On April 2nd last two buses left the Rossecourt day centre, in Lucan, west Dublin operated by Stewarts Care, bringing 11 people and seven staff on a trip to a nearby swimming pool in Palmerstown.
A couple of hours later on the return journey, there was an empty seat in one of the buses. A 19-year-old man had been left behind and was later found by gardaí walking in the middle of a dual carriageway near the M50 motorway.
A report into the incident carried out by barrister Mary Linehan and a senior Stewarts human resources official, is scathing.
Completed in recent weeks, it found the young man had been “abandoned” and could have been killed or seriously injured.
“This is not to say that it has not had a detrimental impact on him or his family. There must be an obvious loss of trust, which would seriously undermine his confidence in Stewarts Care in providing him with a safe environment,” it said.
Stewarts Care is one of the country’s largest organisations providing services for people with disabilities.
Original list
Several factors led to the young man being left behind. An original list of people to travel on each bus was drawn up and later changed. A female member of staff had been providing support to the young man on the trip. After the group left the pool she waited outside the male changing rooms. There were two male staff members inside. On three occasions she checked on the young man, and was told by the last staff member leaving the changing rooms that he had gone back on the first bus which had already left.
But the young man was still inside, changing in one of the accessible toilets.
Before the second bus left the sports centre, staff noticed an empty seat. One employee left to conduct a check of the sports centre, which he described as a “quick scan” in his interview for the report. He did not check the changing room, which the report found was a “serious error”.
Nobody was found
When nobody was found during this sweep the employee returned to the bus, which left the centre shortly afterwards. Staff did not realise the young man was missing until they got back to the Rossecourt centre.
Upon realising this, staff members returned to the sports centre believing the young man would have waited there. The report described the young man as a “very vulnerable service user,” and gardaí who found him said they “knew he was in trouble as he appeared lost,” the report said.
When he was brought back to Rossecourt, staff said he looked “very distraught” and “really shocked”.
The investigators said they had uncovered “numerous safeguarding matters” which required the organisation’s “immediate attention”.
They found people with “high support needs were left unsupported in the water” during the swimming trip. “It is inconceivable that one staff member was supporting 11 service users” in the water, the report said.
It found if the searches following concern over the empty seat had been adequate the man would have been found. “The inadequate searches carried out constitute poor professional practice and neglect”.
The staff member who conducted the search maintained he did not know the missing man had been on the trip at the time and did not see him at any stage. The investigators said this account was “scarcely credible” given they were in the changing room at the same time.
A more senior staff member on the trip also came in for criticism. As the situation developed he “failed to take adequate control to prevent the abandonment of a service user,” the report said.
Change the lists
He had allowed bus drivers to change the lists of who went on either bus, he did not know who was on what bus, and did not have any concerns about the empty seat or make appropriate inquiries to establish if someone was missing, the report found.
He also failed to contact his line manager to inform them someone was missing, only calling his senior manager after the young man was found. The more senior staff member told investigators on the day he was
short-staffed, and decided to fill in to support a service user in a one-to-one role and as a result “he was not acting in the capacity as a manager” during the trip.
