Battered or confused?

CASE STUDY:

The names of all service users  mentioned in this
article have been changed.

Situation: Sandra Meadows, 88, lives with her
second husband, Ken, 79, in a ground floor council flat. They
married three years ago. Ken is a recovering alcoholic. Sandra has
also recently become mildly confused and attends a day centre
(without Ken) twice a week.

Problem:  At her day centre, Sandra broke down
in tears and told her keyworker that Ken had been hitting, grabbing
and hurting her. There was extensive bruising on her arms and
wrists. The day services manager called the duty social worker who
turned up to meet Sandra in the company of her keyworker and the
centre manager. Sandra kept saying that she did not want to make a
fuss and that Ken lashed out or grabbed her only occasionally. It
was usually following any time that Ken managed to get himself a
drink – although he was supposed to be on an abstinence programme.
Sandra said that she did not need any hospital or medical input and
simply wanted to go home as usual at the end of the day. The social
worker suggested that she could take her home and perhaps meet with
Ken and carry out an assessment. Sandra said Ken must not find out 
or she could be in “big bother”. She also said that nobody should
confront Ken because he  can be very aggressive and Sandra did not 
want that to happen.

Panel Responses

Mick Ryan

This case falls within the remit of adult protection. Sandra is
a vulnerable adult by virtue of her being in need of community care
services and has made a disclosure of physical harm inflicted on
her by her husband.

In view of Sandra’s subsequent statement that “she does not want
to make a fuss” any further action needs to be handled sensitively.
Sandra is worried and frightened by the consequences of Ken being
confronted with his alleged actions, but she was distressed enough
to feel the need to disclose. Her anxiety about consequences is
understandable and not unusual in these circumstances. Reassurance
that she has done the right thing is essential.

Capacity to consent may be an issue due to Sandra’s mild
confusion. It is also a care issue that needs further exploration
and psychiatric assessment. An immediate assessment of mental
health is unlikely on the day, but information from previous
assessments may shed light on capacity and also provide further
background.

These checks are important as they may indicate previous
concerns about Ken’s aggression. It seems unlikely, if Ken is
aggressive when drinking, that this is a new phenomenon. The fact
that he is on an “abstinence programme” may indicate professionals
are already involved with him. Their views could be sought.

Ultimately, Sandra could refuse to allow further investigation,
but this seems unlikely. Her immediate safety is important and this
issue needs to be discussed with her. She does not need to return
home and could be provided with emergency accommodation. Another
option could be family members (if there are any) who might take on
Sandra temporarily.

Any home visit should have Sandra’s agreement and she should be
reassured that she does not have to remain at home if she is too
frightened.

It would appear that Ken has been trying to control his drinking
but this remains an open question. He may be in drink on Sandra’s
return in which case any meaningful discussion with him about what
has happened may not be possible. In these circumstances it would
be prudent to offer Sandra alternative accommodation.

Jackie Dawson

The importance of multidisciplinary working is reinforced in
Sandra’s situation. Although the co-ordinator would be a social
worker, if this were my case my role would be reporting and
documenting any concerns I had about Sandra’s condition. These
would be reported to the designated key social worker and also to
the GP.

I could be involved if Sandra developed wounds or skin damage.
Establishing a good rapport and enabling Sandra to trust the
district nursing team would be a priority. However, should either I
or my team members observe any bruising or other injuries we would
openly discuss our concerns with Sandra. However, even if she
requested that these concerns were not shared with other
professionals, I would explain that, should Sandra’s personal
safety and well-being be at risk, I would have to disclose this
information.

Any wounds would be recorded on a wound tracing (a manual way of
measuring the wound) and, with consent, photographs might be taken.
Should Sandra disclose her concerns during a visit, a referral
would be made to the duty social worker.

All information from the visit would be documented in the
nursing notes. To maintain confidentiality as the nursing notes are
left in the home, a second set of notes would be made to ensure no
sensitive information was read by a third party. Furthermore, a
nursing incident form would be completed and senior nursing
management would be informed. Additionally, owing to Ken’s
behaviour, district nurses would ideally visit Sandra at the day
centre.

Another concern that I would seek to address is the report of
Sandra having mild confusion. After discussion with the GP, I would
undertake a test to rule out a urine infection which could be the
cause. Sandra may require a referral to the community mental health
team. An assessment from the team may involve attendance at the
memory clinic.

Communication – both verbal and written – between each
professional would be a crucial factor in ensuring Sandra’s
situation is monitored closely. Regular case conferences with
attendance from each professional involved would enable the
situation to be continuously reviewed.

User View 

This problem may not be as straightforward at it first seems,
write members of Knowsley Older People’s Voice. Was Sandra
attending the day centre before she became confused or has she
started attending the day centre because of her confusion?

Sandra’s safety is paramount. The day centre manager and her
keyworker need to try to persuade Sandra to let the social worker
go home with her.

The first issue to be raised is consent. If Sandra does not want
anyone to approach Ken her wishes must be respected and she should
not be overruled.

Is Ken’s abstinence programme with a voluntary support
organisation or is it with health or social care? If it is with
health or social care, Ken will also have a keyworker assigned to
him.

An urgent case conference should be called with keyworkers for
Sandra and Ken. The social worker should contact the lead for the
vulnerable adults procedure, and the vulnerable adults team needs
to be involved at the case conference. The needs of Sandra and Ken
have altered and they should both be reassessed for new care
packages.

We only have Sandra’s version of what is happening at home. In
her confusion, she may be hitting out at Ken and he may have to
restrain her. It is probable that she would have no memory of this.
Or Ken may be trying to help her with daily activities of life: for
example, washing, feeding, help to the toilet; and Sandra, in her
confusion, is resisting, thinking he is trying to hurt her.

After the case conference, Sandra should have a full health
check with her GP. Both Sandra and Ken should have annual checks
routinely, as they are both older than 75.

Has the cause of the confusion been established? Sometimes
infections can cause people to become confused. Also, medication
can cause personality changes so this should be reviewed urgently.
Once these avenues are ruled out, Sandra’s GP could refer her to
the community mental health team.

Both Sandra and Ken should have a benefits health check as they
may not be claiming benefits that they are entitled to.

There is no mention of any family for either Sandra or Ken. Some
enquiries should be made to see if there are any relatives living
close by.

We do not know if Sandra or Ken are churchgoers or have any
religious beliefs. There may be links in the community to offer
support to them.

Knowsley Older People’s Voice is an older people’s forum
based in Knowsley, Merseyside.