January 2016

Date: 01 January 2016

  • Details:

    Patient had a fall and in order to gain access to the patient, entry to the property via the back gate and back door had to be forced. The back door needs to be replaced and the back gate needs to be repaired. Complaint wanted to know who forced the entry, what our policies say about leaving a vulnerable person in an unsecured property and/or if we involved another emergency service, what is their policy on leaving a vulnerable person in an unsecured property?

    What our policies say about contacting the next of kin in the event of a forced entry. Why we didn't arrange for emergency boarding up of the property.

    Why the crew didn't feel the need to investigate the cause of her fall (i.e. the dehydration and anaemia). And why was the patient, who is very frail and unsteady on her feet, in an unsecured property without notifying you as her next of kin.

  • Findings:

    999 call to Chelmsford Emergency Operations Centre (EOC) was received at including a message that the crew would have to force entry into the property. The crew arrived at the scene and they took the following actions when assessing potential access to the property:

    • Tried knocking on the front door in case a third party had arrived and were now able to let them in.
    • Tried to establish verbal and visual contact with your mother via windows and the letter box, but were unsuccessful.
    • Checked if any doors or windows were open, unlocking the back gate in the process (without any damage that they recall).
    • Had searched for any signs of a key safe.
    • Contacted the Duty Locality Officer (DLO) for further assistance and guidance on how to gain entry to the property at which point the DLO advised he would attend the scene.
    • The crew then confirmed these actions with EOC and again asked them to confirm with your mother that there was no other access available.

    On arrival of the Duty Locality Officer, it was agreed that the back door would be the easiest and safest way to The crew stated that they tried to force the bottom wooden panel through, but found this had metal reinforcements behind it, so tried to force the top lock on the door, but unfortunately the force on the wood caused the window to shatter. After clearing the glass and using blankets to protect themselves, a crew member was able to climb through the broken window to gain access. He firstly went to find your mother to assess her needs and on finding the patient was sitting on the floor, fully conscious and conversing well, he went to open the front door to allow the other crew members access to the property. The patient was assessed and mobilised with her frame as she normally did and declined to be taken to A&E. There was no acute illness identified at the time of the assessment that would require hospital treatment.

    The patient did not want anyone contacted. She was informed that the door had been made as secure as possible for the time being and EOC were arranging an emergency repair to be completed as soon as possible. The crew documented the incident and the patient’s wishes not to attend A&E in the patients care plan book so the carer would be aware on their arrival in the morning. There are no policies in place currently with regard to contacting next of kin. The patient was asked if she wanted her next of kin informed and she declined.

  • Lesson learnt / action taken:

    The crew were reminded to add accurate and detailed information on the Care Plan for future visits of the Carers attending. They were also reminded to leave the ‘leave at home form’ when a patient is not conveyed to hospital and to complete a ‘capacity to consent form’ to demonstrate that they had fully assessed your mother’s mental capacity. This would have evidenced that she was entirely capable of understanding the information being given to her, was able to retain the information and able to make her own decisions based upon that information.

  • Date:
    01 January 2016