Why is moving and handling a particular risk in rehabilitation?
Rehabilitation involves asking people to do things that carry some risk: standing for the first time after surgery, walking with a new aid, transferring to a chair or practising stairs. Some risk is necessary, because removing it all would stop rehabilitation. The aim is to understand the risk and manage it.
Moving and handling is a significant cause of back and shoulder injuries among healthcare staff. Patients can be harmed too, through falls during transfers, skin tears, joint injuries and misuse of hoists and slings. Many incidents share the same features: an out-of-date assessment, the wrong equipment, or a task attempted with too few staff.
Promoting independence and keeping people safe are not in conflict when risk is properly assessed. A clear, documented assessment lets you take reasonable therapeutic risks, such as walking with one assistant, with controls in place, such as a chair close by and a second person available.
What does the law say about manual handling in healthcare?
Moving and handling in UK health and care settings is governed by health and safety law. Employers and employees both have duties.
| Law | Key requirement |
|---|---|
| Health and Safety at Work etc. Act 1974 | Employers must protect the health and safety of employees and others so far as reasonably practicable; employees must take reasonable care and cooperate |
| Management of Health and Safety at Work Regulations 1999 | Suitable and sufficient risk assessments, training and information |
| Manual Handling Operations Regulations 1992 | Avoid hazardous manual handling so far as reasonably practicable, assess what cannot be avoided, and reduce the risk; employees must use the safe systems provided |
| Lifting Operations and Lifting Equipment Regulations 1998 (LOLER) | Lifting equipment such as hoists and slings must be suitable, used by competent people and thoroughly examined; equipment for lifting people is usually examined at least every six months |
| Provision and Use of Work Equipment Regulations 1998 (PUWER) | Equipment must be suitable, maintained and used only by trained people |
The law sits alongside patients' rights. People can make decisions about how they are moved, including declining a hoist, and the Mental Capacity Act 2005 applies in England and Wales where someone may lack capacity for that decision. Blanket rules applied without individual assessment can harm dignity and independence. If you are unsure how the law applies to a specific task, speak to your manager or moving and handling adviser and check current HSE guidance.
How do you use TILEO for a moving and handling risk assessment?
HSE guidance groups the factors to consider into Task, Individual, Load and Environment, often extended to TILEO with Other factors. In patient handling, the 'load' is the patient.
| Factor | Questions to ask |
|---|---|
| Task | What exactly are we doing? Does it involve twisting, stooping, reaching, sustained holding or sudden movement? Is it therapeutic or a functional transfer? |
| Individual (staff) | How many staff are needed and available? Are they trained in this technique and equipment? Does anyone have an injury, health condition or pregnancy that affects what they can do? |
| Load (patient) | Weight, height and shape; how much they can help; cognition, communication, pain, fatigue and alertness today; lines, drains, catheters or oxygen; weight-bearing restrictions, wounds or fragile skin; observations |
| Environment | Space, floor, lighting, bed or plinth height, temperature, equipment within reach |
| Other | Right equipment available, checked and in date for examination; correct sling; suitable clothing and footwear; time pressure or interruptions |
Ali, aged 68, is five days after a stroke with right-sided weakness and expressive aphasia. Yesterday's plan says 'sit to stand with two staff and a standing frame'. Before the session, Nadia, his physiotherapist, runs through TILEO. The nurse reports Ali was drowsy overnight and his blood pressure is lower than usual; he is harder to rouse than yesterday. Nadia decides not to stand him. She escalates the change to the nursing and medical team, since it may signal infection, low blood pressure or an extension of the stroke, does a bed-based session instead, and documents her reasoning. This is not a failed session. It is safe clinical reasoning.
What does safe practice look like during a session?
- Check before you start: Read the handling plan and recent notes, check with the nurse in charge, review observations, pain and alertness, and explain the plan to the patient and gain consent.
- Prepare the space and equipment: Clear the area, set the bed height, apply brakes, position the chair, check equipment is clean, working and in date, and secure catheters, drains and lines.
- Agree roles and commands: Decide who leads and the commands you will use, such as 'ready, steady, stand', and what everyone will do if the patient becomes unwell or starts to fall.
- Let the patient do as much as they safely can: Give clear instructions and time. Guide rather than lift.
- Monitor throughout: Watch for fatigue, pain, dizziness, breathlessness or colour change. Stop and return the patient to a safe position if they become unwell.
- Document and update the plan: Record what you did, the help needed and equipment used, and update the handling plan the same day so the next person has accurate information.
Some techniques are widely regarded as unsafe because they can injure the patient's shoulders and skin and the handler's back. The best known is the drag lift, where staff lift by hooking their hands or arms under the patient's armpits. Lifting a patient's whole body weight manually is another. Use slide sheets, transfer boards, standing aids and hoists, and follow your organisation's approved techniques.
Transferred bed to chair with assist. Tolerated well.
Obs checked with nursing staff, stable. Patient alert and consenting. Bed to chair via transfer board, therapist leading with one therapy assistant. Patient shuffled along board with verbal prompts and minimal help at the pelvis. Mild right knee pain during transfer, settled at rest; no dizziness. Handling plan updated: transfer board with two staff remains appropriate. Aim to progress to one staff if pain settles.
How do you check a hoist and sling before use?
Hoists greatly reduce manual lifting, but they cause serious harm when used incorrectly. In September 2026 the MHRA issued a National Patient Safety Alert on patient hoists and slings (NatPSA/2026/005/MHRA). It reported continuing deaths and serious injuries from falls out of hoists and slings, linked to detached or damaged attachment points, incompatible hoist and sling combinations, wrong sling size or type, missed pre-use checks, overdue examinations and gaps in training. It asks organisations to introduce standardised pre-use checks, keep a register of compatible combinations, track all hoists and slings, remove overdue or defective equipment, and train staff, with completion by September 2027. Check how your organisation is implementing it.
- Use the sling type and size assessed and recorded for this patient.
- Check the hoist and sling for wear, fraying, damaged stitching or missing labels, and confirm both are within their examination date.
- Confirm the hoist and sling are a compatible combination under your local register or manufacturer's instructions.
- Check the patient's weight against the safe working load.
- Attach the sling exactly as instructed, with the correct loop configuration, and check every attachment point together.
- Take up the load slightly and pause to confirm the patient is secure and comfortable before lifting fully.
- Use the number of staff in the handling plan and never leave a patient suspended unattended.
What should you do if a patient starts to fall?
Trying to hold a falling patient's full weight puts both of you at risk of serious injury. If a patient starts to fall during a transfer or walk, the safer approach is usually to guide them towards the bed, a chair or the floor in a controlled way, protecting their head where you can, rather than trying to stop the fall. Follow the technique taught in your organisation's training.
Once the patient is on the floor, do not get them up straight away. Follow your post-fall protocol: check for head injury, spinal injury and fractures, take observations, use a lifting cushion or hoist rather than lifting by hand, arrange medical review, document and report.
Zainab, a physiotherapist on an orthopaedic ward, sees a 79-year-old woman two days after hip fracture repair whose plan says 'stand and pivot with two staff and a frame'. The ward is short-staffed and the therapy assistant has been called away. The patient is keen to sit out, so Zainab tries alone. The patient becomes dizzy, her knees buckle, and Zainab tries to hold her but cannot. The patient slides to the floor with a bruised forearm, and Zainab injures her back. In her reflection, Zainab names the departure from the plan, recognises that dizziness is common early after hip surgery and she had not checked lying and standing observations, explains why she should have guided rather than held the patient, and acknowledges staffing pressure without using it as a reason. She now checks observations and the plan before every transfer and does not start without the staff the plan requires; her team lead has observed and signed off her practice.
Reporting, reflection and learning more
Report every handling incident and near miss, including staff injuries and faulty equipment. Be open with the patient about what happened. Staff who are injured should seek occupational health advice. If a serious incident leads to involvement from your regulator, seek advice from your trade union, professional body or defence organisation before responding.
Useful habits for CPD and revalidation include auditing a few of your own handling records, asking a colleague to observe a complex transfer, and reflecting on a session you decided to change or postpone and why.
Our course Moving and Handling Safety in Rehabilitation covers the law, TILEO risk assessment, balancing independence with safety, hoist and sling checks, managing a falling patient and reflecting on incidents, with worked examples and a guided reflection. It is written for physiotherapists, occupational therapists, therapy assistants, nurses and others in rehabilitation, and complements, rather than replaces, your organisation's practical moving and handling training.
Frequently asked questions
What does TILEO stand for in manual handling?
TILEO stands for Task, Individual, Load, Environment and Other factors. It comes from HSE guidance on the Manual Handling Operations Regulations 1992. In patient handling, the load is the patient, so you consider their weight, ability to help, cognition, pain, attachments, restrictions and condition on the day, alongside the task, the staff involved, the environment and equipment.
How often do hoists and slings need a LOLER examination?
Under LOLER, equipment used to lift people should normally have a thorough examination by a competent person at least every six months, unless a written examination scheme sets a different interval. Staff should also check hoists and slings before every use. A 2026 MHRA National Patient Safety Alert asks organisations to remove equipment with overdue examinations from use.
Can a physiotherapist refuse to do an unsafe transfer?
Yes. Employees must follow safe systems of work and should not attempt a task they have assessed as unsafe. If the handling plan requires two staff and only one is available, the safer decision is to postpone, explain why to the patient, document it and escalate staffing concerns. Professional standards also expect you to work within your competence.
Is the drag lift ever acceptable?
The drag lift, where staff lift by placing hands or arms under the patient's armpits, is widely regarded as unsafe because it can injure the patient's shoulders and skin and the handler's back. Use alternatives such as slide sheets, transfer boards, standing aids or a hoist, and follow your organisation's approved techniques and training.
What should I do if a patient starts to fall while walking?
Do not try to hold their full weight. Guide them in a controlled way towards a bed, chair or the floor, protecting their head where possible, as taught in your organisation's training. Then follow the post-fall protocol: check for injury before moving them, take observations, use a lifting cushion or hoist, request medical review, document and report.
Can a patient refuse to use a hoist?
A patient with capacity can decline a hoist or particular method of moving. Explore their reasons, explain the risks and alternatives, and look for an approach that is safe for them and for staff. Document the discussion. You are not obliged to use a method that puts staff at unacceptable risk, so involve your manager or moving and handling adviser where needed.
How often should a moving and handling assessment be updated?
Whenever the patient's condition, ability or equipment changes, and in rehabilitation it is good practice to check the plan at the start of every session. An assessment completed on admission and never revisited is a common factor in incidents. Record changes and update the handling plan the same day so the next person has accurate information.
Related courses
Moving and Handling Safety in Rehabilitation
This course teaches you how to plan and carry out moving and handling safely during rehabilitation, balancing the patient's goals and independence…
Maternity Care and Fetal Monitoring Concerns
This course teaches safe fetal monitoring in labour, including intermittent auscultation, structured CTG review and escalation, using UK guidance and…
Paramedic Practice: Assessment and Non-Conveyance Decisions
This course teaches a structured approach to assessment and safe decision-making when a paramedic considers discharging a patient on scene or…
Sources and further reading
- Manual handling: Manual Handling Operations Regulations 1992 (as amended), guidance on regulations (L23). Health and Safety Executive.
- Lifting Operations and Lifting Equipment Regulations 1998. legislation.gov.uk.
- National Patient Safety Alert: patient hoists and slings (NatPSA/2026/005/MHRA). Medicines and Healthcare products Regulatory Agency.
- Guidance on Manual Handling in Physiotherapy (4th edition). Chartered Society of Physiotherapy.
- Standards of conduct, performance and ethics. Health and Care Professions Council.
- Mental Capacity Act 2005. legislation.gov.uk.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
More guides
NEWS2 Explained: How to Score It and When to Escalate
NEWS2 explained: the seven parameters, how to score each one, Scale 1 versus Scale 2, worked examples and what to do at scores of 3 in one, 5 and 7.
Sepsis Signs and the Sepsis Six: A UK Guide for Clinicians
Sepsis signs and the Sepsis Six explained for UK clinicians: recognising sepsis, NICE NG253 risk levels with NEWS2, antibiotic timings and escalation.
Post-Fall Assessment in Hospital: What to Do After a Patient Falls
Post-fall assessment in hospital: checks before moving a patient, head and spinal injury, safe lifting, neuro obs, medical review and documentation.