7.1 - Principles of Safe Practice in Health and Social Care
Case study 2: Wellings NHS Trust, Ward 3B
Ward 3B is a female surgical ward with 32 beds in bays and two side wards for more serious cases.
Amina Patel is the ward manager and she is supported by a team of registered nurses, nursing
associates and healthcare assistants.
The keypad used to gain entrance to the ward is broken and so the doors are propped open to save the
staff having to leave their duties to let people in.
The service users come into the ward for surgical procedures, some of which are planned and others are
emergency procedures
Lizzy D. was admitted to the ward for a routine procedure on her left hand. The surgery went smoothly
and there were no complications. Following a visit from her husband, Lizzy complained of pain in her
hand and on examination, the nurse on duty, noticed that it was swollen and discoloured.
Lizzy stated that this had ‘suddenly happened’ and that she could not explain it. She was given
medication to reduce the swelling and the pain. Because the nurse was busy, she did not record either
the issue or the medication given to Lizzy. This particular nurse often forgets to record medication, and
Amina has spoken to her about this on several occasions.
The following day, Lizzy’s husband again visited and following this, Lizzy complained of the same
swelling and pain in her hand. The husband had insisted on drawing the curtains around the bed at the
visit, stating that he had important mattes to discuss with his wife. Visiting is never supervised on the
ward, and staff leave people to chat.
Amina administered pain relief but didn’t record this. She did question Lizzy about her hand, but Lizzy
turned her face away and refused to answer.
Duty of care and its significance when promoting safe practice (P1+D1)
In health and social care, a duty of care is a legal obligation to protect oneself, colleagues, and service
users from harm, work in the best interests of the service user, and promote the safety of all involved. This
means it is law and a worker who fails in this duty can face criminal investigation and legal charges.
Professionals are also expected to promote their service users’ rights and interests at all times and if they
experience abuse or neglect. Duty of care can be practiced successfully when employers and their staff
understand their rights and responsibilities, are trained and qualified appropriately, and work only within
the limits of their own competence and skillset to ensure the safety of themselves and their service users.
They must work to protect the health, safety and wellbeing of their service users and balance individual
rights with risk.
Protecting service users from abuse or neglect is one of the primary aspects of a duty of care. Abuse
can be physical, such as hitting, biting, scratching, or kicking; financial, such as scamming or stealing from an
individual; verbal such as name-calling; emotional, such as manipulation or gaslighting; sexual; or neglect.
Unsafe practice can lead to accidents, and in severe cases can be fatal, and failure to uphold codes of
practice and work within legislation can lead to criminal investigation or losing the right to practice.
Many individuals in care settings are vulnerable, putting them at increased risk of being victims of
abuse or neglect. This can be because they are physically unwell and therefore less able to defend or stand
up for themselves, or due to a pre-existing or more permanent reason, such as a physical disability, learning
disability, mental incapacity due to a condition such as dementia, being a child, or elderly. Another reason
abuse can occur in care is as a result of the imbalance of power between staff and service users. There are
many steps that can be taken to prevent these vulnerable individuals becoming victims of abuse and neglect,
which will be discussed further on.
At Wellings NHS Trust, staff’s duty of care means they must care for patients with competence and
diligence, protecting them from harm and preserving their safety. This means adhering to the company’s
policies and procedures and the recommendations of the Care Quality Commission and their professional
bodies, such as the Nursing and Midwifery Council and General Medical Council. They must also abide by all
,relevant legislation, such as the Health and Safety at Work Act 1974 and the Care Act 2014. These laws
outline best practice to protect both staff and service users and promote each party’s wellbeing.
On Ward 3B, some of the staff have not upheld their duty of care sufficiently when caring for Lizzy,
which has occurred through failure to follow correct procedures. The first act of omission took place when
staff kept the doors propped open, leaving Lizzy and other patients vulnerable to harm from anyone who
may enter the ward from the outside who is not authorised. The patients on Lizzy’s ward are all likely to be
vulnerable in some way or another, mostly on account of their physical ill-health, which means they are less
able to defend themselves and may be medicated and less alert, meaning they could easily be targeted by
anyone who wished to abuse them physically, sexually, or steal from them. The doors left open are also a
danger to the patients themselves; if any of the patients are not in sound mind due to medication, head
injury, mental illness, or learning disability, for example, they could easily become confused and walk out of
the hospital and be a danger to themselves. If the staff had exercised their duty of care by keeping the doors
closed, the patients on ward 3B would be protected and the risk of abuse or harm would be reduced.
Another way the staff at the hospital have not performed their duty of care is by not reporting Lizzy’s
hand injury following her husband’s visit nor the fact medication was administered for the pain. This is very
dangerous because it can be inferred that Lizzy may need safeguarding from abuse from her husband and
this process will not take place if the first instance is not recorded. If it had been reported, the likelihood of
Lizzy being appropriately safeguarded would increase, and the likelihood of further abuse from her husband
occurring would reduce. The hospital staff would have been able to pass the information on and Lizzy would
have a better chance of being protected.
Duty of care is of great significance in practice because it fundamentally supports the safety and
wellbeing of each party involved in service provision. It is a basic outline reminding care professionals of
their primary responsibility at work: keeping themselves and others safe and well-looked after. Sometimes,
duty of care may cause conflict with other responsibilities. This can occur when institutions are understaffed,
or staff are asked or expected to perform a duty outside their training and competence level. It is likely the
case on Ward 3B that the nurses caring for Lizzy were rushed to care for other patients and therefore forgot
or did not prioritise writing her notes.
It has been acknowledged that upholding duty of care at all times is of great difficulty for medical
staff, particularly when balanced with many other responsibilities. The increased need for accurate and
thorough documentation can make it difficult for nurses and hospital staff to balance their care duties with
the administration tasks required of them, meaning one or the other suffers in quality and thoroughness.
Abdelraham & Abdelmageed (2014) describe the importance of proper notetaking in healthcare and
acknowledge that it is sometimes not prioritised enough, with notes being illegible and missing information.
This can quickly become an issue when complaints or accusations of poor practice are made, as one of the
key lines of enquiry in a legal investigation is the patient’s notes (NHS, 2017). If the staff involved do not
have an acceptable standard of notes, it can be difficult for them to defend themselves against accusations
of neglect or abuse, which is why thorough documentation is an important part of duty of care; not just
because it protects service users, but it maintains accountability and enables easier communication and
sharing of information between the professionals.
It could be argued that duty of care is not required, or should not be a priority, when professionals
are supported by other guidance and information from training, both initial and ongoing, policies and
procedures given by their workplace, codes of conduct given by their professional bodies, and legislation
such as the Care Act and Health and Safety at Work Act. However, the information and guidance given in
these and other relevant acts, the codes of conduct outlined by professional bodies, and the guidance given
from the CQC largely align and overlap with the description of duty of care, which emphasises its importance
since it is discussed as a priority across the board of the sources referred to by staff. The Royal College of
Nursing (2022) describes duty of care as important both legally and professionally, and reminds
,professionals that the Nursing & Midwifery Council’s code of conduct ‘The Code’ (NMC, 2015) gives useful
guidance for following duty of care for all professionals, not just nurses and midwives. Furthermore, safety
and safeguarding from abuse are within the CQC’s description of standards that all service users can expect,
which reflects the description of what duty of care means, meaning the CQC considers these duties to be at
the heart of good service provision (CQC, 2017). Therefore, duty of care is of great significance in the
promotion of safe practice because it requires professionals to maintain a high standard of care provision
while ensuring the safety of each party involved.
Balancing individual rights with risk and duty of care (M1)
When caring for vulnerable individuals, it is important that their rights are balanced with risks to
promote rights and choice for the service user while simultaneously taking reasonable measures to prevent
harm to everyone in the setting and carrying out duty of care appropriately. This can sometimes cause
conflict for service providers and staff because it can be difficult to determine which action to take in certain
circumstances; there is no rule that applies universally, and each case must be handled individually with
careful consideration. Minimising risk is part of duty of care and should be taken very seriously, particularly
where service users exhibit a vulnerability.
On the ward at Wellings NHS Trust, there is conflict between Lizzy and her husband’s right to privacy
and the need to safeguard Lizzy from potential abuse. This occurs when Lizzy’s husband comes to visit and
wants to draw the curtains. The staff need to assess the situation and understand that Lizzy’s dignity and
independence should be respected and promoted, achieved by allowing the curtain around her bed to be
drawn and the visit unsupervised. However, particularly following her husband’s visit where Lizzy’s hand is
injured, it should be identified that there are signs of abuse present and therefore it may be safer for visits
to be supervised and have the curtains open to protect Lizzy from being hurt by her husband. This, however,
poses complications as the staff do not have any definitive evidence that Lizzy’s husband is abusive and
therefore imposing these measures may come across as a strong accusation which could offend Lizzy and
her husband if abuse is not present. It may also be difficult for staff to explain to the couple why their visits
must be supervised when other patients at the hospital are allowed unsupervised visits, and such
conversations might cause frustration and offense for Lizzy and her husband, which may create a risk that
her husband could become verbally or physically aggressive towards the hospital staff or complain about
unfair treatment.
It is important that rights are balanced with duty of care to maintain service users’ independence
and dignity while upholding the obligation to protect them from harm. Lizzy’s rights include those outlined
by the Human Rights Act, one of which is respect for a private and family life, home and correspondence
(Gov.uk, 1998). It could be argued that this piece of legislation means that it is not justifiable for the hospital
staff to insist on supervising Lizzy’s visits or having the curtains open, as doing so would be an infringement
of her rights under this act. Additionally, it could be argued that it is Lizzy’s own choice whether to ask for
protection from her husband and that it is not the hospital staff’s place to take responsibility for protecting
Lizzy. In contrast, duty of care is a legal obligation and failure to practice duty of care can, in severe cases, be
fatal. The staff may suspect Lizzy’s husband is abusive and if they decide that promoting her rights is more
important than safeguarding her, there is a potential risk that during a future visit, Lizzy could be injured far
more severely, or even killed by her husband. Therefore, it could be said that duty of care is in some cases
more important than respecting privacy and dignity.
A similar argument applies to safeguarding Lizzy following discharge. The hospital staff may assess
that Lizzy is at risk of further abuse when she returns home with her husband and wish to exercise their duty
of care to prevent this by helping her to access support for domestic violence victims. They can do this by
providing Lizzy with the resources needed to escape her situation safely and making her aware of what is
available. However, if Lizzy does not want to access this support, without solid evidence it will be hard for
the nurses at Wellings NHS Trust to do very much to help Lizzy. This is unfortunately very common, but
, policy regarding this leans more toward respecting Lizzy’s individual rights in terms of privacy and right to
make her own decisions about her situation. Once she is discharged and the nurses’ duty of care to Lizzy as a
patient is over, it is no longer their responsibility to safeguard her from the domestic abuse she may be
experiencing. Only eighteen percent of women who experience domestic abuse report it to the police
(Women’s Aid, N/A), and it is likely that Lizzy does not want to receive help, which can be inferred because
she turned away and did not want to answer questions about the cause of her hand injury following her
husband’s visit.
Finally, something to be considered when balancing rights with duty of care is mental capacity. The
Mental Capacity Act 2005 states that each individual is assumed to have capacity until there is evidence to
suggest otherwise, and that an unwise decision does not mean lack of capacity (Gov.uk, 2005). This is
relevant when caring for Lizzy because if Lizzy chooses not to disclose the abuse she may be experiencing or
accept help, some staff may think that she is making a poor decision, however this piece of legislation gives
clarity that this is not valid grounds to declare Lizzy as lacking capacity. On the other hand, it could be said
that prolonged exposure to domestic abuse could affect someone’s capacity, particularly if there has been
psychological abuse involved, which can alter an individual’s way of thinking severely over time and leave
them feeling unable to ask for help or to leave, sometimes even feeling convinced that everything is fine and
that they wish to stay with their abuser, often known as Stockholm Syndrome (Westcott, 2013). In some
severe cases, it may be found that an abuse victim lacks capacity to make their own decisions and
authorities may be able to take over to protect the individual, but more commonly it is the victim’s own
choice whether to accept help and press charges against their abuser.
Complaints and appeals procedures and their significance when promoting safe practice and addressing
failure in duty of care (P2+D1)
If a service user or their family feels unhappy or unsatisfied with the quality of care provided, or feel
that staff failed in duty of care, they have the right to complain. The way this is done will vary on the
individual’s preference and the procedure in place for that service, but every organisation should have a
policy available to service users and their families upon request. Complaints procedures are of utmost
importance in health and social care because they enable service users to give feedback about the quality of
care they have received to give providers the opportunity to reflect and improve their service where
necessary. Complainants may highlight areas of poor or dangerous practice that the providers would
otherwise not have considered, and their comments give a perspective that the staff and management
might not otherwise experience themselves. There may be causes for concern within an institution that the
staff overlook or fail to notice that can be brought to attention through a complaint, which is essential for
preventing unsafe practice and potential abuse or neglect.
At Wellings NHS Trust, Lizzy may feel that she wants to complain about the service she received, as
the nurses have failed in some of their responsibilities and have not carried out their duty of care effectively.
The act of complaining addresses failures by alerting the professionals that something has been done wrong
or inadequately, giving them the chance to reflect, respond, and adjust their behaviours and procedures
appropriately. This may involve the staff member or members responsible attending additional training,
disciplinary measures, and in severe cases, dismissal or criminal charges. Poor conduct can be classed as
clinical negligence or a criminal offence, in some cases. Legal proceedings are taken against health and social
care workers who have caused harm to a service user. At Wellings NHS Trust, failing to record Lizzy’s injury
and the medication administered, the doors propped open and lack of safeguarding when Lizzy presented an
injury following her husband’s visit are acts of clinical negligence. Because these acts are classed as clinical
negligence, if Lizzy were to complain, the case would be taken very seriously. Lizzy may be entitled to
financial compensation from the Trust as well as an apology from the staff and a promise to change their
working practices, all of which may be of great value to Lizzy (Dutton Gregory Solicitors, N/A). The
potentiality for these outcomes makes complaining of significance to Lizzy and she may feel somewhat
compensated for the dangerously poor care she received at Wellings NHS Trust. Additionally, the pay out
