From Volume 39, Issue 8, October 2012 | Pages 555-564
Abuse of vulnerable adults is largely under reported. The most common forms of abuse amongst this group are neglect and financial abuse, although an individual may be at risk of any or all forms of abuse. Certain individuals are at an increased risk of abuse due to their domestic environment and any physical or mental disability they may have.
The term ‘vulnerable adult’ is defined as ‘a person aged 18 years or over who is, or may be in need of, community care services by reason of mental or other disability, age or illness; and who is, or may be, unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation’. It encompasses those with physical disability, mental illness including dementia and other degenerative illnesses.1
‘Abuse’ is defined as, ‘a violation of an individual's human and civil rights by any other person or persons’.1
There are many different forms of abuse which can occur in a variety of circumstances and situations. The document No Secrets produced by the Department of Health classifies six broad categories of abuse:1
Not all vulnerable adults are at equal risk of abuse or neglect. Several characteristics of the individual, the abuser and the situation they are in make adults more vulnerable to abuse, or neglect. These are summarized in Table 1.2
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Risk factors in the vulnerable adult
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Risk factors in the abuser
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Risk factors in institutions
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The signs and symptoms of abuse and neglect are various. Dental practitioners should be alert to such signs in patients at risk (see Table 2).3
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GENERAL |
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Behaviour of patient
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Behaviour of carer
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Features of the domestic environment
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PHYSICAL ABUSE |
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Oro-facial signs
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NEGLECT |
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Oro-facial signs
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PSYCHOLOGICAL ABUSE
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FINANCIAL ABUSE
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SEXUAL ABUSE
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Fortunately, abuse and neglect are uncommon but practitioners should be aware that they might have a patient in this situation.
King's College London recently carried out a survey of GDPs' knowledge concerning abuse of older people. Data from a questionnaire survey of 380 respondents (78.4% response rate) from the Dorset and Somerset area showed that, with regard to experience of abuse and neglect of older people, 85% had heard of abuse, 8% had known of specific incidents of abuse or neglect of older people, 3% had seen or treated an abused older patient, 7% had seen or treated a neglected older patient. Additionally, the survey found that, in 64% of cases, the abuse was brought to attention by personal observation and that most incidents occurred to people in nursing homes.
Additional comments made include:
The General Dental Council (GDC) states that dental professionals are responsible for ‘putting patients first and acting to protect them’. With regard to vulnerable adults (and children), ‘dental professionals have a responsibility to raise any concerns they may have about the possible abuse or neglect of children or vulnerable adults. It is their responsibility to know who to contact for further advice and how to refer to an appropriate authority (such as your local health trust or board)’.4
The General Dental Council (GDC) expects all registrants to be aware of the procedures involved in raising concerns about the possible abuse or neglect of children and vulnerable adults. ‘Find out about local procedures for child protection. Make sure you follow these procedures if you suspect that a child might be at risk because of abuse or neglect’.5
The document No Secrets gives guidance on the management of abuse of vulnerable adults from a multi-agency approach.1 GDPs should play a key role in identifying abuse of vulnerable adults, and prevention of abuse, as well as introducing systems to support staff in these roles.
All dental practice staff should receive training relating to the protection of vulnerable adults from abuse and neglect. Training should be provided as part of the induction process for all new members of staff and should be provided regularly for all staff to ensure that up-to-date local procedures can be followed.
Training should include:
It is good practice for all dental teams to identify one person to be responsible for ensuring that practice protection procedures and protocols are up-to-date. Procedures for reporting abuse may vary slightly between local authorities and it is incumbent upon GDPs to ensure that a referral protocol is obtained from their local social services department, and is kept up-to-date by the designated person on an annual basis. The designated person should also keep other helpful information such as websites for useful organizations for vulnerable adults up-to-date; for examples of such organizations see Table 3. Keeping protocols and information up-to-date may also involve liaising with the local Area Child Protection Committee and Domestic Violence Forum. The designated person should also be responsible for training the practice team in the recognition and management of abuse, including the training of new members of staff. GDPs are responsible for the well-being of their patients and should personally ensure prompt referrals are made to the appropriate agencies, and all necessary treatment is provided. There should be a designated senior person in the practice who is responsible for receiving concerns about the conduct of staff within the dental practice.6
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ACTION ON ELDER ABUSE
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All applications should be made in writing and written references should be taken up prior to employment of any individual. All prospective employers should make all reasonable efforts to check that references are bona fide and, if there is doubt, should ask for alternatives. Ideally, references should be obtained from two referees, neither of whom are family members, and should include the applicant's last employer and/or someone who has first-hand knowledge of the applicant's experience and expertise in working with children and vulnerable adults. Referees should be asked to comment on the applicant's suitability to work with these groups of people.1,6
The Home Office requires all dentists, dental hygienists and dental auxiliaries to have an enhanced disclosure CRB check when applying for a position.
The government's ‘Vetting and Barring Scheme’ was developed to prevent people who are deemed unsuitable to work, either paid or as volunteers, with children and/or vulnerable adults from doing so. The Independent Safeguarding Authority (ISA) holds lists of individuals who may pose a risk to these groups and has the authority to bar them from working with the vulnerable. Additional safeguards were introduced in October 2009, which include a duty to share information. Employers are required to notify the ISA of any relevant information to ensure that people who pose a threat to vulnerable groups are prevented from working with them. It was proposed that new employees would need to register with the ISA from July 2010, with it becoming mandatory in November 2010 for all new employees, followed by a phased introduction of all people already working with these groups by the end of July 2015. The new government, however, has announced that the registration aspect of the vetting and barring scheme is to be halted pending a review. The new safeguards put in place in October 2009, which include a duty to share information, still stand and the ISA are still taking referrals.
It is likely that policy in this area will change in the future once a review has been carried out.
The process to be followed when abuse or neglect is suspected is outlined in Figure 1.
It is important to seek the patient's consent before disclosing an incident or suspected incident of abuse to social services. The disclosure must be carried out in an appropriate manner so that the patient is not put at increased risk of harm. Details of the discussions and agreement of the patient to disclosure of information to social services should be recorded in the dental records. Disclosure of information can be made without consent in a number of situations:
In such situations as these, it is the responsibility of the GDP to ‘act at all times in the best interests of the patient based on a risk-benefit assessment, accept final responsibility for his or her actions, and be able to justify them if subsequently challenged’.7 Disclosure of information about a competent adult without the patient's consent should be discussed with a senior colleague and the GDP's defence organization.
Local social services are the lead agencies to which disclosures of abuse should be made. Relevant local contact details should be made available in the practice handbook or manual, and kept up-to-date by the designated responsible person.1
Telephone referrals to social services should be followed up in writing within 48 hours.
It is essential that accurate contemporaneous records be kept of all allegations or suspicions of abuse. Where abuse has been disclosed, the precise factual information of the alleged abuse must be recorded. Details of any discussions and decisions taken and reason for those decisions should be clearly recorded.8
In addition, comprehensive documentation of injuries should be made, including details of site, size, colour, swelling and other distinguishing features. Body maps are recommended to illustrate physical injuries. Where appropriate, clinical photos should be taken. Again, it is important that informed consent is gained before clinical photos are taken. In cases where the patient is unable to give informed consent, the GDP should take clinical photos if it is considered to be in the patient's best interest. The decision to take clinical photos without consent should be discussed with a senior colleague and the GDP's defence organization. As with all patient information, it is essential that all records are kept entirely confidential.8
It is important that continuity of care and on-going treatment are carried out in a supportive manner which builds trust between the GDP and the patient who has experienced abuse. All injuries should be treated, or a referral made for treatment. If the GDP feels competent to treat the oral injuries, treatment should be initiated. Referrals to appropriate specialist departments should be made if the problems or injuries are more severe.9
In cases where a patient does not wish for a disclosure to be made to social services, it is not the place of the GDP to give advice. However, patient leaflets should be offered with the contact details of various organizations, voluntary agencies, helplines, etc who may provide the patient with helpful information.
