Friday, 23 May 2014

Story Seventy Two - Management Investigation

Steven escaped from the Unit on 24th October 2010. It was nighttime and he was barefoot and in his pyjamas. Despite what the following report says, he must have been gone for at least 20 minutes to reach the point where he was found.

An internal investigation was carried out and I got the council's response on 11th January 2011 (2 weeks after Steven came home). Needless to say, the outcome of the enquiry wasn't available for the court hearing on 21st December.

This is what their report into the escape came up with:

"I carried out the investigation in accordance with the Council's policy and procedures and as such interviewed all of the staff on duty as well as the management team members for that service.

I viewed records relating to procedures within the home, care plan requirements and registration requirements,as well as reporting procedures. I have completed a report in relation to this matter to my manager and made recommendations for improvement where necessary.

I found that Steven left the main house through the porch door and the front door, leaving the internal door closed (?) and the external door open. He proceeded through the front garden, pulling out the secured bolt on the double locked front gates and walked up to C Road and R Lane. I found that he later reported that he wished to walk to "Julie's house". Staff noticed that Steven was not in the dining room where he was last seen after a very short period of time (2-3 minutes [bollocks] and begun to look in the house for him. It was then noticed that the external front door and gates were open and 2 members of staff went to look up the road briefly, before getting in their cars to look for him. A member of public confirmed the way that he walked. Staff drone and picked him up. He got into the car and was returned to M House. He had no injuries and it is reported that he was distressed at not reaching his destination, but not anxious about leaving M House itself.

I found that the staff on duty reported this incident to the management of the service and completed the required documentation.

I have made recommendations in relation to staff training in recording and reporting incidents and M House have had alarms fitted to the external doors to the service. I would like to reiterate that this service is not a secure service and as such doors are not locked to keep users in. However, in the case of Steven and other users, the alarms will alert them, when the service users are choosing to open the doors or leave the building.

I have also recommended that family carers are informed of any incidents within reasonable time scales."

And that was that. The next DoL was authorised a couple of weeks later without any reference to the escape and what Steven was intending to do. It wasn't considered relevant to the best interests assessor!

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