Fatal hoist accident 'inevitable' - coroner

It was inevitable that a hoist involved in a fatal accident when it lifted an elderly woman at a Tauranga rest home would fail, a coroner's report released today has found.

Coroner Wallace Bain released his report into the death of Lillian Wilson, who died after falling from a hoist machine at Tauranga rest home Cedar Manor.

Mrs Wilson died on February 15, 2010 of lobar pneumonia as a complication of severe closed head injury, from the fall.

Mrs Wilson fell to the floor between two metal bars of the hoist and the right side of her head struck one of the bars.

Following the fall, Mrs Wilson was conscious but unresponsive and pale. She could hear people speaking to her and moved her eyes.

In the report, Mr Bain referred to the Department of Labour's findings that at some stage the bolt and screw attachment of the support block on the hoist had been modified.

The bolt had been shortened, resulting in an insufficient holding ability within the thread of the block - creating an insecure connection.

Mr Bain said there was insufficient information to determine when and who modified the nut and bolt, and the adhesive seal on the bolt.

"This is indeed a very sad case and demonstrates the need for high standards in checking medical devices. Patients and families put their whole trust in the health system and the health professionals who are caring for them and operating various medical devices and looking after them."

The court recommended removal of all weighing scales of the hoist's type to be removed from service; immediate removal of any equipment if it fails in use (despite best efforts); and more frequent basic checks to be made by a designated person based at Cedar Manor.

"This type of check would most likely have captured this problem before it had such tragic results," Mr Bain said.