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.

     

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