A timely reminder

CASENOTES:

PRACTITIONERS: Dawn Cattanach, community care
worker, and Giles Gardner, operations manager.

FIELD: Older people’s services.

LOCATION: West Devon.

CLIENT: Dora Roberts is an 83-year-old woman
who lives alone in a bungalow. Her husband, Brian, died 18 months
ago. She has two daughters: Lisa, who lives in northern Scotland;
and Rosa, who  lives about 15 miles away but is dependent on a
wheelchair. Dora was unknown to social services.

CASE HISTORY: Following Brian’s death it was
Lisa, who had come down for the funeral, who made the initial
referral to social services because she was worried about her
mother’s forgetfulness. For example, Dora did not believe that
Brian had died. Cattanach, at first, wasn’t sure if this was
because Dora was still grieving but it became apparent that she had
very short-term memory. Dora proved very resistant to having any
help. Cattanach returned a week later after Lisa had gone back to
Scotland, to find that Dora, who was unhealthily thin and weighed
less than six stone, had no recollection of her first visit
following Lisa’s referral.

DILEMMA: While the aim was to keep Dora at home
this could only be achieved with family support – which was proving
difficult to obtain.

RISK FACTOR: Dora’s forgetfulness, physical
condition and vulnerability put her at risk of self-neglect and
harm.

OUTCOME: With family and agency support Dora,
whose forgetfulness is worsening, remains at home and is eating
well and keeping warm.

Forgetfulness can just be part of the normal ageing process. We
all have experiences, for example, of not remembering where we put
a pen we had a few seconds earlier. However, people with cognitive
impairment, who may experience pronounced forgetfulness (but not
dementia), may not only be unable to recall where the pen has gone
but what a pen is used for.

For older people forgetfulness is a major risk factor
particularly if they are living alone. Forgetting to eat or to turn
off the gas can be fatal. Dora Roberts, 83, who was not previously
known to social services, had begun to fit the risk profile. Her
worsening forgetfulness coincided with the death of her husband of
over 50 years, some 18 months before social services became
involved.

“She was painfully thin and not eating,” says community care
worker, Dawn Cattanach, who was allocated Dora’s case. “She would
also sometimes switch the gas fire on but not light it; but then
sometimes when it was lit she would throw papers on it thinking it
was a normal fire. And she’d leave the gas cooker on. At night she
would wander, knocking on the next-door neighbour’s door asking if
her daughters were there: believing them to be still small
children.”

Dora’s weight loss was a serious concern; not only was she not
eating but when she did remember to cook, the food was often not
fresh. “She would put frozen food in the fridge rather than the
freezer; and food would be found in bizarre places – cucumber and
tomatoes which had gone mouldy were found in the cloakroom,” says
Cattanach.

Dora’s daughters, Rosa and Lisa, who had referred their mum in
the first place, seemed unaware of the risks involved. “We had a
case conference with the community psychiatric nurse manager, Rosa
and Rosa’s son to discuss the risk – specifically of leaving the
gas on,” says operations manager, Giles Gardner. “We were trying to
maintain Rosa in the community but we would need their
co-operation. We asked if they could get the gas disconnected and
we’d look at her food arrangements after that.”

However, Rosa seemed strangely resistant. “She said how Dora
liked to see the flames and didn’t want to upset her mother. Rosa
really wasn’t aware of the risk,” says Cattanach.

A mental health support worker, who works with care managers
supporting the care plan, started visiting daily. “That was a huge
benefit. Although Dora would never remember her or that she had
ever met her, she did allow her to take her shopping and let her
stay and cook some food – so she was getting at least one hot meal
a day,” says Cattanach.

However, uncertainty over cost seemed to be at the root of
Rosa’s reluctance to co-operate fully. Says Gardner: “It boiled
down to the daughter’s concern about how much Dora would have to
pay for services. Nobody had any idea what monies she had. However,
the court of protection appointed Rosa to manage Dora’s affairs.
With the financial assessment completed Rosa was more comfortable
about putting in a service.”

Also around this time Dora stayed with Rosa for a week. “That
showed her just how forgetful Dora could be – so that was also a
turning point,” adds Cattanach.

With Rosa on board, the gas was cut off; daily support visits
were set up to make sure Dora was eating three times a day and the
GP advised vitamin pills and build-up drinks. Says Cattanach: “The
other thing was her isolation because she didn’t really see anybody
else. However, Rosa said Dora had never been a social person. The
support worker took Dora to the day centre a couple of times but
she wouldn’t even get out of the car.”

Because she was so thin, Dora often got cold and would be found
wearing layers of clothes. “She had gas central heating but she
would turn it off, and would unplug things – such as lights and
telephone. But if you put up signs saying ‘do not touch’ she
wouldn’t touch it – so heating and water were set to timers,” says
Cattanach.
Gardner says that the mental health team who were involved early on
suggested residential care. “But she was absolutely adamant she
didn’t want that. We’re always focusing on maintaining people in
the community. I know it sounds like rhetoric but if we can keep
them in their own homes even when their cognition is really poor,
we will.”

And even if Dora forgets who is helping her, she is, thanks to
the commitment of community care workers, where she wants to be –
at home.

ARGUMENTS FOR RISK

• Services offered should follow, where possible, the wishes of
  the service user. Dora wanted to be in her home.
• However, this could only happen with Rosa’s support. According
  to Gardner, Cattanach won Rosa around by “being transparent in her
  dealings with her – involving her in all discussions and meetings –
  but being very clear about the risks being managed. I think it was
  a gradual appreciation of the level of risk and a gradual
  acceptance that the team was working very much towards maintaining
  her at home,” he says.
• With the main risks minimised any deterioration can be
  monitored effectively. Says Cattanach: “She doesn’t go out alone
  any more; the gas is off; she’s eating more; the house is warm; she
  has company because she gets two hours a day support and the agency
  calls us if her behaviour becomes different. Her behaviour is
  usually odd but as long as it’s the same odd behaviour then that’s
  good.” 

ARGUMENTS AGAINST RISK

• Cattanach, rightly, at first referred Dora onto the mental
  health team. It thought Dora’s needs would be best served by
  residential care. Although things have turned out fine, it could
  have easily spelt disaster. The reluctance of the family to cut the
  gas was a clear indicator of potential risk – not only to Dora and
  her property but to neighbours. If things went wrong then Dora’s
  family and Cattanach would have to explain the decision to keep
  Dora in her own home to the grieving relatives of the neighbours
  and, undoubtedly, to a posse of lawyers and insurers.
• There is an undoubted dilemma about sticking rigidly to a
  policy – no matter how good. As Gardner points out: “Clearly if the
  risks increased we would need further meetings to explore what
  else, if anything, can be done. And maybe, as we have done before,
  we make a decision that it’s just not safe and if there is a
  consensus we would move her into residential care – but that is
  never our starting point.”

INDEPENDENT COMMENT

On the face of it, Cattanach and Gardner took major risks with
the welfare, even the life, of Dora Roberts. If a serious accident
following a gas explosion had occurred, or if her health undermined
by malnutrition had suddenly deteriorated, the care staff, who had
been aware of her vulnerability but left her living alone, would
probably have faced heavy public criticism, writes Jef Smith. 

If they were registered as social workers by the General Social
Care Council, they might even have been accused of professional
misconduct for failing to comply with paragraph 4.3 of their code
of practice, which obliges them to take “necessary steps to
minimise the risks of service users from doing actual or potential
harm to themselves”.

The alternative strategy involved action on several fronts.
Relatives were engaged, educated, and reassured once the financial
position had been clarified; Dora’s trust was built up through
daily monitoring by the mental health worker and immediate sources
of danger were neutralised by cutting off gas appliances, putting
up warning notices and installing timers; support was provided with
shopping, cooking and diet. Removal to a home would have been
safer, tidier and less time-consuming, but quite unacceptable to
Dora.

Although Dora demonstrably lacked the ability to make informed
decisions about her own safety, she was clear that she wanted
neither residential nor day care. So what the workers bravely
achieved, again in the words of the code of practice – paragraph
1.2 – was “respecting and, where appropriate, promoting the
individual views of both service users and carers”. 

Jef Smith is a writer, trainer and consultant in care
for older people.