Inadequate risk assessment
Thursday, August 2, 2012 at 12:04PM A Foundation Trust (along with a care home provider) has recently received a heavy fine for inadequate risk assessment when placing a man at the care home; he subsequently killed one and seriously injured another care home worker. The degree of tragedy should not be underestimated, but you can instantly feel the bureaucratic knees jerking across the managerial universe. Larger tick-box forms will be required in greater frequencies so we can all rest assured 'this will never happen again', or so the political rhetoric goes!
I don't know the full details of the case, but I do know these are extremely rare incidents that should not be allowed to cloud over the vast majority of good decisions and good practice that does happen across our stretched public bodies. However, there is a wider case to be answered in the quality of information being communicated when a person with complex issues is required to be placed out of the health care system into the social care system. There is a 'tip of an iceberg' effect happening here, but it is not one that is going to trigger a rash of homicides. What I observe in my travels around the care and support landscape is a wholly inadequate approach to referrals, mostly driven by fear of the commissioning and managerial stick that drives the pursuit of numbers and throughput.
The result is often one of referral being a process of withholding relevant information (particularly risk information) for fear that it will be used to refuse the placement. Practitioners are under pressure to get people moved on, not to find the most suitable place for their continuing progress and support. Even when risk information is passed on, it is more frequently in the format of the dreaded tick-box exercise that communicates little of any use or relevance for planning appropriate support.
For me this case does raise the issue of poor examples of practice, but I would like the starting point for addressing the issue to be one that investigates the crazy 'system' we have evolved, whereby staff are under constant pressures from the bureaucracy that completely undermine any chance of delivering good and safe practice. If you want to develop a system that thrives on good practice it has to be a bottom-up approach; if you want a system that demonstrates what schizophrenia actually is then use the top-down managerial approach of 'talking the talk while actively disabling the walk'.
Reader Comments (1)
Unfortunately the poor care given by a few do overshadow the hard work that other care givers and health care professionals give on a regular basis