The particular incident reported in this case study occurred in the year 2011 when a patient who was already in a critical stage of her disease happened to walk through a fire gate and met with an incident. The patient was unable to get back to the ward because the fire gate behind her was locked immediately she crossed it and therefore she reached the hospital ground. The patient died 24 hours and 30 minutes after the incident leaving many important factors highlighted regarding the organizational structure of palliative care department.
Apparently all the staff members working with the patient were well trained and professional having a reasonable experience of the field and that is the reason that any sort of negligence was not expected on their part. The woman who was being treated in the palliative care was a young woman of 32 and her husband was staying with her at hospital ward in order to take care of her. I order to ensure her care her husband and she, were placed in a twin room at the end of ward so that their privacy can be ensured. Her position was deteriorating and she was faced with restricted mobility in the end days of her life. As far as the duty of staff is concerned it was to make both of them feel comfortable in theterminal stage of her life.
That particular incident happened around 5am in the morning when the nurses took round of the room and found her and her husband sleeping. After the nurses left the patient got out of the bed and went out of the room. The patient further opened a fire door and while walking through the fire area reached the hospital ground. A guard happened to see her and tried to identify her. She herself was blind due to her illness and therefore she was unable to identify the fire door and anything else to help her. In addition to this she was not able to walk for more than 20 meters without having an assistance of oxygen tank. She managed to walk fir about 100 meters and tried to open the hospital door but she fell down. Meanwhile the security guard identified her and called the department to inform about the situation/. After getting a call from security guard the department got an idea about the incident and before that everyone did not had any idea about what has happened inside the department. At the same time an alarm was rang by patient’s partner that she was not on her bed.