[2024] UKUT 250 (AAC)

JW was on waking night shift, with primary duty of caring for Mr Y;

Miss X was generally asleep during the night;

caring for Miss X was not JW’s responsibility; she was not trained to help Miss X with her PEG; she had not read Miss X’s care documents; nevertheless, the management of the care home had allowed a ‘working practice’ to develop such that JW would look in on Miss X if she woke during the night;

in each of the incidents, Miss X woke (in the middle of the night or in the early morning), wishing to have her pad changed; JW responded by going to look in on Miss X’s room to see what was the matter;

JW could not help Miss X by changing her pad; it required two female carers to do so;

Miss X became upset because JW told her that her pad could not be changed and she had to go back to bed until the morning shift arrived;

when upset, Miss X would not uncommonly lunge at and try to hit carers; this happened here; JW responded by leaving the room and holding the door shut for several minutes;

JW’s motivation in holding Miss X’s door shut was both to prevent Miss X from coming after her and to de-escalate the situation; JW kept a listening ear for any indication that Miss X was in danger; the episode on 14 June 2022 ended with another carer, NJ, taking over from JW and managing to calm Miss X.

there being no way to change Miss X’s pad, if she woke in the night, as only one female carer was available

JW being expected to look in on Miss X, if she woke in the night

JW being ill-equipped to deal with Miss X, as her principal duty was to look after Mr Y

Miss X’s proclivity to become violent with carers, when she was upset and frustrated.

We would describe this state of affairs as one of management dysfunction: in other words, those responsible for managing the home had organised things such that there was no satisfactory way of dealing with the possibility of Miss X waking during the night wanting to have her pad changed.