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Following the death of her husband and carer in 1995, Carole Browne, an 85 year old with Alzheimer's, was referred to social services. Caroline Ensor, Browne's only daughter, returned home from Hereford, following the break-up of her marriage, to take over the caring role. It seemed the perfect answer.

But the perfect answer soon raised questions. "There were concerns that the daughter could not care adequately for Browne," says team manager John Hannaway, who would inherit the case some five years later. "For instance, not having food in the house and not having adequate clothes. Care workers would find her in a T-shirt and nothing else, and be unable to find any other clothes or underwear in the house." Neither would they find soap, flannel or towels. The department felt that residential care was the best place for Browne. And for the next five years, it tried to work with her daughter to achieve that. But Ensor fervently and consistently resisted.

Given the impasse, it was decided in early 2001 to allocate Hannaway and social worker Joanne Welch to look afresh at the case. Ensor was still causing concern. As Hannaway recalls: "She'd agree, for example, for Browne to attend day services and then take her home again an hour later - or to take her to the cashpoint, which suggested potential financial abuse. She'd agree to respite care, only to arrive at the home at two or three o'clock in the morning and take her back."

After assessing and investigating the history of the case, Hannaway called a planning meeting. Considering the case history, which also included Ensor withholding prescribed medication (scabies cream) from Browne, and shouting and slapping incidents in the street to which police were called, it was again agreed that residential care was the safest option.

"Browne had respite for a couple of years," adds Welch, "and all indications were that she loved it there and would be able to settle there permanently." But how to achieve this? It was agreed that if Ensor objected, social services would pursue a guardianship under the Mental Health Act 1983, a way of seeking compulsory control over a person who needs help: in effect, displacing her as Browne's nearest relative.

Ensor's response was predictably hostile. "She went ballistic," says Hannaway, "and not only would she oppose the guardianship but she'd go to court and the newspapers." She also wanted her mother, who was in respite care at the time, to come home with her until things were sorted. "But I explained that that wouldn't be in her mother's best interests," says Hannaway.

Ensor sought court intervention. Her solicitor - a mental health commissioner - tried unsuccessfully to persuade Hannaway and Welch to reconsider the guardianship. "We said we'll look at anything again in 'x' months time, but we need a period of stability." From October until the court date in December, Ensor visited her mother at all hours, including very early in the morning. "Yes, to prove a point," says Hannaway, "but also because she was lost."

Soon there were worrying concerns about Ensor's obsession with her mother's cleanliness. She would physically inspect her mother's genitalia and backside. This was stressful for Browne, not least because Ensor's estranged husband would also be present in her room. "On one occasion," says Hannaway, "staff knocked on the door and entered only to find Browne in the corner with Ensor holding a flashlight looking at her mother's backside. She then remonstrated with staff that her mother was not clean.

"This was reported back to us," he continues, "and we spelt out to Ensor the unacceptability of her behaviour. We made it a rule that she could only visit her mother in the communal areas of the home." However, in the residents' lounge Ensor again operated the same cleanliness check regime, to the great distress of Browne who was screaming, with Ensor screaming back at her.

Then the day before it was due in court Ensor withdrew her case. Thus with the guardianship secured Browne's residential placement was made permanent. Browne is now settled and thriving. The guardianship continues. "I also understand that currently Ensor is banned from the home because of her disruptive behaviour," says Hannaway. "She was doing things like taking other residents to the toilet."

Despite her behaviour, Hannaway doesn't believe Ensor was knowingly abusive. He says Ensor cared passionately for her mother but it manifested itself in unacceptable ways. And in such circumstances, tough as it was to intervene, it was the duty of Hannaway and Welch to put the interests of Carole Browne first.

The names of family members mentioned in this article have been changed.

Case notes

Practitioner: John Hannaway, team manager and Joanne Welch, social worker.

Field: Older people's services.

Location: Stockport, Manchester.

Client: Carole Browne is 85 years old and has Alzheimer's disease.

Case history: Browne was first referred by her GP to social services in 1995 following the death of her husband who had cared for her. Browne's only daughter, Caroline Ensor, 48, at around the same time moved back to the area from Hereford following the break-up of her marriage and to "look after mum". Ensor moved into a flat but spent most of her time at Browne's house. Ensor's estranged husband also moved back to Stockport, primarily to support his wife, although he moved into a different flat. However, over the years the care provided for Browne was characterised by a growing conflict, which was engineered by Ensor who disagreed with almost all care arrangements for her mother. Various home care agencies and workers have been used because they have frequently been "sacked" by Ensor.

Dilemma: While residential care was the preferred professional option it was clear that the daughter, who would fight it every step of the way, would potentially suffer as a result.

Risk factor: To permit the situation to continue would be to risk further neglect, and financial and physical abuse.

Outcome: Browne is now well settled in residential care. However, recently Ensor has been banned from visiting the home owing to further inappropriate behaviour.

Arguments for risk

- Browne was unable to care for herself and without guaranteed 24-hour care in her own home, residential care was necessary.

- Ensor had no routine of care and therefore often left her mother - unable to use keys - locked in her house alone. Sometimes she should simply forget to turn up.

- Ensor failed to provide adequate food, heating, toiletries, clothes and bedding. At times, she prevented home carers from gaining access to her mother.

- Ensor gave cause for concern over her removal of medication, her physical emotional and financial abuse (slapping incidents, distress caused by being locked in the house alone, taking her confused mother to cashpoint machines at all times of day and night).

- Concerns over how Ensor might react to losing the role of caring for her mother were offset by setting up a scheme for social services to work with her.

Arguments against risk

- Given that Ensor's life now revolved around caring for her mother, there would be undoubted consequences for the removal of this situation. There were concerns over Ensor's mental health and indeed she had once declared that if her mother was taken into care she would commit suicide.

- Other concerns that centred on Ensor were the impact of the loss of status as nearest relative and the loss of not being able to see her mother as often as she wants.

- Despite all the concerns, the department had let the situation carry on for well over five years. Browne had never shown signs of being non-compliant with her daughter's wishes. Even when being collected late at night from respite care she did not show any fear or worry about her daughter.

- Ensor presented as very articulate and astute, and any enforced action might slip up as she could give a very convincing account of herself.

Independent comment

This case illustrates the daily dilemmas faced by social workers who have to balance the often-conflicting needs of vulnerable people, writes Martin Green. It also highlights the ageism in a system where even vulnerability is viewed according to age. I doubt whether this level of neglect would have gone on for five years before a child was removed to a place of safety.

It is clear that in this case the social workers were trying to balance the needs of two vulnerable people: their client and her daughter. But I believe the social workers should have focused on the needs of the older person and dealt with the needs of her daughter separately.

That Browne's daughter presented "as articulate and astute" seems to have influenced decisions about when to take enforcement action. In these situations it is important that social workers focus on their role to advocate for their client and do not take responsibility for what the courts may decide.

The move to residential care was in the best interests of Browne and, when placed, she seemed happier with a better quality of life despite the unacceptable behaviour of her daughter. The care home seems to have handled the daughter's behaviour appropriately and made Browne's needs central. In the end, the social workers acted correctly to ensure Browne's well-being, but the fact that this took five years is of serious concern. For many elderly and vulnerable people time is a luxury they do not have.

Martin Green is chief executive of advisory service Counsel and Care.