The deceased was 82 years of age, was severely frail and suffered from dementia. The deceased was assessed as being at high risk of falls and had a reputation for wandering around the establishment. The deceased was not unique amongst the other residents in having such vulnerabilities. The lounge areas of the nursing home have doors leading to the garden. The garden has within it potential hazards to a vulnerable resident with a high risk of falls. The doors are kept wide open in warm weather. Whether a resident has entered the garden is only known if they are observed by a member of staff to do so. Members of staff are frequently distracted by other duties hindering their ability to fully and effectively observe vulnerable residents entering the garden. There is an absence of an effective exit control process to ensure that those with a recognised risk of entering the garden alone are prevented from doing so or an effective alert system is triggered when they do so.