Against the stream

Case notes

The name of the service user mentioned in this article has been changed

PRACTITIONERS: Ian Leeson, social worker, and Giles Gardner, operations manager.
FIELD: Older people’s services.
LOCATION: Devon.
CLIENT: Michael Morgan, 81, lives alone in a first-floor council flat. He has prostate cancer, mobility problems and poor memory (for which he writes copious notes) and uses a catheter. None of his family is in contact and his nearest relative, a nephew, has returned letters stating he wants no further contact.
CASE HISTORY: Morgan is considered “odd” by his neighbours who complain about his strange behaviour, his playing loud music and banging on the floor overnight. They say he appears “drunk” and is abusive. In three months he was admitted to hospital seven times with urinary tract infections, raising concerns that his increasing dementia was making it impossible for him to live independently. Most recently Morgan discharged himself from hospital against medical advice and returned home where he has been behaving “strangely”. The emergency duty team worker referred Morgan to the older people’s team for assessment.
DILEMMA: Despite the social worker’s commitment to keep Morgan at home, all professional medical advice is pressurising for a care home placement, and the housing department and Morgan’s neighbours do not want him home.
RISK FACTOR: Morgan’s forgetfulness and weak physical health could deteriorate causing further hospitalisation.
OUTCOME: Morgan remains at home with home care and district nurse support. He now gets on with his neighbours.

The Soviet dissident toast “To the success of our hopeless cause!” is a sentiment that could sum up the challenge facing social worker Ian Leeson in the case of 81-year-old Michael Morgan. Leeson’s voice was an isolated one in danger of being silenced through consultant, GP, nursing staff, housing department and neighbour pressure to prevent Morgan returning home from what was his seventh hospital admission in three months.

Morgan had repeated urinary tract infections caused by poor management of his catheter. “After a few days in hospital with good hygiene, health care, diet and antibiotics, his infection would clear and he would go home,” says Leeson. “But as a pattern of hospitalisation developed, staff began thinking that he couldn’t manage on his own and should be placed in a care home.”

Morgan’s GP agreed saying that to keep him at home would stretch their resources, particularly given Morgan’s rural location. “The overall feeling was that Michael was a bed-blocker and that I had better get it sorted,” says Leeson.

However, Morgan did have one ally: his social worker. “There was an awful lot of pressure exerted by health staff essentially saying that an inordinate amount of time was being spent on this man,” says operations manager Giles Gardner. “It’s not uncommon for us to be fighting the corner for the individual to maintain them at home because some health staff generally look to placements perhaps quicker than we would.”

Leeson found that Morgan had never finished a course of antibiotics because of his poor memory, so picked up infections again. “The hospital discovered he wasn’t drinking enough fluid because he wasn’t remembering to drink enough,” says Leeson. “He needed to be somewhere where his ability could be assessed and in a non-judgemental setting where they haven’t already decided he should be in care.”

However, before a care package could be set up Morgan was again back in hospital. The pressure to have him placed in care intensified. “They agreed to keep him overnight ostensibly while I found him a placement,” says Leeson.

Morgan believed that everything was out of his hands. “He kept copious notes and likes to see the written word so he can think it through,” says Leeson. “So I faxed him a letter which outlined his choices. The ward staff said, ‘We can’t give him this, it tells him his rights’. But the hospital social work team gave him a copy.”

Later that day Morgan declared his choice to go home. To facilitate this, he was placed for assessment in an intermediate care unit for older people with mental health needs. “He thought I was conning him and this was residential care by the back door,” says Leeson. “But he held on to his letter saying, ‘I have my rights!'<2009>. The staff were very good with him, saying ‘We expect you to go; you’re not going to live here for the rest of your life’ – and that reassured him.” He would be there for up to six weeks.

For Gardner, all parties should have been working together to secure an appropriate plan. “But it was Ian’s personal crusade to insist that Michael’s rights were respected. All I did was support Ian through that process. Michael was hospitalised seven times and on the third or fourth they wanted him placed in care.”

A support worker started making home visits with Morgan to help re-familiarise him with the environment and re-establish routines. Leeson says: “As he liked his lists, we wrote down what he needed when he got home and where everything was. Also because he was feeling better his neighbours found him more communicative, and you could see they were thinking about giving him a second chance.”

Morgan’s care package now includes four daily visits from home care, concentrating on his fluid intake and catheter management. A district nurse also visits weekly.

“Even his neighbours now think he’s a nice guy,” Leeson says with a smile. “He was a DJ and he gave his music collection to a local youth group and got a ‘thank you’ letter; that made him feel happy and part of the community. He just feels he is worth something again, which he hadn’t felt for a long time.”

Morgan has been at home for nearly a year now. He continues to keep extensive notes as reminders, and all agencies add to these notes to give him time to read their messages.

“It’s a real success story,” says Gardner. “And one that is down to Ian’s perseverance in upholding Michael’s rights. There is no question that otherwise he would have been in care with no chance of rehabilitation into the community.”

Arguments for risk

  • It is always crucial to find out what the service user wants to do, and once Morgan realised he had a choice he was adamant that he wanted to go home. According to Leeson, he said: “I don’t have many options but I choose not to go into residential care. I’ll just curl my toes up and die if I go into a home.”
  • If he had been placed into care he may have thrived in the short term but could have become institutionalised. Gardner says: “If people go into care too early they get used to the surroundings and they never or rarely move from residential care back into the community.”
  • Although his health was weak, Leeson assessed that Morgan’s hospital admissions were based on his forgetfulness about finishing a course of antibiotics and to connect or empty his catheter. With the right support and guidance from an at-home package, including home care and the district nurse, these difficulties could be managed effectively.

    Arguments against risk

  • The social worker was acting in isolation against all available medical advice which was advocating, with sound reasons, a placement in a residential or nursing care home. Housing officers and neighbours were also clear that they did not wish Morgan to return home.
  • Morgan’s mental health, although the subject of much work, appears not to have been assessed, but there is seemingly a query on dementia which appeared to be deteriorating. His physical health was poor. He displayed symptoms of self-neglect: poor diet, hygiene concerns related to catheter, social isolation, no immediate effective emotional support from friends or family. This could all be best managed with 24-hour care.
  • The picture appeared to be one of physical, mental and emotional ill health all spiralling out of control.
  • There was also the risk of neighbours becoming angry with his continued presence and making their feelings known to him, further increasing his isolation and emotional distress

    Independent comment

    What exactly was the risk being taken by Ian Leeson in this situation?  Michael Morgan was unlikely to face a major crisis, since he was apparently – just about – coping with his domestic arrangements; no one had accused him of turning on the oven without lighting the gas, the sort of story which is often produced to justify institutionalising people, writes Jef Smith. His health was not being managed ideally, but again there was no immediate threat to his life. Indeed, to have been admitted to hospital seven times in three months suggests that someone was monitoring his health and taking prompt action.

    In short, Leeson’s risk was to the reputation of social services. Practitioners from health and housing were at one with the neighbours in wanting the social care system to get an awkward problem off their territory. Not going along with their anxieties could have brought on well-rehearsed accusations of the uselessness or unhelpfulness or otherworldliness of social workers, swiftly followed by “I told you so” when the situation deteriorated. So what? Better than breeching the Human Rights Act 1998!

    Morgan, whose views matter most, was the person really taking the risks, and he was clear on what he was doing. His making of lists showed insight into his problems with memory, his position on not going into a home was wholly rational, and his statement of his rights was precisely in line with current political and legal opinion. The task of the social worker was to support the client to take decisions independently and help other agencies to reach that position; which is exactly what Leeson did. 

    Jef Smith is writer, trainer and consultant in the care of older people

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