Safeguarding vulnerable adults Abstract
Nurses have a professional duty to safeguard vulnerable adults from abuse under the provisions of the Nursing and Midwifery Council’s (NMC) revised Code (2015). With adult abuse continuing to increase, all members of the nursing team are well placed to identify and take action to safeguard the vulnerable. This article sets out how the Care Act 2014 seeks to improve the safeguarding of vulnerable adults and the role of nurses in that process. Key words: Safeguarding ■ Vulnerable adults ■ Abuse ■ Human rights
A
buse of vulnerable adults has changed little since the Health Committee of the House of Commons report found that an estimated half a million people suffer abuse— equivalent to between 5% and 9% of the older population (House of Commons Health Committee, 2004). The committee also found that the great majority of abuse (67%) occurs in the person’s own home. Nurses are well placed to recognise those people who have injuries as a result of abuse and to raise concerns about the welfare of vulnerable people. The Care Act 2014 aimed to tackle vulnerable adult abuse by introducing Adult Safeguarding Boards that will work cooperatively with health and social services to identify and alleviate vulnerable adult abuse.To fulfil their role, nurses must be able to recognise a vulnerable adult and the forms of abuse they can suffer, so they can raise concerns under local Adult Safeguarding Board procedures (Care Act 2014, section 43).
Defining abuse Abuse and neglect can take many forms and the circumstances of the individual should always be considered. Physical abuse includes assault, hitting, slapping, pushing, misuse of medication, restraint or inappropriate physical sanctions. In R v Francis [2003] a man was convicted of the attempted murder of his mother whom he
Richard Griffith, Senior Lecturer in Health Law, College of Human and Health Sciences, Swansea University
708
lived with and cared for. Francis claimed he had been suffering from depression and had decided to commit suicide. He said he wanted to kill his mother before doing so, as there would be nobody to look after her after his death. Francis had hit his mother over the head twice with a shillelagh (wooden walking stick or club), had held her by the throat, and had then struck her on the back of the head with her walking stick—all of which had failed to kill her. Sexual abuse includes rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography, subjection to pornography or witnessing sexual acts, indecent exposure and sexual assault or sexual acts to which the adult has not consented or was pressured into consenting. In Re SKR (1994), a 27 year-old woman was indecently assaulted at a clinic by a member of staff who inserted his finger into her vagina and asked her to touch his genitals. The woman had learning difficulties and a schizo-affective disorder and was living in sheltered accommodation. After the incident she was admitted to hospital on a number of occasions with a flare-up of her schizophrenic symptoms and she developed severe depression. Her behaviour became more aggressive, and at times regressed to child-like activities. She lost her sense of independence and self-confidence, showing that as well as the primary abuse, the victim is left with the psychological impact. Psychological abuse can be a discreet form of abuse that includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, cyber bullying, isolation or unreasonable
and unjustified withdrawal of services or supportive networks. In R v Collard [2002] a sentence of 4 years’ imprisonment had been imposed for an offence of blackmail. Collard had made several demands for money from a 65 year-old man having threatened to tell of an allegation of indecent assault if he failed to pay. The victim paid a total of £74 000 to Collard: the bulk of his life savings. He then committed suicide. Financial or material abuse includes theft, fraud, internet scamming, coercion in relation to an adult’s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions, or the misuse or misappropriation of property, possessions or benefits. In R v Hinks [2001] a man of limited intelligence was persuaded by his carer to make a series of transfers from his bank account to her own. She maintained that the transfers were a gift. The jury, however, held that accepting such a large sum from a vulnerable adult was dishonest and convicted Hinks of theft. Modern slavery encompasses slavery, human trafficking, forced labour and domestic servitude. Discriminatory abuse includes forms of harassment, slurs or similar treatment because of race, gender and gender identity, age, disability, sexual orientation or religion. In R v Bell [2001] a man was given an 18-month sentence for a racially aggravated assault. Bell subjected an elderly neighbour to a physical attack and racial abuse. Organisational abuse includes neglect and poor care practice within an institution or specific care setting, such as a care home, or in relation to care provided in one’s own home. This may range from one-off incidents to ongoing ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation. Neglect and acts of omission include ignoring medical or physical care needs, failure to provide access to appropriate health, care and support or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating. In R v Stone & Dobinson
© 2015 MA Healthcare Ltd
Richard Griffith
British Journal of Nursing, 2015, Vol 24, No 13
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 23, 2015. For personal use only. No other uses without permission. . All rights reserved.
LEGAL [1977] a couple took in the elderly anorexic sister of Stone. She took to her bed, refusing to eat and was found some months later, dead. Her body was found in a bed stained with faeces and urine. Stone and Dobinson were convicted of the sister’s manslaughter for failing to care for her and failing to seek medical attention for her. Self-neglect covers a wide range of behaviour, neglecting to care for one’s personal hygiene, health or surroundings, and includes behaviour such as hoarding. Domestic violence has been redefined, with the Home Office changing the definition of domestic abuse to an incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse by someone who is or has been an intimate partner or family member, regardless of gender or sexuality. It therefore includes psychological, physical, sexual, financial and emotional abuse, and so-called ‘honour’ based violence (Home Office, 2012). It is clear that the Home Office does not limit the definition of domestic abuse to intimate partners, but extends the definition to encompass other family members as well.
Vulnerable adults The statutory guidance to the Care Act 2014 at 14.2 sets out when the safeguarding duty applies. A vulnerable adult is one who has:
© 2015 MA Healthcare Ltd
‘Needs for care and support whether or not a local authority is meeting any of those needs and; is experiencing, or at risk of, abuse or neglect; and as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.’ Local authorities have statutory adult safeguarding duties under the Care Act 2014. When a nurse has any concerns about the abuse or neglect of a vulnerable adult whose situation meets the threshold for triggering the safeguarding duty set out above, he or she must report the matter through their organisation’s safeguarding policy. This will result in the concern being raised with the local authority adult safeguarding team. The statutory adult safeguarding duty of local authorities is widely defined under the Care Act 2014. It applies equally to those adults with care and support needs, regardless of whether those needs are being met, regardless of whether the adult lacks mental capacity or not, and regardless of the care setting (Department of Health (DH), 2014).
British Journal of Nursing, 2015, Vol 24, No 13
Duty to safeguard vulnerable adults Safeguarding is defined as protecting an adult’s right to live in safety, free from abuse and neglect (DH, 2014). It requires people and organisations working together to prevent and stop the risks and experience of abuse or neglect. To achieve this local authorities must work with relevant partners to protect adults. A local authority must also cooperate with such other agencies or bodies as it considers appropriate in the exercise of its adult-safeguarding functions, including health services. The Care Quality Commission (CQC), the statutory regulator for adult health services in England, also imposes an organisational duty to safeguard adults. The CQC introduced revised fundamental standards that came fully into force on 1 April 2015. The standards are underpinned by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, giving them legal force. Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires health services to safeguard the users of their services from abuse and improper treatment. To meet the requirements of Regulation 13, health services must ensure they take appropriate steps to impose a zero-tolerance approach to abuse, including neglect and subjecting service users to degrading treatment, and to prevent service users from being abused by staff or others, including visitors.The health services must also take appropriate steps to ensure a zero-tolerance approach to unlawful discrimination or restraint, and to unnecessary or disproportionate restraint or deprivation of liberty. Where any form of abuse is suspected or reported, even by a third party from outside the organisation, then the hospital or primary health service is required to take timely and appropriate action to investigate and refer on to an appropriate body such as the police, CQC or local authority under their adult safeguarding procedures (CQC, 2014). In situations where service users do suffer abuse or are placed at risk of any form of abuse, then it is open to the CQC to move directly to prosecution without having to serve
a warning notice first. The CQC also considers breaches of other regulations that have led to abuse, or are a major contributory factor in not preventing abuse. Again, in these cases, the CQC can move directly to prosecution without serving a warning notice, as well as take action for breaches of the other regulations (CQC, 2014).
Conclusion Adult abuse remains a significant problem in our society with 1 in 20 people reporting being abused. The Care Act 2014 aims to tackle adult abuse by reinforcing the safeguarding duties of local authorities and their partners, including health services. The 2014 Act will create adult safeguarding boards to coordinate local adult safeguarding procedures for preventing and alleviating abuse through multiagency working. Services regulated by the CQC now have an additional duty to ensure that their patients or service users are safeguarded from abuse when receiving treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 13, which form the fundamental standards of the CQC. To avoid criminal prosecution and having their fitness to practise as a nurse called to account it is essential that all nurses are able to recognise adult abuse and know how to take action and report suspected incidents of adult abuse that their patient’s may be experiencing BJN or be at risk of. Conflict of interest: none Care Quality Commission (2014) Guidance for providers on meeting the fundamental standards and on CQC’s enforcement powers. CQC, London Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936) Home Office (2012) Domestic Violence Disclosure Scheme Guidance. Home Office, London House of Commons Health Committee (2004) HC 111-1 Elder Abuse: Second Report of Session 2003-4 Volume 1. The Stationery Office (TSO), London Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. NMC, London R v Bell [2001] 1 Cr App R 108 R v Collard [2002] EWCA Crim 2219 R v Francis [2003] EWCA Crim 1220 R v Hinks [2001] 2 AC 241 R v Stone & Dobinson [1977] QB 354 Re SKR (1994) Criminal Injuries Compensation Board (Manchester) January 13
KEY POINTS n Nurses have a duty to report abuse against vulnerable adults n Nurses must be familiar with the multiagency adult protection policy for their area n Abuse may be physical, psychological, financial, sexual or through neglect n Health services have a duty to safeguard patients from abuse and improper treatment that might arise when the person is receiving care
709
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 23, 2015. For personal use only. No other uses without permission. . All rights reserved.
Nurses have a professional duty to safeguard vulnerable adults from abuse under the provisions of the Nursing and Midwifery Council’s (NMC) revised Code (2015). With adult abuse continuing to increase, all members of the nursing team are well placed to identify and take action to safeguard the vulnerable. This article sets out how the Care Act 2014 seeks to improve the safeguarding of vulnerable adults and the role of nurses in that process. Key words: Safeguarding ■ Vulnerable adults ■ Abuse ■ Human rights
A
buse of vulnerable adults has changed little since the Health Committee of the House of Commons report found that an estimated half a million people suffer abuse— equivalent to between 5% and 9% of the older population (House of Commons Health Committee, 2004). The committee also found that the great majority of abuse (67%) occurs in the person’s own home. Nurses are well placed to recognise those people who have injuries as a result of abuse and to raise concerns about the welfare of vulnerable people. The Care Act 2014 aimed to tackle vulnerable adult abuse by introducing Adult Safeguarding Boards that will work cooperatively with health and social services to identify and alleviate vulnerable adult abuse.To fulfil their role, nurses must be able to recognise a vulnerable adult and the forms of abuse they can suffer, so they can raise concerns under local Adult Safeguarding Board procedures (Care Act 2014, section 43).
Defining abuse Abuse and neglect can take many forms and the circumstances of the individual should always be considered. Physical abuse includes assault, hitting, slapping, pushing, misuse of medication, restraint or inappropriate physical sanctions. In R v Francis [2003] a man was convicted of the attempted murder of his mother whom he
Richard Griffith, Senior Lecturer in Health Law, College of Human and Health Sciences, Swansea University
708
lived with and cared for. Francis claimed he had been suffering from depression and had decided to commit suicide. He said he wanted to kill his mother before doing so, as there would be nobody to look after her after his death. Francis had hit his mother over the head twice with a shillelagh (wooden walking stick or club), had held her by the throat, and had then struck her on the back of the head with her walking stick—all of which had failed to kill her. Sexual abuse includes rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography, subjection to pornography or witnessing sexual acts, indecent exposure and sexual assault or sexual acts to which the adult has not consented or was pressured into consenting. In Re SKR (1994), a 27 year-old woman was indecently assaulted at a clinic by a member of staff who inserted his finger into her vagina and asked her to touch his genitals. The woman had learning difficulties and a schizo-affective disorder and was living in sheltered accommodation. After the incident she was admitted to hospital on a number of occasions with a flare-up of her schizophrenic symptoms and she developed severe depression. Her behaviour became more aggressive, and at times regressed to child-like activities. She lost her sense of independence and self-confidence, showing that as well as the primary abuse, the victim is left with the psychological impact. Psychological abuse can be a discreet form of abuse that includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, cyber bullying, isolation or unreasonable
and unjustified withdrawal of services or supportive networks. In R v Collard [2002] a sentence of 4 years’ imprisonment had been imposed for an offence of blackmail. Collard had made several demands for money from a 65 year-old man having threatened to tell of an allegation of indecent assault if he failed to pay. The victim paid a total of £74 000 to Collard: the bulk of his life savings. He then committed suicide. Financial or material abuse includes theft, fraud, internet scamming, coercion in relation to an adult’s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions, or the misuse or misappropriation of property, possessions or benefits. In R v Hinks [2001] a man of limited intelligence was persuaded by his carer to make a series of transfers from his bank account to her own. She maintained that the transfers were a gift. The jury, however, held that accepting such a large sum from a vulnerable adult was dishonest and convicted Hinks of theft. Modern slavery encompasses slavery, human trafficking, forced labour and domestic servitude. Discriminatory abuse includes forms of harassment, slurs or similar treatment because of race, gender and gender identity, age, disability, sexual orientation or religion. In R v Bell [2001] a man was given an 18-month sentence for a racially aggravated assault. Bell subjected an elderly neighbour to a physical attack and racial abuse. Organisational abuse includes neglect and poor care practice within an institution or specific care setting, such as a care home, or in relation to care provided in one’s own home. This may range from one-off incidents to ongoing ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation. Neglect and acts of omission include ignoring medical or physical care needs, failure to provide access to appropriate health, care and support or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating. In R v Stone & Dobinson
© 2015 MA Healthcare Ltd
Richard Griffith
British Journal of Nursing, 2015, Vol 24, No 13
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 23, 2015. For personal use only. No other uses without permission. . All rights reserved.
LEGAL [1977] a couple took in the elderly anorexic sister of Stone. She took to her bed, refusing to eat and was found some months later, dead. Her body was found in a bed stained with faeces and urine. Stone and Dobinson were convicted of the sister’s manslaughter for failing to care for her and failing to seek medical attention for her. Self-neglect covers a wide range of behaviour, neglecting to care for one’s personal hygiene, health or surroundings, and includes behaviour such as hoarding. Domestic violence has been redefined, with the Home Office changing the definition of domestic abuse to an incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse by someone who is or has been an intimate partner or family member, regardless of gender or sexuality. It therefore includes psychological, physical, sexual, financial and emotional abuse, and so-called ‘honour’ based violence (Home Office, 2012). It is clear that the Home Office does not limit the definition of domestic abuse to intimate partners, but extends the definition to encompass other family members as well.
Vulnerable adults The statutory guidance to the Care Act 2014 at 14.2 sets out when the safeguarding duty applies. A vulnerable adult is one who has:
© 2015 MA Healthcare Ltd
‘Needs for care and support whether or not a local authority is meeting any of those needs and; is experiencing, or at risk of, abuse or neglect; and as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.’ Local authorities have statutory adult safeguarding duties under the Care Act 2014. When a nurse has any concerns about the abuse or neglect of a vulnerable adult whose situation meets the threshold for triggering the safeguarding duty set out above, he or she must report the matter through their organisation’s safeguarding policy. This will result in the concern being raised with the local authority adult safeguarding team. The statutory adult safeguarding duty of local authorities is widely defined under the Care Act 2014. It applies equally to those adults with care and support needs, regardless of whether those needs are being met, regardless of whether the adult lacks mental capacity or not, and regardless of the care setting (Department of Health (DH), 2014).
British Journal of Nursing, 2015, Vol 24, No 13
Duty to safeguard vulnerable adults Safeguarding is defined as protecting an adult’s right to live in safety, free from abuse and neglect (DH, 2014). It requires people and organisations working together to prevent and stop the risks and experience of abuse or neglect. To achieve this local authorities must work with relevant partners to protect adults. A local authority must also cooperate with such other agencies or bodies as it considers appropriate in the exercise of its adult-safeguarding functions, including health services. The Care Quality Commission (CQC), the statutory regulator for adult health services in England, also imposes an organisational duty to safeguard adults. The CQC introduced revised fundamental standards that came fully into force on 1 April 2015. The standards are underpinned by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, giving them legal force. Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires health services to safeguard the users of their services from abuse and improper treatment. To meet the requirements of Regulation 13, health services must ensure they take appropriate steps to impose a zero-tolerance approach to abuse, including neglect and subjecting service users to degrading treatment, and to prevent service users from being abused by staff or others, including visitors.The health services must also take appropriate steps to ensure a zero-tolerance approach to unlawful discrimination or restraint, and to unnecessary or disproportionate restraint or deprivation of liberty. Where any form of abuse is suspected or reported, even by a third party from outside the organisation, then the hospital or primary health service is required to take timely and appropriate action to investigate and refer on to an appropriate body such as the police, CQC or local authority under their adult safeguarding procedures (CQC, 2014). In situations where service users do suffer abuse or are placed at risk of any form of abuse, then it is open to the CQC to move directly to prosecution without having to serve
a warning notice first. The CQC also considers breaches of other regulations that have led to abuse, or are a major contributory factor in not preventing abuse. Again, in these cases, the CQC can move directly to prosecution without serving a warning notice, as well as take action for breaches of the other regulations (CQC, 2014).
Conclusion Adult abuse remains a significant problem in our society with 1 in 20 people reporting being abused. The Care Act 2014 aims to tackle adult abuse by reinforcing the safeguarding duties of local authorities and their partners, including health services. The 2014 Act will create adult safeguarding boards to coordinate local adult safeguarding procedures for preventing and alleviating abuse through multiagency working. Services regulated by the CQC now have an additional duty to ensure that their patients or service users are safeguarded from abuse when receiving treatment under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 13, which form the fundamental standards of the CQC. To avoid criminal prosecution and having their fitness to practise as a nurse called to account it is essential that all nurses are able to recognise adult abuse and know how to take action and report suspected incidents of adult abuse that their patient’s may be experiencing BJN or be at risk of. Conflict of interest: none Care Quality Commission (2014) Guidance for providers on meeting the fundamental standards and on CQC’s enforcement powers. CQC, London Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936) Home Office (2012) Domestic Violence Disclosure Scheme Guidance. Home Office, London House of Commons Health Committee (2004) HC 111-1 Elder Abuse: Second Report of Session 2003-4 Volume 1. The Stationery Office (TSO), London Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives. NMC, London R v Bell [2001] 1 Cr App R 108 R v Collard [2002] EWCA Crim 2219 R v Francis [2003] EWCA Crim 1220 R v Hinks [2001] 2 AC 241 R v Stone & Dobinson [1977] QB 354 Re SKR (1994) Criminal Injuries Compensation Board (Manchester) January 13
KEY POINTS n Nurses have a duty to report abuse against vulnerable adults n Nurses must be familiar with the multiagency adult protection policy for their area n Abuse may be physical, psychological, financial, sexual or through neglect n Health services have a duty to safeguard patients from abuse and improper treatment that might arise when the person is receiving care
709
British Journal of Nursing. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 23, 2015. For personal use only. No other uses without permission. . All rights reserved.
