Introduction
This essay examines a tragic patient safety incident involving Faiza, an elderly woman with a learning disability, who experienced a critical health event at Walsall Haven Care Home in March 2022. As a social work student, the analysis focuses on the systemic and human factors contributing to this incident, with particular attention to risk assessment, human factors, and change theory. These concepts are pivotal in understanding and addressing patient safety in care environments. Risk assessment, as defined by Vincent and Amalberti (2016), involves identifying potential hazards and implementing measures to mitigate them, a process crucial in care homes where vulnerable individuals reside. Human factors, encompassing the interplay between individuals, tools, and environments, often influence the efficacy of care delivery (Hollnagel, 2014). Meanwhile, change theory, such as Lewin’s model of unfreezing, changing, and refreezing, provides a framework for implementing necessary reforms in care practices (Burnes, 2020). This essay will explore how deficiencies in these areas contributed to Faiza’s incident, critically analyse specific risk management and human factors, and propose recommendations for improvement, situating the discussion within the context of the care home environment.
Insight: Risk Management Factors Contributing to the Incident
Three key risk management failures contributed to Faiza’s incident at Walsall Haven Care Home. Firstly, there was a lack of an updated and individualised care plan addressing her learning disability, despite family concerns raised in January 2022. Secondly, inadequate supervision in communal areas left Faiza unattended, directly leading to the incident in March 2022. Thirdly, the absence of environmental risk assessments failed to identify hazards such as accessible non-food items, like the latex glove that obstructed her airway. This section will critically analyse the first of these factors—the outdated care plan—in detail.
The failure to update Faiza’s care plan represents a significant oversight in risk management. Care plans are essential tools for ensuring personalised care, particularly for individuals with learning disabilities who may have unique needs (NHS England, 2017). Despite family requests in February 2022 for a comprehensive review, the care plan remained static from March 2019, lacking accommodations for Faiza’s specific challenges, such as her tendency to eat non-food items. This omission aligns with findings by Mencap (2012), which highlight that individuals with learning disabilities often receive substandard care due to insufficient personalisation of services. In Faiza’s case, the unchanged care plan in the care home environment directly increased her vulnerability, as staff were not guided on how to mitigate risks associated with her condition. This oversight arguably contributed to the tragic outcome, as a tailored plan could have prompted closer monitoring or environmental adjustments. Furthermore, the care home’s apparent inaction reflects broader systemic issues in resource allocation and training, which often hinder timely updates to care plans (Department of Health and Social Care, 2019).
Involvement: Human Factors Linked to Risk Management Failures
Human factors played a critical role in exacerbating the risk management failures surrounding Faiza’s care. Specifically, linked to the outdated care plan, three human factors stand out: inadequate staff training, communication breakdowns between staff and family, and workload pressures. This section critically analyses the impact of inadequate staff training within the care home setting.
Staff training is a cornerstone of effective care delivery, yet in Faiza’s case, there appeared to be a significant gap in understanding and addressing learning disabilities. Research by Heslop et al. (2014) indicates that insufficient training often leads to misjudgements about the needs of individuals with learning disabilities, resulting in preventable harm. At Walsall Haven Care Home, the lack of specialised training likely contributed to the staff’s inability to recognize the need for an updated care plan or to implement strategies to prevent Faiza from accessing harmful items. This human factor directly impacted the safety incident, as untrained staff may not have identified or prioritised the risks associated with her behaviour, such as ingesting non-food items. Moreover, the care environment—characterised by communal areas with potential hazards—amplified the consequences of this training deficit. Staff, potentially unaware of best practices, were ill-equipped to adapt their supervision or communication approaches, underscoring how human factors interplay with systemic failures in risk management to compromise patient safety.
Impact of the Care Environment on the Incident
The care environment at Walsall Haven Care Home significantly influenced the circumstances leading to Faiza’s incident. Communal areas, while designed to foster social interaction, posed inherent risks for someone with Faiza’s needs, particularly when left unattended. The lack of environmental risk assessments meant that hazards, such as latex gloves, were accessible, directly contributing to the tragic outcome. Additionally, the care home’s operational context, potentially marked by staffing shortages or high turnover—common in many UK care settings (Skills for Care, 2021)—may have compounded human factor issues like workload stress and inadequate training. This environment failed to provide the necessary safeguards, amplifying the impact of the outdated care plan and insufficient supervision. Indeed, as Vincent and Amalberti (2016) argue, safety in care settings depends on aligning environmental design with individual needs, a principle clearly neglected in Faiza’s case.
Recommendations for Improvement Using Change Theory
To prevent similar incidents, recommendations grounded in Lewin’s change theory are proposed. Firstly, in the ‘unfreezing’ stage, care home management must acknowledge the need for change by reviewing current practices and recognising gaps in risk management and staff training (Burnes, 2020). This could involve engaging with Faiza’s family and external experts on learning disabilities to build a case for reform. Secondly, during the ‘changing’ phase, implementing updated, individualised care plans and mandatory training on learning disabilities should be prioritised. This step would address both the risk management failure and human factor deficiencies identified. Finally, in the ‘refreezing’ stage, new policies should be embedded through regular audits and family feedback mechanisms to ensure sustainability. These recommendations, tailored to the care home context, aim to create a safer environment for vulnerable residents like Faiza, ensuring that systemic and human factors are better managed.
Conclusion
This essay has explored the patient safety incident involving Faiza at Walsall Haven Care Home, highlighting critical failures in risk management, notably the outdated care plan, and associated human factors such as inadequate staff training. The care environment exacerbated these issues by failing to mitigate inherent risks. Through a critical analysis supported by literature, it is evident that systemic and individual lapses contributed to the tragic outcome in March 2022. Recommendations based on change theory offer a pathway to improve care practices, ensuring greater personalisation and safety. The implications of this case underscore the urgent need for care homes to prioritise individualised care and training, particularly for vulnerable residents with learning disabilities. Addressing these issues is essential to prevent future incidents and uphold the principles of safe, compassionate care within social work and broader health settings.
References
- Burnes, B. (2020) The origins of Lewin’s three-step model of change. Journal of Change Management, 20(1), pp. 1-25.
- Department of Health and Social Care. (2019) Adult Social Care Outcomes Framework 2019-20. UK Government.
- Heslop, P., Blair, P., Fleming, P., Hoghton, M., Marriott, A. and Russ, L. (2014) The Confidential Inquiry into premature deaths of people with intellectual disabilities in the UK: a population-based study. The Lancet, 383(9920), pp. 889-895.
- Hollnagel, E. (2014) Safety-I and Safety-II: The Past and Future of Safety Management. CRC Press.
- Mencap. (2012) Death by Indifference: 74 Deaths and Counting. Mencap.
- NHS England. (2017) Transforming Care: A National Response to Winterbourne View Hospital. NHS England.
- Skills for Care. (2021) The State of the Adult Social Care Sector and Workforce in England. Skills for Care.
- Vincent, C. and Amalberti, R. (2016) Safer Healthcare: Strategies for the Real World. Springer.
