An 81-year-old mother does not realise that she is at risk of physical and financial abuse from her son. What can staff do?
The names of the service user and family members have been changed
Situation: Pauline Morris is 81 and lives alone in her own house. She receives four visits a day from a home care service agency which ensures she is up, put to bed and has meals. The rest of the time her family – she has one son and two daughters – help whenever they can. However, as the son – Barry, 57 – lives alone close by in a council flat (the daughters live a long distance away) he spends more time checking in on his mother. He was recently sacked from his job with a skip hire company for overcharging clients and pocketing the difference.
Problem: Home care staff turning up to make an evening meal have been regularly finding Pauline in bed – put there by Barry “because she was tired”. She contracted some pressure sores which the district nurse began treating. It was the district nurse who began to notice household items, such as vases and pictures, missing. Pauline was unsure where they were but did not mind and didn’t like them anyway. The district nurse was also present when Barry delivered Pauline’s pension money – having taken £10 “for going”. When asked about this, all Pauline would say was that Barry “was a good boy”. Home care staff then reported that Pauline had only one set of clothes left and that Barry was asking why his mother could not have direct payments. He has also been saying that he could move in and look after his mother full-time as he cannot get another job.
Practice Panel – Leeds social services department and primary care trust
This case raises clear issues of adult protection. Pauline is a vulnerable adult and appears to be at risk of physical harm and financial abuse at the hands of her son, Barry, who has been dishonest at work and may now be targeting his mother.
The key issue is to assess whether Pauline has the capacity to decide whether she is the victim of abuse and whether she would like action to be taken to stop it. Police intervention may be needed if Barry’s actions constitute a crime.
On a professional level this appears clear-cut, but for Pauline probably less so as she has a positive view of Barry and seems unaffected by his behaviour. As with any family dynamic, Barry and Pauline’s relationship is probably far more complex than the care he provides and financial transactions. Pauline may be unhappy at what is happening but has fears of repercussions or the complete loss of the relationship.
Any intervention needs to be centred on Pauline’s wishes. The issue of Barry’s behaviour needs to be approached sensitively with Pauline and her options discussed directly with her. A review of current need should be undertaken. A psychiatric assessment may be useful to determine capacity. The review should be inclusive of all parties, particularly Barry, but should not exclude the two daughters despite their geographical distance.
A carer’s assessment would provide the opportunity to discuss Pauline’s care needs directly with Barry and to challenge his activities. It is crucial to point out to Barry the detrimental effect of him putting his mother to bed early has on her health – and his other activities.
The request for a direct payment needs careful scrutiny. Does Pauline want – and is she able to administer – a direct payment? Is it Barry’s idea in order to gain access to money? If Barry is the prime mover a negative response is the likely outcome. There is evidence that Barry’s fitness to closely help his mother process a direct payment is in grave doubt. The suitability of him being paid as his mother’s carer is also in similar doubt and, while being a non-residing relative would not exclude him from fulfilling this role, his past and current behaviour surely would.
As the district nurse is already visiting Pauline, a referral with Pauline’s consent would be made to the attached social worker, responsible for Pauline. The referral would be made owing to the areas of concern surrounding Pauline having possessions going missing. Additionally, after Barry’s request to become Pauline’s main carer, a review of the care package would be needed. Alongside the referral to social services, the district nurse would request the GP to visit Pauline to assess her medical condition.
A reassessment of Pauline’s nursing needs would be undertaken so that her changing needs could be reviewed. First, the district nurse would discuss with Pauline her lethargy and why she needed to go to bed early. Pauline may be suffering from anaemia, a common problem in older patients. It would be necessary to take a blood test to determine this.
The district nurse would emphasise how being laid in one position for long periods increases the incidence of pressure sores. Particularly in Pauline’s case, going to bed early may be preventing healing. A reassessment of the current pressure-relieving equipment would be undertaken. Her condition may be resolved by using a different mattress on which to sleep.
The district nurse would also explore Pauline’s nutrition status and examine whether her appetite had changed or she had lost weight. If she is found to have lost weight, the assessment would include questioning about any other symptoms Pauline may have, such as diarrhoea, pain or nausea. Concerns would be discussed at length with the GP. Additionally, as Pauline is a little vague about her missing items, the GP could perform a memory test.
Following on from the referral, the district nurse and the social worker could undertake a joint visit to Pauline. Initially, this may involve solely Pauline; an assessment would enable the social worker and district nurse to discuss the issues identified. The visit would help both the district nurse and the social worker to highlight problems and determine a suitable action plan. Following on from the initial visit, an appointment would be made to discuss changes of Pauline’s care with Barry, with her consent.
This case needs to be handled with great care as it would be fair to assume that there was a serious threat of financial abuse. Pauline’s situation presents a combination of factors, which individually might not give cause for concern but become more worrying when considered together, write members of Knowsley Older People’s Voice.
An initial concern is that Pauline may feel a need to protect Barry and may be choosing not to recognise the apparent problems. She may not consider the actions of Barry to be wrong and may be protecting him. This is evident in her comments on the missing items. Even if she realises that he may be abusing their relationship, Pauline may not want to take action due to a sense of responsibility for her son. There may also be a lot of anxiety about a potential breakdown in the relationship of what seems to be her closest family member.
We should look at the type of care Barry is providing for Pauline. Barry’s practice of leaving Pauline in bed for long periods of the day is wrong and negatively affects Pauline’s health. It may be that Barry is unaware of such consequences. We feel the district nurse and social worker should inform Barry on correct standards of care.
We do feel there are concerns about dignity and choice. Has anyone spoken to Pauline to find out whether she is happy with Barry – as her son – providing some aspects of her care?
It is important for a member of staff to take the lead in investigating this situation and becoming the keyworker for co-ordinating any response. We would hope that the social worker who commissioned the care package responds to the reports of the home care staff. This could be carried out through a review of the care package, while acting in accordance with adult protection policies.
To try to interpret the facts, efforts need to be made to create an opportunity to talk privately with Pauline to ask her what she wants to do. Her wishes should be the key factor in any actions undertaken but, placed in context, Pauline may find it difficult to express her needs because of the family relationship with Barry.
It may be helpful to identify a member of care staff whom Pauline trusts. This would be a key factor in building an accurate picture of Pauline’s situation.
It is clear that the concerns raised by the home care staff cannot be ignored.
Knowsley Older People’s Voice is an older people’s forum based in Knowsley, Merseyside