Organisational Abuse: Understanding Neglect in Care Settings

1. Clinical error, poor care or neglect?Does the Act help a practitioner deal with organisational abuse? Lynne Phair Independent Consultant Nurse & Expert Witness www.lynnephair.co.uk

2. Organisational abuse- my area of interest

3. The balancing act of frailty Level and quality of care delivered to compensate for frailty Frailty Imbalance = Possible neglect of fundamental care needs

4. Poor care or neglect a contextual definition( L Phair 2008 unpublished) Neglect Action / omission of care /treatment Poor Care Speed of consequence i.e how quickly is the person harmed Factors affecting person . Health/ environment frailty indicators Frequency, repetition and combinations of low level issues Neglect Neglect

5. How will the Act protect older people in institutional settings? • 11.4 million people over 65 in the UK • 8 million -47% of hospital admissions were aged 65+ • Approx 405,000 people aged over 65 live in residential care Source Age UK 2015 • 905,000 adults aged 18+ (530,000 men and 375,000 women) in England have a learning disability Source Learning disability statisitcs 2015

6. The Statutory guidanceWhat I think it is for • Helps practitioners interpret the law and understand how to apply it. • Helps practitioners understand the difference between concerns of that are contracting, regulation, quality or safeguarding in nature • Helps the development of local policy to avoid misinterpretation • Requires that local policies are in line with the law.

7. My review of how the guidance will help me do my job For me, there is lack of guidance about • The difference between safeguarding, contract monitoring, regulation or quality issues • How the duty to cooperate should operate • How agencies inform the LA about issues that could become safeguarding matters • How to manage and prevent incidents of organisational abuse developing. • Fails to identify that some matters that may be perceived as quality matters (such as the development of pressure ulcers or drug errors) could become criminal investigations and thus are a safeguarding matter. • How safeguarding is the umbrella to all the agency activity

8. So how will the scenarios in the guidance help me? • Scenarios that should help understanding – • 13 scenarios ( about safeguarding matters) in guidance • People with LD -4 scenarios all in their own homes or community • Topics covered- family, strangers, exploitation, financial abuse • Adults -3 scenarios all in own homes or community • Topics -Domestic Violence, verbal abuse

9. So how will the scenarios in the guidance help me? • Older People – 4 scenarios – 2 in a care homes and 3 in their own homes. • Topics covered –family financial abuse(care home) Self neglect x 2 in own home. Disrespectful communication (care home) • No scenarios to illustrate how organisational abuse may be either prevented, suspected, investigated or managed

10. So how will the local SAB policy and procedures help me? • Straw pole –review of 12 Policies and procedures found on the internet • Number that described what is and what is not a safeguarding matter 0 • Number that described how they will decide what is safeguarding and what is not ( a criteria/threshold) 0 • Number that described how information and intelligence muse be collected centrally 0 • Number that described how to respond to pressure ulcers in the NHS /Care Homes 0 • Number that described how organisational abuse may be identified, investigated and managed 0

11. Are Pressure Ulcers a safeguarding matter? • 14.33 The nature and timing of the intervention and who is best placed to lead will be, in part, determined by the circumstances. For example, where there is poor, neglectful care or practice, resulting in pressure sores for example, then an employer-led disciplinary response may be more appropriate; but this situation will need additional responses such as clinical intervention to improve the care given immediately and a clinical audit of practice. Commissioning or regulatory enforcement action may also be appropriate. Is this language contained in disciplinary procedures? • Neglect is still a taboo word

12. Are health & social care professionals expected to know criminal law? • 14.32 The circumstances surrounding any actual or suspected case of abuse or neglect will inform the response. For example, it is important to recognise that abuse or neglect may be unintentional and may arise because a carer is struggling to care for another person……( continues) In other circumstances where the safeguarding concerns arise from abuse or neglect deliberately intended to cause harm, then it would not only be necessary to immediately consider what steps are needed to protect the adult but also whether to refer the matter to the police to consider whether a criminal investigation would be required or appropriate. What about Reckless practice and duty of care?

13. A serious drug error- professional, safeguarding, or criminal issue

14. Same drug two stories Care home- drug given at end of life Hospital care- drug given for agitation No agitation present, family refused. Drug given anyway. Family complained – no action. Formal complaint then investigated. Nurse subject to disciplinary but is still working as a nurse in the hospital No Police, No safeguarding, no referral to the NMC • Police, Coroner, Safeguarding referral Disciplinary- dismissal- NMC referral- all initiated by home. • Arrested for gross negligence manslaughter but not charged • NMC- hearing this week • Safeguarding tried to say it was institutional abuse

15. Pressure Ulcers – Safeguarding or a clinical matter

16. Lack of response when a person collapses- Safeguarding or a clinical matter?

17. Commissioning, contracting and regulation concerns- and a few safeguarding matters- whose responsibility is it?

18. Orchid View Serious Care Review June 2014 • 34 recommendations- here are a few of them • The financial arrangements of some care providers • Training should be meaningful, current and correct • Senior managers must be able to be held to account • Risks associated when there is no registered manager • Patterns of deaths should be monitored by Coroners • Information should be shared • Informing the public about significant safeguarding concerns

19. The call for a Public Inquiry by the families • The Coroner has written to the Lord Chancellor- now passed to the DH. • There are numerous concerns that affect the whole country • Complex governance and finances of care homes- profits V quality of care • Why the government did not think about how the demise of SC was affecting quality & safety- not just bed numbers

20. The call for a Public Inquiry by the families • No national observatory of concerns about large care organisations • Coroners have no system of sharing concerns about deaths • No monopoly commission for care homes to see if rapid large expansion will affect safety and care • Why were there no prosecutions?- why is shredding and rewriting care records not a criminal offense? • The variation across England of prosecutions • Senior Managers have never been held to account and are even now running services. How can this be safe? • Slowness of NMC and whether they do keep the public safe

21. Moving forward –prevention and explanation A couple of ideas Devise a continuum of how issues change who reviews the issue Help care homes understand what prevention of organisational abuse really looks like

22. My plea for review of the guidance • Illustrate organisational abuse and what it is • Give examples of organisational abuse • Develop continuum of concern examplars • Remove the words “deliberately intended” from 14.32 • Give examples of how information should be shared and stored and trends monitored.. however small • Explore and describe the continuum of poor care- neglect • Give examples of real prevention- not examples of how things changes after abuse occurred. e.g Resiliance model ( Phair2015) • Recommend cross boundary information sharing .e.g for Coroners. Police, HSE, Trading Standards, LAs and Health

23. My plea to the Minister for Care • Agree to the request of the Senior Coroner for West Sussex and the families of Orchid View and allow a Public Inquiry

24. References and useful reading The Care Act Statutory guidance https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/366104/43380_23902777_Care_Act_Book.pdf Later Life in the United Kingdom December 2015 Age UK http://www.ageuk.org.uk/Documents/EN-GB/Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true Learning disability statistics http://www.learningdisabilities.org.uk/help-information/Learning-Disability-Statistics-/ Orchid View Serious Case Review https://www.westsussex.gov.uk/media/5171/orchid-view-serious-case-review.pdf Elm View Serious Case Review file:///C:/Users/Lynne%20&%20John/Downloads/elm-view-nursing-home.pdf Sussex Institutional Care Neglect Risk Assessment Tool http://www.lynnephair.co.uk/good-practice.html Phair L (2015) Adult Safeguarding: a care leaders guide. Hawker publications London (How to apply the resilience model to prevention of organisational abuse)