52140 safeguarding vulnerable adults print_ethics tool kit - bma

Safeguarding vulnerable adults – a tool kit for general practitioners

52140 Safeguarding vulnerable adults PRINT_Ethics tool kit 06/10/2011 15:14 Page 2

British Medical Association 1


Contents

Contents

CARD 1 ............................................................................................. 5A stepped approach to safeguarding

CARD 2 ............................................................................................. 8Safeguarding vulnerable adults: basic principles

CARD 3 .......................................................................................... 11What is safeguarding?

CARD 4 .......................................................................................... 18Which adults may be vulnerable?

CARD 5 .......................................................................................... 23What constitutes abuse and neglect?

CARD 6 .......................................................................................... 26What part does mental capacity play in safeguarding?

CARD 7 .......................................................................................... 33Adults lacking capacity

CARD 8 .......................................................................................... 38Care and treatment amounting to deprivation of liberty – the deprivation of liberty safeguards (DOLS)

CARD 9 .......................................................................................... 41When can information be shared about vulnerable adults?


2 British Medical Association


Contents

CARD 10 ....................................................................................... 45What part does good communication play in safeguarding

CARD 11 ....................................................................................... 48How can safeguarding adults be made part of ordinary care?

CARD 12 ....................................................................................... 52When should GPs refer through multi-agency safeguarding adults service?

CARD 13 ....................................................................................... 55When should concerns about patient safety be reported?

CARD 14 ....................................................................................... 59What is the structure of adult protection services?

CARD 15 ....................................................................................... 61Guidance on protecting vulnerable adults

CARD 16 ....................................................................................... 63Adult protection legislation

CARD 17 ....................................................................................... 65Useful names and addresses



Introduction – About this tool kitThis tool kit is about promoting the wellbeing ofadults who may have difficulty in protectingthemselves from harm and abuse and in promotingtheir own interests. Designed principally withgeneral practitioners (GPs) in mind, it willnonetheless be useful for any professional workingin a health care setting who encounters adultswhose ability to promote their own rights andinterests may be challenged, either directly by anabuser, or because they are in a situation ofdependency, or through institutional neglect ordisempowerment. Although GP consortia will have a critical role in ensuring that adults areappropriately safeguarded throughout the care they commission, the focus of this tool kit is on GPs as practitioners.

In 2005 the Department of Health (DH) publishedthe findings of an inquiry into how the NHShandled allegations about the performance andconduct of two consultant psychiatrists, WilliamKerr and Michael Haslam who had been convictedof indecent assault involving their female patients.Although such high profile cases are rare, they havenevertheless placed adult safeguarding at the centreof debate around health care. Involving vulnerablefemale psychiatric patients, they raised keyquestions about trust, differences in power betweendoctors and patients, and the extent to whichmonitoring, audit and complaints systems weresufficiently robust to prevent abuse. Despite thisincreased awareness, a 2009 DH consultation onsafeguarding adults reported a pervasive sense fromprofessionals that the NHS was failing to ‘own’ theconcept of safeguarding adults. The aim of this tool


Introduction – About this tool kit



kit is to set out in straightforward terms keyconcepts and responsibilities in relation tosafeguarding adults in England. It contains a seriesof cards that address specific areas of practice,including adults lacking capacity, definitions ofabuse and neglect and approaches to multi-agencyworking. As each card is designed to be readseparately, there is some deliberate repetition.


Introduction – About this tool kit



CARD 1A stepped approach to safeguarding

Safeguarding vulnerable adults is a complex area ofpractice. The potential client group is extremelywide, ranging from adults who are incapable oflooking after any aspect of their lives, to individualsexperiencing a short period of illness or disability. Awide range of services and service providers can alsobe involved, making it difficult to identify those withresponsibility to act. Another key distinction isbetween adults who have decision-making capacityand those on whose behalf decisions have to bemade. There is also the question of whether theadult can best be safeguarded through ordinarycare routes, or whether the risks require theinvolvement of dedicated multi-agency safeguardingprocedures. This card sets out a stepped approachto safeguarding that highlights key points indecision-making in relation to vulnerable adults.

Step one: Prevention – identifying adults whomay be vulnerableGPs should be able to identify those adults in theircare who may be vulnerable, using, whereappropriate, the criteria laid out in Cards 4 and 5below. Identifying and recording factors that maycontribute to a patient’s vulnerability can be a vitalfirst step in ensuring that he or she receivesnecessary support.




A stepped approach to safeguarding

Step two: Assessing the individual’s needsOnce an individual has been identified asvulnerable, the next step is to assess his or herneeds. Where harm or abuse has occurred, orwhere an individual is at immediate risk, it isimportant to consider whether the local multi-agencyadult safeguarding procedures should be engaged.

Step three: Responding to harm or abuse –assessing competenceIn accordance with Cards 6 and 7 on mentalcapacity, where there are any doubts about anadult’s decision-making capacity this should beassessed. Adults with capacity have the right tomake decisions about their own care and treatment.Treatment decisions made on behalf of adultslacking capacity should be made on the basis of anassessment of their best interests.

Step four: Responding to harm or abuse:identifying relevant servicesFollowing discussion with the patient, taking intoconsideration the need to look laterally beyonddirect health needs to wider personal and socialfactors, relevant supporting services should beidentified and offered. This could involve referral tosocial care, or to other sources of support such ascitizens’ advisors or to charitable organisationsoffering support and advice for individuals sufferingfrom specific disorders or with particular social needs.



Step five: Responding to harm or abuse –taking a consensual approachThe majority of adults with capacity take up theoffer of support services. Where adults with capacitydecline services, the reasons should be explored andalternatives offered where appropriate. Ultimatelythe decision about accepting care and treatmentrests with the competent. Where adults lackcapacity, they should be involved in decision-makingas far as possible. Those close to the adult,including specifically anyone with the power of ahealth and personal welfare or property and affairsattorney should be involved as appropriate.Information may need to be shared without consentwhere others are at risk of significant harm.

Step six: SafeguardingWhere significant incidents have taken placeinvolving vulnerable adults, GPs will frequently bekey contributors, both to any investigation processand in terms of the post-incident care of patientsand the development of the protection plan.Although the local authority will have acoordinating role in any multi-agency response, itmay also include the individual’s GP taking a keyrole in the patient’s protection.


A stepped approach to safeguarding



The DH has developed a list of key principles thatshould articulate and inform good practice inrelation to safeguarding vulnerable adults. Theseare given below and are reflected throughout thefollowing guidance.

Principle 1 – EmpowermentThis foregrounds the strong presumption that adults should be in charge of their care and of anydecisions that affect their lives. Safeguarding mustinvolve promoting the independence and quality of life of adults and must maximise their ability tocontrol their own lives. Where adults cannot makedecisions, as a result for example of a lack ofcapacity to make the specified decision, they shouldstill be involved in the decision as far as possible.Legally and ethically, however, adults with capacityhave the right to make decisions about their careand treatment, even where those decisions may not be thought to be in their best interests.

Principle 2 – ProtectionPatients should be offered the support necessaryfor them to protect themselves. Where adults areless able to protect or promote their owninterests, health professionals should takereasonable and appropriate measures to ensuretheir protection. This also involves assessingwhether more proactive measures may berequired to protect a person, such as where,

CARD 2Safeguarding vulnerable adults: basicprinciples



for example, an adult may lack the capacity tomake a specified decision. This may require theinvolvement of dedicated multi-agency procedures.

Principle 3 – PreventionPrevention of harm or abuse is the primary goal.Prevention involves working with individuals toreduce risks of harm or abuse that they findunacceptable. Prevention involves delivering high quality person-centred services in safeenvironments. All adults have a right to holisticcare that is focused on their individual needs,including their need to be kept safe.

Principle 4 – ProportionalityIn addition to respecting the informed choices of competent adults, safeguarding responsesshould be proportional to the nature andseriousness of the concern. Options should be presented that are the least restrictive ofindividual rights and choices while remainingcommensurate with the desired goals.

Principle 5 – PartnershipSafeguarding adults is most effective whereindividuals, professionals and communities worktogether to prevent, detect and respond to harmand abuse.

Principle 6 – Transparency and accountabilityAs with all other areas of health care delivery,responsibilities for safeguarding should form partof ongoing assessment and clinical audit in orderto identify areas of concern and to improvedelivery. Good safeguarding requires collaborationand transparency with partner agencies.


Safeguarding vulnerable adults: basic principles



In addition to these principles, care providers mustavoid discriminating unfairly between groups ofpatients. Care and treatment decisions must bemade on the basis of a fair and objectiveassessment of individual needs and not onassumptions about age or disability.


Safeguarding vulnerable adults: basic principles



CARD 3What is safeguarding?

Safeguarding is about keeping vulnerable adultssafe from harm. It involves identifying adults whomay be vulnerable, assessing their needs andworking with them and with other agencies inorder to protect them from avoidable harms. It is achallenging area of practice. The group of adultsinvolved is extremely diverse, making a one-size-fits-all approach inappropriate. Adults who may be thefocus of safeguarding range from those whosedecision-making capacity is severely impaired, toadults with no underlying cognitive impairment butwhose physical situation, or a brief period of illness,has temporarily affected their ability to protect theirown interests. The nature of the harms involved canalso range from violent physical and psychologicalabuse through varieties of personal, financial orinstitutional abuse or neglect to a failure to providetimely access to key services such as dentistry orprostheses. Abuse or neglect of vulnerable adultscan also take place in a wide variety of contexts,including private homes, nursing or residential careunits, hospitals and custodial settings. Perpetratorsof abuse can be family members, professionals, paidcare workers, volunteers or other service users. Thisdiversity of contexts and relationships reinforces thecomplex, multi-agency nature of safeguarding andthe extent to which opportunities to promote thewelfare of adults who may be vulnerable permeateall aspects of health care.



Just as the nature and context of harms can vary, so can the nature of the response. An importantdistinction to be made in relation to safeguarding is between meeting the needs of vulnerable adultsas part of ordinary care, and the recognition ofvulnerable adults who are at risk of significant harmand require intervention from adult protectionservices provided by local authorities. Both aspectsare set out in this tool kit.

A person-centred approachAlthough the phrase ‘vulnerable adult’ is widelyused, it is not without its problems. Competentadults have a right to make decisions that affecttheir lives, even where this may result in exposure torisk. Labelling adults ‘vulnerable’ can be stigmatisingand lead to unfounded assumptions that individualslack the ability to direct their own lives. This canlead to unacceptably paternalistic interventions andresult in the kinds of disempowerment that thisguidance is designed to avoid. Alternatively,drawing too narrow a definition of vulnerabilitycould mean that opportunities to identify adultswho may benefit from additional consensualsupport can be lost. Recognising the wide range of circumstances in which safeguarding issues canarise, a key message in this tool kit is the need foran approach that addresses the specific needs ofindividuals. Such a person-centred approach, rootedin good communication skills and respectful of eachindividual’s dignity and independence is likely tolead to optimal outcomes.


What is safeguarding?



GPs and safeguarding – promotingprofessional standardsGPs and other health professionals haveconsiderable experience of promoting the interestsof their adult patients, including those adults whomay, in varying degrees, be vulnerable. The majorityof GPs will have experience, for example, of victimsof domestic abuse, of patients whose mental andphysical health problems lead to difficultiesprotecting and promoting their interests and ofadults experiencing difficulties in their relationshipswith partners, family members or carers. Doctorsare advocates for their patients, and the supportthat GPs in particular offer their patients oftenextends beyond narrowly defined health needs towider welfare considerations. Safeguarding hasbeen defined as that range of activities aimed atrespecting an adult’s fundamental right to be safe.Many of the activities associated with safeguardingwill therefore already be familiar to doctors as partof good practice. The maintenance of professionalstandards for example has a direct impact on thewelfare of patients, and, in particular patients whomay have difficulty promoting their own interests.Clinical governance procedures, including adverseincident reporting, peer review and revalidation thatare aimed at ensuring that poor practice is identifiedand that the highest standards of clinical practiceare maintained are central to safeguarding.





Identifying vulnerable adultsIn addition to promoting professional standards, the ability to identify those adults who are at risk of either abuse or neglect, is critical. Card 4 in thisguidance gives some indication of those adults whomay be at risk, either from individuals or from healthcare systems that may be failing them, while Card 5looks at what constitutes abuse. Protecting andsupporting these adults will ordinarily entail both the identification of risk factors, assessing the natureand extent of those risks and the provision, or atleast the offer, of targeted and proportionateservices. Where an adult lacks capacity in relation to a specific decision, for example, this will involvemaking an appropriate decision on his or her behalf.It will also frequently involve the identification ofcare partners in order to provide, where appropriate,a comprehensive, multi-agency approach.

Meeting the challenges to safeguarding –multi-agency workingIn addition to the variety of circumstances in whichadults can be vulnerable and the complexity ofindividual needs, which can bring together physical,psychological, social and interpersonal factors,safeguarding presents challenges in relation to thewide range of agencies with safeguardingresponsibilities. It is important therefore that wheremulti-agency support is required, healthpractitioners identify and agree the appropriateagencies to act or be the lead agency. It is alsoimportant to understand the scope of each agency’sresponsibility and the limits of its authority tointervene. Authority boundaries are not alwayscoterminous, and appropriate support for avulnerable adult can require cooperation between





agencies that have not always worked togethersuccessfully. It is vital that agencies workcooperatively to ensure that vulnerable adults donot fall between services, particularly where there isconfusion about responsibility and ‘ownership’ ofthe safeguarding process. (Practical advice onensuring continued care for vulnerable adults isgiven in Card 11, safeguarding adults as part ofordinary care.)

Checklist of key pointsAlthough systems and procedures forprotecting vulnerable adults are not yetuniform across England and Wales thefollowing key points apply to all healthprofessionals who may encounter vulnerableadults.

• Health professionals should be able toidentify adults whose physical, psychologicalor social conditions are likely to render themvulnerable (see Card 4)

• Health professionals should be able torecognise signs of abuse and neglect,including institutional neglect (see Card 14)

• Health professionals need to familiarisethemselves with local procedures andprotocols for supporting and protectingvulnerable adults





Good practice example – managing risk to patientsMr Hart was recovering from a stroke in anursing home. As he began slowly to recoverhe remained quite confused. When heregained the ability to walk he started towander beyond the confines of the building.The home was fronted by a busy road andthe carers in the home became concernedabout his wellbeing. Although they did notwant to restrict his freedom of movementthey were concerned both that he mightcome to harm and also that they might befound negligent.

Discussing his care with the nursing staff theGP heard that although Mr Hart could beconfused, when they talked about thepotential risks that he was exposing himselfto, he seemed to understand what he wasdoing. Mr Hart had always worked outdoorsand been active and he at times feltconstrained and uncomfortable in his room.Following further discussion with Mr Hartand the care staff it became clear that heunderstood the risks involved and that hisability to walk and to get fresh air wasimportant to his wellbeing. As, in the carehome manager’s view, Mr Hart retainedcapacity, and was aware of the risks, it wouldbe inappropriate, as well as unlawful, tointroduce restrictions beyond the ordinarysecurity measures required to keep all theresidents safe.





After careful discussion Mr Hartacknowledged the concerns of staff andagreed that he would try to avoid the road infront of the building, confining himself to thegardens. If he did want to leave the buildinghe would inform the care staff and wait untilsomebody was able to accompany him. Awritten record of the discussions, and of theassessment of Mr Hart’s capacity to managethe risks, was made.





Definition of ‘vulnerable adult’The term ‘vulnerable adult’ is contentious. Bylabelling adults ‘vulnerable’ there is a danger thatthey will be treated differently. The label can bestigmatising and result in assumptions that anindividual is less able than others to make decisionsand to determine the course of his or her life. In thisway the term can lead to subtle forms ofinappropriate discrimination. Throughout this toolkit, the distinction between adults with the capacityto make decisions and adults lacking capacity isemphasised. Adults who have capacity retain theright to make their own decisions and to direct theirown lives. Adults lacking capacity to makedecisions, though they retain the right to beinvolved in decision-making as far as possible,nevertheless require decisions to be made on theirown behalf, and the overall approach shifts topromoting their best interests. The judgement thatan adult is vulnerable should not be confused witha decision about his or her capacity. They aredistinct questions, although a lack of capacity willordinarily contribute to an adult’s vulnerability.

The Safeguarding Vulnerable Groups Act 2006 givesa wide-ranging definition of a vulnerable adult. Thisincludes anyone aged 18 or over who is in receiptof ‘any form of health care.’ This definition is tooinclusive to enable appropriate distinctions to bemade between the needs or vulnerabilities of adults.The overwhelming majority of adults in receipt of

CARD 4Which adults may be vulnerable?



health care are able to look after their owninterests, and to label them vulnerable can bepatronising and pejorative. Too much attention tothe definition of a vulnerable adult could also leadto a failure to recognise that systems can also play a part in neglect and abuse. Systemic failures inhealth care can render adults vulnerable where in all other aspects of their life they are competent andin control. As emphasised throughout this tool kit,neither capacity, nor vulnerability is an all-or-nothingstate, but is subject to degrees of variation. Aconcern with definitions should not interfere withan objective assessment of an individual’s needs.

The most widely-used current definition ofvulnerable adult is set out in the Government’s No Secrets guidance. It is taken from the 1997consultation paper Who Decides? issued by thethen Lord Chancellor’s Department. According tothis definition a vulnerable adult is a person aged18 or over:

Who is or may be in need of communitycare services by reason of mental or otherdisability, age or illness; and who is or maybe unable to take care of him or herself,or unable to protect him or herself againstsignificant harm or exploitation.


Which adults may be vulnerable?



Factors contributing to vulnerabilityThere are a number of factors that can contributeto vulnerability, although their presence is by nomeans determinative and individuals will varyaccording to their circumstances and needs. It isnevertheless broadly accepted that the followinggroups are at enhanced risk of being vulnerable to neglect or abuse:

• an older person who is particularly frail• an individual with a mental disorder, including

dementia or a personality disorder• a person with a significant and impairing physical

or sensory disability• someone with a learning disability• a person with a severe physical illness• an unpaid carer who may be overburdened,

under severe stress or isolated• a homeless person• any person living with someone who abuses

drugs or alcohol• women who may be particularly vulnerable as a

result of isolating cultural factors.

The presence of one or more of these factors doesnot necessarily mean that the adult is vulnerable –age, disability or physical illness for example shouldnot lead to the automatic assumption that theindividual is vulnerable. A key factor in each case iswhether the individual is able to take steps toprotect and promote his or her interests.





The Government’s 2009 review of its No Secretsguidance accepted that there were some concernsabout the current definition of ‘vulnerable adult’.The definition outlined above may thereforechange. The web version of this guidance will beupdated as appropriate.

Good practice example – identifying andresponding to vulnerabilityMrs Granger was a wealthy elderly lady livingon her own in a large town house. She had nofamily or close friends and was supported by apaid carer. She visited her GP complaining thatshe was losing things and becoming slightlyforgetful. It was clear to the doctor thatalthough her decision-making capacity wascurrently unimpaired, investigation would beuseful and together they agreed that it wouldbe a good idea to refer her to a consultant forassessment. She was diagnosed as being in theearly stages of Alzheimer’s and at her next visitto the GP she became distressed. She hadalways been fiercely independent and hadtaken good care of her financial assets. Thediagnosis had left her very concerned for thefuture. During the consultation her GP spentsome time discussing options for the futurewith her, including the possibility of nominatinga property and affairs attorney. Although MrsGranger felt confident in looking after herself,they also discussed the possibility of socialservices support should the need arise.Although the GP recognised that there wereaspects of vulnerability, Mrs Granger clearly





retained the right to make decisions about herlife. They both decided that it would be in MrsGranger’s interests for her to make quarterlyappointments with the GP so they could reviewher needs on a reasonably regular basis.

Checklist of key points• The term ‘vulnerable’ adult is contentious

and care must be taken to avoid using itpejoratively or in ways that underminefundamental rights, interests or freedoms

• A clear distinction must be drawn betweenadults who retain capacity to make decisionsand those whose capacity has been lost orimpaired

• Attention must be paid to systemic sourcesof vulnerability

• A key factor in assessing vulnerability iswhether individuals are able to protect orpromote their interests





CARD 5What constitutes abuse and neglect?

The term ‘abuse’ is subject to a variety ofdefinitions, and the distinction between abuse andneglect is not always clear. Neglect can also lead toharms as significant as direct abuse. The 2009review of No Secrets identified that within healthcare, neglect is the most serious form of abuse andthat in some care settings, poor levels of servicesamounting to neglect were accepted as a result ofstaff and other resource shortages. In practicalterms this tool kit therefore treats neglect as acategory of abuse. Abuse can occur in anyrelationship and in a wide range of circumstances.The No Secrets guidance identifies a number offactors that categorise abuse:

• it may consist of a single act or repeated acts• it may be physical, verbal or psychological• it may be an act of neglect or an omission to

act including an unintended lack of attentionto someone who requires it

• it may occur when a vulnerable person ispersuaded to enter into a financial or sexualtransaction to which he or she has notconsented, or cannot consent

• it can occur in any relationships and may resultin significant harm to, or exploitation of, theperson subject to it.



Abuse and neglect can amount to serious violationsof an individual’s human and civil rights. Many actsof abuse constitute criminal offences and vulnerableadults are entitled to the full protection of the law.Where a crime has been committed, or is likely tobe committed, it may be necessary to involve lawenforcement agencies. In addition, abuse andneglect are often characterised by a lack of respectfor, or a violation of, the respect for individualdignity, agency and integrity that are at the core of both good patient care, and of fundamentalsocial norms.

Although abuse can take many forms, there isbroad agreement that the following are among the most significant:

• physical abuse including hitting, the misuseof medication, inappropriate or unlawfulrestraint or other sanctions

• sexual abuse including any sexual act towhich the person did not or could not consent

• psychological abuse including coercion,emotional abuse, humiliation, harassment,bullying, verbal abuse, enforced isolation orwithdrawal from services

• financial abuse including theft, fraud, themisuse of property, finances and benefits,including coercion in relation to wills and otherforms of inheritance


What constitutes abuse and neglect?



• neglect and acts of omission includingdeliberate or neglectful failure to meet healthor physical care needs or to provide thenecessaries of life including food andappropriate shelter. It can also includethoughtless forms of neglect such as leavingfood or drink out of reach, the removing ofspectacles, hearing aids or false teeth and theplacing of them out of reach

• discriminatory abuse including racial,religious, gender-based abuse, or abuse basedupon an enduring condition or disability, or aperson’s age.


What constitutes abuse and neglect?



Capacity is a vital concept in relation to the care andtreatment of adults who may be vulnerable. Manyof the respondents to the Government’sconsultation on the review of the No Secretsguidance expressed frustration that the voices ofadults were insufficiently listened to. Althoughpeople wanted to be informed of options for careand support, they wanted to retain control. Therewas also a clear message that comparisons withchild protection were inappropriate: adults quiteobviously have very different needs and capacities tochildren. Retaining control means that competentadults have the right to assess and manage the risksto which they are exposed, and support willnormally involve talking through those risks andoffering support where appropriate. In the absenceof serious crime, and of significant risks to thirdparties, competent adults retain the right to makedecisions about how they wish to direct their lives.Neglecting or violating these decision-making rights,even where the intentions are to protect theindividual, can itself amount to a form of abuse.

For many adults vulnerability can develop over time.Deteriorating health, declining alertness or a changein residence or care regime can exacerbatevulnerability and present challenges to the ability ofadults to manage risk. Vulnerability is not thereforestatic, and may vary according to the individual’scircumstances. Assessments of an individual’s needs

CARD 6What part does mental capacity playin safeguarding?



must therefore be made on a case-by-case basisand be subject to regular review. A key feature ofadult safeguarding is to consider how best tobalance an appropriate respect for agency, or theability of adults to make informed choices abouttheir lives, with the requirement to provideappropriate support to help people manage risks. In ethical terms the challenge is managing a respectfor autonomy with the requirement to act toprevent avoidable harms. Support and advice should be offered as appropriate, but basicfreedoms cannot be infringed.

Adults with capacityIt is a fundamental principle of English law thatadults have the right to make decisions on theirown behalf, and are assumed to have the capacityto do so. This is known as the ‘presumption ofcapacity’ and extends to decisions that may entailpersonal risks and that may not be in accordancewith an objective view of their best interests. Wherethere are doubts about capacity the responsibilityfor demonstrating that an individual lacks capacityfalls upon the person challenging it. The fact thatan adult is regarded as ‘vulnerable’ is not by itselfevidence that he or she lacks capacity and greatcare must be taken to avoid any such assumption.

Where an adult has capacity in relation to a specificdecision, such as a health intervention, consent isrequired and his or her decision must be respectedunless treatment is being provided under mentalhealth legislation. Where a health professionalbelieves an adult with relevant capacity may beboth vulnerable and at risk of harm, but refuses theoffer of assistance, this decision should ordinarily be


What part does mental capacity play in safeguarding?



respected although health professionals should keepan accurate and contemporaneous record of thesupport offered and the reasons for the adult’srefusal. Such decisions should also be kept underreview and ongoing support should be offered.Examples here might be where an adult is offered aprotective measure, such as a bed rail, but refuses.Such a situation is likely to be challenging to healthprofessionals, and where possible, the optionsavailable to the individual, and the nature of theprofessional’s concerns should be discussed in detail,including presenting, where possible, a range ofoptions to manage risk. Having said this, where acompetent adult explicitly refuses any supportingintervention, this should normally be respected.Exceptions to this may be where a criminal offencemay have taken place or where there may be asignificant risk of harm to a third party. If, forexample, there may be an abusive adult in aposition of authority in relation to other vulnerableadults, it may be appropriate to breachconfidentiality and disclose information to anappropriate authority. Where a criminal offence issuspected it may also be necessary to take legaladvice. Ongoing support should also be offered.Because an adult initially refuses the offer ofassistance he or she should not therefore be lost toor abandoned by relevant services. The situationshould be monitored and the individual informedthat she or he can take up the offer of assistance atany time.





Good practice example – assessing capacityMrs Jones’ relatives were concerned that shewas sliding into dementia as she seemedincreasingly confused, acted out of character,dressed strangely and appeared rude, givingbizarre answers to questions. The family alsoreported that her confusion had also led to herbeing exploited by a door-to-door salesmanwho had talked her into agreeing to 10,000pounds worth of unnecessary building work.Her GP was asked to carry out an assessmentof mental capacity with a view to admission ina specialist care home. The GP had known herfor years and was familiar with her reluctanceto admit to health problems or ask for help.

After careful discussion with Mrs Jones, sheconcluded that her declining hearing wasbehind her bizarre answers as she oftenmisheard the question. Macular degenerationwas affecting her eyesight and led to hermaking unusual clothing choices, ignoringfriends and greeting strangers. Fear ofincontinence had also led her to start refusingliquids, resulting in dehydration and somemental confusion. Although appropriatetreatment rectified her confusion, her failingeyesight meant that she required a higher levelof support than she could receive in her home.Rather than being diagnosed with dementiashe was instead assessed as being partiallysighted. Given her needs, she agreed to moveto a supported care environment near to herrelatives. Safeguarding in this context involved





a careful clinical assessment and anidentification and treatment of factors thatwere impairing capacity. This reduced the riskof further exploitation. Following appropriateclinical support, Mrs Jones was identified ashaving decision-making capacity in relation tothe decision to move to a care home. Theprovision of additional social support enabledMrs Jones to regain a high level ofindependence.

Where there are doubts about a person’scapacityAlthough, as discussed above, where an adult hasrelevant capacity, he or she has the right to makedecisions that affect his or her life, includingdecisions that involve risk, particular difficulties arisewhere some capacity exists but its extent isuncertain. In these circumstances very difficultdecisions may need to be made involving a balancebetween respecting the decision-making freedom of adults and the requirement to intervene. Wherethere is doubt about an adult’s capacity a formalassessment should be undertaken. The more seriousthe decision – and this will include identifying thescale and seriousness of any risks the adult’sdecision may expose him or herself to – the moreformal the assessment of capacity is likely to be.Depending upon the circumstances it may beappropriate to refer the patient to a psychiatrist orpsychologist with particular experience in assessingcapacity. Where there are doubts about a person’scapacity that cannot be resolved using moreinformal methods, the Court of Protection can beasked for a judgement.





What do you do when an individual refuses to be assessed?Occasionally an individual whose capacity is indoubt may refuse to be assessed. In most cases, asensitive exploration of the consequences of such a refusal, such as the possibility that decisions maybe challenged at a later date, will be sufficient forpeople to agree. In the case of an assessment fortestamentary capacity, for example, pointing outthat a person’s wishes may be contested in theabsence of such an assessment can be persuasive. Ifthe individual flatly refuses, however, in most casesno one can be required to undergo an assessment.

Good practice example – managing apotentially abusive situationMr Carmichael’s wife was experiencing anepisode of mental illness. Although she hadbriefly been an in-patient she was now beingtreated at home. Largely as a result of hermental illness, there were times when she wasverbally aggressive to her husband to an extentthat at times amounted to psychological abuse.On one or two occasions she had also struckhim. Mr Carmichael was in his 80s, andalthough physically not strong he had onlyexperienced some minor decline in hiscognitive abilities. During a routine visit to hisGP, Mr Carmichael discussed the problems hewas experiencing with his wife. Althoughdistressed, he was very clear that he wanted tocontinue living with and supporting his wife,despite recognising that there were abusiveaspects to his wife’s behaviour. Mr Carmichael





clearly had the capacity to make decisionsabout the kind of behaviour he could manageand the risks he was willing to accept. Aftersome discussion, Mr Carmichael agreed thatthe GP would contact social services on hisbehalf to look into the possibility of providing

Mr Carmichael with some support, such asrespite care. In this way, Mr Carmichael’sdecision-making freedom was respected, buthelp was offered in order to mitigate some ofthe potential harms.

Checklist of key points• All adults are presumed to have the capacity

to make decisions on their own behalf• Exceptions to the obligation to respect the

informed decisions of adults include wherethe decision or action results in a threat ofsignificant harm to a third party

• An assessment of mental capacity isdecision-specific – it relates to the specificdecision that needs to be made at the timeit needs to be made

• Where there is doubt about an adult’scapacity, a more formal assessment shouldbe made





CARD 7Adults lacking capacity

Decision-making in relation to adults who lackcapacity is regulated in England and Wales by theMental Capacity Act 2005 (MCA). The BMAprovides extensive guidance on the Act which isavailable on its website. A link is given at thebottom of this card. This section contains a verybrief outline of the legislation emphasising thoseaspects most relevant to a safeguarding approach.Professionals are strongly advised to refer to detailed guidance.

Adults lacking capacity to make decisions thatwould protect and promote their own interests are potentially extremely vulnerable. Although, inaccordance with the principles of the Act, adultslacking capacity should be at liberty to participate as far as possible in decision-making, and expresstheir views, emphasis should shift to ensuring thatdecisions made on patients’ behalf promote theiroverall best interests.

Mental Capacity Act 2005The MCA sets out a number of basic principles thatmust govern all decisions taken in relation to adultslacking capacity. A brief list is given below.

• A presumption of capacity. Adults are assumedto have the capacity to make decisions on theirown behalf unless it is proven otherwise.

• Maximising decision-making capacity.Everything practicable must be done to support



individuals to make their own decisions, beforeit is decided that they lack capacity.

• The freedom to make unwise decisions. Thefact that an adult makes a rash, unwise orimpulsive decision is not in itself evidence oflack of capacity.

• Best interests. Where it is determined that anadult lacks capacity, any decision or actiontaken on his or her behalf must be in his or herbest interests.

• Less restrictive alternative. Whenever a personis making a decision on behalf of an adult wholacks capacity, he or she must consider if it ispossible to make the decision in a way that isless restrictive of that person’s fundamentalrights or freedoms.

An assessment of mental capacity is decision-specific. The question is whether the individual hasthe capacity to make a specific decision at a specifictime. Although some patients, such as those whomay be unconscious, will not be able to make anydecisions, most individuals will be able to participatein at least some decisions, even very straightforwardones such as what to wear.


Adults lacking capacity



Best interestsUnder the MCA, all decisions taken on behalf ofsomeone who lacks capacity must be taken in his orher best interests. A best interests judgement is notan attempt to determine what the person wouldhave wanted, although this must be taken intoaccount. It is as objective a test as possible of whatwould be in the person’s actual best interests takinginto account all relevant factors including:

• the likelihood that the person will regaincapacity, and whether the decision can bedelayed until that time

• the person’s past and present wishes andfeelings, including any relevant writtenstatement

• his or her beliefs or values where these wouldhave an impact on the decision

• other factors the person would haveconsidered if able to do so, such as the effectof the decision on other people.

A crucial part of any best interests decision willinvolve a discussion with those close to theindividual, including, where appropriate, family,friends or carers, bearing in mind both the duty ofconfidentiality (see Card 9) and the caution thatwould be required if the adult was believed to be inan abusive relationship.





Lasting Powers of Attorney (LPA)The MCA allows individuals aged 18 or over andwho have capacity to appoint an attorney under an LPA, to make financial and health and welfaredecisions on their behalf once they lose capacity.Unless it is an emergency, consent from theattorney is required for all decisions that would have required consent from the adult had he or she retained capacity. Attorneys are under a duty to act in the incapacitated adult’s best interests.

Independent Mental Capacity AdvocatesThe MCA has introduced a new role ofIndependent Mental Capacity Advocates (IMCA).Under the Act, an IMCA must be instructed inrelation to individuals who lack capacity and whohave no family or friends whom it is appropriate toconsult when:

• an NHS body is proposing to provide, withholdor withdraw ‘serious medical treatment’; or

• an NHS body or local authority is proposing toarrange accommodation, or a change inaccommodation, in a hospital or care home,and the stay in hospital will be more than 28days, or the stay in the care home more thaneight weeks.

Responsibility for instructing an IMCA lies with theNHS body or local authority providing the treatmentor accommodation. In some situations where adultsrequire safeguarding local authorities are also ableto instruct IMCAs.





Checklist of key points• Decision-making in relation to adults who

lack capacity is regulated in England andWales by the Mental Capacity Act 2005

• Adults lacking capacity to make decisionsthat would protect or promote their owninterests are potentially extremely vulnerable

• All decisions made on behalf of individualslacking capacity must be made in their bestinterests

• Where appointed, welfare attorneys areunder a duty to act in an incapacitatedadult’s best interests

BMA guidance on the Mental Capacity Actwww.bma.org.uk/ethics/consent_and_capacity/mencaptoolkit.jsp





Where adults lack the capacity to consent totreatment, the Mental Capacity Act, as indicated inCard 7, makes it clear that they should be caredfor using the less restrictive of the availableoptions. There will be occasions however whereadults lacking capacity will need to be cared for ina manner that amounts to a ‘deprivation ofliberty’. In April 2009 the deprivation of libertysafeguards (DOLS) were introduced to provideprotection for this particularly vulnerable group ofadults. A brief outline of what factors mightamount to a deprivation of liberty, and thesafeguards are given below.

What is deprivation of liberty?Although the concept of ‘deprivation of liberty’ isnot straightforward, the courts have identified thatthe following factors are likely to result indeprivation of liberty:

• restraint is used, including sedation, to admit aperson who is resisting

• professionals exercise complete and effectivecontrol over assessments, treatment, contacts andresidence

• the person would be prevented from leaving ifthey made a meaningful attempt to do so

• a request by carers for the person to bedischarged to their care is likely to be refused

CARD 8Care and treatment amounting todeprivation of liberty – the deprivationof liberty safeguards (DOLS)



• the person is unable to maintain social contactsbecause of the restrictions placed on access toother people

• the person loses autonomy because they areunder continuous supervision and control.

How can deprivation of liberty be authorised?Under the MCA, the deprivation of liberty of aperson lacking capacity to consent to treatment canbe authorised in one of three ways:

• by the Court of Protection exercising its powersto make personal welfare decisions under theMCA

• where it is necessary in order to give life-sustaining treatment or do any ‘vital act’ while adecision is sought from the court

• in accordance with the DOLS scheme as outlinedbelow.

In addition, it remains possible to authorisedeprivation of liberty where a person falls under theprovisions of the Mental Health Act 1983.

Deprivation of Liberty Safeguards (DOLS)Where health professionals identify that anindividual lacking capacity is at risk of beingdeprived of his or her liberty in a hospital or carehome setting, the ‘managing authority’ of thehospital or care home has to make an application toa ‘supervisory body’ to request an authorisation ofthe deprivation. In the case of an NHS hospital, themanaging authority will be the NHS bodyresponsible for its running. In the case of a privatehospital or care home, the managing authority willbe the person registered, or required to be


Care and treatment amounting to deprivation of liberty –

the deprivation of liberty safeguards (DOLS)



registered, under Part 2 of the Care Standards Act2000. In England, the supervisory body will beeither the body responsible for commissioning orthe local authority, in Wales it is either the NationalAssembly for Wales or a Local Health Board.If the supervisory body agrees that the applicationshould be made, it will commission an assessmentto determine whether the qualifying criteria aremet, and if appropriate, will grant an authorisation.In an emergency, the managing authority of thehospital or care home can grant an urgentauthorisation, but must simultaneously apply for astandard authorisation. This urgent authorisation isusually valid for seven days, although the supervisorybody may extend this for up to another seven days.


Care and treatment amounting to deprivation of liberty –

the deprivation of liberty safeguards (DOLS)



CARD 9When can information be shared aboutvulnerable adults?

Duty of confidentialityHealth professionals owe the same duty ofconfidentiality to all their patients regardless of age,vulnerability or the presence of disability. Theexistence of a mental disorder, a serious physicalillness or a learning disability should not lead to anassumption that the individual lacks capacity tomake decisions relating to the disclosure ofconfidential information. Competent adults haveconsiderable rights about the extent to which theirinformation is used and shared and these areprotected both by law, and by professional andethical standards. Although there is a presumptionthat information will be shared between healthprofessionals involved in providing care to a patient,where a competent adult explicitly states that thisinformation should not be shared, this shouldordinarily be respected.

Sharing informationThe multi-agency approach to safeguardingvulnerable adults nevertheless means that, where itis lawful and ethical to do so, appropriateinformation should be exchanged between relevantagencies in order to ensure that support that is rightfor the individual can be provided. Healthprofessionals can sometimes feel challenged when acompetent adult refuses to agree to the sharing ofinformation that would seem to be in their bestinterests, or that could help mitigate a potential



harm. Where a health professional is in this positionand believes that information should be exchanged,the reasons for this should be carefully explained,the benefits that are likely to accrue, and the dutyof confidentiality that the various agencies aresubject to. The reasons for the refusal should alsobe sensitively explored, and, where appropriate,options that might prove more amenable to thepatient offered. At the end of the day, however,where a competent patient refuses to permitdisclosure, this should be respected. The onlyexceptions to this are where confidentiality can beoverridden either by a court order or other legalauthority, or in the public interest. Public interestjustifications usually relate to disclosures to preventsignificant harm to third parties or to prevent or toprosecute a serious crime.

Adults lacking capacityWhere an adult lacks capacity, information can bedisclosed in accordance with the Mental CapacityAct, where, in the opinion of the relevant healthprofessional, it would be in the incapacitatedperson’s best interests. Where an adult lackscapacity to consent to disclosure it is usuallyreasonable to assume that they would want peopleclose to them, or directly involved in their care to begiven appropriate information about their illness,prognosis and treatment, unless there is evidence tothe contrary.


When can information be shared about vulnerable adults?



Checklist of key points• Health professionals owe the same duty of

confidentiality to all their patients• Competent adults have the right to

determine how their information is used,although this right is not absolute andconfidentiality may be overridden by legalauthority or where there is a significant riskof harm to others, or to prevent or prosecutea serious crime

• Where an adult lacks capacity relevantinformation can be disclosed where it is inhis or her best interests

• The principle of proportionality entailsmaking balanced decisions about whether toshare information without consent

Good practice example – disclosure ofinformation in an individual’s bestinterestsMr Atjit is an elderly man living in residentialcare. His son is concerned about the carehome’s ability to meet Mr Atjit’s needs as heis becoming increasingly confused. The soncontacted Mr Atjit’s GP requesting sight ofhis father’s medical records. After a routinevisit to Mr Atjit at the care home, the GP felthe was unable to consent to disclosurebecause of Mr Atjit’s deteriorating mentalability. Given that the son was so concernedabout the support being offered to his father,in the GP’s view it was clearly in the father’s





best interests for the son to have access torelevant information about the support hewas receiving.

The GP decided, however, that it would notbe appropriate to disclose the entire medicalrecord as some of it contained sensitiveinformation not relevant to the currentepisode of care. The GP therefore gave theson access to current and relevantinformation but not the entire record.





CARD 10What part does good communicationplay in safeguarding?

Good communication is a basic medical skill, andmuch of what appears in this card will be commonto all discussions between doctors and patients.Good communication can, however, take time,particularly where there may be languagedifficulties, or some degree of cognitive impairment.There can often be time constraints in hospitals,surgeries and care homes, which can presentchallenges to the delivery of personalised healthcare. In these circumstances, it is important thatprofessionals are sensitive to the potentially coerciveeffects of pressurised decision-making.

The basic principle is that all individuals should beoffered information about their condition and aboutoptions for treatment or support in a mannerappropriate to their needs. This should extend tothe offer of information about their wider care.Vulnerable adults should be supported to explorechoices about their safety and wellbeing. Thisincludes adults who may lack capacity but whohave some ability to participate in decision-making.Listed below are key aspects of good communication.



• Good communication involves an honest andsensitive exploration of health conditions,treatment options, prognosis, risks and side-effects. Euphemism should be avoided, andthought should be given to timing of discussionsand to the use of communication aids whereappropriate.

• Information should be tailored to the individual’sneeds. This may, for example, involve the use ofpictures, or, where English is not a first language,translators.

• Consideration should be given to the use of factsheets and other written communicationsupports.

• All patients should be encouraged to participateas far as possible in decision-making.

• Most patients will want those close to them to be involved in communication and decision-making, but all patients have a right toconfidentiality and where an individual hasindicated that information should not be shared this should be respected.

• Health professionals must avoid the use ofcommunication styles that inadvertently implythat patients lack autonomy, dignity orcompetence.

• Good communication is about more thanconveying information; it is also aboutestablishing positive professional relationships.

• Time should be taken to identify the patient’sunderlying values and beliefs that may have abearing on decisions that need to be made.


What part does good communication play in safeguarding?



• Where the criteria in the Mental Capacity Act aremet, consideration should be given to involvingan advocate, such as an Independent MentalCapacity Advocate (IMCA). Although the IMCA’srole is to promote the best interests of theincapacitated adult, they can also help facilitategood communication.

• Discussion with vulnerable adults, includingdiscussion of concerns about harm or abuse, caninvolve broaching sensitive subjects and thisrequires good communication skills. Where healthprofessionals are likely to be working with adultswho may be vulnerable appropriate trainingshould be provided.


What part does good communication play in safeguarding?



High profile cases where adults have been subjectto violent or serious abuse or even murdered bythose in a position of trust have put adultprotection in health services into sharp focus.There is a danger however that a minority ofhorrific cases, which must be dealt with bycriminal justice procedures, detract attention from the work of committed health professionalsin the provision of health care and support tovulnerable adults. While abuse of any sort cannotbe tolerated, the overwhelming concern of themajority of doctors and other health professionalsis with meeting the health and care needs of theirpatients. It is in this day-to-day work that themajority of support is provided to vulnerable adults.

Exploring the needs of vulnerable adultsA central feature of safeguarding adults in thecontext of ordinary care is the need for sensitiveand supportive communication, particularly wherefactors such as poor health, or problems withunderstanding or retaining complex or challenginginformation may lead to difficulties in decision-making. In addition to taking a normal medicalhistory, it may also be helpful for doctors to thinkmore laterally, to look beyond specifically medicalconcerns and to explore wider aspects of thepatient’s experience, such as social, financial andemotional factors that may be contributing to aloss of overall wellbeing. This can help to establish

CARD 11How can safeguarding adults be madepart of ordinary care?



a richer understanding of the needs of vulnerableadults. Time spent in this way can be vital inidentifying those adults for whom a multiplicity offactors – mobility issues, financial or otherdifficulties in providing for the necessaries of life,health deficits, the presence of domestic or otherabuse – can combine to put adults at risk ofserious harm.

Working with carersAnother source of possible harms to vulnerableadults can result from carers who may be undersevere and long-term stress. Good practice canalso, therefore, involve discussion with those whoare in a long-term non-professional care role witha vulnerable adult, including partners and familymembers. Respite care and the provision of someprofessional care support can be importantcontributors to supporting both the carer and thevulnerable adult.

Prevention as part of ordinary careTragically, every winter older people die fromhypothermia. Such deaths are avoidable. Themajority of these older people will have been inreceipt of health and social care services, somewill have been living in social housing or willotherwise have been known to supportingservices. Such appalling deaths are often theresult of failures within – and between – systems,often where adults who are unable actively topromote their own interests, and have no familyor friends who can offer support and assistance,become lost to the services that are geared tosupport them.


How can safeguarding adults be made part of ordinary care?



Prevention is clearly critical to safeguarding andmany GP practices have developed innovativemethods for ensuring continuity of contact withvulnerable adults, including appropriate use of flagsin electronic notes, regular practice meetings todiscuss vulnerable adults, or, where required, theuse of successive appointments, home visits or otherreminders. In this way, targeted support can beoffered to patients with the highest levels of need.Some practices allocate lists of vulnerable patientsto specific doctors. In this way, doctors, who areextremely busy, can be supported by a system thathelps them look out for vulnerable adults. Suchapproaches are obviously not limited to those whomay be at risk of hypothermia or malnutrition, butcan be used wherever doctors have concerns thatadults may be at risk. Some practices have alsointroduced early warning systems in relation todeveloping trends or where, for example, concernsare emerging about the standards of care inparticular care homes.

Good practice example – effectivecommunication as part of ordinary careMrs Edgman had been active well into her 80s,but as a result of a faulty heart valve, herhealth began to deteriorate and she began toneglect herself. She lived on her own and hadbecome gradually more self-neglectful. Herneighbours were concerned as she seemedconfused and disorientated. Following acollapse she was admitted to hospital whereshe was diagnosed as suffering frommalnutrition and dehydration. After emergencytreatment she was started on anti-depressants





and when she had recovered sufficiently shereturned home. After receipt of the dischargeletter, her GP arranged for a consultation.Although dehydration had temporarilyaffected her capacity, following treatmentthere was no evidence of any decline in hercognitive abilities. The GP discussed MrsEdgman’s circumstances and needs andtogether they explored the way herdepression had led her into a downwardspiral of self-neglect. Although anti-depressants would probably improve hermood, they nevertheless agreed that it wasimportant that they worked together todevelop a care plan to ensure that any earlysigns of deterioration would be acted upon.Mrs Edgman agreed to a referral to socialservices. Her GP discussed with her thepractice scheme whereby individuals in needof support were identified and ongoingfollow-up was offered. This would includeregular check-ups and, where necessary,home visits. Identified as being at-risk, MrsEdgman’s case was subject to ongoing reviewat the practice’s weekly meeting designed todiscuss vulnerable patients.





Overall responsibility for coordinating multi-agencyresponses to the harm or abuse of vulnerable adultsrests with the local authority, and it is important thatGPs are familiar with the relevant local contacts.Where adult patients are at risk of harm due to alack of appropriate health resources, or poor clinicalperformance, doctors have clear responsibilities,outlined by the General Medical Council (GMC), totake appropriate action via established channels toprotect patients (see Card 13). This will includeengaging multi-agency safeguarding services.Through multi-agency procedures, agreement canbest be reached about how to support vulnerableadults and how to investigate the concerns of abuseor neglect. Although, for example, health servicesmight lead any investigation into allegations ofmisconduct about a health professional, a multi-agency approach can ensure openness andaccountability, as well as a multi-agency approach tosupporting the vulnerable adult.

Significant harmA key question for health professionals is the pointat which they should consider involving localauthority adult protection procedures. A usefulstarting point here is the concept of ‘significant’harm. This is likely to include not only violent andunlawful acts including hitting, sexual abuse andharmful psychological coercion, but also any acts, oromissions, likely to lead to a serious impairment of

CARD 12When should GPs refer through multi-agency safeguarding adults service?



physical or mental health. Factors that should betaken into account when considering theinvolvement of adult protection services will include:

• the vulnerability of the individual• the nature and extent of the abuse• the length of time it has been occurring• the effect of the abuse on the individual• the risk of repeated or increasingly serious abuse• the likelihood that other vulnerable individuals

may also be put at risk• the risk of serious harm• whether criminal offences are involved.

Although these factors are important considerations,the nature of the response, and the agencies thatmay be contacted, will vary according tocircumstances and to local procedures and protocols.It is therefore important that doctors and otherhealth professionals ensure they are familiar withlocal procedures, in particular the local authorityadult protection leads, and the relevant multi-agencyadult protection panels.

Serious crimeWhere doctors or other health professionals suspectthat a serious crime may have been, or maybe aboutto be, committed, action should be taken as amatter of urgency. Although health professionalsowe a duty of confidentiality to all their patients, thisduty is not absolute (see Card 9). Where an adulthas the relevant decision-making capacity, theyretain the freedom to decide how best to managethe risks to which they may be exposed, includingwhether a referral through multi-agency procedureswould help them. Where other individuals may be at


When should GPs refer through multi-agency safeguarding

adults service?



harm, however, or where there is concern that aserious crime may be, or may have been committed,referral must be made through appropriateprocedures. In these circumstances healthprofessionals should discuss the matter with thesocial services adult protection team as a matter ofurgency. It may also be necessary directly to contactthe police.

Checklist of key points• Where harm or abuse has occurred or there

is significant risk, multi-agency proceduresprovide a means of investigating andprotecting the person

• Where adults have relevant mental capacitythey have the right to decide how to managerisks, including whether a referral throughmulti-agency procedures would assist them

• Where other individuals are at risk of harminformation may need to be shared withoutconsent

• Where adult patients are at risk of harm dueto a lack of appropriate health resources, orpoor clinical performance, doctors have clearresponsibilities to take appropriate action viaestablished channels, including multi-agencysafeguarding procedures, in order to protectpatients

• Where doctors or other health professionalssuspect that a serious crime may have been,or maybe about to be, committed, actionshould be taken as a matter of urgency


When should GPs refer through multi-agency safeguarding

adults service?



CARD 13When should concerns about patientsafety be reported?

A key component of safeguarding is ensuring thatvulnerable adults are kept as safe as possible. Whilethis may mean identifying abusers and working toensure that adults are protected from them, it canalso mean identifying both systemic failures and poorprofessional performance that can lead to harm.

Health systems and poor resourcesWhere systemic problems or poor performance areidentified, early intervention is important, leading tobetter outcomes for vulnerable adults, and for health professionals. There are currently a range ofsafeguards in place, such as regular inspection ofnursing and care homes, and strict licensingspecifying what kinds of patients certain homes canadmit. Properly implemented, these safeguards canbe very effective at minimising harms. In terms ofmedical regulation, in its guidance, Good MedicalPractice the GMC states that, in relation to concernsabout patient safety:

If you have good reason to think thatpatient safety is or may be seriouslycompromised by inadequate premises,equipment, or other resources, policies orsystems, you should put the matter right ifthat is possible. In all other cases youshould draw the matter to the attentionof your employing or contracting body. Ifthey do not take adequate action, you



should take independent advice on howto take the matter further.

In relation to concerns about the conduct andperformance of colleagues, the GMC states:

You must protect patients from risk ofharm posed by another colleague’sconduct, performance or health. Thesafety of patients must come first at alltimes. If you have concerns that acolleague may not be fit to practise, youmust take appropriate steps without delay,so that concerns are investigated andpatients protected where necessary.

Information gatheringWhere doctors or other health professionals haveconcerns about colleagues, or about the impact ofservices on vulnerable adults, they may first need togather information to establish the facts, taking intoconsideration patient confidentiality as appropriate.Where patients are at risk, health professionals havea responsibility to act. Although local policies andprocedures will differ, every practice andcommissioning body should have procedures inplace to deal with concerns about health services,and individual performance.

In relation to the performance of doctors, finalresponsibility lies with the GMC. In the firstinstance, concerns can be discussed with the GMCwithout necessarily revealing the identity of thedoctor concerned, and advice on how to proceedcan be sought. Where patients are at risk, however,it may be necessary formally to refer the matter tothe GMC for further action.


When should concerns about patient safety be reported?



Whistle-blowingWhere these remedies are exhausted, and patientsare still at risk, it may be necessary to considerraising the issue more widely – by ‘whistle-blowing’,for example, which may involve providinginformation to media or MPs. The Public InterestDisclosure Act protects whistle-blowers who discloseinformation ‘in good faith’ to a manager oremployer. Within the NHS, disclosure in good faithto the DH is protected in the same way. Widerdissemination of information is protected, as long asit is reasonable, not made for gain and meets thefollowing conditions:

• whistle-blowers reasonably believe they would bevictimised if they raised the matter internally orwith a prescribed regulator

• they believe a cover-up is likely and there is noprescribed regulator

• they have already raised the matter internally orwith a prescribed regulator.

Further advice on whistle-blowing can be obtainedfrom the BMA or from support organisations suchas Public Concern at Work.





GP’s responsibilities as employersWhere GP’s are employers, they have specific legalresponsibilities in relation to ensuring that theiremployees do not present a threat to vulnerableadults. Under the Safeguarding Vulnerable GroupsAct 2006 employers such as GPs have an obligationto refer an employee to the IndependentSafeguarding Authority (ISA) when ‘they remove aperson from a regulated or controlled activity, orthat person resigns, retires, is made redundant or istransferred to a position which is not regulated orcontrolled activity’ because the employing GP thinksthat the person:

• has engaged in conduct that endangers or islikely to endanger a vulnerable adult, includingemotional, sexual, psychological or financialabuse or has failed to meet a vulnerable adultsbasic physical or psychological needs

• may harm, may cause to be harmed, put at riskof harm or may attempt to harm or may inciteanother person to harm a vulnerable adult

• has been cautioned or convicted of a relevantspecified offence involving harm to a vulnerableadult

In a GP context, a ‘regulated activity’ means workthat involves or can involve contact with vulnerableadults either ‘frequently’ (once a week or more),‘intensively’ (four or more days in an period of 30days) or ‘overnight’ (between 2am and 6am). Therelevant specified offence refers to any of a verylarge number of offences laid out in the Act’sRegulations.





The Safeguarding Vulnerable Groups Act and theobligations to refer employees to the ISA areexplained in detail on the ISA’s website(www.isa.homeoffice.gov.uk). Where a GP identifiesthat an employee, whether a health professional orancillary or support staff such as administrators orcleaners has access to vulnerable adults and haseither harmed a vulnerable adult, or presents a riskof harm to a vulnerable adult, then the GP needs toconsider his or her legal duty to refer. Where thereis any doubt, GPs should take advice from the ISA.Contact details are given in Card 17.

Checklist of key points• Where patients are at risk of harm from

substandard services or poor clinicalperformance, health professionals have aresponsibility to act and this will usuallyinvolve liaising with local multi-agencyprocedures

• Initial concerns about the performance ofcolleagues can be discussed with the GMCwithout necessarily revealing the identity ofthe doctor concerned

• The Public Interest Disclosure Act protectswhistle-blowers who disclose information ‘in good faith’ to a manager or employer





Throughout this tool kit a distinction has beenmade between ordinary health services provided toadults who may be vulnerable, the systemsdesigned to ensure the quality of those services, anddedicated adult protection services designed toprotect vulnerable adults from a risk of seriousabuse. In regard to the latter, all local authoritieshave dedicated services designed to protectvulnerable adults. Protection is delivered by a widerange of agencies and these can vary from authorityto authority.

Although all professionals have safeguardingresponsibilities in relation to adults in their care, the lead role in coordinating dedicated adultprotection services rests with the local authority.They coordinate the local safeguarding adultsboard, the multi-agency partnership reponsible forleading all safeguarding adults work. Each LA willhave local procedures for safeguarding adults,jointly agreed with their commissioning body andother local partners. Most will have a website withinformation about what do to if health professionalssuspect that a vulnerable adult is being abused,including a telephone number for direct referrals to local authority adult protection services. Thesafeguarding team will contact the referrer as soonas possible to discuss the concern and next steps.Referral forms can generally be downloaded fromtheir website.

CARD 14What is the structure of adult protection services?



In addition to these there may be other localagencies with which health professionals mightneed to work in relation to vulnerable adults. These can include, but are not limited to:

• Multi-agency risk assessment conference(MARAC). MARACs main focus of concern is toidentify individuals at risk of domestic violenceand to reduce the risk to victims.

• Multi-agency public protection arrangements(MAPPA). MAPPAs support the assessment andmanagement of violent and sexual offenders.


What is the structure of adult protection services?



British Medical Association and the Law Society(2010) Assessment of mental capacity. 3rd Edition.

General Medical Council (2009) Confidentiality.www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp

British Medical Association (2009) Confidentialityand disclosure of health information tool kit.www.bma.org.uk/ethics/confidentiality/confidentialitytoolkit.jsp

General Medical Council (2008) Consent: patients and doctors making decisions together.www.gmc-uk.org/guidance/ethical_guidance/consent_guidance_index.asp

British Medical Association (2009)Consent tool kit. 5th Edition.www.bma.org.uk/ethics/consent_and_capacity/consenttoolkit.jsp

HM Government (2008) Information sharing:guidance for managers and practitioners.www.dcsf.gov.uk/everychildmatters/resources-and-practice/IG00340/

CARD 15Guidance on protecting vulnerable adults



Department for Constitutional Affairs (2007)Mental Capacity Act 2005 Code of Practice.www.dca.gov.uk/legal-policy/mental-capacity/mca-cp.pdf

Mental Capacity Act 2005: Deprivation of libertysafeguards - Code of Practice to supplement themain Mental Capacity Act 2005 Code of Practice.www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085476

British Medical Association (2008) Mental Capacity Act tool kit.www.bma.org.uk/ethics/consent_and_capacity/mencaptoolkit.jsp

Department of Health (2000) No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protectvulnerable adults from abuse.www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008486

British Medical Association (Wiley) (2009) The ethicsof caring for older people. 2nd Edition.

Department of Health (2009) Safeguarding adults:report on the consultation on the review of ‘No Secrets’.


Guidance on protecting vulnerable adults



The law surrounding the protection of vulnerableadults is complex and wide-ranging. Key pieces oflegislation and statutory provisions in this area areoutlined below.

The NHS Constitution. The NHS constitution setsout a number of core values and patient rights,including the commitment to promote acomprehensive service available to all irrespective ofage, gender, disability, race, sexual orientation,religion or belief.

The Human Rights Act (1998). The Human RightsAct incorporates the rights set out in the EuropeanConvention on Human Rights. It embeds the valuesof fairness, non-discrimination and dignity intopublic services.

Equalities Act (2010). This links equality with dutiesto take positive action in relation to groups withdefined protected characteristics.

Disability and Discrimination Act (DDA 1995).Prohibits unlawful discrimination against disabledpeople in relation to access to health care.

Mental Health Act 1983 (Amended). Renders lawfulcompulsory treatment of mentally disorderedindividuals in certain circumstances and puts inplace statutory safeguards.

CARD 16Adult protection legislation



Mental Capacity Act 2005. Provides acomprehensive framework for making decisions onbehalf of adults lacking capacity.

Safeguarding Vulnerable Groups Act 2006. Providesa statutory framework for a vetting and barringscheme. It includes the development of a list ofindividuals barred from working with vulnerableadults. Individuals will be checked against the listbefore they will be able to start working withvulnerable adults.

Public Interest Disclosure Act 1998. Sets out aframework for public interest whistle-blowing that provides protection from reprisal for thewhistle-blower.


Adult protection legislation



British Medical AssociationMedical Ethics DepartmentBMA House, Tavistock Square, London, WC1H 9JP.Tel: 020 7383 6286; Fax: 020 7383 6233Web: www.bma.org.uk/ethics

Ministry of JusticeSelborne House, 54 Victoria StreetLondon, SW1E 6QW.Tel: 020 7210 8500Web: www.gsi.gov.uk

Department of HealthWellington House133-55 Waterloo Road, London, SE1 8UG.Tel: 020 7972 2000Web: www.doh.gov.uk

General Medical CouncilRegents Place, 350 Euston RoadLondon, NW1 3JN.Tel: 020 7189 5404; Fax: 020 7189 5401Web: www.gmc-uk.org

Office of the Public GuardianPO Box 15118BirminghamB16 6GX Tel: 0300 456 0300; Fax: 0870 739 5780 Web: www.publicguardian.gov.uk/

CARD 17Useful names and addresses



Independent Safeguarding AuthorityWeb: www.isa.homeoffice.gov.ukTel: 01325 953 795



British Medical AssociationBMA HouseTavistock SquareLondon, WC1H 9JPwww.bma.org.uk

BMA Ethics020 7383 [email protected]

October 2011


52140 safeguarding vulnerable adults print_ethics tool kit - bma

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