have followed.
‘The department has conducted a thorough investigation, and a series of measures has been put in place to address the matters that have been raised and to emphasise the paramount importance of patient safety.
‘I hope that the actions taken by the Health Department will provide some small comfort to members of the woman’s family, but appreciate it will not alter the distress that they suffered. Our thoughts are with them as they continue to deal with their sad loss.’
