House of the chastising son

Case notes   

Practitioners: Yvonne Jones, adult protection co-ordinator, social services; and Michel Le-Straad, a senior nurse and adult protection lead for the health care trust. 

Field: Adult protection. 

Location: Liverpool. 

Client: Doreen Lane is an 82-year-old woman. She has a son, Robin, 57, and a daughter, Joanne, 52. Robin, although he has his own property, lives with his mother as her main carer. 

Case history: In January 2001, Doreen was admitted to the urology ward at her local hospital. Before her discharge a home visit by the hospital’s occupational therapist raised concerns as her son was refusing point blank any help or adaptations. It had also transpired that he had been giving his mother the herbal remedy St John’s wort which affected her other medication and could have made her very ill. However, despite these concerns she returned home to the care of her son. Doreen was readmitted towards the end of 2002 with a head injury following a fall at home and a chest infection. In poor health, she was also observed to be agitated following visits from her son.  

Dilemma: Once moved into the safety of residential care, Doreen began to long to return home and her health began to deteriorate noticeably. 

Risk factor: By agreeing to her wish to return Doreen to her son’s care, she was at risk of further neglect. 

Outcome: Doreen has moved in with her son, who has agreed to support and monitoring from social services.

For those working in adult protection the everyday realities can be as frustrating as they are troubling. For no matter how potentially abusive a situation, if the person you are working with has capacity to consent, you need to follow their wishes despite what you may feel either professionally or personally.

And it was in following the wishes of 82-year-old Doreen Lane that practitioners Yvonne Jones and Michel Le-Straad took her from an abusive situation but later placed her back. It was exactly what she wanted.

Doreen’s main carer was her son Robin. “He was very controlling about her care,” says Le-Straad. “For example, she’d been seeing her current GP for 14 years – and he had always presumed her profoundly deaf. He had never spoken to her and she had never answered him – it had always been done through the son.”

With poor mobility and heart and chest problems, she needed help to make meals and with using the toilet. Robin would leave the house at around 7am and not return for 12-14 hours. Her daughter, who was terrified of Robin, was only permitted to visit on Wednesdays, when she would clean, shop and do some washing – the only time that soiled bed linen and clothing was cleaned.

“The son refused all help,” says Le-Straad, “she had no home helps, no meals-on-wheels, no day care, no nothing.” Following a second admission to hospital, Jones and Le-Straad became involved.

“We spoke to Doreen together and she appeared quite lucid,” says Jones. “She was clear that she didn’t want her son to visit as she was getting agitated by his behaviour. For example, he tried to block up the air conditioner with chewing gum.”

Le Straad continues: “He became more abusive and aggressive with the nurses – and we had to call security on a number of occasions. And he was refusing to allow his mum to have pain relief – it was just unacceptable really.” After being observed giving his mother un-prescribed medication, he was excluded from the hospital.

“She began then saying that she wanted to go into residential care,” says Jones. “She seemed very positive about it, very upbeat about not going home.”

Doreen was in hospital for some months, her “discharge planning was delayed partly because she was so ill and partly because of the situation,” according to Le-Straad. There were also question marks around her capacity to consent as well. “Sometimes she’d forget that she said she didn’t want to go back – and actually ask for her son,” says Jones.

“She was assessed as dementing but retained her capacity to consent,” adds Le-Straad. “It was ultimately decided she would go into residential care because that was what she wanted.”

However, once transferred to residential care, Robin’s interference in her care began again. “She didn’t like it once she was there and began pining for her son, basically,” says Le-Straad.

Jones agrees: “The problem was that it became clear quite quickly to everyone that despite what had gone on in the past these people loved each other dearly. They had lived together so closely for so long. Even the daughter didn’t believe for one minute that the son was doing anything to deliberately injure or harm his mum.”

“Normally social workers are the big, bad individuals who take all the blame,” Le-Straad continues. “But in our work, we sometimes become the figure of hate, which can bring positive outcomes. And this is what happened here. The social worker was able to work more closely with Robin and did a really good job. Robin was made to understand that it wasn’t acceptable to leave his mother on her own all day lying in a sodden bed without a drink.”

Following a further re-admission to hospital all those involved in her care met. “We agreed that letting her return home with her son – as she requested – was the most humane thing to do provided that social services could help and that we were able to monitor the situation,” says Le-Straad.

So with social care support, Doreen has moved permanently in with her son. The process has brought the whole family closer together. Joanne now has more access to her mother and has begun rebuilding her relationship with Robin. “It’s worked out well for everyone,” says Jones. 

Arguments for risk

• Importantly Jones and Le-Straad always listened to what Doreen wanted to do. She wanted to move into a home but didn’t like it nor could she be without her son. She wanted to move back with him and they, correctly, facilitated this.
• There was a strong unconditional love between mother and son. Robin’s care of his mother was poor but was not considered to be malicious.
• Given Robin’s track record it was an important move to secure support and monitoring for Doreen’s return to her son’s care. With support she would receive help with daily tasks which would not only lessen the burden on Robin but the care workers could monitor Doreen’s health, condition and continuing relationship with Robin.
• The social worker was able to side with Robin and exert a positive influence upon him. This defused the anger that Robin had directed at adult protection staff and helped alleviate his distrust of services generally.

Arguments against risk

• Robin’s relationship with his mother was most definitely abusive. Robin’s character is a very controlling one and there may be the suspicion that – having regained access to his mother, once she moved out of hospital and into residential care – he once again manipulated her and made her feel bad about moving away from home.
• His near-obsession with interfering with his mother’s medication is particularly worrying. He is putting his mother’s health at great risk by refusing to allow her to take painkillers and by substituting St John’s wort preparations, which are unlicensed herbal remedies. These can help with anxiety and depression, but sometimes prevent other medicines from working properly.
• It is worrying that despite visiting her mother once a week and seeing the effects of her brother’s care, Joanne, knowing what her brother was like, still thought he meant no harm by his actions

Independent comment

This case highlights some of the complex issues we face when caring for very vulnerable older people, writes Martin Green. In particular, the difficulties of balancing the well-being of clients with their rights to self-determination and the needs and preferences of their carers.

In Doreen’s case there was the added complication of a question mark over her capacity to give informed consent and the tensions that existed between her son and daughter. These tensions gave the workers a further insight into the intimidating and controlling nature of Doreen’s son and combined with the evidence of neglect, raised doubts over his suitability as primary carer. As with most social work decisions, getting them right would have very positive outcomes for Doreen and her family; getting them wrong could be disastrous for everyone.

I believe the workers in this case did an excellent job in finding a balance between responding to Doreen’s desire to return home, but at the same time minimising the risks to her. The essence of this success was an approach that required a lot of social work input into the needs of the carers while keeping the primary focus on Doreen.

The real issue that concerns me about this case is the role of the GP, who had been seeing Doreen for 14 years but had never spoken to her in all that time. If social work is to succeed it requires practitioners to take some calculated risks and for all elements of the system to support each other and work together.

Martin Green is chief executive of Counsel and Care for the Elderly.