Case 33 A surprising turn of events

Mrs Whittaker is a 68-year-old lady who has been referred to the Acute Medical Unit (AMU) from the Emergency Department. Mrs Whittaker had been visiting her daughter Samantha, an inpatient on the gynaecology ward, when she had collapsed a couple of moments before the end of visiting hours. A staff nurse who witnessed the episode described how Mrs Whittaker had let out a loud scream before slumping gradually to the floor, her eyes closed, before exhibiting coarse rhythmical movements of the upper limbs, associated with grunting sounds. The episode had lasted for approximately five minutes. Following the episode, Mrs Whittaker appeared mute and was staring blankly forward but seemed physically stable and orientated. Samantha explained to the staff nurse that Mrs Whittaker had occasional fits and that she had been started on a medication by her GP following an appointment with a neurologist, Professor Raymont.

What do you think is the likely diagnosis?

Dr Wallace, the Core Medical Trainee on duty, is not entirely sure what to make of Mrs Whittaker’s presentation. The episode does not sound to be typical of epilepsy and there were no features to suggest a cardiac aetiology. Against this, Dr Wallace notes with interest the neurological review and commencement of medication. He elects to send some basic blood tests, undertake a urinary dipstick, and observe Mrs Whittaker overnight. Dr Wallace’s Consultant reviews Mrs Whittaker at 21.30 that evening and agrees with the plan for overnight observation. Mrs Whittaker then states that she is sure she will be feeling better by morning. She is fully orientated although she says she has poor recollection of the episode.

The next morning, Dr Wallace reviews Mrs Whitaker first thing. The nurses report no problems overnight. Dr Wallace tells Mrs Whittaker that she can be discharged at which point she refuses point blank to go home. She states that her husband has dementia, that he spends the weekly household budget on prostitutes and escorts, and that every so often he hits and kicks her.

What should Dr Wallace do?

Dr Wallace is considering what he ought to do next when the Mrs Whittaker’s old medical records are delivered to the ward. Letters confirm that Professor Raymont, who had met Mrs Whittaker in clinic a few months earlier, considered her to have pseudo-seizures on a background of bipolar disorder. He had recommended recommencement of lithium which Mrs Whittaker had stopped taking some years prior. The letter mentions that Mrs Whitaker was seen with her husband, who is variously described as supportive, caring and attentive.

What would you do?

Given this interesting presentation and emerging evidence of a psychiatric history, Dr Wallace elects to discharge Mrs Whittaker and asks the nursing staff to send her to the discharge lounge until her husband can come and collect her. Simultaneously he telephones the GP practice to see if there is any additional medical or social history of which he should be aware. The practice receptionist described the file as very thin and says that there does not appear to be anything out of the ordinary. The duty doctor is currently with a patient and cannot be disturbed.

Whilst Dr Wallace is on the telephone, his consultant comes to the ward. Mrs Whittaker approaches him in tears and states that she cannot go home. She is concerned that her husband will physically or sexually assault her, telling him that this has happened frequently of late, before lifting up her blouse to reveal multiple bruises over her flank.

What options are available to the consultant at this point?

Expert opinion

At this point, any doubts about the veracity of Mrs Whittaker’s story should be put to one side. Sufficient concerns have been raised to warrant further action even if her account turns out to be fabricated. The presence of medically unexplained symptoms may be associated with abuse.

Dr Wallace and the rest of the team should focus upon the protection of Mrs Whittaker, pending further assessment. She should remain in hospital for the time being and it may be appropriate to move her so that her precise location cannot be determined by her husband.

The team’s approach should have three elements: protection, information gathering and escalation of concerns to the appropriate professional or body.

In relation to protection, the team should contact the duty social worker and the Trust’s lead for safeguarding adults in order to obtain further advice.

Information gathering will involve determining whether Mrs Whittaker, or indeed Mr Whittaker or anybody else living at the home address, is on the local authority’s vulnerable adult register. A discussion with the relevant GP may also prove useful: is there a history of other episodes suggestive of abuse; does Mr Whittaker indeed have dementia and behavioural challenge; does Samantha live with her parents and how is their relationship?

Mrs Whittaker should be encouraged to see a social worker and if she does decide to leave before her full assessment, contact details for support should be provided to include specialized police teams and any local refuge for victims of domestic violence.

It should be noted that at this point in time, the confidentiality of the doctor–patient relationship can be set aside to a degree. The priority now is ensuring the protection and safety of all members of the family going forward.

Legal comment

Every NHS Trust has a vulnerable adult lead and a safeguarding policy for adults. It is also likely to be part of a local multi-agency agreed response network. A vulnerable adult is a person aged 18 years or over who is unable to take care of themselves or protect themselves from being exploited or harmed. This may be because they have a mental health problem, a disability, a sensory impairment, because they are old and frail or have some form of illness. Mrs Whittaker falls into the category of vulnerable adult.

If she has capacity then the safeguarding concern should be discussed with her. If she does not have capacity then there is a duty to act in her best interests in accordance with the local safeguarding protocol. If her daughter Samantha is still an inpatient, it would be acceptable, as part of the wider best interests information gathering, to ask for information about her parents’ relationship and her mother’s recent medical history.

Abuse is a violation of the individuals civil or human rights by another person or persons. It may consist of a single or repeated act. There may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded into a transaction to which he or she has not consented or cannot consent. Abuse ranges from treating someone with a lack of respect to causing actual physical harm. Abuse can be physical, sexual, psychological/emotional, financial or material and includes domestic abuse.

Physical abuse is physical harm caused deliberately by rough or thoughtless behaviour. Sexual abuse is making somebody do something of a sexual nature that they do not want to do or cannot consent to. Psychological or emotional abuse is behaviour that makes the individual feel anxious, intimidated or frightened, including verbal abuse, demeaning or threatening behaviour. Financial or material abuse is theft, fraud or exploitation putting pressure on an individual to use their money in a way that they do not want to or is not in their best interests.

Mrs Whittaker alleges that her husband spends the weekly household keeping as he wishes. If so, this may lead to her neglect, by failing to meet her physical care needs (for example withholding necessities such as adequate food and water, medicines and heating).

As the consultant is worried, he should document his concern and record any physical injury – in this case the severity of the bruising-in the healthcare records. If Mrs Whittaker has capacity he should discuss his concerns with her and seek her permission to take action. The consultant should make an adult protection referral to the local social services and if serious harm is suspected, he should also, report the matter to the police. Mrs Whitaker is making allegations of physical and sexual assault and, as the Consultant is aware that she has multiple bruises, this case does raise a suspicion of serious harm and so it should be referred to the police and social services.

There are local arrangements for adult safeguarding and a safeguarding adults board. There are likely to be county-wide codes of practice for the protection of vulnerable adults from abuse, exploitation and mistreatment. The safeguarding adults board is responsible for creating a framework within which all responsible agencies in the county work together to ensure a coherent policy for the protection of vulnerable adults at risk of abuse and a consistent and effective response to any circumstances giving ground for concern, formal complaints or expressions of anxiety.

It is likely that the local safeguarding adults board also have a policy statement on the criteria for the use of Independent Mental Capacity Advocates (IMCAs) who were introduced following the introduction of the Mental Capacity Act 2005.

Patient confidentiality

There is a legal obligation on doctors to keep confidential what a patient tells them; but this obligation is not absolute. There are situations where the law obliges doctors to breach confidentiality and there are also situations where the law allows doctors to breach confidentiality. The General Medical Council provides professional guidance on this topic and although it does not have the force of law, it is taken seriously by the courts. There is no breach of confidentiality if a patient gives consent or cannot be identified. Sharing information about patients with other members of the Healthcare Team for the purpose of providing treatment is not generally viewed as a breach of confidentiality. There are a number of situations (for example, where the public health is at risk) when the law imposes a duty on doctors to disclose specific information to third parties. The GMC guidelines advise doctors who are asked to release information to weigh the possible harm both to the patient and to the overall trust between the doctor and the patient against the benefits likely to arise from the release of information. For example, disclosure to an appropriate person in authority may be desirable for the prevention or detection of a serious crime. Serious crime in this context, is defined as a crime which will put someone at risk of death or a serious harm which would include abuse of a vulnerable adult.

Discharge of patients who are clinically fit and refuse to be discharged

The legal duty on the hospital is to provide treatment to the patient until they are clinically fit for discharge from the acute hospital environment to a more appropriate setting; whether this be home with community support or to a nursing home or a care home. The grounds for Mrs Whittaker’s refusal are that she is seeking to distance herself from domestic abuse. It is likely that if discharge is to a place of safety suitable for her current psychological/care needs whilst investigations are undertaken, then Mrs Whittaker will consent.

There is usually a Trust policy on discharge and transfer of care and a multi-agency cooperation agreement to provide either supported placements at home or suitable accommodation. When a patient who is clinically fit resists discharge, a meeting has to be convened to discuss the next steps. The measures available to the Trust are to charge the patient for the bed space and even (although rarely used) to obtain a possession order on the bed. Difficulties with patient discharge are usually the result of family disputes or lack of assistance from another public agency.

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