Situation: Theresa Kennedy is 76 and lives with her son, Martin, 50, who has learning difficulties. Her husband died last year after a long illness through which Theresa nursed him. Her daughter, Alice, lives nearby with her husband and five children. Theresa has always been Martin’s carer, and has always resisted outside help because Martin is her son and it is her motherly duty to stick by him.
Problem: Theresa has become more prone to forgetfulness. She seriously scalded her hand when she put it into a deep pan of hot fat, forgetting that it was on. It was during her visit to the accident and emergency department after this incident that she was referred to the social work service. She brushed off their offers of help and discharged herself. Alice has been popping into her mother’s house but has her hands full with her own young family and should things deteriorate would not be in a position to accommodate Theresa or Martin. Theresa has some awareness that she is not coping as readily as before, but sees it as a minor irritant rather than a potential long-term problem. Martin also disclosed to the hospital social worker that his mum hits him with a riding crop when he, as he says, “doesn’t pull his weight around the house” and says that, although it hurts and makes him cry, it’s OK because he “deserves it”.
The name of the service user has been changed.
This is a complex family situation compounded by the fact that there is a disclosure of adult abuse. The adult protection concerns are worrying and need to be addressed but form only a part of the potential family breakdown. An urgent and full assessment of both Martin’s and Theresa’s health and social care needs should be undertaken. The aim would be to establish a baseline needs assessment to investigate the abuse and to find out whether the current living arrangements are safe in the short term. Also to explore with both parties what are realistic longer-term plans. How long can Martin and his mother be supported in the community and what plans can be agreed as to Martin’s future when his mother is no longer able to care for him? Does he have the ability to live in the community with support or will he require admission to care?
It would be useful for these assessments to be carried out by separate workers, and in Martin’s case some input either jointly or wholly from specialist learning difficulty services would be best. Martin also needs some help to talk about the abuse and some appropriate advice to consider his options. Specialist assessment from the mental health team for older people would also be crucial in order to gauge the causes of Theresa’s cognitive impairment. This could have a huge bearing on any future plans made if the cause was due to a dementia and not due to any physical cause or, for example, her recent bereavement. The input and views of her daughter would also be helpful to understand current and past problems.
Both assessments would need to be carried out in a highly sensitive way to reflect Martin’s level of understanding and the possibility that Theresa may minimise the situation or even block the process. She has always been resistant to help in the past. Eliciting the help of Alice may help to break down some of these barriers.
The continuing assessment needs to encompass a realistic protection plan informed by Martin’s wishes, depending on his capacity, the nature and extent of the incidents and Theresa’s attitude. In the interim practical services, such as home care and respite care or some day care for Martin, may alleviate some of the stresses until a longer-term plan can be agreed.
After Theresa Kennedy’s visit to the hospital a district nurse would probably be involved in assessing any wounds to Theresa’s hands received after scalding. While tending these wounds the district nurse should conduct a thorough assessment referring the case on to appropriate agencies and professionals.
Often a district nurse develops a uniquely personal relationship with a patient when performing such personal care. Building a personal relationship with Theresa might encourage her to talk more openly about personal issues and she may well express some of her concerns about Martin and her own forgetfulness.
The district nurse would discuss with Theresa how she felt after her husband died and her current coping – perhaps referring on to bereavement counselling with her consent.
It would be crucial to focus on a risk assessment based on Theresa’s forgetfulness. The nurse could advise on highlighting general safety issues, such as prevention of falls, and also possible safety techniques, for example using a deep-fat fryer instead of a chip pan. The nurse would also refer Theresa to the memory clinic to assess how serious her forgetfulness is and what dangers it may imply.
The district nurse would also discuss with Theresa how she cares for Martin and discuss what preparations have or can be made for his future when Theresa is no longer there or able to care for him. To this end, the district nurse – with consent – would suggest referring Martin to the learning difficulties team for assessment, possible respite or working towards moving him into supported housing.
The forming of a relationship will also help in the discussion of Theresa’s methods of punishing Martin. If any disclosure were made to the district nurse about hitting Martin with the riding crop, this must be referred on to social services for his protection and safety.
Opportunities should be sought by the district nurse to talk to Martin and also observe family dynamics in order to help facilitate a safe environment for him while supporting Theresa’s need as a carer through offering a carer’s assessment.
Theresa and Martin seem to have lived in a stressful family situation for many years, write members of Knowsley Older People’s Voice. An initial question we would like to raise involves the level of support received during Theresa’s husband’s illness. At this point Theresa seems to have become the main carer for her husband and Martin.
Early intervention might have helped to provide a support network for the family. The accident with the chip pan merely highlights the seriousness of the situation and need for support. Perhaps at this point the family’s GP’s practice nurse may become involved, visiting Theresa to help with her recovery from the accident. At this point it may be possible to talk to Theresa about the situations she has faced and offer counselling following the recent bereavement.
The comment made by Martin concerning physical abuse cannot be ignored and raises enough concern for social services to make contact with the family to offer support. It may be that a conversation with the daughter Alice is needed to assist with social services in opening a dialogue with the family as to the types of services available to Theresa and Martin. The area of most difficulty seems to be helping Theresa recognise her need for assistance and the benefits it would bring to her.
It may be that an offer made to Martin to take him out of the family situation, starting with one morning a week in a day centre for a trial period, could help the situation. If this proves successful further days may be added.
One means of engaging with the family is to address the fire risk following the chip pan accident. Contact could be made on behalf of the family to a local fire prevention officer. This might help in developing contact with the family and a practical way of offering support.
It is clear that there is the potential for future problems and that Theresa will need to come to terms with the fact that, in time, her ability to provide for all the support needs of Martin will lessen.
The key seems to be building a relationship of trust with the family and helping Theresa understand the support available to help her make some very difficult decisions.
Sheila Bersin, Arthur Page, Cathy Ericksen, Bill Bailey, Kate Holt and Paul Mavers are representing Knowsley Older People’s Voice.