Select Committee on Health Written Evidence

APPENDIX 19

The Abuse of Older People

ACTION ON ELDER ABUSE

  Action on Elder Abuse recognises that each country of the United Kingdom has different systems for managing health and social care. In England and Wales the health services provided by the NHS are managed by Health Authorities or Health Trusts. In Scotland it is provided by Health Boards and Trusts and in Northern Ireland by Health Boards and Trusts.

  Similarly statutory social services are delivered by Social Service Departments in England and Wales, Social Work Departments in Scotland and Social Service Boards in Northern Ireland.

  However for ease of reading and to avoid repetition this booklet uses the English and Welsh service names.

THE ABUSE OF OLDER PEOPLE—INFORMATION FOR DOCTORS

  Doctors are often the first professionals others turn to if they are worried about abuse. They are also in a key position to identify patients who are being abused or at risk of abuse. The role of doctors in the prevention of, and intervention in, abuse is therefore crucial.

  In the community abuse can be carried out by a relative, friend, volunteer or paid worker. In hospital or care settings it can also be the wilful act of a single worker or a reflection of a wider culture where poor management and low standards can lead to abusive practices.

  This booklet has been produced to help all doctors working within the community and in hospital to recognise, prevent and respond to the abuse of older people. It examines the different types and indicators of abuse, and provides guidance on what doctors should do if they suspect that abuse is happening.

  It is recommended that doctors should read this paper in conjunction with their practice's or employing body's policy and procedures on abuse.

WHAT IS ABUSE?

  Action on Elder Abuse defines elder abuse as: "A single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person".

  There are five main types of abuse:

  1.   physical—for example, hitting, slapping, burning, pushing, restraining or giving too much medication or the wrong medication;

  2.   psychological—for example, shouting, swearing, frightening, blaming, ignoring or humiliating a person;

  3.   financial—for example, the illegal or unauthorised use of a person's property, money, pension book or other valuables;

  4.   sexual—for example, forcing a person to take part in any sexual activity without their consent—this can occur in any relationship; and

  5.   neglect—for example, where a person is deprived of food, heat, clothing, comfort, stimulation or social contact or essential medication and attention.

  An older person may also experience abuse which is racist, religious or cultural in nature.

WHO IS ABUSED?

—  Any older man or woman can be abused.

—  Those with dementia or who have difficulties communicating may be more vulnerable to abuse than others.

—  People with dementia can be very distressed by the unfamiliar environment of a hospital or care setting. They may wander, interfere with other people or remove their belongings and in doing so, become victims of abuse by others. They may be unable to communicate that they have been abused and must rely on a worker to be observant.

WHO ABUSES?

—  A partner, child or relative.

—  A friend, neighbour or visitor.

—  A patient or resident.

—  A health, social care or other worker.

—  A home owner or manager.

—  A volunteer worker.

WHERE DOES IT OCCUR?

  Abuse can occur in any setting including an older person's home, their carer's or relative's home. In hospital it can occur in accident & emergency departments, acute wards, rehabilitation and continuing care wards, outpatients departments, as well in as day care, residential care or nursing home settings.

WHY DOES IT HAPPEN?

  Abuse occurs for many reasons and the causes are not fully understood. Research, which has been limited in the United Kingdom, has shown that the following risk factors (one or more may be present in any abusive situation) are associated with physical and psychological abuse in a domestic setting:

  1.  social isolation—those who are abused usually have fewer social contacts than those who are not abused;

  2.  there is a history of a poor quality long-term relationship between the abused and the abuser;

  3.  a pattern of family violence exists (the person who abuses may have been abused as a child);

  4.  the person who abuses is dependent upon the person they abuse, for example for accommodation, financial and emotional support; and

  5.  the person who abuses has a history of mental health problems or a personality disorder, drug or alcohol problem.

  As well as the known risk factors listed above, a range of other factors may increase the likelihood of abuse occurring where:

  1.  the older person has an illness such as Parkinson's disease or dementia which may affect their intellect, memory or physical functions and cause unpredictable psychological or physical behaviour;

  2.  the older person has communication difficulties as a result of hearing, visual or speech difficulties;

  3.  the older person has behavioural problems or major changes in personality which result in repetitive behaviour, wandering or aggression;

  4.  the older person demands or needs a level of care beyond the capacity of the carer;

  5.  a family undergoes an unforeseen or unfavourable change in circumstances;

  6.  a person has been forced to change his or her lifestyle as a result of being a carer;

  7.  a carer is isolated and lacks other relationships which give social, physical and emotional satisfaction and support;

  8.  a carer has other conflicting responsibilities or financial difficulties;

  9.  difficulties emerge because of a role reversal, for example if a father or mother becomes dependent on a son or daughter;

  10.  a carer has not received appropriate help or support; and

  11.  an older person exhibits aggressive or violent behaviour towards a carer.

  (This extract is taken from the publication The abuse of older people at home—information for workers—published by Action on Elder Abuse, 1996.)

FACTORS WHICH MAY LEAD TO ABUSE WITHIN HOSPITALS OR CARE SETTINGS

  All doctors should be aware of the following factors, which may make abuse more likely to happen within a hospital or care setting:

  1.  staff who work in isolation;

  2.  staff who are inadequately trained to provide care and to respond to challenging behaviour;

  3.  staff who are poorly supervised;

  4.  low staffing levels and/or frequent use of agency staff;

  5.  rapid turnover of staff or high staff sickness levels;

  6.  staff who have poor self esteem;

  7.  staff who are stressed or "burnt out";

  8.  staff who have a criminal history or a personality disorder;

  9.  inappropriate/poor staff skill mix;

  10.  poor staff/patient ratio;

  11.  inappropriate patient mix on wards;

  12.  inadequate management support;

  13.  over-cramped or poor working conditions and environment—inadequate equipment, poor catering arrangements;

  14.  the ward or care setting is isolated from other parts of the hospital or community; and

  15.  there is a disregard for the safety of patients or residents.

TYPES OF ABUSE

  The following are further examples of the five main types of abuse.

  1.   Physical—A patient is given drugs to control their "difficult" behaviour, or tied to a chair to "keep them quiet", or force fed when they don't wish to eat, or is incorrectly positioned.

  2.   Psychological—A patient is embarrassed by being undressed in front of others, or isolated as punishment for "bad behaviour" or humiliated because of their racial, religious or cultural background.

  3.   Financial—A patient's cash or other belongings "disappear".

  4.   Sexual—A patient is inappropriately touched when being helped to bathe. Unwanted involvement in sexually suggestive conversations.

  5.   Neglect—A patient is denied adequate food and drink, medical treatment, or social stimulation.

THE POSSIBLE SIGNS OF ABUSE

  A range of indicators, if present, may suggest the possibility of some kind of abuse or neglect. None of them means that abuse has taken place but should raise suspicions and encourage a more thorough investigation.

General signs:

  1.  difficulty getting access to the patient;

  2.  difficulty in interviewing the patient;

  3.  isolation of the patient in one room of their home, care setting or ward;

  4.  requests for help to numerous, different agencies, or frequent transfers from one agency to another;

  5.  repeated visits to a general practitioner or accident and emergency department or repeated admissions to hospital especially when there is no obvious medical reason or change in medical condition;

  6.  refusal by patient and/or a carer to accept necessary support services;

  7.  a patient who is abandoned by their spouse, family or carers;

  8.  a history of unexplained or repeated falls or minor injuries;

  9.  unusual pattern of accidents or deaths in a ward or care setting;

  10.  inappropriate use of medication and restraint, for example use of cot-sides;

  11.  a patient or resident given another person's medication;

  12.  excessive complaints about a ward, care setting or worker, or history of previous investigation; and

  13.  a denial of problems by staff or management.

Physical signs:

  1.  multiple bruising—including bruising in well protected areas, eg the inside of the thighs or upper arms or bruising at different stages of healing;

  2.  finger marks;

  3.  burns, especially if in unusual places such as the inside of the thighs or buttocks;

  4.  an injury similar in shape to an object;

  5.  unexplained fractures;

  6.  skin ulcers or bed sores or untreated wounds; and

  7.  a patient who tries to hide part of their body on examination.

Psychological signs, eg a patient:

  1.  appears depressed, frightened, withdrawn, apathetic, agitated, anxious or aggressive;

  2.  makes great efforts to please;

  3.  appears afraid of being, or unwilling to be, treated by a specific member of staff;

  4.  appears afraid of a relative or carer;

  5.  displays fear or apprehension or distress before or after a visit from a relative, carer or other visitor;

  6.  displays reluctance to be discharged to their previous circumstances; and

  7.  a patient's behaviour or mood suddenly or uncharacteristically changes.

Financial signs:

  1.  unexplained withdrawals from a patient's savings account;

  2.  an unexplained shortage of money, despite an adequate income;

  3.  sudden transfer of assets to a relative;

  4.  the disappearance of bank statements, other documents and valuables, including jewellery, clothes, personal possessions and money;

  5.  a patient's inability to explain what is happening to their income;

  6.  unpaid bills;

  7.  reluctance on the part of family, friends or the person controlling funds to pay for replacement clothes or furniture or other necessities; and

  8.  inappropriate request to a doctor to witness changes to a patient's will.

Sexual signs:

  1.  pain, itching or injury in the anal, genital or abdominal area;

  2.  difficulty in walking or sitting due to discomfort in the genital area;

  3.  bruises or bleeding in external genitalia;

  4.  torn, stained or bloody underclothing;

  5.  venereal disease or recurrent bouts of cystitis;

  6.  unexplained problems with catheters; and

  7.  an uncharacteristic change in a patient's behaviour or attitude to sex.

Neglect signs:

  1.  weight loss;

  2.  unkempt appearance, unshaven, inadequate or dirty clothing, or poor hygiene;

  3.  pressure sores or uncharacteristic problems with continence;

  4.  inadequate food and drink;

  5.  inadequate or inappropriate medical treatment or withholding treatment; and

  6.  a patient who is left in a wet or soiled bed.

Within Hospitals or Care Settings, Institutional Attitudes and Practices may Exist which can Indicate Abuse, for Example:

  1.  inflexible routines which suit the needs of staff and not patients;

  2.  patronising or bullying attitude of staff towards patients;

  3.  lack of choice, privacy and respect for patients;

  4.  run-down facilities and lack of suitable equipment;

  5.  poor continence management;

  6.  inappropriate and frequent use of restraints; and

  7.  lack of care plans for patients.

TAKING ACTION

  Doctors are often the first professionals that others turn to in situations of abuse; therefore, they have a key role to play in identifying abuse and in providing guidance to others.

  1.  Learn to recognise the signs and types of abuse, both obvious and hidden.

  2.  Know how you should respond in cases of abuse. Find out about your practice's or employing body's policy and procedures on abuse.

  3.  Elder abuse is a complex issue and requires a multi-disciplinary response. Collaborate with other professionals when responding to abuse. Identify the key agency or professional in your area who takes the lead on elder abuse.

  4.  Consider developing your own policy and procedures in conjunction with other local agencies (contact AEA for information).

  5.  Listen to patients and colleagues and observe any unusual or sudden changes in behaviour or practice.

  6.  Routinely ask patients and carers appropriate questions (see appendix).

  7.  Teach junior staff members about abuse and encourage them to incorporate it into their history taking and clinical audit.

  8.  Encourage research into abuse and intervention techniques.

WHAT YOU SHOULD DO IF YOU COME ACROSS OR SUSPECT ABUSE

  1.  You must always act if you come across abuse or you have strong suspicions that it is happening.

  2.  Never ignore your feelings, but try to get facts to support them. You do not have to prove that abuse has taken place, only that you have reasonable cause to suspect that it is happening.

  3.  Take notes and record incidents of abuse.

  4.  If you suspect or come across a case of abuse, seek guidance on how to proceed by referring to internal procedures and/or by consulting with the lead professional or agency in your area.

  5.  Always speak in private to an older person who might be the victim of abuse. Unless an older person wishes it, never discuss the matter with them if others are present, as they may be too afraid or ashamed to talk.

  6.  Be aware that discussions with a possible abuser at an early stage in your enquiry might put the older person at risk and could lead to further problems.

  7.  Always respect the needs and wishes of the older person who might be the victim of abuse. A competent older person does have the right to choose to remain in a potentially vulnerable situation.

  8.  Be sensitive to an older person's racial, religious and cultural background.

WHAT YOU SHOULD DO IF YOU SUSPECT A COLLEAGUE OF ABUSE

  1.  Be aware that doctors (as well as other health and social care workers) may abuse—this can be a wilful act or one of neglect.

  2.  It can be very stressful and traumatic to uncover and report abuse. It is therefore important that you seek support from a trusted colleague, medical director (if appropriate) or from an independent organisation, such as Public Concern at Work, which is a charity which offers free legal advice to people concerned about serious malpractice at work (refer to "Who to Contact" section at end of this paper).

  3.  Where you suspect that a colleague is abusing older people you should raise the matter directly with them or report it to the appropriate consultant who is obliged to investigate. The GMC should only be contacted after all internal procedures have been followed through and proved ineffective.

  4.  If a patient or relative wishes to report abuse they should follow the procedures outlined in the complaints procedure of the hospital or general practice. If this is not satisfactory they should contact the Chief Executive of the Health Authority, the Medical Director of the Health Trust, or the Community Health Council in their area.

  5.  Residents and/or their relatives in a care setting who wish to report abuse should follow the procedures outlined in the home's complaints procedure. If this is unsatisfactory, the abuse should be reported to the Health Authority Registration and Inspection Unit (where it occurs in a nursing home) or to the Social Services Registration and Inspection Unit (where it occurs in a residential home).

  6.  Always check that action has been taken, particularly if you have passed on the case to another professional or agency.

Mental capacity

—  In cases of actual or suspected abuse, a doctor's ability to take action is governed by an individual's mental capacity. In law, this is a term which defines whether a person can make decisions and understand their consequences. Where mental capacity is questioned, a full assessment of the individual's mental state must be undertaken and a firm decision reached as to whether the individual has capacity or not.

  This assessment should always be carried out by an experienced professional.

—  Where someone has the mental capacity to make their own decisions, interventions can normally only be made with that person's consent, unless other patients are put at risk.

—  Where a person does not have mental capacity, the social services department may take one of a range of actions; these might include a multi-disciplinary case conference, regular support, supervision or rehousing or organising a move to another care home. Relatives should be consulted whenever possible about a person's history.

—  (For further information refer to publication produced by the British Medical Association & the Law Society. Assessment of mental capacity. BMA 1995).

FINANCIAL PROTECTION

  In relation to a person's financial affairs a range of measures currently exist.

—  Appointeeship—where a person does not have mental capacity an appointeeship can be made by the Department of Social Security. An appointee claims and uses state benefits on behalf of a person who is unable to manage their own affairs. All money collected by the appointee must be used for the benefit of the claimant and the appointee's power does not extend beyond handling the social security benefits. Where there is suspicion of fraud in relation to agency* or appointeeship, the Department of Social Security should be informed.

—  Power of Attorney—this is a legal document by which one person can authorise another person or persons to undertake transactions on their behalf, usually a close relative or family solicitor.

  In England, Wales and Northern Ireland the power of attorney is automatically cancelled by operation of law when the individual loses mental capacity to manage their own affairs.

  In Scotland it is possible to have a continuing power of attorney which is still valid even if the person loses capacity. The original document should indicate whether or not it continues after loss of capacity.

—  Enduring Power of Attorney (EPA) —this applies to England, Wales and Northern Ireland and is a special form of power of attorney which, unlike an ordinary power, continues even if the person who grants it becomes incapable of managing their own financial affairs. When this happens the power must be registered with the Court of Protection in England and Wales or by the High Court in Northern Ireland.

—  The Court of Protection (England, and Wales) —a friend, spouse or relative of a person can apply to the Court of Protection if the person is no longer capable of managing their own financial affairs. The Court can appoint a receiver for the person, who is described by the court as a "patient". In Northern Ireland it is the High Court and the Office of Care and Protection which looks after the interests of people unable to manage their financial affairs due to "mental disorder" and in such cases in Scotland a Curator Bonis can be appointed.

*Agency—where one person collects a pension or benefit at the request of another.

LIAISON WITH, AND ROLE OF, THE POLICE

  If the police are to be involved in cases of abuse, early reporting or contact by agencies is advised. This can help to ensure that prompt and consistent action is taken and evidence retained. The police have clear policies on the prosecution of detected crime and, in particular, crimes against vulnerable members of society. Each case is assessed individually and consideration is given to the victim's surroundings. At present no specific policies are in place to deal with residential, nursing homes or hospitals.

  It should be remembered that criminal proceedings need not necessarily follow if the police are involved, either because of lack of evidence, because it is not in the public interest or because the injured party does not wish to proceed.

  The police welcome a multi-agency approach in dealing with issues of elder abuse, and recognise that their role is part of a wider one involving all the relevant agencies.

  Be aware of your own guidelines on police involvement in abusive situations.

  Where appropriate, establish a working relationship with the police officer responsible for dealing with elder abuse in your area. If the police in your area do not have a specialist unit, it is advisable to identify and establish good links with the appropriate police officer.

LEGAL INTERVENTIONS

  No single piece of legislation relates to elder abuse in England, Wales, Northern Ireland or Scotland. Existing civil and criminal legislation can be used in cases where legal action needs to be taken. It is important to realise that even where there is a legal remedy, an older person may be reluctant to use it.

  The following is intended to provide a brief outline to the legislation, doctors are advised to refer to their practice's or employing body's procedures or solicitor for comprehensive information on the law as it applies in their own area.

Civil legislation

  A person who is abused can bring a civil case against the abuser. This may be in relation to either personal violence or financial wrongdoing.

  Legislation on domestic violence may be used against a wide range of abusers who live with the abused person.

—  The Family Law Act 1996—Part IV (England and Wales)—this provides a single consistent set of remedies for those suffering domestic violence and standardises the types of orders that can be obtained. It will be relevant to abuse between older spouses and also applies to a new class of "associated persons."

—  The Family Homes and Domestic Violence (Northern Ireland) Order 1998—Refer to sections 4 & 5 of the Order.

—  The Matrimonial Homes (Family Protection ) (Scotland) Act 1981—if a person is suffering abuse from a spouse causing injury to physical or mental health, a court order under the Act can exclude the spouse from the matrimonial home and in certain cases from its vicinity.

Criminal legislation

  Abuse may constitute a crime, for example assault, theft, rape, incest, drugging or murder and action can be taken against those who abuse by using existing criminal legislation.

  The following legislation is the basis for interventions in this area by health and social services departments.

  1.   The Carers (Recognition and Services) Act 1995—enables local authorities to assess the needs of carers as well as individuals thought to be in need of community care services. This does not extend to Northern Ireland, however, Boards and Trusts have been directed to carry out separate carers' assessments.

  2.   The National Health Service and Community Care Act 1990—the local authority is required to carry out an assessment of need where a person appears to be in need of community care services.

  3.   The Health and Personal Social Services (Northern Ireland ) Order 1972—under this legislation the Department of Health and Social Services is responsible for all aspects of service provision and assessment.

  4.   The Social Work (Scotland) Act 1968—social work authorities must provide advice, guidance and assistance to people who are in need of care and attention arising out of age or infirmity and those suffering from illness or mental disorder.

  5.   The Mental Health Act 1983—the local authority can be appointed "guardian" to a person who has a mental disorder, including mental illness. The guardian has the power to require the individual to live at a particular place, to attend particular places for medical treatment, occupation or training, and to require access to be given to doctors, social workers and others at any place where the individual resides. For legislation in Northern Ireland and Scotland refer to Mental Health (Northern Ireland) Order 1986 and the Mental Health (Scotland) Act 1984.

  6.   The National Assistance Act 1948—Section 47—a local authority has the power to seek an order from a magistrate's court authorising the removal from their home of a person at severe risk. The application must be supported by a certificate from a community physician that the person is:

—  suffering from a grave and chronic disease or being aged, infirm or physically incapacitated, is living in unsanitary conditions; and

—  is unable to look after him or herself and is not receiving proper care and attention from others.

  Seeking an order for removal should be a last resort after all other options have been tried.

—  The Race Relations Act 1976 (Race Relations (Northern Ireland) Order 1997) —this may be appropriate in cases where abuse is racist in nature.

GUIDANCE FOR PROFESSIONALS

  In 1993 the Department of Health published Guidance for staff relations with the public and media, in which it states that "individual members of staff in the NHS have a right and a duty to raise with their employer any matters of concern they may have about health service issues concerned with the delivery of care or services to a patient or client in their authority, trust or unit".

  In 1995 the General Medical Council published guidance on the principles of good medical practice, contained in the booklet Duties of a Doctor. These duties entail a professional responsibility on the part of doctors to report concerns they may have about incompetent colleagues. The guidance states that "You must protect patients when you believe that a colleague's conduct, performance or health is a threat to them".

  In 1992 the United Kingdom Central Council for Nursing, Midwifery and Health Visiting in its Code of Professional Conduct reminds those it regulates that it is their professional responsibility to "act always in such a manner as to promote and safeguard the interest and well being of patients and clients".

  The Public Interest Disclosure Act 1998 (due to come into force in 1999 in England, Wales and Scotland and extended to Northern Ireland in 1999). This will protect employees against dismissal or victimisation for disclosing a public concern, provided the employee has acted reasonably and responsibly.

WHO TO CONTACT AND FURTHER READING

  The following organisations can be additional sources of information and support.

  1.   Action on Elder Abuse, Astral House, 1268 London Road, London SW16 4ER.

Tel: [phone] (freephone), 10am-4.30pm—Monday-Friday

—  This organisation raises awareness about the abuse of older people, encourages education and research, and provides information to a wide range of groups and individuals. The organisation operates Elder Abuse Response, a telephone and letter service, which provides information for anyone, and confidential support for those concerned or involved when an older person is being abused.

  2.   Age Concern England, Astral House, 1268 London Road, London SW16 4ER.

Tel: [phone], 9.30am-5.00pm—Monday-Friday.

—  This organisation offers information and advice, on a wide range of issues. Some local groups offer advocacy. Local groups are listed in the telephone directory under Age Concern.

  3.   Age Concern Cymru, 4th Floor, 1 Cathedral Rd, Cardiff CF1 9SD. Tel: [phone].

—  Operates at both local and national levels in Wales with and for older people and their carers.

  4.   Age Concern Northern Ireland, 3 Lower Cresc, Belfast BT7 1NR. Tel: [phone].

—  Provides an information and advice service, advocacy and user involvement schemes.

  5.   Age Concern Scotland, 113 Rose Street, Edinburgh EH2 3DT. Tel: [phone].

—  Promotes the welfare of older people in Scotland. Provides information, training and support for local groups.

  6.   Alzheimer's Disease Society, Gordon House, 10 Greencoat Place, London SW1P 1PH. Tel: [phone], 9am-5pm—Monday-Friday.

—  This organisation is the leading care and research charity for people with dementia. It provides information and education, support for carers, and quality day and home care. It funds medical and scientific research and campaigns for improved health and social services and greater public understanding of dementia.

  7.   Alzheimer's Disease Society, Wales Development Office, Tonna Hospital, Tonna, Neath SA11 3LX. Tel: [phone].

  8.   Alzheimer's Disease Society, 403 Lisburn Rd, Belfast BT9 7EW. Tel: [phone].

  9.   Alzheimer Scotland—Action on Dementia, 22 Drumsheugh Gardens, Edinburgh EH3 7RN. Tel: [phone].

—  This organisation aims to be the national voice of people with dementia and their carers. It operates a 24-hour Dementia Helpline (freephone): 0800 317 817.

  10.   British Geriatrics Society, 1 St Andrew's Pl, London NW1 4LB. Tel: [phone].

—  This organisation exists to promote the scientific development of geriatric medicine and to influence the providers of medical and social services to improve the quality and provision of such services.

  11.   British Medical Association, BMA House, Tavistock Square, London WC1H 9JP. Tel: [phone].

—  This organisation is a voluntary, professional association of doctors, which promotes the medical and allied sciences and maintains the honour and interest of the medical profession. Contact for offices in Wales, Scotland and Northern Ireland.

  12.   Carers National Association, 20-25 Glasshouse Yard, London EC1A 4JS. Tel: [phone], CarersLine 0345 573 369, 10am-12 and 2-4pm—Monday-Friday.

—  This organisation provides advice, information and support for carers.

  13.   Carers National Association Scotland, 3rd Floor, 162 Buchanan Street, Glasgow G1 2LL. Tel: [phone].

  14.   Carers National Association Northern Ireland, 113 University Street, Belfast BT7 1HP. Tel: [phone].

  15.   Carers National Association Wales, Pantglas Industrial Estate, Bedwas Newport NP1 8DR. Tel: [phone].

  16.   Counsel and Care, Twyman House, 16 Bonny Street, London NW1 9PG. Tel: [phone], Advice line 10.30am-4pm—Monday-Friday.

—  This organisation has specialist expertise in residential and nursing home care and runs an advice line for older people.

  17.   Help the Aged, St James's Walk, London EC1R OBE. Tel: [phone], SeniorLine 0800 65 00 65, 9am-4pm—Monday-Friday.

—  SeniorLine is a free, national telephone advice and information service for older people, their relatives, carers and friends. Trained advisors can help with queries about benefits, housing and community care.

  18.   Public Concern at Work, Suite 306, 16 Baldwin Gardens, London EC1 7RJ. Tel: [phone], 9am-6pm—Monday-Friday.

—  This is a charity, which offers free legal advice to people concerned about serious malpractice at work.

  19.   The Relatives Association, 5 Tavistock Place, London WC1H 9SN. Tel: [phone], 10am-12.30 and 1.30pm-5pm.

—  Provides information, advice and support for relatives and close friends of older people in care and nursing homes and long stay hospitals. Also provides advice and support to homes staff.

  20.   The Relatives Association for Northern Ireland, 20 Postboys Walk, Ballymoney BT53 6DA. Tel: [phone].

  21.   The Relatives Association (Scotland), 13 Pitt Terrace, Stirling FK8 2E2. Tel: [phone].

—  This organisation gives advice and help to relatives and friends about care of older people in continuing care settings and runs a 24 hour helpline—01786 478 898.

  22.   Women's Aid Federation of England, PO Box 391, Bristol BS99 7WS. Tel: National Helpline 0345 023 468, 10am-5pm—Monday to Thursday and 10am-3pm—Friday.

—  This organisation provides advice, information and temporary refuge for women threatened by abuse.

  23.   Welsh Women's Aid, 38-48 Crwys Road, Cardiff CF2 4NN. Tel: [phone].

  24.   Northern Ireland Women's Aid, 129 University Street, Belfast BT7 1HP. Tel: [phone].

  25.   Scottish Women's Aid, Norton Park, 57 Albion Road, Edinburgh EH7 5QY. Tel: [phone].

FURTHER READING

—  Ashton, G. Elderly people and the law. Butterworths, 1995.

—  Bennett, G and Kingston, P. Elder abuse, concepts, theories and interventions. Chapman & Hall, 1993.

—  Bennett, G, Kingston, P and Penhale, B. The dimensions of elder abuse. Macmillan, 1997.

—  BMA & The Law Society. Assessment of mental capacity. British Medical Association, 1995.

—  Burton, J. Managing Residential Care. Routledge, 1998.

—  Centre for Policy on Ageing, A better home life. Centre for Policy on Ageing, 1996.

—  Counsel & Care. Harm's way, 1997.

—  Decalmer, P and Glendenning, F (eds). The mistreatment of elderly people. Sage, 1993.

—  Eastman, M (ed). Old age abuse—a new perspective. Age Concern England Chapman & Hall, 1993 (2nd ed).

—  Public Concern at Work. Abuse in care: a necessary reform, 1997.

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APPENDIX

QUESTIONS TO ASK PATIENTS*

  These questions should be used sensitively and only in appropriate circumstances.

—  Has anyone at home ever hurt you?

—  Has anyone ever touched you without your consent?

—  Has anyone ever made you do things you didn't want to?

—  Has anyone taken anything that was yours without asking?

—  Has anyone ever scolded or threatened you?

—  Have you ever signed any documents you didn't understand?

—  Are you afraid of anyone at home?

—  Are you alone a lot?

—  Has anyone ever failed to help you take care of yourself when you needed help?

  (*Source: Diagnostic and treatment guidelines on elder abuse and neglect—American Medical Association, 1992).


QUESTIONS TO ASK CARERS*—  It can be very hard looking after someone like this. Do you find it difficult?

—  When things get difficult do you feel angry?

—  Do you feel like shouting at him/her?

—  Do you ever feel like hitting him/her or anything like that? If yes: Do you do it?

—  What sort of situations are the worse—what things make shouting, hitting likely to happen?

  Only carry on with these questions if the answers are "yes". Carers who deny problems or who are evasive will find further questioning difficult. (*Source: Homer & Gilleard, 1990)

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Prepared 20 April 2004