Serious Incident Report

Topics: Medical restraint, Restraint, Report Pages: 4 (810 words) Published: May 7, 2011

To:The Proprietor
cc:Social Services Inspector
cc:Health Authority Inspector


The purpose of this report is to analyse the causes of the incidents which lead up to, and resulted in, the death of a resident at your home, Mrs X. The report will further draw conclusions from the incident, and will make several recommendations to assist in the prevention of such an incident occurring again in the future.

Account of the incident

Mrs X was an elderly resident who suffered from osteoporosis – a condition which causes the bones to become fragile and brittle.

On the day in question, it appears that a Care Assistant employed by yourself, had cause to restrain Mrs X, and did so by “pulling her shoulder”. As a result of this action, Mrs X sustained a fracture to her shoulder joint, and subsequently died of trauma.

No further medical details are available to suggest an alternative cause of death.


There appears to have been several factors which contributed to the death of Mrs X. Each one is detailed as follows:

1. On said occasion, it was reported that Mrs X was poking a fellow resident with a stick. This behaviour was deemed to be inappropriate, and Mrs X was restrained by a Care Assistant, who “… pulled her shoulder”.

2. It has been reported that it is common practice in the home for care staff to use physical means, to restrain or redirect residents, however none of the care assistants appear to have received any training in this regard.

3. It is not clear whether or not there were any senior staff, or supervisors, present when the incident occurred.

4. The care assistant made a verbal report of the incident to yourself as Proprietor.

5. A written report was subsequently prepared by yourself, and in it there was a suggestion that the care assistant lost his temper with the resident. This suggestion was subsequently denied by the care assistant, and it is unclear whether or not the care...
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