Introduction
This essay examines the timeline of Faiza, a woman with a learning disability who experienced significant challenges in her care provision within a UK care home setting. The purpose of this analysis, from a nursing perspective, is to identify three critical risk management issues in Faiza’s case, with a detailed critical evaluation of one specific issue. Faiza’s journey—from her relocation to England in 1965, through the tragic loss of her husband in 2012, to her care home placement in 2019, and ultimately a critical incident in March 2022—reveals systemic and individual failures in care delivery. The essay will first outline three key risk management issues: inadequate care plan individualisation, insufficient staff training on learning disabilities, and poor supervision and monitoring. Subsequently, it will critically analyse the issue of inadequate care plan individualisation, exploring its impact on Faiza’s safety and wellbeing, while drawing on relevant nursing literature and guidelines. The discussion aims to highlight the importance of person-centred care and robust risk management in nursing practice, particularly for vulnerable populations.
Identification of Key Risk Management Issues
Faiza’s case presents several risk management concerns that are pertinent to nursing practice. The first issue is the inadequate individualisation of her care plan. From March 2019 onwards, the care plan established at Walsall Haven Care Home lacked specific accommodations for her learning disability, despite clear indications of her unique needs. This oversight persisted even as her condition evolved, with no updates made by January 2022 to address emerging risks such as her tendency to ingest non-food items.
The second risk management issue is the apparent lack of staff training and understanding regarding learning disabilities. Throughout Faiza’s time at the care home, from late 2019 to early 2022, there were instances of agitation and confusion noted by staff and family. However, there is no indication that the care team was adequately equipped to interpret or manage these behaviours as manifestations of her disability, which likely compounded her distress and increased risk.
Finally, the third issue is poor supervision and monitoring, most starkly evident in the critical incident on 10th March 2022. Faiza was found unresponsive in a communal area, having been left unattended, which led to the tragic discovery of a latex glove lodged in her airway. This incident suggests a failure in basic oversight, a fundamental component of safe care delivery in residential settings.
These three issues—inadequate care plan individualisation, insufficient staff training, and poor supervision—represent significant lapses in risk management. While all are critical, the following section will focus on a deeper analysis of the first issue, given its foundational role in shaping Faiza’s care trajectory.
Critical Analysis of Inadequate Care Plan Individualisation
The failure to develop and update a personalised care plan for Faiza stands out as a primary risk management issue with profound implications for her safety and quality of life. Person-centred care, a cornerstone of modern nursing practice, emphasises tailoring interventions to the individual’s specific needs, preferences, and circumstances (McCormack and McCance, 2017). In Faiza’s case, the initial care plan in March 2019 was not adapted to address her learning disability, despite its impact on her daily functioning and safety. Moreover, by January 2022, despite clear warning signs—such as her attempts to eat non-food items—the plan remained unchanged, exacerbating risks to her health.
The consequences of this failure are evident in the tragic incident of March 2022. The presence of a latex glove in Faiza’s airway suggests a preventable harm linked directly to unaddressed risks. Literature highlights that individuals with learning disabilities are at a higher risk of pica (the ingestion of non-food items), a behaviour necessitating specific safeguarding measures in care plans (Ali, 2001). UK guidelines, such as those from the National Institute for Health and Care Excellence (NICE), stress the importance of dynamic risk assessments and care plan reviews to mitigate such dangers (NICE, 2015). Yet, in Faiza’s case, the lack of updates to her care plan, even after family advocacy in February 2022, indicates a systemic failure to adhere to best practice.
Furthermore, this issue reflects broader challenges in nursing care for individuals with learning disabilities. Research indicates that care plans often adopt a ‘one-size-fits-all’ approach, neglecting the nuanced needs of vulnerable groups (Mencap, 2012). In Faiza’s situation, this generic approach arguably contributed to her vulnerability, as staff were not guided by specific strategies to manage her behaviours or ensure her safety. A critical perspective might question whether resource constraints or inadequate policy implementation at Walsall Haven Care Home hindered the prioritisation of individualised care. While budget limitations are a known challenge in the care sector, ethical nursing practice demands that patient safety supersedes such constraints (Nursing and Midwifery Council, 2018).
Indeed, the emotional and practical toll on Faiza’s family, who repeatedly raised concerns, underscores the relational dimension of this failure. Their calls for a comprehensive review in early 2022 were a desperate attempt to bridge the gap left by the care home’s inaction. This situation highlights a need for more robust family involvement in care planning, as advocated by contemporary nursing frameworks (McCormack and McCance, 2017). Had Faiza’s care plan been co-produced with her family, who understood her history and needs, potential risks might have been identified and mitigated earlier.
However, it must be acknowledged that individualising care plans is not without challenges. Staff workload and time pressures can impede thorough assessments, while a lack of interdisciplinary collaboration may limit the integration of specialist input. Nevertheless, these barriers do not justify the prolonged neglect of Faiza’s needs. Nursing practice must prioritise risk management through continuous evaluation, ensuring care plans evolve with the patient’s condition (NICE, 2015). In Faiza’s case, even a basic review mechanism could have flagged the need for environmental adjustments (e.g., removing hazardous items) and behavioural interventions, potentially averting the critical incident.
Conclusion
In conclusion, Faiza’s timeline reveals critical risk management issues in her nursing care, namely inadequate care plan individualisation, insufficient staff training on learning disabilities, and poor supervision. The in-depth analysis of inadequate care plan individualisation demonstrates its profound impact on her safety, culminating in a preventable incident in March 2022. This failure, rooted in a lack of person-centred planning and dynamic risk assessment, contravened established nursing principles and guidelines, highlighting systemic and practical gaps in care delivery. The implications for nursing practice are clear: there must be a renewed emphasis on tailored care plans, regular reviews, and family collaboration to safeguard vulnerable individuals like Faiza. Moreover, this case underscores the need for enhanced training and policy enforcement to ensure that learning disabilities are understood and addressed within care settings. Ultimately, addressing these issues is not merely a matter of compliance but a moral imperative to uphold dignity and safety in nursing care.
References
- Ali, Z. (2001) Pica in people with intellectual disability: A literature review of aetiology, epidemiology and complications. Journal of Intellectual and Developmental Disability, 26(3), pp. 205-215.
- McCormack, B. and McCance, T. (2017) Person-Centred Practice in Nursing and Health Care: Theory and Practice. 2nd ed. Wiley-Blackwell.
- Mencap (2012) Death by Indifference: 74 Deaths and Counting. Mencap.
- National Institute for Health and Care Excellence (NICE) (2015) Challenging behaviour and learning disabilities: Prevention and interventions for people with learning disabilities whose behaviour challenges. NICE.
- Nursing and Midwifery Council (NMC) (2018) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. NMC.
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