School didn't give medicine on residential

[ChocHotolate]

DS was on his Y6 PGL residential last week. It turns out that he wasn't given any of his medication which I'd sent labelled with the correct forms filled in as required.
I've emailed the school but had no response yet. It's fortunate that it's not a critical medicine but rather one which prevents a flare up of a chronic condition.
Just wondering what I should be expecting and if anyone had had a similar experience ?

How do you know there was no master list? Have they told you there wasn't?

There isn't really room for error when it comes to a child's medication.
There are processes that could be put in place that aren't going to significantly add to the paperwork load - a simple table listing all the children who have medication, the times, the dosage and a tick box to say it's been done are all that is needed. Phone alarm reminders if needed. It's not rocket science and there's no need to hysterically proclaim it'll be the end of school trips.

The only hysteria is currently coming from posters telling the OP to sue and what-if-ing about dramatic scenarios that she herself has already said were never in danger of happening.

Human error happens.

There should be a list.

There should be one person responsible for the list, even if another person is responsible for giving the medication

School trips are already under threat and some schools are already refusing to give any form of medication even on the school premises. With the backing of the teaching unions.

That is exactly one of the reasons why you write risk assessments - to reduce the opportunity for human error. The risk assessment should detail all the risks and how to reduce or prevent them. One of the risks is leaders forgetting to administer medication. How do you reduce that? Well the risk assessment could detail measures such as

• ensuring one leader has overall responsibility for ensuring medication is given
• ensuring that leader has added alarms for all the times when medication needs to be given
• ensuring there is documentation available to record what medication has been given to who and when it was given

The risk assessment should include the name of the person responsible for making sure that the mitigating measures have been implemented and when they will do that. So for example, if your risk assessment says the adult responsible for first aid will put alarms on their phone for every dose of medication that needs to be administered, someone should named on the risk assessment to be responsible for reviewing that action to make sure it's been done (e.g. the overall trip leader checks on the first evening that first aider has put all the alarms on their phone and then initials the risk assessment to say they have done that). Obviously human error exists but it can be reduced significantly with proper risk assessments in place.

As a previous poster said, if youth group volunteers can do this, so can teachers.

The event has happened you can’t have a retrospective risk assessment. It is highly likely that a risk assessment was in place. Risk assessments consider both the chance of something happening and also the severity of the adverse outcome should the event occur. This would always be likely considered to be low risk because the outcome of this child not receiving their medication is low harm/no harm. Indeed given the low harm/no harm nature of the outcome it may actually be considered no risk/acceptable risk for which no mitigations would be required.

Obviously what has been done (or not) cannot be undone in this case and it happened despite (one would sincerely hope) a risk assessment being in place.

You're right, risks assessments consider the likelihood of something happening and the severity of outcome. As it turns out, there is a very real likelihood that teachers/leaders will forget to administer medication so, assuming that wasn't on this risk assessment, it needs to be added to future ones.

The fact that this child has fortunately not suffered any harm this time is a red herring. Whilst risk assessments may identify some risks which may be so unlikely/unpredictable or result in such low harm that no mitigations are required, this situation would never be one of those. Where children are involved and where you are in loco parentis, the bar is set a lot higher. The compiler of the risk assessment is not in a position to decide that failure to give prescribed medication is an acceptable risk, unless they have been informed of that by the child's doctor or parent, which they clearly weren't. Besides, the steps I suggested should have been taken to prevent this happening were not so onerous as to outweigh the potential harm which is the general rule when deciding whether mitigations need to be in place or not.

The outcome of the OP complaining to the school should be that they need to reconsider this aspect of their risk assessment to ensure it doesn't happen again.

Having an accident / near miss/ mistake is exactly one of the times you should review a risk assessment. It is one of the key points in risk assessment training. (Particularly on the assumption there will be a residential for Y6 next year)

It’s not a red herring as risk assessments should deal in the actual situation not all possibilities. This situation is a situation where the outcome is low harm/no harm/ acceptable risk. The fact that for other children in other circumstances it wouldn’t be is neither here nor there.

I am not sure anything should happen. They made a mistake by only giving the medication in the morning. It was clearly an error but not one with very serious consequences. I should imagine they will be apologetic and you should accept the apology.

The consequences for the OP's son weren't too serious, no. But that in a way is luck, for other children they might have been. This is something that should not happen.

And we do.

What cannot be factored in is the designated person forgetting or misunderstanding.

The RA template is written, adapted, submitted to SLT and signed off by HT. (in my school)

And as @jenandberrys says, this particular outcome, that a non life threatening situation arises because of human error, would be in the "amber" RA category. The "shouldn't have happened, they all live" category.

The school will apologize, and will note the event. The next RA will perhaps include "remember that non urgent medication still needs to be handed out". In the "actions to be taken to ensure it doesn't happen again" they might write "child to remind staff" At the age of the OP's child, and on the information she has given, that would be a perfectly acceptable solution.

I run a rsidential camp every year.

As others have said we have detailed RA and lists.
One designated first aider who has all the medicines and a list of who needs what when.

We take it very seriously, and I would be very unhappy with a child missing meds.
It may not be an emergency, but can still have knowkc on effects. My friend's son who has Crohns, a reduced does of his would be a slow burn, leading to a flare up later, and flare ups can take months to come back from.
Not good.

I think you and I are going to have to disagree on this.

Risk assessments absolutely should deal with forseeable risks - i.e. possibilities. That's exactly what they are for. They don't deal with "the actual situation" because the point of them is to consider what might happen prior to the event taking place.

I'm not sure what type of risk assessments you have experience of, if any, but I have considerable experience of writing risk assessments and signing off other people's risk assessments for exactly this sort of event - one where you are an adult taking other people's children on residential trips.

The point is that something that should have been done to keep a child safe wasn't. It was a near miss since, if they can forget for this child despite the correct forms and information being provided by the parent as required, they can forget for any child. The outcome for this particular child is entirely irrelevant going forward. As you yourself say "the fact that for other children in other circumstances it wouldn’t be [low harm/no harm/acceptable risk]" is exactly the reason why it should be included on future risk assessments. They clearly need to put measures in place to prevent this happening to another child and the best place for that is on future risk assessments

I agree with Owl

and are first aid RA includes a set time each morning and evening when the first aiders only job is to check the meds and the lists and make sure everyone has what they need.

I am not sure we are actually disagreeing. I was simply pointing out that risk assessments are not retrospective and that with regard to this situation the risk was low harm/no risk.

The only hysteria is currently coming from posters telling the OP to sue

Has anyone on this thread done that? If so, I missed it. The only poster I can see who even mentioned 'sue' was talking about a completely different case in a different situation, and even then was in no way encouraging it, merely pointing out that it could be a possible consequence if severe harm was caused as result. Similarly, people can sue hospitals if sub-optimal treatment leads to harm or death. But none of that is relevant to this instance, where it strikes me that OP is being eminently reasonable and would just like an explanation...

@jenandberrys you are incorrect, I'm afraid. Formal RA training does exactly this – looks at all sorts of worst-case scenarios and attempts to put in place specific plans for them. They 100% DO try to cover all possible eventualities.

A risk assessment is just a risk assessment. It’s one part of risk management and is a bit useless on its own. Risk assessments should always be made prospectively, and then measures put into place to control the risks.

If an incident happens there should be an incident investigation. This will look at what should have happened, and whether the planned controls failed. If the planned controls failed, why? If they did not fail and the incident happened anyway, should this have been foreseen and covered by the original risk assessment, or was it genuinely unforeseeable?

In all cases the root causes should then be identified. Only then can a new risk assessment be made to identify any new controls that are required. Human error is never a root cause and is a cop out. Poor processes, inadequate resources, lack of knowledge, lack of competence… all of these should be addressed. Usually it’s poor processes, in my experience. In general, teachers are teachers, not process designers or risk management specialists - why would they be?

Also that no harm to the child occurred is a red herring. The next time there might be, and there are also other harms e.g. loss of trust.

Completely unacceptable. I was in charge of meds when I went on residential and it was really scary. I was do paranoid about getting something wrong with someone else's child, I set multiple reminders on my phone and set my watch alarm (and the majority of meds we had was hay-fever related!)

I think (but am not sure) that @jenandberrys is a teacher (like me) and so very well aware of what RAs need to cover.

(I'm the member of SLT who does the final tweaking of ours before the HT signs off)

Everything that group leaders on the thread have said, is of course relevant and included in RA protocols. As basics. Nobody disputes that.

What people seem to be missing is that a RA isn't a silver bullet. That's also one of the things we underline in RA/safeguarding training.

The medicine should have been given.
It wasn't.
It's a mistake.
The named member of staff responsible for the mistake will be told.

I'm not sure what you're so anxious about OP?
Obviously you're meant to ask them how the error occurred. For all you know it's you who might have ticked the wrong box on a form or something. Or they transferred data to a master sheet and mistyped something.
Then asked how they'll prevent it in future.
The end.
Also while teachers etc should be responsible a child that age should absolutely be able to ask for their medication in the absence of SEN which you've already clarified.

What else do you expect to happen?

It sounds like this wasn't human error but a failure in process. The child was given his medicine every morning and wasn't given it every evening, so whatever system the staff had to prompt them wasn't given the right data. E.g. if it was a handwritten list, the evening medication was left off. The school should identify how that happened and fix it for the future.

No you are incorrect. RA training does no such thing unless it is extremely poor quality. The point of a RA is not to imagine a raft of worst case scenarios and plan for them, though this is a common misunderstanding. If what you are saying is true every day at school or work would be accompanied by a raft of risk assessments to cover every eventuality.

I'd agree that that is the most likely explanation as to how it happened, especially as the morning medicine was given.

oh for god sake everything doesn't boil down to autism for heavens sake.

Actually everything boils down to autism for some families. Your able privilege is showing.

I'm not a teacher, so maybe in-school RAs can be less rigorous because teachers and support staff already know their environment (classrooms, communal areas, outdoor areas etc) so well that they have a high degree of awareness of likely hazards? In that case the occasional review or possible updating of the relevant plans/documents may suffice? That would seem logical to me.

The RAs which my organisation uses most definitely do attempt to assess every aspect of potential risk (in as far as that is possible) and to anticipate and pre-empt them. Maybe in-school RAs and out-of-school RAs are different? In which case, neither of us is necessarily incorrect, we just have different experiences of RAs?