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Problem
It's so difficult for me to put blame on a system when there is a death- probably because I work in a human service profession. I have worked in a state prison for 20 years and when tragedies occur, the finger is immediately pointed at staff. Although there is always room for improvement, I am bias toward blaming a system for personal decisions. This being said, I would not hold the facility responsible for the death of the patient. From what we know, the patient was mentally competent and of sound mind. Because of this, she should know that going down steps in a wheelchair may cause serious injury. The patient is responsible for their own death. Although this was a decision made by the patient, I do believe the staff and nurses could have done more to prevent the fatality. I would like to know more about the note being taken out/ edited out of the chart. Was this done at the request of the patient or their guardian and what is the reason behind it?
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