Wrong kind of care

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

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

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

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

– 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.

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