Practitioners: Pat Harvey, social worker and Ian McAlpine, team leader, community care and community development.
Field: Older people’s services.
Client: Alistair Caldwell is 72 years old and lives alone in a low-level council flat in north Glasgow on an economically deprived estate. He has a son and a daughter, both of whom live locally.
Case history: Following a routine visit to Caldwell’s house, the district nurse, concerned about his living conditions, which she described as “grim”, referred him to social work services for a community care assessment in November last year. He was only known to the department through a welfare rights enquiry many years before, which required no follow-up. The intake team visited to carry out an initial assessment and urgently passed it on to older people’s services, citing concerns over Caldwell’s physical and mental health.
Dilemma: Caldwell was a vulnerable and isolated man whose flat was being exploited by a drinking den and who was being financially abused by his son. Any improvement might only be short term.
Risk factor: The immediate dangers could be managed but given his isolation and frailty, it might only be a matter of time before his physical and mental health deteriorated seriously again.
Outcome: He continues to live independently at home, his confidence, self-esteem and happiness restored, while his drinking is under control and his financial affairs are now looked after in his best interests.
It’s said that crowded cities can be the loneliest of places. Economically disadvantaged estates may be home to high numbers of people but poverty, crime, and drug and alcohol misuse make people feel isolated and vulnerable – leaving them open to neglect and exploitation.
Older people in particular can be susceptible to environmental and financial abuse, which while perhaps less often discussed than physical or sexual abuse, can still be acutely damaging and life-threatening. Such was the case of Alistair Caldwell, who was referred to social work services in Glasgow by a district nurse concerned about his lifestyle and living conditions.
“In over 30 years in social work, it was one of the most appalling cases of neglect I have ever seen. Caldwell was small, frail and reluctant to open the door. He didn’t want to engage and kept saying that he was fine,” says social worker Pat Harvey, who picked up the case. “He didn’t want to bother anybody,” adds team leader, Ian McAlpine.
It was extremely cold, with temperatures as low as -90C. “The central heating was broken in the flat, wires were exposed, walls and windows appeared damaged through violence. He was bereft. He only had the clothes he stood up in. There was no food or hot water and little furniture except for a number of urine-soaked beds. And no cooking facilities,” says Harvey.
Her first concern was hypothermia: “You could see your breath in the flat when talking. There was a one-bar electric fire in the lounge which had been upturned to heat up cans of food,” she recalls.
However, despite Caldwell’s protestations that he was fine, Harvey kept going back, trying to be positive and establish a relationship. The signs were that the flat was, against Caldwell’s wishes, being used as a drinking den. “A lot of communal street drinking has gone indoors. And if you’re drinking all day in an enclosed area, there’s always the chance of aggression – and there was evidence that Caldwell had been assaulted as well as his property damaged,” says Harvey.
However, seeking to engage him with local services was far from easy: “He was so poorly motivated to change and had little insight into his own vulnerability. We tried desperately hard to link him in with day care and lunch groups – we knew he needed to eat nourishing hot meals and he wasn’t going to do that at home.
“He didn’t want to go out and didn’t want a home help service. Fortunately, he accepted meal deliveries from a local voluntary sector cook and care service. This also meant that somebody else would be checking to see if he was OK and could flag up any concerns to me,” says Harvey.
As their relationship built, Harvey uncovered evidence of financial abuse by Caldwell’s son who, it turned out, had also taken his motability car. Caldwell never saw it. And Harvey, who worked intensively with Caldwell over a five-month period, did not see the son once. “On paper this elderly, vulnerable man had an income of £217 a week and yet in reality didn’t have a tea bag,” she says.
An adult protection case conference brought together all the agencies and sorted out roles and responsibilities. For example, the housing department made the property safe. Health services became more involved. Local community volunteers helped clear the flat of the urine-soaked beds. “Without us working together, we wouldn’t have been able to minimise the risk as we did,” adds Harvey.
Harvey also began to challenge the financial situation with Caldwell’s daughter emerging as appointee. “Interestingly, wherever I have come across financial abuse, the older people have been getting the maximum they can – the abusers have made sure of that,” says Harvey.
With his flat made safe, cleared and cleaned, Caldwell needed to take control of his surroundings. “To help him regain his tenancy, we did things like putting his name plate on the door – positively reinforcing to him that this is his home,” says Harvey. With busy input from a number of agencies, a restored home and pride, locks and alarms fitted, the other drinkers who abused the flat as a den have moved on elsewhere.
“He is still at home, he’s cleaned up and he’s happier. He’s warm, he has money, he still drinks but it’s under control following counselling,” says McAlpine.
Harvey adds that Caldwell now has a pair of curtains. These may be a minor possession but by allowing him to decide when he looks out and who can look in those curtains have an enormous symbolism for a man claiming back his life.
Arguments for risk
- Research shows that people want to stay in their own homes where possible. As McAlpine says: “In the past, without a doubt, we would have taken him into residential care, considering the condition he was in. But nowadays, with the remarkable range of services and resources we have in Glasgow, we don’t have to do that.”
- When refurbishing his flat, Caldwell was reluctant to accept even respite care. “He was desperate to stay at home. We worked around him. He was thrilled to be able to choose the colour it was to be painted – simple things like that gave him a sense of self-worth and confidence,” says Harvey.
- With his daughter and several agencies involved, Caldwell’s isolation is reduced, lessening the chances of exploitation. “There are simply more people to check up, so the likelihood is that we’ll pick things up before they go too far,” says Harvey.
Arguments against risk
- Older people – particularly single men – tend not to go to their GP or attend community information open days, so do not readily access services. Poorly motivated, they are difficult clients to identify and engage with. Inevitably, they only become known at times of crisis. Caldwell was at a time of crisis. It is likely that he would have been dead by the end of the winter, if not sooner. Although efforts were being made to persuade him to accept services, they might have proved too little, too late.
- Caldwell’s lifestyle and isolation marked him down as vulnerable. His son was financially abusing him. The group of drinkers were invading his flat and taking it over. There is a risk they may return with a vengeance.
- Unsafe carpets, beds on the floor and poor lighting create conditions that would put any older person at high risk of falling – let alone one who is drinking heavily.
The case of Alistair Caldwell graphically illustrates the potential for lonely and isolated people to be abused, writes Martin Green.
This potential for abuse is particularly strong in some of the most socially deprived estates, where populations are transient, people do not know their neighbours and where crime, drugs and alcohol abuse are major problems.
The professionals faced a dilemma of balancing their role in providing support with the rights of the user to refuse it. The social workers persevered with contact until they had established a relationship of trust. From this point, they were able to start helping Alistair to regain his physical strength, his confidence and self-esteem.
This approach can often be time-consuming and staff have to balance the benefits of co-operation with the danger of leaving people at risk. In this case they got the balance right, but if these strategies go wrong, the consequences could be fatal. Good inter-agency working brought the whole system together. However, I am surprised that the housing provider did not pick up the dilapidated state of the house earlier. In some ways Alistair was lucky. He lived in a deprived and socially excluded urban area, but when his condition came to light, there was a range of good services and high-quality professionals available to help him. There are many older people in the UK who are equally vulnerable, abused and isolated and whose plight is neither acknowledged nor helped.
Martin Green is chief executive of Counsel and Care.