Proceed with caution – practice panel Staff from Leeds primary care trust and Leeds social services

Panel responses

Jackie Dawson

My role as a district nurse would be to carry out a variety of
strategies to enable a safe discharge home, while gaining trust
from both Peter and his sister. First, I would discuss with Peter
and the nursing home staff his needs. A joint assessment would
determine what Peter needs to allow him to return home. This would
also enable the nursing home team to highlight any concerns that
they may have.

Second, to address the issue of Peter’s sister’s refusal of
equipment and social care, I would contact her to arrange a care
planning meeting involving nursing home staff, a social worker and
intermediate care staff. The involvement of the intermediate care
team would enable any potential rehabilitation issues to be
tackled. This meeting would enable all professionals to highlight
concerns and potential problems, should equipment and social care
not be in place.

Once trust was gained with Peter and his sister a home visit would
enable the workers involved, including an occupational therapist
and intermediate care worker, to determine what pressure relieving,
lifting and handling, bathing and safety equipment would be needed
at home.

To establish that problems of neglect and physical and
psychological abuse were not reappearing regular multi-agency
meetings might be needed. In my own professional experience when
service users or patients have been “at risk” a range of workers
have met to discuss any concerns that have become apparent and how
they can be addressed. However, I believe the key to this situation
is establishing both a trusting and supportive link with Peter and
his sister. This can take time and patience, particularly when
people are adamant about their needs. Though discussion in a
non-patronising manner and friendly approach does help.

On Peter’s discharge, if I was working on this case, my role would
be to monitor Peter’s needs and to provide support to his sister,
in her role as the main carer. Finally, I would discuss with the
social worker how to proceed should it become apparent the
situation at home is breaking down, to make sure that Peter does
not reach a situation where he may become neglected again.

Mick Ryan

This case centres around the tension between Peter’s wishes to
determine his own future and the responsibilities of professionals
to protect vulnerable adults. Peter was clearly the victim of
neglect and is now expressing the desire to return to the
community. Peter’s capacity and his ability to make an informed
choice are critical; psychiatric opinion may be needed if capacity
is in question. If there is a lack of capacity, guardianship may be
considered as a way of protecting Peter’s interests. This would not
be an easy resolution of the situation and would require firm
evidence that he would be at risk with his sister. Even with
capacity there is a judgment to be made whether he is exercising
free choice or is in some way being coerced by the sister.

The sister is keen to expedite a discharge and it is important to
slow this process down so that no hasty and potentially damaging
decisions are made. It would be reasonable to discuss concerns with
both Peter and his sister, together and separately, revisiting
Peter’s previous experiences of living at home and pointing out
that while Peter’s needs are well met in his current placement, an
unplanned return to the community could be disastrous. Discussions
would need to be at Peter’s pace, taking into account his
communication and possible cognitive difficulties. It would be
useful to appoint an advocate to provide an independent perspective
and some individual advice for Peter, in particular regarding the
financial implications of granting power of attorney to his
sister.

An urgent multi-disciplinary planning meeting involving all
relevant health and social care professionals and Peter and his
family should be held to share concerns. Setting an agenda and
timetable for a multi-disciplinary reassessment of Peter’s needs
would also point out the gravity of a return home without the
appropriate services being in place.

Despite the above, Peter has the right to ignore professional
advice and move out. If this happened, it would be important for
the case to be monitored closely. Services should continue to be
offered and any professionals who gain access should report any
concerns.

If the sister failed to provide adequate care, there may be a need
to investigate under adult protection procedures.