FORT WORTH, Texas - State investigators say a worn out brake is to blame for an elevator accident that crushed a John Peter Smith Hospital nurse.
Carren Stratford suffered serious and life altering injuries in the January incident at JPS.
The Texas agency that oversees elevator safety found a lack of maintenance on that elevator.
In the wake of this new report, the state Department of Licensing and Regulation put out a statewide alert.
It's a reminder for building owners and elevator contractors to routinely check elevators.
Newly released videos show state inspectors getting their first look at the elevator bank where JPS Hospital nurse Carren Stratford's life was changed forever.
Three days after the incident on January 20, the elevator was still in the spot between the 10th and 11th floors where Stratford was crushed after the hospital says she stepped on the elevator and it continued to rise.
A JPS official recalls what she was told about the rescue.
“They had someone up here pushing the person down and someone downstairs pulling the person out,” the official said.
During the inspection, a mechanic manually moved the elevator.
The state inspection noted that should not have worked, since the brakes should have been set.
Mechanics took apart the brake assembly.
State inspectors found signs of "excessive wear," which "illustrated a lack of routine maintenance and equipment checks." Ultimately determining the incident was caused by "brake failure."
“The state report is another piece of the puzzle we've been looking at and it's really consistent with the evidence we've seen so far as to what caused Ms. Stratford's injuries,” said attorney Frank Branson, who represents Stratford.
Both Branson and JPS Hospital CEO Robert Earley have criticized Thyssen Krupp Elevator, the vendor JPS contracted with to take care of the elevators at the time of the incident.
Thyssen Krupp has shot back, releasing a letter they sent out before the incident warning against JPS employees resetting the elevator.
Several weeks into a war of words between the two, JPS severed ties with Thyssen Krupp in March.
Stratford, meanwhile, is now in a long-term care facility.
Branson says she has permanent brain damage and will need attendant care the rest of her life.
“This is just a terrible tragedy at a public county hospital that should never have occurred,” Branson said.
A spokesman for Thyssen Krupp said they are still reviewing the report.
This state investigation now moves into the enforcement phase, where officials could decide if they'll issue penalties.