Adult protection cases in a hospice: an audit

Journal of Adult Protection, The, Aug 2005 by Payne, Malcolm

abstract

An audit of the 12 adult protection cases arising in a south London hospice during 2004 is reported, including case studies illustrating issues arising and information about the introduction of a new policy and procedure following No Secrets guidance (Home Office/Department of Health, 2000). Introducing reporting to local authority social services and adult protection co-ordination raised various issues.

key words palliative care end of life care dangerous drugs hospice vulnerable adults local authorities

Introduction

This paper reports an audit of all cases referred by staff as potentially raising adult protection issues in a large hospice serving a socially and ethnically diverse area of south London during the year 2004. It also identifies issues arising from the introduction of a new adult protection policy and the first year's work. Raising awareness of adult protection in palliative care settings may be important, since Cohen (2003) argues that it may be one of the outcomes of the emotional isolation of dying patients. Fisher (2003) recently argued that this is an 'invisible' issue in palliative care because it is generally assumed that families are caring and supportive at the time of death. However, FuImer et al (1999), in an American study, argued that day care settings, common in palliative care, may be an important source of support and a place for disclosure of abuse in other settings. So raising adult protection issues may go against the present culture in palliative care, but help to protect patients.

Context

Founded by Dame Cicely Saunders in 1967, St Christopher's Hospice was the first modern hospice, and now provides a comprehensive palliative care service to an ethnically and socially diverse area in south London. Over 1800 people each year are cared for in its 48-bedded Hospice, and in people's homes through a home care service. It is a registered charity with a service level agreement for the provision of specialist palliative care with a consortium of five local primary care trusts. Services include:

* in-patient medical and nursing care led by consultant physicians and nurses

* 24-hour, seven days a week home care led by clinical nurse specialists in teams focused on each local authority and primary care trust areas

* home nursing and other care to patients in their own homes

* day care including creative therapies

* social work, including bereavement support and welfare rights services

* chaplaincy providing spiritual and religious care

* psychiatric treatment

* physiotherapy and occupational therapy

All these are incorporated into a complex texture of care. This reflects the historic commitment of palliative care to a multiprofessional holistic model of practice working with people, their social networks and their communities in total so that the service '... reaffirms a person's life and relationships' (Saunders, 2004).

Introduction of adult protection policy

Prior to 2003, the Hospice had an 'abuse policy', establishing procedures for investigation in the event of a report or complaint of abuse by a staff member with a patient in the in-patient unit (IPU). This was designed to meet the requirements of the then regulator of care homes. The separately administered children's bereavement project had a child abuse policy. There are also complaints, grievance and public interest immunity procedures for staff and procedures for a volunteer to raise 'concerns'. All patients, both in the community and in the IPU and day unit, and visitors to the Hospice are also given anonymous feedback forms, which they may use to make complaints or comments about anything. Independently administered forums, to which all users are invited, take place three times a year. Regular service audits are carried out as part of the work of staff.

As a result of these arrangements, the Hospice was reasonably confident that someone with concerns about abuse by staff would have a way of raising them. However, new multi-agency 'adult protection' guidelines issued by the local authority for the area in which the IPU is located led to the development of additional procedural safeguards against wider abuse.

A policy and associated procedures were drafted reflecting the need for protection of patients from abuse in the community. The document consists of a procedure enabling the Hospice to comply with the requirements of the local multi-agency guidelines for the Hospice's location, and an addendum classifying and illustrating the main types of abuse that might be encountered, drawn from the multi-agency guidelines. The guidelines, in turn, were largely based on the Home Office/Department of Health (2000) document No secrets. All cases raising protection issues would be referred to the local/ hospice co-ordinator, who would give advice and contact the relevant authorities in accordance with the guidelines. The draft was sent to the directors of adult social services for the five local authorities in the Hospice's catchment area, in particular to identify whether there would be any difficulties arising from variations in procedure in the different areas. Two declined to comment on the grounds of pressure of work, one did not reply and two referred the document to adult protection co-ordinators, who provided helpful comments that were incorporated into the document.