State inspectors found a lack of routine maintenance and equipment checks led to a brake failure on the elevator that crushed a nurse at John Peter Smith Hospital in January, according to a report released Wednesday.
As nurse Carren Stratford tried to step onto elevator No. 29, the unit’s brake shoes didn’t set properly as the elevator attempted to come to halt on the 10th floor. Both the left and right brakes were worn out and had frozen pins, according to report, whose findings were first announced by JPS on Twitter.
The findings also prompted the Texas Department of Licensing and Regulation to issue a statewide warning to building owners and elevator contractors urging better elevator maintenance.
“Routine maintenance is critical to the safe and reliable operation of elevators,” Brian E. Francis, executive director of the licensing department, said in a statement.
JPS in March cut ties with its elevator contractor, Thyssenkrupp, and in April started a contract with Southwest Elevators Inc.
Asked if the findings proved JPS was not at fault for the elevator’s failure, a spokeswoman for the hospital declined to comment.
A spokesman for Thyssenkrupp said the company had not received the report and couldn’t comment.
Stratford’s attorney has previously said that they were conducting their own investigation before they considered filing civil lawsuits. Stratford suffered severe brain damage, internal injuries and has had multiple seizures and surgeries, her attorney said.
The elevators at JPS have been plagued with problems for several years, according to documents obtained by the Star-Telegram through an open records request.
A review of records found that people had been trapped in elevator No. 29 at least 13 times between March 2018 and January 2019. In all of 2018, the hospital averaged a work order a day involving its 47 elevators.
In most of the cases, work orders say that the elevator was “reset.”
Thyssenkrupp sent hospital officials a cease-and-desist letter on Jan. 11, telling them to stop resetting the elevators themselves.
Additionally, hospital officials knew in 2017 that the elevator that crushed Sratford needed upgrades, according to a report reviewed by the Star-Telegram. Lerch Bates, a consulting company that reviewed the hospital’s elevators, said that elevator No. 29 needed a “full scope modernization,” which would have included replacing the elevator’s control system and hydraulic power unit.
Instead, the hospital requested bids for work on two other elevators. Officials said those elevators were used more than elevator No. 29.
According to the Department of Licensing and Regulation, the No. 29 elevator used drum brakes, a less-modern system than disc brakes.