"Sending a vulnerable adult home alone"

About: Crosshouse Hospital / Accident & Emergency

(as other),

Recently I had a chance meeting with a service User that I key work, This person had a stroke quite recently has mobility issues and is very vulnerable. When I met them at 10pm in the evening they appeared confused and worried about the situation they had found themselves in, the service user explained to me that they had been discharged from Crosshouse Hospital after undergoing tests as they had a fall and felt that there may be some underlying issues possibly a small stroke, Patient transport picked them up from home to take them to hospital but after undergoing tests was found to be healthy enough to go home, the service user was then given a bus pass and told to make their own way home.  I think this is a blatant disregard of the duty of care, sending a vulnerable adult to find ther way home in a strange place with no jacket, no money and no way of contact friends or family.  After boarding one bus into town, they had missed the last bus to their destination and decided that they would get a train home(with no money) meaning a 1 mile walk to the nearest train station where I luckily bumped into them.  After 2 hours and various phone calls to colleagues it was agreed that I would escort the person to the nearest police station in the hope that they could take them home, Luckily and thankfully supported the person to get home.

I dread to think what would have happened if I never had that chance meeting, this complaint could have been a lot more strongly worded and regarding a different issue entirely.

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Responses

Response from Eunice Goodwin, Patient Feedback Manager for NHS Ayrshire and Arran, Quality Improvement and Governance Team, NHS Ayrshire and Arran 7 years ago
Eunice Goodwin
Patient Feedback Manager for NHS Ayrshire and Arran, Quality Improvement and Governance Team,
NHS Ayrshire and Arran

I respond initially to most of the posts and ensure they are passed to the appropriate team whether they are compliments, observations or grumbles. It is important to make sure all issues are addressed and I try to encourage that to happen for all the posts as required.

Submitted on 03/10/2017 at 08:43
Published on Care Opinion at 11:42


picture of Eunice Goodwin

Dear Jack Burton,

I must say that this does not seem right at all. Will you please pass on my sincere apologies to this person for the distress they must have been in. I think we have lessons to learn from this but I am not absolutely sure where this patient attended. So we can look into the situation, could you possibly contact me and give me their name, date of birth and information about what clinic was attended? I clearly don't know enough detail to understand this but it is a shame there was not an escort with the person either.

I can be contacted on 01563 826222 or by email on eunice.goodwin@aapct.scot.nhs.uk.

May I also thank you for making sure they got home safely, it was a very fortunate 'chance' meeting.

Kind regards to you both,

Eunice

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Response from Claire Gilroy, Specialty Doctor, Emergency Department, University Hospital Crosshouse, NHS Ayrshire and Arran 7 years ago
We are preparing to make a change
Claire Gilroy
Specialty Doctor, Emergency Department, University Hospital Crosshouse,
NHS Ayrshire and Arran

Emergency

Submitted on 03/10/2017 at 16:39
Published on Care Opinion at 16:54


picture of Claire Gilroy

Dear Jack Burton,

Thank you for taking the time to provide feedback on care opinion. The situation you have described was upsetting to read. I cannot image how distressed the service user must have been and it is clear from what you have written that you have been left feeling angry and upset too. I am sorry that this happened.

Thank you for providing more details to Eunice, this will allow us to look into what happened during this attendance. I will then update you with what we plan to do as a department to prevent this from occurring again. I am away from the office until Thursday but will aim to have an update by Friday afternoon. I want to assure you that we will work hard to prevent a similar event from happening in the future.

Claire

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Response from Claire Gilroy, Specialty Doctor, Emergency Department, University Hospital Crosshouse, NHS Ayrshire and Arran 7 years ago
We are preparing to make a change
Claire Gilroy
Specialty Doctor, Emergency Department, University Hospital Crosshouse,
NHS Ayrshire and Arran

Emergency

Submitted on 05/10/2017 at 21:14
Published on Care Opinion on 06/10/2017 at 09:11


picture of Claire Gilroy

Dear Jack Burton,

I wanted to let you know that we read your feedback as a team this morning. We were then able to discuss some of the issues that we identified from your feedback;

1. How do we reliably identify vulnerable adults in our department?

2. How do we ensure that these patients are then given any extra support they may require?

There is no easy answer to these questions however I can promise you that as a team we are committed to improving our processes to prevent a similar scenario from happening again.

Our initial thoughts are;

1. Introduce an 'access support card'. This was developed to help patients attending out-patient clinics. The idea is that the card should be shown to staff and they will then know that the patient requires extra support. Additional information can also be placed on the card highlighting what staff can do to make sure the patient gets the right support.

2. Place a flag on our electronic records which will then highlight to staff that the patient is vulnerable or has additional needs. We could also add additional information that the patient/relatives/key workers etc would want us to know to ensure that, if/when they need to use our service, we can provide the right support.

We would like to invite you to help us with this. If you would be interested in providing feedback on these ideas or if you had any ideas yourself please get in touch. In particular,it would be invaluable to get your thoughts on how we could adapt the Access Support Cards. My email address is Claire.gilroy@nhs.net.

Finally I would just like to thank you for taking the time and effort to get in touch. I hope the improvements we make as a direct result of your feedback will improve outcomes for our most vulnerable patients.

Claire

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