Safeguarding Vulnerable Adults glass house and stones institutional abuse on our own doorstep

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Safeguarding Vulnerable Adults-glass house and
stones institutional abuse on our own doorstep

• Lynne Phair
• Consultant Nurse for Older People
• (Safeguarding Adults)
• West Sussex Health
• Care closer to home
• West Sussex PCT

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What are Consultant Nurses?

• Role of a Consultant Nurse
• The role of the consultant nurse has 4 main areas
  of work (as directed by the Department of Health)
• Expert practice, and consultancy (50 of time)
• Professional leadership, and service development
• Education practice development and training
• Research and evaluation

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The Cycle of Safeguarding
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What is institutional abuse?

• Abuse as described in the No Secrets ( 2000)
  guidance
• is a violation of an individuals human and
  civil rights by any other person or persons
• It may consist of a single act or repeated acts
  and can take the form of physical abuse,
  financial or material abuse, neglect and acts of
  omission and discriminatory abuse.
• The guidance also refers to institutional abuse
  and provides the following example
• Neglect and poor professional practice also
  need to be taken into account. This may take the
  form of isolated incidents of poor or
  unsatisfactory professional practice, at one end
  of the spectrum, through to pervasive ill
  treatment or gross misconduct at the other
• Patterns of institutional abuse features poor
  care standards, lack of positive responses to
  complex needs, rigid routines, inadequate
  staffing and an insufficient knowledge base
  within the service
• Remember an institution does not need to have a
  building- community nursing teams are also
  institutions

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Abuse and Neglect in the NHS some examples

• Joint investigation into the provision of
  services for people with Learning Disabilities
  at Cornwall Partnership Trust Healthcare
  Commission Report July 2006 found serious
  concerns about the care and treatment of people
  with a learning disability in this Trust
• Investigation into the service for people with
  Learning Disabilities provided by Sutton Merton
  PCT Healthcare Commission Report January 2007
  found Institutional abuse
• it was largely unintentional but it is abuse
  never the less. It was mainly due to a lack of
  awareness, lack of specialist knowledge, lack of
  training and lack of insight
• Caring for dignity a national report on dignity
  in care for older people while in hospital.
  Healthcare Commission September 2007 found
  neglectful practice, lack of dignity and poor
  leadership
• Investigation into outbreaks of clostridium
  difficile at Maidstone and Tunbridge Wells NHS
  Trust Healthcare Commission October 2007 90
  people died between April 2004 September 2006
  Poor nursing care- No strategic direction Staff
  shortages, poor hygiene

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And closer to home The Department of
Health dignity challenge- Standard 1 Have a
zero tolerance of all forms of abuseStandard 2
Support people with the same respect you would
want for yourself or a member of your family
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Neglect from a District Nursing Team involved in
a Residential Care Home

• Home was being investigated under SVA for
  possible institutional neglect. DN involvement
  with1 lady caused concern
• Lady was receiving palliative care, had cancer,
  dementia, had developed a pressure ulcer and was
  dehydrated.
• DNs visited twice a week to manage catheter and
  dress pressure ulcer

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The Investigation

• Investigation showed
• Twice weekly visit was by a care assistant not DN
• No continence , pain or pressure risk assessment
  or care plan
• No pressure relieving mattress or profiling bed
• No wound care plan or evaluation
• No evidence of partnership working with home
• No leadership from DN lead

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Outcome

• DN team found to have neglected lady.
• Lack of understanding that neglect is not just
  poor care
• Lack of understanding of this failure to care and
  their NMC registration requirements
• Action taken by PCT was one of Sensitive
  Authority - focused practice development,
  education and awareness training

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Within an acute Hospital in September 2007

• 74 year old man with Vascular Dementia, diabetes
  admitted with fractured neck of femur. Before
  fall was mobile, continent able to eat and drink
  independently
• During operation identified needed a blood
  transfusion, catheterised and was in renal
  failure
• Operation was technically completely successful

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After 5 days

• Dr told wife that he was not to have blood
  transfusion . Daughter complained asked for an
  explanation. He got 2 units of blood that
  afternoon
• Physios did not help him to mobilise for 4 days
  despite the family being told he would be
  because they were busy ( but they helped others)
• His catheter was not taken out for a week. Only
  removed when daughter complained he went into
  retention
• He lost his appetite so his diabetes became
  unstable
• He became constipated and he became more
  confused and more difficult to care for.

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After 42 days

• He was unable to return to his residential care
  home because of his unstable diabetes
• He was classed as a bed blocker and was parked on
  the delayed discharge ward
• He no longer knew his family
• He lost 19 Kg in weight
• He could hardly weight bear
• He was doubly incontinent
• His haemoglobin fell again but was not treated
• His renal function was not re tested
• He stopped eating and drinking completely, and
  lost his ability to manipulate food in his mouth-
  Dietician said it was behavioural he was
  choosing not to eat
• Was very dehydrated and toxic causing aggressive
  outbursts
• No referral was made to the Mental health
  Liaision nurse

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After discharge

• GP took bloods within 6 hours of arriving at the
  new Nursing Home he had a urea level of 33, was
  anaemic and in chronic renal failure
• The new nursing home nurtured him, within 3 days
  he began eating and drinking small amounts
• 6 months later although frail he knows his
  family again can walk a little with a zimmer, is
  only occasionally incontinent. His diabetes is
  stable and he eats like a horse. He even went to
  the Grand hotel for afternoon tea in February for
  his 75th Birthday

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What did the Hospital say?

• Family raised an adult protection alert while he
  was still in hospital alleging serious neglect
• Social Workers decided it was minor, allowed ward
  to investigate itself
• Report to family said
• he needed to loose weight, it helped his diabetes
• He chose not to eat
• They checked his renal function 6 times They
  checked it twice
• He was aggressive all the time ( the records show
  it was in last 6 days when he was very toxic)
• Another 6 months has passed. After fighting and
  submitting their own expert report, the family
  have succeeded in getting an independent enquiry
  commissioned by the Hospital which will be heard
  at a Safeguarding Case Conference chaired by
  Social Services

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May 2008 Eastbourne Sea front
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Why is it going wrong who is to blame?

• Its everyone elses fault but is it?
• The Government, Trust Managers, NMC, Nurse
  Education(the Universities) Staff shortages, the
  catering department, care homes ( they keep
  filling up hospital beds!) difficult patients,
  objectionable relatives.
• So why does it still go on? Some theories
• Cognitive Dissonance- denial and turning a blind
  eye or is it ignorance ?
• An inability to have crucial conversations
  -Silence kills
• Group think ( Janis Mann 1977)

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What must be done to stop abuse in the state
sector?

• Accept our own responsibilities - Our
  Professional Code of Practice
• There is no excuse for poor practice mitigation
  does not make it ok, it might go someway to
  explain why some things have happened
• Health Care Commission 2007
• We must develop a better understanding of
  institutional abuse and how it occurs.
• We must understand the interrelationship and
  causative factors which result in neglect being
  caused by an individual, a team, and an
  organisation - corporate neglect.
• We must accept the part the profession plays even
  within the state sector
• We must put a stop to organisational arrogance

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What can I do? What I
can do !

• Understand ourselves and our own unconscious
  prejudices
• Understand and acknowledge unconscious
  conformity to poor care practices
• Be honest reflect
• Understand it
• Acknowledge it and decide to take no further part
  in it
• Implement the campaigns that are currently
  available
• Leadership training programmes
• Dignity challenge
• Nutrition now campaign
• Review your Adult protection training does
  your training balance the need to spot abuse in
  others as well as the potential to abuse in
  ourselves?
• Speak up and speak out
• Dont turn a blind eye any more at ward level
  team level or as a senior manager
• Document on risk assessments and registers how
  potential cuts or actions by the Trust may
  constitute institutional abuse and neglect
• Work towards our own form of Reconciliation
• Glasnost
• Truth and Reconciliation Commission
• Give ourselves a symbol of hope

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But what can we do?
What can I do?The Velvet Revolution The
Purple Revolution
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Light just one candle in the darkness
Encourage 10 others to do the sameTogether we
can light up the futureLet us lead the Purple
Revolution
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References

• Investigation into the outbreaks of clostridium
  difficile at Maidstone and Tunbridge Wells NHS
  Trust October 2007 Healthcare Commission
  www.healthcarecommission.org.uk
• Caring for dignity. A national report on the
  dignity in care for older people while in
  hospital September 2007 Healthcare Commission
  www.healthcarecommission.org.uk
• Data on patient safety incidents relating to
  nutrition and hydration in hospital October 2007
  National Patient Safety Agency www.npsa.nhs.uk
• Maxfield D Grenny J McMillan R Patterson K
  Switzler A ( 2005) Silence Kills the seven
  crucial conversations for healthcare
  www.silencekills.com
• Festinger L ( 1957) A theory of cognitive
  dissonance, Evanston, IL row Peterson
• Hungry to be heard ( 2006) Age Concern London
• Investigation into matters arising from the care
  on rowan Ward Manchester Mental Health 7 Social
  Care Trust September 2003 Commission for Health
  Improvement www.healthcarecommission.org.uk/_db/_d
  ocument/04004963.pdf
• Investigation into the service for people with
  learning disabilities provided by Sutton and
  Merton Primary Care Trust Healthcare Commission
  January 2007 www.healthcarecommission.org.uk
• Joint investigation into the provision of
  services for people with learning disabilities at
  Cornwall Partnership NHs Trust Healthcare
  Commission July 2006 www.healthcarecommission.org.
  uk
• Janis I, L Mann L ( 1977) Decision making. A
  psychological analysis of conflict, choice and
  commitment. New York Free Press
• Contact for correspondence lynne.phair_at_westsussexp
  ct.nhs.uk