Dorothy McDermott was 80 years old. She had been housebound for 234 years. She had been diagnosed with a urinary tract infection and was confused. On the 17 th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.3Opm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18 th January. It was envisaged that Mrs McDermott would be reassessed on the 19 th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision was one of availability with the facility of a ground floor bedroom which had been newly decorated. Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.