05/06/2026
Storytime.
A participant absconded from a SIL home.
The on‑shift worker panicked, left another participant alone, called an off‑duty colleague for help, and made a series of pressured decisions that weren’t theirs to make.
The participant was eventually found by police at 3am.
Everyone cared. Everyone tried. But caring isn’t enough when the systems aren’t clear.
This wasn’t a “bad staff” situation. It was a systems problem:
– unclear procedures
– no quick reference under pressure
– no clear hierarchy of decision‑making
– no clarity about who to call
– no structure to fall back on when stress spikes.
When systems aren’t clear, people guess.
And in disability support, guessing is where risk lives.
The moral?
In high‑pressure moments, people don’t rise to the occasion... they fall to the level of their systems. And for some providers, that's downright terrifying, because their procedures live in their head or are buried in the back of their admin drive.
If this story made you think of your own “near misses,” you're not a bad person and you’re definitely not alone.
The good news is it's absolutely fixable.
Happy to chat anytime.