Tasmanian aged-care homes have been urged to service their mobility hoists more frequently after an elderly woman died when one malfunctioned.
Two workers were using the hoist to lift Janet Patricia Oates from her bed at a Hobart nursing home in July 2019 when the device failed.
The 83-year-old woman fell a metre to the ground, with her shoulder and neck area striking one of the hoist's legs.
Mrs Oates was conscious as she was taken to hospital, where she was diagnosed as having fractures to her T1 and T4 vertebrae.
She died in hospital the next day as a result of hospital-acquired pneumonia caused by her injuries, coroner Olivia McTaggart found.
In her findings, she said Mrs Oates' two experienced carers checked the hoist and used it on two other patients that morning without any mechanical or operational issues.
They followed correct procedures to lift Mrs Oates from her bed and it was a nut and bolt failure that caused one of the hoist's bars to detach, Ms McTaggart said.
The hoist was inspected by an independent expert, who found the lower bolt and nut under the hoist's scale were worn down.
The hoist was last serviced in May 2018 and was due for its next annual service in May 2019, a month before Mrs Oates' death, but it did not happen.
"If the hoist had been subject to an annual service on or before that date, it is quite feasible that the defects with the crucial nut and bolt would have been apparent and remedied," Ms McTaggart said.
"The failure to have the hoist serviced on or before the due date represented a lost opportunity to have prevented the failure of the hoist and Mrs Oates' death."
The coroner recommended all facilities using mobility hoists review their maintenance schedules to ensure they were serviced more frequently.
Technicians who service mobility hoists should use thread-locking adhesive or split pins to provide additional security to critical nuts and bolts, Ms McTaggart added.