Collaborative Safety – Systems Mapping 
Case Summary
October 14, 2019
Hennepin County


Learning Point #1: Staff lost sight of a person at the State Fair.

Learning Point #2: Staff brought his son along on this community outing. 

Incident report description
•	Incident date: 8/24/2019, between 12:30 PM and 5:30 PM
•	Report date: 8/27/2019 4:11PM

Staff and person went to the Minnesota State Fair on a Saturday afternoon. During this outing, the person was unsupervised for approximately thirty minutes. The person had a rental scooter and took off on it to go to use the bathroom. The staff could not keep up with the scooter and lost sight of the person. Approximately 30 minutes later, staff found the person near the bathroom. 

Two days later, the reporter found out about the incident during an appointment between the person and a Psychologist when the person told the Psychologist "while at the Minnesota State Fair on Saturday, I was alone for about thirty minutes." 

Debriefing information for learning Point #1, October 25, 2019

Staff participated in a human factors debriefing, led by a Safety Analyst, on October 25, 2019.

Upon arrival at the State Fair, the person rented an electric mobility scooter for people with disabilities. The staff brought his 10 year old son along to the event. The staff’s attention was influenced by the person’s behavior as they began walking into the Fair, when the person said she wanted to go to the beer garden and drink beer. This action triggered the staff to wonder if this was a good idea. 

Shortly after arriving, the staff and his son sat down to eat some food while the person used the scooter to go and browse at a souvenir stand within eyesight. The crowd at the Fair impacted the staff’s focus when he lost sight of the person on the scooter during the outing. Staff reported he was not distracted by his son’s presence. 

Debriefing information for learning Point #2, October 25, 2019

During the debriefing session for Learning Point #1, Staff shared he brought his son along to the outing after the VA told him she thought it was fine. He explained it was a last minute decision because of issues around child care coverage.

Result of Incident
Staff reported going to the beer garden to search for the person. She was not there, so he called her on her cell phone. She answered his call, but could not tell staff exactly where she was. This phone call went on for about 30 minutes until staff located the person.

