Situation: Shirley Booth is 77 and lives with her elder son, Peter, 56 and daughter-in-law, Dareen, 49, who look after her. Following a fall Shirley was admitted to hospital with head and leg injuries. Hospital staff noticed that Shirley became agitated before and after Peter and Dareen visited. However, she said she was happy to return home. Problem: Shirley’s younger son, Michael, 54, who lives some distance away, contacted social services. He was concerned that his mother was being neglected. Dareen worked long shifts as a care assistant for people with learning difficulties in the day and as an evening carer in a very sheltered housing project. Peter would go out all day – fishing mostly. So Shirley would be left on her own for 12 or more hours a day. Peter had refused any help for his mother from social services. Shirley’s mobility had been poor but with her injuries she couldn’t get up without help – so was being left all day in bed with a sandwich box, newspaper and a commode by the bed (which proved too difficult at times to use). Peter has warned Michael to keep his nose out and says that Shirley didn’t mind. Shirley, indeed, didn’t mind – saying Peter had worked hard all his life, did his best by her and deserved some relaxation time. Shirley had also just signed over her house to Peter.
This case falls within the remit of adult protection. Shirley is a vulnerable adult and a referral has been received suggesting that she is being left alone. She has also had a fall requiring hospital admission. There is evidence that recent contact with her carers has distressed her. There is no indication that Shirley lacks capacity but this needs to be considered from the outset. Further discussion is needed with her to establish how she feels about her current home circumstances, the hours she is left on her own, her recent fall and that no coercion was involved in the signing over of the house.
It is often difficult for older people to accept and disclose neglect against their own families. There may be a fear that saying anything untoward may result in the loss of that family and sometimes their home too. This can lead to denial. Shirley therefore needs to be interviewed in a sensitive way so that any decisions rest with her.
However, within this it is important to help her explore her options thoroughly with acknowledgement that if she has capacity she is fully entitled to state that no further action be taken.
A comprehensive assessment of need should establish Shirley’s health and social care needs. The sharing of the summary of these needs with Peter and Dareen would be useful for looking at how these needs can be best met. A carer’s assessment would also be important in setting a baseline for a possible package of care and one would be striving for family co-operation in this process. It would also be useful to explore why the couple have refused help in the past. Dareen, in her work, has some experience of how agencies meet the needs of vulnerable individuals.
If Shirley decides she is going to remain in a potentially vulnerable position I think it would be beneficial if solutions are found through negotiation rather than confrontation. If co-operation is lacking, a decision needs to be made as to the degree of confrontation and authority that can be used to point out the potentially harmful consequences of the situation to both Shirley and her family. That would depend on a judgement balancing risk, user wishes and the potential for co-operation. The aim would be to keep involvement so as to gain trust and effect positive change.
There are several issues here: rehabilitation; risk of falls; social isolation; financial dependence; relationships; the needs of the carers; and abuse of older people.
If I was advising our nursing or allied health professionals on this case I would suggest that we take a look at Shirley’s potential for rehabilitation, possibly in the home environment, in the care of Peter and Dareen. This could be provided by the intermediate care team at no cost to the individuals and thus may be more acceptable to patients and families.
In providing care in the home environment there is an opportunity to develop a close relationship with Shirley and also to assess the family dynamics. This period of rehabilitation can assist in developing a future plan for Shirley.
Elements that we would need to focus on include Shirley’s ability to get on and off the commode or toilet unaided and, if this was not possible, to consider other alternatives. Shirley’s diet would also be looked at with a possibility of providing meals-on-wheels.
It may be possible to arrange for Shirley to attend a local day centre or luncheon club either for social activities or for rehabilitation. These may help reduce her social isolation. A falls assessment and referral to the falls team may also promote some level of independence.
The issues surrounding Shirley signing her house over to Peter could be explored by involving a social worker. The implications of the impact this has on the services that Shirley may be able to access would also need to be considered.
It may be appropriate to involve Age Concern or other voluntary agency to act as an advocate or befriending service for Shirley in any discussions, and may give Shirley the opportunity to voice any concerns that she has about returning home.
Dareen and Peter should be offered a carer’s assessment as to their needs and to work with them in assisting them to keep Shirley with them in their home, if that is the most appropriate place for Shirley to live.
Throughout, staff would need to establish if Shirley was the victim of elder abuse and if so to follow the adult protection procedures.
In the hospital, staff should be speaking to Shirley to find out what caused the fall in the home, write members of Knowsley Older People’s Voice. Through unobtrusive questioning they should be able to build up a picture of the care Shirley is receiving at home.
Shirley’s mood changes when visited by Peter and Dareen, and this cannot be ignored. Health and social care practitioners should be able to recognise the signs of different types of abuse and to respond appropriately.
Shirley should be provided with information on the choices available to her and the support that social services can provide for her at home. It is a real possibility that Shirley is afraid or too embarrassed to speak out about what is happening at home and feels trapped. It is important to speak to Shirley while she is in the hospital setting and away from the control of Peter and Dareen, who may influence Shirley’s responses.
Shirley’s choice to return home should not be taken as an indication that she feels safe or is happy to return home. She may fear being moved to residential accommodation, scared she will lose her house or afraid of Peter and Dareen’s reaction to her not returning home.
The concerns of neglect that Michael highlighted need to be taken seriously, the refusal by Peter to accept input from social services is not his decision to make. Shirley seems able to make her own decisions, therefore the complaint needs to be investigated further.
A home visit is necessary to assess how Peter and Dareen are caring for Shirley and time to outline details on appropriate care and other options such as home helps, who could monitor the situation in which she is living.
Maybe there is a day care centre that Shirley could attend rather than being left home alone; this may also give her access to services or forms of exercise and help with her rehabilitation following the fall. Centre staff could then assist in monitoring Shirley’s well-being.
The case shows signs of elder abuse both physically and possibly financially and health and social care staff cannot overlook these warning signals.
Knowsley Older People’s Voice is a self-advocacy group in Merseyside with support from service users from St Mary’s day care centre in Halewood.