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Research and Account Essay Two carers were moving a service user from a bed to a chair using a hoist. they placed the hoist sling underneath the service user and then attached it to the hoist. Whilst the hoist was stationary one carer turned away to pick up the service users slippers and as a result the service user fell forward to the ground. The service user suffered wounds on their scalp and bruising to their head. The service user was taken to hospital but passed away 10 days later. It was found that the sling loop fixings were wrongly adjusted and a safety pommel was not used. In this report the carers were lacking in training and guidance to use the hoist from the company they worked for. One carer was not focused on the task of the service user being in hoist as she took on another task to get the slippers which meant she wasnt aware of what the service user was doing. If the correct equipment was used and adjusted properly then that would have prevented the fall and death of this service user. When assisting a service user with a task whether it be small or large we always need to carry out the task using the correct equipment, and the correct members of staff to be present. Also our full attention should be on the task at all times and aware of what the service user is doing and what is happening around them. if not doing so then this could result in the service user falling or being injured and equipment could be damaged. Carers should always carry out a visual check of the equipment prior to using and if a problem arises should not be used and reported to the relevant person. Report 2 Michael Shorthouse suffered from Downs Syndrome, learning difficulties and dementia. He moved into Cedars Care Home in May 2007 but, despite hes families pleas over hes treatment, within five months his health had deteriorated so much he had to be admitted to hospital. Whilst in hospital doctors found that he was seriously dehydrated, had developed acute kidney problems and pressure sores, and had aspiration pneumonia, which is an inflammation of the lungs caused by breathing in foreign material like food or liquids. Michael Shorthouses condition improved once he had been transferred to hospital and then moved into a different nursing home, but later died in 2010. Cedars Care Home was reported to Social Services and the Safeguarding Adults Office (SAO) which investigated and found that there had been overall neglect in the care given to Michael. Two years after Michael was admitted to hospital, the care home hadnt improved and was given a zero-star rating in a Care Quality Commission inspection.