Some questions had haunting answers. If Mr. Banks had received the level of supervision one staff had prophetically indicated was needed in order to protect him, perhaps the accident could have been avoided. Honoring and fostering consumers' everyday interests is a vitally important role played by service providers. It also has attendant risks, which providers must be mindful of and safeguard against. Sometimes the risks associated with some of these interests are readily apparent, for example, risks associated with learning cooking skills, independent travel skills, or vocational skills in industrial settings.
Risks associated with leisure time or recreational interests, however, are often less appreciated.
After all, swimming, bike riding, hiking, etc. are things we all do to relax, to take pressure off. They are things we do when we want to have fun and not work. Lester Banks' death taught his agency that it did not pay sufficient attention to the leisure-recreational interests of clients in a way that would promote abilities and at the same time safeguard against harm. Had Mr. Banks engaged in serious maladaptive behavior, such as fire setting, assault, etc., as he had done in the past, it would have been amply documented, reviewed and communicated to all staff. But when he engaged in a healthy recreational activity which potentially posed as serious a risk of harm, it was not well documented, appreciated and communicated to all staff.