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16th December 2011

Incidents and accidents

There is one thing for sure in the care sector – things will not go to plan, and the unexpected will happen. The author’s own unofficial company motto was a variation of Murphy’s Law specific to the care sector; “If it can go wrong it will, and it will go wrong at the most inconvenient time”. The consequence of this hard and fast rule is that things in a care service will go wrong when the registered manager is not on the premises to take immediate control. That fact is not surprising given that care services often operate 168 hours a week, a manager works 40 hours a week (if they are lucky), leaving 128 hours not under their direct supervision. In addition, given the low economic rates paid to many care services, there is often an underdevelopment of middle management due to cost restraints. This dynamic places a great strain on the system when something goes wrong, because day to day operational staff have to make decisions which they may not have been fully prepared for.

Take for example an incident.  The manager of a care home for the elderly is woken at 5.15 am by a phone call from the home, and hears the message that William has had an accident in the lift, and something about a call bell.  On hearing the triple whammy of “resident”, “accident” and “lift”, the manager jumps out of bed, quickly dresses and drives the handful of miles to the home.  The manager is also concerned that the call bell was mentioned, as they have been having maintenance problems with some call bells, and had only that week ordered a replacement system, to be installed the following week. She arrives at the home as an ambulance is opening its doors, and staff are admitting the paramedics.  Quick questioning establishes that William has amputated the end of one of his fingers.  The paramedics quickly dress the freely bleeding wound, and take William off to Accident and Emergency.

The time is now about 5.45 am, and the manager takes report from the three night staff on the premises.  William occupies a 2nd floor bedroom.  He is a long standing resident, well used to the home and his surroundings, but with developing dementia.  The dementia has in the past not been too much of a management problem, but it is episodic in its intensity.  Williams was in the habit of getting himself up early in the morning and coming downstairs to have a cup of tea with the night staff as they prepared breakfast and early morning tea.  The staff report that William’s call bell was triggered just after 5 am, and that one of the staff went to the room, to find William sitting on his bed, very agitated, holding one hand in the other and blood dripping down his arm.  The staff member set the call bell to emergency call, and was joined by the other 2 staff while she was unwinding William’s hands to see what the problem was.  They were shocked to find that half of one of his fingers was missing.  They quickly emergency dress the wound, while one rang first of all the ambulance service, then the manager.  While dressing the wound, the staff found the severed finger in the corridor a couple of metres from the bedroom door, on the way to the lift.  The rest was as the manager found it.

Of immediate concern in terms of overall safety was the fact that William had said that he had trapped his hand in the lift door, and it is that which had severed his finger, and that “the lift hasn’t been working for weeks”.  Warning bells immediately flashed in the manager’s head, fearing a dreaded lift accident scenario, with all its possible consequences.  However, being an experienced professional, she knew immediately that the key was to investigate and establish the facts, and gather evidence.  Any consequent problems for the management and Provider would be best served by knowing all the facts, as far as possible, as early as possible. She knew that accidents, and the unexpected, happen, but that the worst sin in response was not to be in possession of as many of the facts as possible, and to be caught out later by something that someone else had established.

The facts in addition to those already stated are that; staff reported that the bedroom door and the door frame had a large splash of blood about half way up.  The hall carpet was red and patterned; therefore it was not possible to see any blood on the floor.  The lift appeared to be working; in fact the ambulance staff had used it to move William downstairs.  There had been no sign of blood on the lift concertina doors, or the outer door.  The initial conclusion was that William had caught his hand in the bedroom door, severed his finger there, had made his way to the lift, by which time the pain had overcome the shock and he realised something was wrong.  He then appeared to have made his way back to the bedroom and made the call.

At about 7.30 the provider’s representative was called and informed, followed by a call to William’s family.  At 9 am calls were made to the lift engineers for an emergency attendance, to the CQC inspector attached to the home, the Health and Safety Executive, and the insurers. By 9.30 the engineer was on site, checking the initial findings.  He could find nothing amiss with the lift doors, and confirmed that he had last attended for a routine check less than 4 weeks prior, and there were no records of problems since.  He stated that in his opinion, nothing in the door setup could have cause a finger to be severed.  Edges were rounded, and the only force that could be exerted was the force used by the lift user - there was no leveraged force multiplier available.  The engineer was happy to make a written report to that effect.  The initial findings therefore seemed to be confirmed by his opinion.  Shortly afterwards the information was reviewed, and the provider involved.  On establishing that the balance of probability was that the accident had happened at the bedroom door, and not the lift, reports began to be written up, and referral was made to the general maintenance engineer to check the door and its closer to establish if the design or operation of either could have contributed to the accident, and also whether any modifications could avoid a similar situation.  The provider asked the manager to include photographs of the relevant areas, particularly the blood splashes on the bedroom door, and the lack of blood on the lift, as they were key evidence to support the conclusions.  The manager replied that by the time she had attended the home, the night staff had cleaned the blood off the bedroom door, leaving only a smear behind, therefore meaningful photographs were not possible.

Later that day, when William had returned from hospital, he was unable to remember what had happened, and was no longer so firm in his accusation that the lift was responsible.  The manager and provider reviewed the incident and the actions around it, and came to the conclusion that it had been handled well, except for the cleaning of the blood before the investigation was complete and photographs taken.  Both realised that simple act meant that they would not be able to produce a definitive report, and would have to rely on testimony without physical backup, not an ideal outcome.  Both also realised that this problem was caused by a widespread factor seen in many care situations.  Staff, with the best intentions, handle situations on the basis of dealing with the problem, rather than dealing with the problem and maintaining a record of what has happened in order to assist examination of the facts in the future, and providing clues as to what caused the incident.  The same attitude permeates many aspects of care; there is a tendency to just get on with it and not keep contemporaneous records.  This works, sort of, when everything goes well, but is totally inadequate when Murphy’s Law strikes.  In addition to assisting in defence against accusations of wrongdoing, which is many people’s assumption why records are needed, the main effect is to rob the organisation of the information it needs to review its performance and improve processes as a result.  Which just goes to show – staff awareness, via training, coaching and constant leadership, the need to record actions and incidents carefully is an essential element of quality care, and more particularly, quality development.

Topics: Care Planning

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