On November 7, 2013, during renovation taking place at a care home in Moston, Great Britain, staff responded to a cry for help, finding a resident underneath a fire door that had been removed and leaned against a wardrobe during the remodeling work. The resident suffered a broken hip and died on December 2nd. The management trust that operated the care home and the renovating firm were both fined under the Health and Safety at Work Act after a Health and Safety Executive (HSE) investigation found that the renovation area, which contained multiple hazards, had been left unlocked the night before.
According to HSE Inspector Laura Moran, “Both firms clearly knew there were vulnerable residents living at the care home but they still allowed the door to what was essentially a building site to be left unlocked on numerous occasions.” Clearly multiple failures led to the resident’s death. Diagramming the cause-and-effect relationships related to this issue can help clarify what happened, and offer areas for improvement.
We can perform an analysis of this incident in a Cause Map, or visual root cause analysis. We begin with the impacted goals. The patient safety goal was impacted due to the death of the patient. In addition, the employee safety goal was impacted due to the potential for employee injury. The fines can be considered an impact to the compliance goal and the patient services goal is impacted due to the insufficient protection provided for residents.
Beginning with an impacted goal and asking “why” questions develops the cause-and-effect relationships. In this case, the patient death resulted from a broken hip. The broken hip resulted from the patient being crushed under a fire door. (It took 3 people to lift the fire door off the patient.) The patient was crushed under the fire door because the fire door fell and the patient was in the renovation area where the fire door was located. Both of these causes are required – had the fire door not fallen, the patient would not have been crushed, even if she was in the renovation area. If the fire door fell but the patient was not present, the patient also would not have been crushed. When both causes are required to produce an effect, the causes are joined by and “and” on the Cause Map.
The fire door fell as it was leaning against a wardrobe due to the renovation. The patient, who suffered from dementia, was prone to wandering and was able to access the area under renovation because it had not been locked. Neither the renovation firm nor the care home staff locked the area, or checked to verify that it was locked.
Other goals can be added as effects in the appropriate locations of the analysis. For example, the patient services goal was impacted due to the insufficient protection of patients. This occurred because the renovation area was unlocked and because the hazards in the renovation area. (Beyond the fire door, the care home staff found exposed wiring, loose boards, and other potential safety hazards.) The insufficient protection of patients resulted in the fine. The impact to the employee safety goal was impacted due to the renovation area hazards as well.
Some amount of hazard always exists in construction sites – this is why hard hats are generally required. It’s also why access to these sites is controlled. In this case, limiting access to only those that need it was determined to be the best way to protect patients. Because the previous process for ensuring the area was locked had failed, according to Inspector Moran, “Following the incident, the companies introduced a new procedure which meant workers had to collect and return a key at the start and end of each day, and lock the door when there was no one inside.”
The lessons learned from this tragedy are applicable not only to the specific situation of care homes undergoing renovation but to all those who have a need to protect a vulnerable population or limit access to a hazardous site to ensure safety. Simple things like making sure doors are locked at the end of the day may save a life.