SAFEGUARDING ADULTS

1. SAFEGUARDING ADULTS Chapter 16 Melanie Robbins, Hilary McCluskey & Jenny Dedmen

2. All health professionals, regardless of their speciality (which may relate to adults, children, people with mental health difficulties or those with learning difficulties) need to know about safeguarding both children and adults. You may hear allegations of abuse from neighbours, friends and relatives, or observe abuse in others, from visitors to the people you would normally be working with. This presentation will examine elder abuse and neglect, in order to help you develop an understanding of the complex issues involved. It includes assessment tools that can be used to provide documentary evidence of potential harm to an older adult. Part 1 – Vulnerability: When, Where, Who? Part 2 – Law and Legislation for Adult Protection Part 3 – Domestic Abuse Part 4 – Types of Abuse Part 5 - Older Adults and Abuse Introduction

3. PART 1: Vulnerability: Where, when, who?

4. Abuse and neglect occurs at any time throughout the lifecycle. Individuals may have repeated experiences of abuse across their lifespan. Individuals may experience domestic abuse or neglect, perpetrated by their partners (boyfriends, girlfriend or spouse), or by siblings, sons or daughters [domestic violence or domestic abuse]. Individuals may experience abuse because they have become more frail and dependent on carers (because of physical or mental health issues or learning disability), who may be paid, voluntary or family members [abuse to vulnerable adults]. Vulnerability

5. Manthorpe et al (2007) surveyed 2111 people over 65 living in their own homes (in the community), and found that 2.6% reported experiences of abuse or neglect during the last year. Neglect by partners significantly increased over age 85. Manthorpe et al (2007) suggestedthis was due to increasing frailty of both partners leading to an inability to continue to provide support for each other.

6. Vulnerability can be affected by: A person’s age A person’s ability to care for themselves A person’s ability to protect themselves from harm A person’s ability to earn money and make financial choices A person’s ability to be able to make friends, socialise and/ or take part in communal activities Who is Vulnerable?

7. Defining vulnerability in adults is difficult and confusing. Consider age: Q. What is it about a person’s age which makes them vulnerable? Q. Is it only older people who are vulnerable? Q. What do we mean by ‘older people’? Society has many thresholds when a person is considered ‘old’: 65 years to qualify for state pension Over 50 years for some insurance policies and financial benefits Over 75 years to receive certain types of NHS treatment Over 60 years to receive winter fuel allowance, Over 85 years to receive the enhanced winter fuel allowance

8. The Department of Health (2000b) defines a vulnerable adult as: “A person who is or may be in need of community care by reason of mental or other disability, age or illness, and who is or may be unable to protect him or herself against significant harm or exploitation.” (p.8,9) This has been criticised as being ambiguous. (ADSS, 2005)

9. The Health Select Committee’s inquiry into elder abuse (2004) called for an expansion of the DH definition of vulnerability to include older adults experiencing abuse who do not, however, need community care services, but live in their own homes and are able to take care of themselves (paragraph 14). The DH response stated that adults who are able to care for themselves and who experience abuse are covered by other pieces of legislation addressing assault, domestic violence etc.

10. Some independent adults may experience harm from a person who is related to them or who lives with them or maintains a close relationship – this is known as domestic abuse or domestic violence. Some dependent adults (requiring community care) experience harm or neglect from a carer, or from a person who is related to them or who lives with them or maintains a close relationship – this is abuse/neglect to vulnerable adults (and may include abuse of carers). Older people may experience abuse or neglect as above, which may be classed as either domestic violence or abuse/neglect to vulnerable adults, depending on whether or not the older person requires community care. This is frequently termed elder abuse.

11. PART 2: Law and Legislation for Adult Protection

12. In England, Wales and Northern Ireland, adult protection is governed by: Community care legislation and related social service guidance Criminal justice legislation for types of abuse which can be termed criminal offences Mandelstam (2005) notes that despite a call for protective legislation for vulnerable adults, similar to child protection legislation, none has been passed: “…substantially no new social services legislation was passed concerning adult protection, equivalent for example to child protection provisions contained in The Children Act 1989. Indeed, central government has failed to adopt proposals made by the Law Commission (1995) that local authorities should be given such protective powers in respect of adults.” (p.402, Mandelstam, 2005). Law and Adult Protection

13. In England and Wales: The National Assistance Act 1948 allows people (with or without full mental capacity) to be removed from the home if they are not able to care for themselves or are not receiving adequate care, providing that the move is necessary to prevent injury. The Mental Health Acts allow detention under certain circumstances for assessment or treatment of people with mental disorders, and to procure the protection of the individual or of others. It also allows the appointment of guardians etc where appropriate and available. Examples of Legislation which could be used in Cases of Abuse or Neglect

14. The Environmental Protection Act 1990, The Public Health Act 1936 and The Public Health Act 1961 can be used to abate issues which present a nuisance to the public or which cause potential health risks to others, such as excessive accumulation of verminous debris and filth. The Family Law Act 1996 provides for regulation on occupation of homes and allows perpetrators of abuse to be removed from the home or to have restricted occupation rights. It can also be used to effect the termination of matrimonial home rights where abuse has been found. The court has to consider the respective needs of both parties and of any children, whose welfare is paramount.

15. Criminal Offences include application of the Sexual Offences Act 2003, The Protection from Harassment Act 1997, Domestic Violence, Crime and Victims Act 2004, The Theft Act 1968 (financial abuse) and also include offences of assault and battery and manslaughter. Notably, there is no criminal offence of neglect to adults. Scotland has recently passed new statute to protect adults: The Adult Support and Protection (Scotland) Act 2001. The application of this legislation will develop over time.

16. PART 3: Domestic Abuse

17. “Domestic violence is the ‘continuum of behaviour ranging from verbal abuse, through threats and intimidation, manipulative behaviour, physical and sexual assault, to rape and even homicide. The vast majority of such violence and the most severe and chronic incidents, are perpetrated by men against women and their children.” (DH 2000a pV). Any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners or family members, regardless of gender or sexuality.’ (ADSS 2005 p10) Domestic Violence

18. In 2005 the government stated that the term ‘domestic abuse’ should be used rather than ‘domestic violence’, as this terminology more easily incorporates the variety of abusive situations women find themselves in, whereas the term “domestic violence” tends to lead people to consider the physical effects alone. When reading relevant literature you will find both terms are used, however when referring to crime statistics the term ‘domestic violence’ is more prevalent, as crime statistics record episodes of violent actions. Domestic Violence or Abuse?

19. Before considering domestic abuse we must consider a few notes of caution: Firstly, caution must be taken when referring to statistics on domestic abuse, as these rely on reported cases. As it is known that abuse is under-reported, statistics represent an underestimation of actual cases. Secondly, statistics suggest that 81% of reported domestic violence is violence perpetrated by men against women (British Crime Survey 2004/ 05) and approx 8% of males who are murdered, are murdered by their female partners, (Criminal Statistics Home office 2000/01) and that

20. Caution is also needed, however, when interpreting statistics: for example, 5% of men who were killed were killed by their female partners and 40% of women killed, were killed by their male partners (2003-4). As there are many more male homicides in any one year than female homicides, direct comparison of these statistics is rendered inappropriate. Statistics of violence from women on men may be under-reported because of other factor. Health professionals need to be alert to the possibility of violence perpetrated by women to either male partners or relatives, or to their female partners or relatives, and to the possibility of male to male violence between partners. Violence may also be perpetrated by adolescent children against their parents (Cottrell, 2001).

21. Domestic violence constitutes 25% of all violent crime (ADSS 2005) and can happen to anyone, from any culture, social class, age or gender. 1 in 4 women will experience domestic abuse. (Council of Europe 2002) 2-3 women a week, in the UK, are murdered by a man they know (usually partner or ex-partner) and these deaths account for 42% of women who were murdered (Criminal statistics, Home Office 2000/01). Prevalence of Domestic Abuse

22. It is not unusual for victims of domestic abuse to try and keep the abuse hidden. This may be due to a number of reasons, including: Embarrassment Fear of not being believed Feeling ashamed Uncertainty as to where to go or who to ask for help Fear that if they seek help it may exacerbate matters Anxiety about living alone They may be fearful about finances – either no skills in the management of finances or financial state is precarious The abuser has control of the family finances They may still love the abuser Some women have experienced abuse for so long that they feel that their situation is ‘normal’. (DH 2000, ADSS 2005). A Hidden Issue?

23. PART 4: Types of Abuse

24. The same types of abuse apply as are outlined in safeguarding children in need of protection documents: Physical Sexual Psychological and Emotional Neglect With the additional category: Financial The survivor may have experienced abuse from more than one category. Types of Abuse

25. Physical Abuse • Comprises of: • Hitting, slapping, smacking, punching, kicking • Biting • Burning • Pushing • Throwing objects near someone • Restraining, tying up • Throwing objects at survivor • Using objects as weapons • Strangling, suffocation • Stabbing/ shooting • Starving • Genital mutilation • “Honour violence” • Making the survivor work excessively • Waking the survivor at night

26. Possible signs of physical abuse include: Bruising, e.g. shape of fist/hand/foot or show finger marks – often 1-1.5 cm apart, 3/4 bruises of about 1 cm diameter Multiple bruising of different colours/ages. Teeth marks or cord marks, object marks. Covered areas of body. Sites where accidental injuries are uncommon e.g. ear pinna, eye sockets, abdomen, inner thighs etc Fractures – differing ages, no treatment sought; spiral fractures; repeated fractures Head injuries Explanation does not match injury, or story is incoherent or changes over time Failure to thrive, signs of malnutrition such as thin hair, increased hair loss, poor skin condition Stab wounds are not always obvious if long thin object used – signs of bleeding (maybe concealed) Signs of physical exhaustion General signs: may include poor health, poor nutrition, depression, eating disorders, suicide attempts, chronic pain, attempts to cover up the injury with clothing or make-up, fear, miscarriage, incontinence (in the elderly).

27. Comprises of: Forced sexual acts (no consent); e.g. rape, buggery, unwanted touching/oral sex Bondage Forced masturbation Forcing victim to participate in group sex, or having sex unwillingly in front of others, or being forced to have sex with others whilst being watched Enforced prostitution Ignoring religious prohibitions about sex Refusal to practice safe sex Sexual insults Preventing breastfeeding Forced pornographic involvement (may be shown images or filmed to make images Portraying sexual images on the internet/forcing use of sexual images on the internet/sexual bullying through internet chat sites Sexual Abuse

28. Signs of sexual abuse may include: Injury to genitals/breasts or injuries showing physical force, but often few signs Presence of semen or blood in genital area Sexually transmitted diseases Psychological distress including shame, humiliation and fear Pregnancy Poor bonding with infant Chaotic or inappropriate dress, with/without accompanying poor hygiene, to divert attention by appearing unattractive Fear of using mirrors Sleeping disorders. Lowered self esteem, recurrent depression or unexplained physical pain (somatic) Pregnancy, termination of pregnancy, or miscarriage – note that violence escalates during pregnancy and midwives are now required to ask all women if they are experiencing domestic abuse Incontinence (particularly in the elderly) General signs: sexual abuse may lead to self-harming, eating disorders, suicide attempts, fear or reluctance to undress, fear of male healthcare staff, fear of being touched, etc.

29. Comprises of: Intimidation, insulting, shouting, swearing, frightening Humiliation Denying the abuse Threatening to harm children or to take them away and/or report so-named ‘inadequate’ parenting to social services Enforcing a distorted perspective Buying gifts to say sorry and create a feeling that it will be alright, or over a time a feeling of being unsure who to trust (fostering distrust of own judgements) Isolating from friends and family, moving frequently, preventing the adult from learning English or from going to places alone where s/he may be able to ask for help Eroding independence Keeping locked in one room, or removing mobility aids so unable to get around Undermining confidence Making racist remarks Psychological and Emotional Abuse

30. Signs of psychological and emotional abuse may include: Women usually experience lowered self esteem May be depressed and appear withdrawn, or may exhibit anger and hostility Unexplained physical pain (somatic) Sleeping disorders, self neglect Eating disorders, particularly bulimia Attempts at self-harming or suicide Lack of confidence, inability to make decisions, unsure of own judgement Attempts to justify relationship or cover up perpetrator’s rudeness if displayed in public Difficulties in socialising, fear Incontinence (in the elderly)

31. Comprises of depriving a person of: Food Comfort Clothing Heat Medication Neglect

32. Signs of neglect may include: Loss or excessive gain of weight Unkempt appearance Loss of false teeth, spectacles, hearing aids or mobility aids Medical conditions which go unresolved for a long time because person has no access to health care, or written prescriptions are not “exchanged” for medication Failing to attend pre-arranged medical appointments, X-rays etc In the elderly or vulnerable – meals and drinks being placed out of reach of person and then removed untouched Lack of stimulation – books, TV etc May be associated with emotional/ psychological abuse (as well as other forms of abuse) May be unintentional Q. Can you think of a situation where neglect may arise unintentionally?

33. Comprises of: Not letting an individual work Undermining efforts to find work or study Refusing to give money Asking for an explanation of how every penny is spent Making an individual beg for money Gambling Not paying bills Using money/valuables illegally Removing pension books, bank books Financial Abuse

34. Signs of financial abuse may include: Changes in demeanour, possessions or dress Obvious changes/restriction in spending power Inability to afford food - in extreme circumstances may lead to malnutrition Inability to afford medication

35. In addition to these signs, further investigation may be necessary if: The story or explanation given does not explain the injuries or the circumstances The story changes over time, or is retold in exactly the same way as though it has been rote-learned Significant delay between time of injury and seeking medical help One partner appears to talk over the other partner, or appears to talk for the other partner – indicating undue exertion of control. Perpetrator will not leave their partner alone One partner appears to be looking to the other partner all the time for permission to respond to questioning Further Investigation

36. Non-verbal signals do not match the verbal story – e.g. the victim may be looking away and not making eye contact whilst talking, she/he may lean away from you when answering questions Abused person may minimise the violence or take the blame on herself (or himself) Fear, indicated again by non-verbal signals and body posture, or by moving suddenly when touched Abused person appears evasive, ashamed, embarrassed or apologetic (Campbell and Soeken, 1999) Frequent attendance at A & E A functionally impaired patient who arrives without their main carer Perpetrator may overtly threaten staff trying to treat the abused person Alcohol/drug abuse (women experiencing violence are 15 times more likely to abuse alcohol and 9 times more likely to abuse drugs (Stark and Filcraft 1996). Suicide/Parasuicide (women experiencing violence are 5 times more likely to attempt suicide (Stark and Flitcraft 1996).

37. Factors affecting male disclosure Disempowerment: those in authority are reluctant to believe that a man may be being abused by a female partner, and mistrust what he is saying Shame: men feel ashamed because they cannot protect themselves from their partners Police are more likely to believe a woman who accuses the man of being the aggressor, and men are then blamed and sometimes charged incorrectly Men do not want to admit to themselves or others that they are being abused Men have not been encouraged to disclose abuse and do not know who to turn to There is limited public (media) information on female abuse of men, and little has been done to encourage men to disclose abuse Factors Affecting Disclosure

38. Factors affecting female disclosure Fear – perpetrator may have threatened further violence if she asks for help Shame - belief that the violence is her fault, or that it is normal among couples Low self-esteem and powerlessness – repeated emotional and physical violence reduces a woman’s belief in her ability to make decisions, and she comes to believe she does not deserve a life free from violence A belief that the partner will change or that he intends to change; episodes of violence are interspersed with episodes of calm which may be signalled by gifts and loving gestures from the perpetrator and leave the woman feeling confused Women may be unaware of services or help which is available to them, and find it hard to access this information Women see the role of the health visitor as being concerned with children rather than other problems

39. Survivors of domestic abuse want: To be safe To be believed, taken seriously and respected Interventions to come at the right time and be proactive – ask her what is happening To have information provided To have independent advocates (e.g. from the voluntary sector) To liaise with different agencies to keep an overview of the case A single person or agency as contact/provide help & support to prevent having to repeat his/her story To be given clearly explained options based on their circumstances, for them to make choices To have contact with other survivors To be kept informed of developments – such as when an abuser is released from a police station or turns up at the child’s school To be given support to cope with the effects of abuse on their children To have their views listened to, respected and incorporated into services that are offered to them Survivors of Domestic Abuse

40. Is everything alright at home? Are you being cared for properly? Is your partner (or carer, daughter, son etc) taking care of you? Can you tell me who hurt you? Can you tell me how you got those injuries? Can you show me how this happened? Have you ever been in a relationship where you were hit or where someone hurt you in any way? Does your partner (carer, son or daughter etc) lose his temper with you, and if he does, can you describe what happens? Has your partner (carer, son or daughter, etc) ever broken things that you care about, threatened to hurt you or those you love (children), forced you to have sex or manipulated you to have sex when you didn’t really want it, or in a way you didn’t want? Questions to Ask if Domestic Abuse is Suspected

41. PART 5: Older Adults and Abuse

42. Granny battering Elder abuse Elder mistreatment The battered elder syndrome Elder mistreatment Granny bashing Older Adults and Abuse The following list is cited in chronological order as terms that have been previously established in the field of elder abuse and neglect: • Old age abuse • Inadequate care of the elderly • Granny abuse • Elder mis-care

43. Q. When does a person become elderly? Terminology may be misleading; for example ‘granny battering’ implies that: (a) it is only females that are affected (b) the abuse is of a physical nature leading to physical harm Both sexes can be subjected to abuse and just as in child abuse and domestic abuse, this takes many forms, not just physical violence. For these reasons, definitions of elder abuse create some problems and have changed over time. Problems with Terminology

44. “Abuse may consist of a single or repeated acts. It may be physical, verbal or psychological, it may be an act of neglect or omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it.” Department of Health “No Secrets” (2000 p9) Current Definitions of Abuse

45. Mowlan et al (2007) highlight the difficulties in defining elderly abuse because of the differing sets of circumstances each older adult may experience, which reflect the different types of relationships between the perpetrator and the abused. For some, elder abuse is an extension of the domestic abuse suffered throughout the relationship with that perpetrator. For others, the abuse started when they became frail and unable to care for themselves completely due to physical or mental health issues. Sometimes the abuse begins when it is the perpetrator who becomes frail due to physical or mental health issues. The abuse may be perpetrated by other family members The abuse may be perpetrated by someone the older adult trusts such as a next door neighbour or a friend The perpetrator may be a stranger (the issue of con men and ‘cold callers’ are frequently the topic of television programmes such as the BBC’s ‘Rogue Traders’) The issue is further complicated by the definition of vulnerability (see previous section)

46. Safeguarding adults is the current terminology which aims to identify the adult who is in need of support or intervention because they are ‘at risk’. Just as in child protection and domestic violence our terminology has changed and developed as our knowledge of the issue has increased, so our growing knowledge of adults who suffer abuse has lead us to the current term ‘safeguarding vulnerable adults’ Safeguarding Vulnerable Adults

47. Abuse of vulnerable adults and of elderly people mirrors domestic abuse, including physical, sexual, emotional, psychological and financial abuse. Mowlan et al (2005) note that elderly people who viewed issues of relationships, social support and religious beliefs with positive feelings of social ‘connectedness’ tended to have more protection from long term harm than those who had fewer social connections or positive feelings about their social network. Abuse of Vulnerable Adults and Elderly People

48. In order to assess the situation the following questions need to be asked: Who is the vulnerable person? (may not be the patient, may be the carer) What is the nature and extent of the abuse? How long has the abuse been going on? What is the impact of the abuse on the individual? Will the abuse be repeated and/or progress to more serious abuse? Key Questions where Neglect or Abuse is Suspected

49. Assess need and put appropriate services in place Where the assessment suggests the individual is vulnerable and abuse is occurring either: Remove them from the home into residential care or Remove the carer (especially if the carer is a paid carer or the individual is in an institutional setting) until a full investigation has been conducted or Make alternative care arrangements for the home Action

50. Work with other professionals to meet health needs Report concerns (to mentor/supervisor/designated person) Use clear, concise questions when asking the individual if they have been abused, explaining your suspicions clearly (i.e. the bruising does not reflect his/her story). (If inexperienced, do not question the person. This must be done by a trained/experienced member of staff. If a person discloses abuse let him/her know you believe him/her, but say you need to notify someone better able to help.) DO NOT QUESTION about suspected abuse in front of anyone else as it may put them in increased danger Document concerns/injuries/comments s/he may make about the cause of the injury Create opportunities to speak to the individual alone if someone else is with him/her Ask what the individual wants to happen Advice for Health and Social Care Staff