A timely reminder

    CASENOTES:

    PRACTITIONERS: Dawn Cattanach, community care
    worker, and Giles Gardner, operations manager.

    FIELD: Older people’s services.

    LOCATION: West Devon.

    CLIENT: Dora Roberts is an 83-year-old woman
    who lives alone in a bungalow. Her husband, Brian, died 18 months
    ago. She has two daughters: Lisa, who lives in northern Scotland;
    and Rosa, who  lives about 15 miles away but is dependent on a
    wheelchair. Dora was unknown to social services.

    CASE HISTORY: Following Brian’s death it was
    Lisa, who had come down for the funeral, who made the initial
    referral to social services because she was worried about her
    mother’s forgetfulness. For example, Dora did not believe that
    Brian had died. Cattanach, at first, wasn’t sure if this was
    because Dora was still grieving but it became apparent that she had
    very short-term memory. Dora proved very resistant to having any
    help. Cattanach returned a week later after Lisa had gone back to
    Scotland, to find that Dora, who was unhealthily thin and weighed
    less than six stone, had no recollection of her first visit
    following Lisa’s referral.

    DILEMMA: While the aim was to keep Dora at home
    this could only be achieved with family support – which was proving
    difficult to obtain.

    RISK FACTOR: Dora’s forgetfulness, physical
    condition and vulnerability put her at risk of self-neglect and
    harm.

    OUTCOME: With family and agency support Dora,
    whose forgetfulness is worsening, remains at home and is eating
    well and keeping warm.

    Forgetfulness can just be part of the normal ageing process. We
    all have experiences, for example, of not remembering where we put
    a pen we had a few seconds earlier. However, people with cognitive
    impairment, who may experience pronounced forgetfulness (but not
    dementia), may not only be unable to recall where the pen has gone
    but what a pen is used for.

    For older people forgetfulness is a major risk factor
    particularly if they are living alone. Forgetting to eat or to turn
    off the gas can be fatal. Dora Roberts, 83, who was not previously
    known to social services, had begun to fit the risk profile. Her
    worsening forgetfulness coincided with the death of her husband of
    over 50 years, some 18 months before social services became
    involved.

    “She was painfully thin and not eating,” says community care
    worker, Dawn Cattanach, who was allocated Dora’s case. “She would
    also sometimes switch the gas fire on but not light it; but then
    sometimes when it was lit she would throw papers on it thinking it
    was a normal fire. And she’d leave the gas cooker on. At night she
    would wander, knocking on the next-door neighbour’s door asking if
    her daughters were there: believing them to be still small
    children.”

    Dora’s weight loss was a serious concern; not only was she not
    eating but when she did remember to cook, the food was often not
    fresh. “She would put frozen food in the fridge rather than the
    freezer; and food would be found in bizarre places – cucumber and
    tomatoes which had gone mouldy were found in the cloakroom,” says
    Cattanach.

    Dora’s daughters, Rosa and Lisa, who had referred their mum in
    the first place, seemed unaware of the risks involved. “We had a
    case conference with the community psychiatric nurse manager, Rosa
    and Rosa’s son to discuss the risk – specifically of leaving the
    gas on,” says operations manager, Giles Gardner. “We were trying to
    maintain Rosa in the community but we would need their
    co-operation. We asked if they could get the gas disconnected and
    we’d look at her food arrangements after that.”

    However, Rosa seemed strangely resistant. “She said how Dora
    liked to see the flames and didn’t want to upset her mother. Rosa
    really wasn’t aware of the risk,” says Cattanach.

    A mental health support worker, who works with care managers
    supporting the care plan, started visiting daily. “That was a huge
    benefit. Although Dora would never remember her or that she had
    ever met her, she did allow her to take her shopping and let her
    stay and cook some food – so she was getting at least one hot meal
    a day,” says Cattanach.

    However, uncertainty over cost seemed to be at the root of
    Rosa’s reluctance to co-operate fully. Says Gardner: “It boiled
    down to the daughter’s concern about how much Dora would have to
    pay for services. Nobody had any idea what monies she had. However,
    the court of protection appointed Rosa to manage Dora’s affairs.
    With the financial assessment completed Rosa was more comfortable
    about putting in a service.”

    Also around this time Dora stayed with Rosa for a week. “That
    showed her just how forgetful Dora could be – so that was also a
    turning point,” adds Cattanach.

    With Rosa on board, the gas was cut off; daily support visits
    were set up to make sure Dora was eating three times a day and the
    GP advised vitamin pills and build-up drinks. Says Cattanach: “The
    other thing was her isolation because she didn’t really see anybody
    else. However, Rosa said Dora had never been a social person. The
    support worker took Dora to the day centre a couple of times but
    she wouldn’t even get out of the car.”

    Because she was so thin, Dora often got cold and would be found
    wearing layers of clothes. “She had gas central heating but she
    would turn it off, and would unplug things – such as lights and
    telephone. But if you put up signs saying ‘do not touch’ she
    wouldn’t touch it – so heating and water were set to timers,” says
    Cattanach.
    Gardner says that the mental health team who were involved early on
    suggested residential care. “But she was absolutely adamant she
    didn’t want that. We’re always focusing on maintaining people in
    the community. I know it sounds like rhetoric but if we can keep
    them in their own homes even when their cognition is really poor,
    we will.”

    And even if Dora forgets who is helping her, she is, thanks to
    the commitment of community care workers, where she wants to be –
    at home.

    ARGUMENTS FOR RISK

    • Services offered should follow, where possible, the wishes of
      the service user. Dora wanted to be in her home.
    • However, this could only happen with Rosa’s support. According
      to Gardner, Cattanach won Rosa around by “being transparent in her
      dealings with her – involving her in all discussions and meetings –
      but being very clear about the risks being managed. I think it was
      a gradual appreciation of the level of risk and a gradual
      acceptance that the team was working very much towards maintaining
      her at home,” he says.
    • With the main risks minimised any deterioration can be
      monitored effectively. Says Cattanach: “She doesn’t go out alone
      any more; the gas is off; she’s eating more; the house is warm; she
      has company because she gets two hours a day support and the agency
      calls us if her behaviour becomes different. Her behaviour is
      usually odd but as long as it’s the same odd behaviour then that’s
      good.” 

    ARGUMENTS AGAINST RISK

    • Cattanach, rightly, at first referred Dora onto the mental
      health team. It thought Dora’s needs would be best served by
      residential care. Although things have turned out fine, it could
      have easily spelt disaster. The reluctance of the family to cut the
      gas was a clear indicator of potential risk – not only to Dora and
      her property but to neighbours. If things went wrong then Dora’s
      family and Cattanach would have to explain the decision to keep
      Dora in her own home to the grieving relatives of the neighbours
      and, undoubtedly, to a posse of lawyers and insurers.
    • There is an undoubted dilemma about sticking rigidly to a
      policy – no matter how good. As Gardner points out: “Clearly if the
      risks increased we would need further meetings to explore what
      else, if anything, can be done. And maybe, as we have done before,
      we make a decision that it’s just not safe and if there is a
      consensus we would move her into residential care – but that is
      never our starting point.”

    INDEPENDENT COMMENT

    On the face of it, Cattanach and Gardner took major risks with
    the welfare, even the life, of Dora Roberts. If a serious accident
    following a gas explosion had occurred, or if her health undermined
    by malnutrition had suddenly deteriorated, the care staff, who had
    been aware of her vulnerability but left her living alone, would
    probably have faced heavy public criticism, writes Jef Smith. 

    If they were registered as social workers by the General Social
    Care Council, they might even have been accused of professional
    misconduct for failing to comply with paragraph 4.3 of their code
    of practice, which obliges them to take “necessary steps to
    minimise the risks of service users from doing actual or potential
    harm to themselves”.

    The alternative strategy involved action on several fronts.
    Relatives were engaged, educated, and reassured once the financial
    position had been clarified; Dora’s trust was built up through
    daily monitoring by the mental health worker and immediate sources
    of danger were neutralised by cutting off gas appliances, putting
    up warning notices and installing timers; support was provided with
    shopping, cooking and diet. Removal to a home would have been
    safer, tidier and less time-consuming, but quite unacceptable to
    Dora.

    Although Dora demonstrably lacked the ability to make informed
    decisions about her own safety, she was clear that she wanted
    neither residential nor day care. So what the workers bravely
    achieved, again in the words of the code of practice – paragraph
    1.2 – was “respecting and, where appropriate, promoting the
    individual views of both service users and carers”. 

    Jef Smith is a writer, trainer and consultant in care
    for older people.

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