[2024] UKUT 258 (AAC)

At the start of the night shift, PK and AW were told that JB had had a covid vaccine injection during the day and been drowsy since then. They were told that JB needed to be supported intermittently (15 to 30 minutes), to monitor any side effect of the injection. JB was in bed asleep at the start of the night shift; he was intermittently awake; he seemed very lethargic; at the 10 pm check JB was not fully asleep but appeared very tired in bed; when AW checked his pad, it was dry; she repositioned him back to bed. At about midnight during intermittent checks, JB was observed to be half awake; AW noticed that he was wet; his pad was changed; she repositioned him back to bed and he slept. JB was wet again at 4:25 am and AW changed him then. At about 6:45 am AW checked JB’s pad; JB was fully asleep at the time. AW’s evidence was that JB’s pad was “damp” but not wet; she decided that it was not necessary to change the pad, particularly as this would (or might) wake JB up. AW’s evidence was that JB’s care plan sanctioned not changing JB’s pad in these circumstances.

AW denied making the entry on JB’s “bowel monitoring chart” showing a check at 5:30 am; she said it was not her handwriting. AW also said she might have made a mistake by writing 5:30 am rather than 2:35 am, which was when (according to the “daily records”) she checked on JB (as it was around this time that the “spot check” occurred, which caused some discombobulation on AW’s part).