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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.