Examination of Witnesses (Questions 1-19)
MR GARY
FITZGERALD, MS
TESSA HARDING,
MR JONATHAN
COE AND
MRS JENNY
POTTER
11 DECEMBER 2003
Q1 Chairman: Can I welcome you to this
session of the Committee, the first session on elderly abuse.
I would appeal to both my colleagues on the Committee and our
witnesses for short, precise questions and similar answers because
we are time-limited with a lot to get through. Can I also particularly
place on record our thanks to all our witnesses for the very helpful
written evidence you have given us and for coming before us today.
Can I briefly ask you each to introduce yourselves to the Committee
and say a little bit about the context of your work on elderly
abuse.
Mr Fitzgerald: Thank you Chairman.
My name is Gary Fitzgerald and I am the Chief Executive of the
charity, Action on Elder Abuse. It is a charity which has been
in existence for the last ten years and it focuses exclusively
on the issue of abuse of older people where there is an expectation
of trust between the older person and the abusing person. One
of the key things that we do is to commission a helpline for the
last six years which provides us with, as you will see from the
evidence, quite a lot of information on the nature of abuse.
Ms Harding: I am Tessa Harding.
I am the Senior Policy Adviser at Help the Aged and my particular
focus is on age equality and human rights. I think there is a
very important human rights dimension to the whole issue of elder
abuse which I would like to draw to the Committee's attention.
Mr Coe: I am Jonathan Coe. I am
the Chief Executive of POPAN which is the Prevention of Professional
Abuse Network. Like Action on Elder Abuse, we run a helpline and
provide support and advocacy to anybody who has been abused by
any health and social care professional, so our brief is really
right across the board on health and social care professionals
and all client groups.
Mrs Potter: My name is Jenny Potter.
I am the National Officer for the Community and District Nursing
Association which is an independent union which takes care of
the nurses who work in the community. Our members have highlighted
the fact that they are seeing elder abuse in the community and
they have no mandatory training to help them deal with this problem
when they meet it.
Q2 Mr Burns: As we start this inquiry
on elder abuse, I think it would probably be quite helpful if
each of you would be able to give us briefly an idea of how you
perceive the definition of the term "elder abuse". Does
it make sense to talk about elder abuse as distinct from the abuse
of vulnerable adults?
Mr Fitzgerald: Our view very clearly
would be that there is a need to separate out the issue of older
people from vulnerable adults and that is primarily because of
the position that older people have within society as opposed
to other adult groups. If I suggest that you look at legislation
and guidance and whatever for, say, the last 100 years, you tend
to see very much that when we are not talking of older people
the legislation says, "You will do this. This is how you
will do it. This is when you will do it". When you look at
legislation for older people, you very much tend to see, "permission
to do if you wish", and what you see is older people being
hidden very much within the global group of vulnerable adults.
We would strongly say that there was a very clear need for older
people to be seen independently and separately.
Ms Harding: I would just agree
with that. I think that elder abuse is an extremely hidden topic.
I think we are about where we were with Maria Colwell some 30
years or so ago and with domestic violence I think there are parallels.
I think the public is very unaware of elder abuse as a whole and
there is a need for a major public information programme as well.
Mr Coe: I would just add to that
that the categories of abuse that are outlined in the No Secrets
guidance are very useful and we would like to see those being
used much more widely.
Mrs Potter: From a nursing point
of view, the vulnerable adult is very similar to the elder person.
They do not have a voice in the community when they are being
abused. There are differences, but also a lot of similarities.
Q3 Mr Burns: Do you feel then that the
wide range of situations that is covered by the term "elder
abuse" possibly limits its value? Is there a great difference
between deliberate physical abuse, for example, and, say, inadvertent
neglect or discrimination?
Mr Fitzgerald: I think when we
are talking about abuse, it really is quite a political term in
the sense that we talk about a spectrum of events ranging from
what we would talk about as being poor practice all the way through
to the scenario of deliberate cruelty being perpetrated by somebody.
I think it is an important point to use the word "abuse"
because it puts all of that together, but I think the way in which
you approach it can be different. For example, the person who
deliberately punches an elder person is doing it consciously and
is knowing what they are doing. The person, for instance, who
is failing to knock when they go through someone's door in a residential
home, it is a different level. It is still abusive, it is still
putting that elder person in a lesser category than others, but
the way that you address it is different. I would strongly argue
that we need to see all of that as abuse, but also recognise that
many of those situations are crimes and we should not lose sight
of that either.
Q4 Chairman: Can I take it a bit further
and look at the prevalence because we have got some interesting
figures in the evidence that has been brought before the Committee.
I think a number of you have quoted the Ogg and Bennett research
in 1992 with the probable figure for abuse as being between 5
and 9 per cent of the elderly population. I think the CDNA evidence
suggests that that would now be 500,000 over-65s, which is a significant
figure. Help the Aged, Ms Harding's organisation, says that the
figure is likely to be higher than that due to under-reporting.
You are all saying that this is a very significant problem and
I am interested in looking at if, as all of you are saying, further
research is needed, how you go about establishing the actual facts
over and above what we have got from the research going back to
1992.
Mr Coe: I think this is one of
the major problems that all of us face, that there is not clear,
comprehensive and repeated information about prevalence. POPAN
is obviously concerned with abuse by any health and social care
professional. We did a very short kind of in-house survey earlier
in the year and one of the big problems is that, for instance,
the regulators of health and social care use different terminology
to describe similar events, so it is very hard even on published
evidence to get a very clear picture of what is happening. What
POPAN would like to see is a lead being taken on that essentially
to ensure that just the known information is pulled together and
published regularly and that is just simply not happening.
Q5 Chairman: If it is true, as you are
suggesting and there seems to be a consensus, that at least half
a million elderly people are being abused, why is there such a
lack of political concern about this issue? I do not know about
my colleagues, but I do not recall really any letters, apart from
organisations specifically like Mrs Potter's, involved with the
issue about this as a serious concern. Is that reflective perhaps
of the views of the elderly?
Mrs Potter: I think with elderly
people, they have got nobody who can be their advocate. They often
do not know where to go and for a lot of them, they are often
prepared to put up with the abuse to have someone visiting them
and it is a sad state of affairs for elderly people. As regards
the figures, I think if we could have training in the recognition
of abuse, you would get an awful lot more figures and a lot more
reporting, but certainly most health professionals do not know
about abuse and how to recognise it.
Q6 Mr Bradley: Just linking that to the
earlier question on definition, the numbers that you are describing
and the spectrum of the definition, have you any view on the distribution
of the numbers from, if I can call it, the softer end of the market,
as you describe, not knocking on the door through to real physical
abuse which may be perceived as being the more serious end of
the spectrum? How do you weight the figures you are presenting?
Mr Fitzgerald: I think there are
probably two answers I would give to that. One is to answer the
question directly and to say that our feeling from our helpline
would be that the vast majority of abuse would fall into the category
of poor practice. It is about neglect, it is about treating people
with less dignity than you would other people. It is about the
attitude and the approach. Our feeling and our hope is that the
actual deliberate, wilful cruelty is a smaller percentage, so
that would be how we would feel about it. Putting that in context,
I often pose the question that I actually do not know what is
worse and I think this is the important point. There is the single
act of cruelty, such as we had with the care of Fitzpatrick last
year who ripped four fingernails out of someone's hand in a care
home, where for that older person it was painful, but then it
was over and she subsequently recovered, or there is waking up
every single day of your life facing the same degradation, the
same humiliation, the same dehumanising day after day after day
by a carer who is responsible for you and you have no escape.
So while we are looking at poor practice and the spectrum, I think
it is important to look at it from the point of view of the person
who is receiving that practice, and I think whether or not you
are talking about the cruelty, and I could list them, headbutting
an 89-year-old, leaving someone for six hours lying in their own
excrement because they have annoyed you, those are extremes, but
not being allowed to go to the toilet or being made to sit in
your own excrement through your dinner time, through to the complete
range of neglectful approaches can be just as damaging to somebody,
so I would strongly urge that although we look at it as a spectrum
because our approach must be different, we do not reduce it in
its importance.
Q7 Chairman: Tessa Harding mentioned
Maria Colwell and some of us, the elderly people around the table,
were actually in social services at that particular time. I am
very conscious that child abuse is a relatively recent concept
in terms of our discovering it, and I was in social services when
we discovered organised child sex abuse and we were not really
aware of what we were finding. I just wonder what your views are
in that context as to why we have a growing awareness of elder
abuse, in particular whether there are connections, for example,
with the extent to which we have to some extent deregulated care
of the elderly over a period of 20 years with the increased role
of the private sector. I am not saying it is just the private
sector because I am certainly aware of abuse in the public sector,
domiciliary situations, but are there factors historically which
led to this growing awareness or not growing awareness, but growing
problem perhaps as well?
Ms Harding: I think we are becoming
more aware of the full citizenship of older people. There is without
doubt age discrimination in our public services and also in our
culture. There is ageism in our culture. We are just seeing a
greater awareness developing of the rights of older people, the
human rights of older people and their ability to voice their
own concerns, influence the services that affect them locally
and so on, so I think there is that general awareness. As far
as abuse is concerned, I think we have hardly started on the path.
I think it is helpful, by the way, to distinguish between abuse
by family members and abuse within the health and care systems
I think partly because the solutions to those are probably very
different. We have become much more aware of abuse in the health
and care system through, for example, the Commission for Health
Improvement Report on Emerging Themes: Services for Older People,
which looked across 17 different clinical government reviews and
was sufficiently concerned to pull out key areas where it felt
that people were receiving not just poor care, but care that was
worse than that, where their lives, health and wellbeing were
being put at risk. It is couched in very measured terms, their
report, but I think the message is absolutely unmistakeable. Increasingly
we are seeing investigation reports on particular hospital wards,
particular care homes and it is coming more into the public domain,
but we are still not seeing, for example, inquests with any frequency
relating to older people who die in care homes or who die while
receiving care at home. There are really very few and cases are
not coming to court.
Q8 Chairman: On that particular point,
I was interested in a case that occurred in Yorkshire a little
while ago, which might be referred to in a subsequent session
in this inquiry, where there were questions raised about the whole
certification of death procedures in care homes. Is that an area
that concerns you?
Ms Harding: Yes, very much.
Q9 Chairman: Mr Fitzgerald, do you want
to be specific about this?
Mr Fitzgerald: Your first question
about the difference in perception between child abuse and adult
abuse I think is an important one because if you look at the changes
which have taken place in society, say, in the last ten years
that our charity has been in existence and if you look at the
change in perceptions of society towards child abuse and domestic
violence, you very clearly see the message that it is intolerable
to society that a child would be hurt and we rightly now talk
about domestic violence as a hate crime. However, if you look
at the perceptions towards the abuse of older people, we do not
see that same response. We see an acceptability and we see explanations
for abuse coming forward that if we were to translate to cases
of child protection, you would not accept. The classic example
I would give you is that as a country we know about Victoria Climbie,
we know what happened to her, we know of the abuses, but many,
many of us do not know about Margaret Panting and the difference
between them is 70 years. Margaret had the same number of injuries
to her, she suffered the same sorts of abuse but we do not know
about this. The local community knows, but as a nation we do not
and that does pose the question: why is it that we do not know
about these things with elder people? I think we have fundamentally
to get to that. I think it is about the human rights, as Tessa
said, of elder people and it is about perception. We have an acceptance
within society that really should be unacceptable to us in terms
of abuse.
Q10 Chairman: You were also going to
come on to the certification of death arrangements in care homes.
Mr Fitzgerald: Certainly there
is an anxiety for us and I cannot give you statistical data or
whatever. We receive many complaints to us about the death of
a mother or a father where there has been an abusive situation
and where the death certificate will refer often to pneumonia
or often to heart failure and there is not a link between the
death of that person and the abuse that may have taken place three,
four or five weeks ago. We do have a real concern that those links
are not being made and the trauma facing an elderly person who
is abused can be very profound even where that is financial abuse
where somebody has had money stolen from them and it can actually
lead, because of the impact, to the death of that person, so I
think there is an issue there.
Q11 Chairman: I am not so sure we have
got a great deal of written evidence on that particular point,
but if any of you wanted to come back to us with more information
about it, it would be very helpful. I was talking about how you
would go about further research and one of the points that concerns
me is whether we can get any reliable research evidence without
proper regulation which enables us fully to understand accurately
what is going on. Secondly, are there some priority issues that
should be pulled out for specific research and, if so, what are
they?
Mr Coe: We talked about prevalence
earlier and the lack of central co-ordination of that. We are
dealing with such a wide set of circumstances and in such a wide
field that it is quite hard to focus only on one area and we need
to produce information right across the board, right across health
and social care services and in all the settings that we have
been discussing. Now, there was a survey ten years ago and we
can do another survey, but that is not going to be the whole answer.
What we need is a really rigorous and systematic approach to recording
and reporting the whole spectrum of abuse and what we would like
to see is that made a requirement of both providers and regulators
and the categories would be those used in No Secrets. They
are perfectly serviceable and usable categories that are understandable
across the board and we would really like to see those being used
by all the key players to ensure that that information is pulled
together so that then you could look at annual reporting of these
figures to help all of us inform the development of services,
the development of policy and practice. If it is possible for
the NHS annually to produce a report on the number of staff who
are abused by patients, surely it must be possible to produce
reports the other way round.
Q12 Chairman: And we know the numbers
of children who died at the hands of parents and carers and we
know similar figures, accurate figures in terms of the number
of elderly people who may have died from an abusive situation.
Mrs Potter: Can I say that I agree
with Mr Coe. Unless we have got staff who actually know how to
recognise abuse, you are not going to get the reports. We have
all got to be singing from the same hymn sheet and we have all
got to know what we are singing.
Mr Fitzgerald: I think that is
a valid point because if you look at the definitions of abuse
that are used with adult protection committees, potentially we
have a lot of information out in the community now that we have
got adult protection processes in place, but each local authority
tends to operate slightly differently as to what a referral is
about, what it is that they responded to and what the outcomes
are, so I do think you need to get some national basis for defining
abuse, defining categories and defining what the responses are.
The information is certainly out there, but then I think it is
also about how we use that information when we have got it. Prevalence
definitely is an important issue, but I think the point that Tessa
made is important. We do need to look at abuse differently when
we are talking of institutional, formal carers abusing and family
carers abusing because the whole nature is different and what
we need to draw out is different.
Q13 John Austin: Could I follow on from
that and refer to abuse within the family and within the home
following on from Ms Harding's point earlier. I think there is
a common assumption amongst many people that a lot of the abuse
that occurs within the family is a result of stress from the care,
the lack of support, the lack of respite care, et cetera. Now,
Age Concern seems to challenge that view and calls in evidence
the fact that often the abusive member of the family is not the
one who is the principal carer.
Mr Fitzgerald: Yes.
Q14 John Austin: It could be argued that
the stress does not just fall on the principal carer, but there
is stress within the family. If you are saying that stress is
not a principal cause of abuse within the family, what do you
put it down to?
Mr Fitzgerald: I think there are
a number of points to make on this and the first one is to acknowledge
and accept totally that caring for somebody who is very dependent
is stressful and I would not want to take that away. We have all
operated, I think, under an assumption for a long time that that
automatically leads to that carer then abusing and what our experience
is from the helpline is that that is not the case. Less than 1
per cent of the reports to us are about that hands-on carer. Now,
that is not to deny the point you are making that there is stress
on the household in total, but when we look at the type of abuse,
we can put it down to, for example, greed, the attitude and approach
of sons and daughters at times to an older person's money, that,
"They are spending my inheritance. I must stop this",
or, "This is my house. I have lived in it as a child and
I am entitled to inherit it". I think it is elements like
that and I think there are elements also about inter-generational
abuse where it is a practice which is passed on. I think it is
actually quite a complex issue and, in our experience, no one
single explanation fits as a model that you can apply. I go back
to the point I was making, that there is an underlying perception
about older people in society that tolerates abuse and then there
are individual reasons that trigger that abuse whether that is
a person's enjoyment of inflicting cruelty or greed or tensions
or whatever. I think we need to keep a mind on the fact that it
is not something that is tolerated with children, so why is it
tolerated with elderly people.
Mrs Potter: I think one of the
other reasons for family members abusing is the fact that your
family have all grown up, your children have grown up and you
are now left with coping with elderly parents and you are just
beginning a period in your life when you actually have got a little
bit of freedom and there is resentment from other members of the
family because the sibling of the older person is torn between
looking after their parent and doing what their husband or wife
wants to do or what their family wants to do and that is a problem.
It is something where we have found it very difficult in the community
to actually relieve that.
Q15 John Austin: But if that is the case,
if there was more external support, if there was more respite
care, would that resentment and those feelings not be lessened
and, therefore, perhaps potentially lessen the abuse that takes
place? One thing that you said earlier was that really no amount
of external support or whatever would necessarily impact upon
the level of family abuse because it is not the stress that causes
it.
Mrs Potter: I think more respite
care would be a help and more assistance in the home would be
a help, but it is getting people to accept that. No older person
wants to go into respite care because they actually perceive that
as going into a home even if it is only for a fortnight and they
are always frightened that they are not going to come back out
again and that is a real barrier to try and get across when you
are working with older people.
Mr Fitzgerald: I certainly would
not want to suggest to you that there are not things that could
be done because there clearly are. The Government, in the Domestic
Violence Bill, has recently introduced unlawful killing of vulnerable
adults. Now, not only will that deal with certain issues, like
the case I referred to earlier, but it sends a strong message
as well out into society that this sort of behaviour is not tolerable.
I think there are things that we can do to relieve stress in families,
but I think you do have to look at the individual abuse. Stress
does not lead to somebody wanting to steal an older person's house
and that clearly is something that we need to tackle head-on.
The misuse of enduring powers of attorney, powers of attorney
that are not registered, that is a deliberate act of theft and
the motivation for that can be clear. It is some of the more complex
issues, psychological abuse, what causes that, what is the nature
of it, that becomes more difficult to get to the root of, so I
think we do need to look at the individual types of abuse and
then work backwards to see what is the motivator.
Q16 Dr Taylor: Could I pick up first
something Mr Fitzgerald said early on. I think you implied that
vulnerable adults should rather be separated off from the elderly.
Is that because vulnerable adults are better protected at the
moment than the elderly?
Mr Fitzgerald: Yes, although I
was actually putting it the other way round, that older people
should be separated off. I think it is the nature of the perception
of older people within society. We have moved a long way with
other adult groups and I am not suggesting for a moment that we
are where we would like to be.
Q17 Dr Taylor: So people are more aware
of the risk of an obviously vulnerable younger adult?
Mr Fitzgerald: Yes, potentially
so.
Q18 Dr Taylor: That then takes us on
to talk about risk factors. I think we have all been most impressed
with the evidence you have all given us and the staggering thing
is that you have all repeated each other. Well, it is not staggering
really. I am really just going to pick out the CDNA evidence and
ask you to somehow put in some sort of order of significance this
huge list of the triggers. First of all, you give us the obvious
list of medical conditions that make people more liable and then
a long list of triggers, ending up with things like staff shortages,
lack of training, which you have already mentioned, non-qualified
staff doing it, inadequate support. Starting with the CDNA, could
you put those in any sort of order of importance?
Mrs Potter: Well, we would like
to see this lack of training and staff shortages, lack of supervision.
A lot of unqualified people in residential care homes and nursing
homes are doing tasks that they should not be doing and in the
community, social services are doing an awful lot of personal
care for people which at one time was undertaken by health services.
It was branched off a few years ago and social services now undertake
more of the personal care in the community. As regards the others,
they are triggers and it is six of one and half a dozen of the
other as to which order you put them in.
Q19 Dr Taylor: But you would put training,
staffing levels, supervision right at the top?
Mrs Potter: Yes, definitely.
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