Assumption is not Assurance

“Familiarity breeds complacency; complacency breeds negligence and something eventually slips through”

Richard Quest – Sunrise Program 7 Network 20th May 2016

Recently, the shocking case emerged of Anne Marie Smith.  Disturbingly, she died from severe septic shock, multi-organ failure, severe pressure sores, malnutrition and issues connected with her cerebral palsy, after allegedly being stuck in a cane chair for 24-hours-a-day for more than a year.

Ms Smith was receiving care from a person working for a care service agency, sub-contracted by a larger organisation.

Ms Smith’s carer has since been sacked, and police have, quite rightly, launched a criminal investigation into the circumstances of her death.

The Federal Government says it “wants answers” on the death of disability care recipient Ann Marie Smith in what police described as “degrading circumstances”, as pressure mounts on federal and state authorities to explain how her case was overlooked.

As reported by the ABC

And don’t we all want to know because, this can NEVER happen again?

In my view, there was one fundamental cause: a cause which has contributed to many other tragedies.  It would appear that those in positions of authority above the carer assumed she was doing the right thing. The fact it went undiscovered for over 12 months tells me that there was absolutely no assurance.

Over recent months, case after case has highlighted the reliance on assumption over assurance and the devastating impacts that can result.

Recently I examined a Coroner’s Report into the death of a psychiatric patient at a hospital. 

The report noted that the patient was upgraded from low to medium for his risk profile and then placed on 15-minute observations after displaying quite agitated and anxious behaviour. Tragically, the patient committed suicide within two and half hours of the administrative change.

What infuriated me was that: despite the visual observations chart recording 15-minute observations, it was clear from the CCTV footage outside of the patient’s room that nobody entered his room in that timeframe.

Clearly, the observations had not been done, despite the chart being completed.  Once again, it was assumed that all the staff were doing their jobs – but they were not.

It was found the nursing staff who had failed to conduct regular 15-minute observations, despite documenting them, had breached professional practice standards and Health Service policy.

It was found this was an individual practice failing, but it was noted these breaches could be considered failings in the context of a workplace culture where non-standard visual observation practices had become routine, rather than an instance of post incident collusion and deliberate falsification.

So, what is the solution? The solution is assurance.

Let’s look at what that assurance may have looked like in these cases.

Disability Care Provider

In most cases, welfare agencies and care agencies have a ‘spot check’ mechanism or a similar policy noted in their contracts and their policies and procedures. While an investigation is yet to be completed, at this stage, it appears that no welfare checks were done.

At a minimum, company policies and procedures should include something along the lines of:

All supervisors of [Agency] carers or contractors are to conduct monthly visits to clients of the carers to conduct a welfare check.

Supervisors are to record the findings in the welfare check register and immediately alert management of any issues identified during the visits.

If these controls were not in place, then they should have been.  If they were in place, it is clear from the length of time Ms Smith had suffered that they had not been followed.  In my view, this is where any investigation needs to focus to ensure it never happens again.

Patient Care at Hospital

Could you imagine the difference in behaviours of the nurses tasked with conducting the 15-minute observations, if there was a policy/procedure that stated:

Each month, the assurance team is to review 24 hours of CCTV footage to compare it with the visual observations chart to confirm correlation.

If such a policy or procedure existed, then it can be safely assumed the nurses would not have taken it upon themselves to choose which procedures and processes they follow.

And there we have the crux of the matter.  While ever we assume that everyone is doing their job, often we find out that, that is not the case, but not until after such an incident has occurred.

If we are doing risk management – we assume everything is being done as documented.  But, if we truly want to manage risk, we need to assure they are being done.

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