The Safeguarding of Vulnerable Adults

29 September, 2015 / clinical
Nicholas Beacher, Petrina Sweeney, Gillian Howie

With each turn of the wheel of time the societal prejudices of the western world have slowly been eroded away. The ethos of pioneering equalitarians from Abraham Lincoln to Emmeline Pankhurst and Martin Luther King Jnr. has begun to resonate within our modern society to include vulnerable adults. As a privileged profession charged with the duty of caring for our patients, the holistic healthcare practice we undertake must endeavour to include safeguarding to protect and promote the welfare of vulnerable people.

The population of Scotland is ageing¹ and the number of people living with chronic medical conditions requiring treatment is rising.² This is in part due to medical advances, whilst environmental and social changes including improvements to living and working conditions have also contributed. Prolonged life can come at a cost as, with pre-term birth rates increasing, there is also a resultant poorer long-term health outlook for these individuals³ whilst those nearing death later in life are kept alive as a result of advanced medical intervention and current ethical beliefs. There is predicted to be a future explosion in the rate of dementia diagnoses burdening our already stretched health and social care systems.⁴ One to three people in every 100 suffer from bipolar disease or schizophrenia⁵ and while often they manage well with their condition they may go through periods of being acutely unwell. Collectively, these points illustrate the number of people within our society who are likely to be vulnerable at some stage in their life.

The neglect and abuse of many vulnerable people has been brought to light in multiple arenas including The Francis Report⁶ which has propelled the issue of adult protection into the foreground of healthcare. Appropriate multi-level measures must now be put in place to ensure these events are never allowed to happen again. This neglected issue must now become a priority for education and training to ensure the profession is able to perform its important role in safeguarding.

The neglect and abuse of many vulnerable people has been brought to light in multiple arenas

Safeguarding

Safeguarding involves a spectrum of measures with the purposes of:

Preventing harm and promoting welfare
Protecting individuals from harm

Safeguarding is more than an acute response to abuse or neglect. It incorporates anticipatory methods which actively seek to improve the welfare of individuals potentially at risk and prevent harm. This role is inclusive of the dental profession as many vulnerable adults experience poor oral health.⁷ Addressing oral health and its common risk factors in order to promote welfare requires input at all levels, from government policy to the essential practices of the clinician.

Protecting Vulnerable Groups Scotland

The Protection of Vulnerable Groups Scheme (PVG) came into existence in 2011.⁸ Its purpose was to improve the disclosure process to better protect both children and vulnerable adults. This measure, whilst not foolproof, is a worthwhile system and plays a vital role in preventing predators and those willing to abuse positions of trust from gaining access to vulnerable groups.

Application to the scheme is necessary for anyone who takes part in regulated work with children or protected adults. This includes dentists and dental care professionals. It is essential as employers, dental practitioners and health boards are actively involved in ensuring all employees are registered with the scheme.

For the purposes of PVG a protected adult is defined as an individual aged 16 or over who is provided with a type of care, support or welfare service and includes health services.

Application to the scheme instigates a search of registers to determine if the applicant is barred from working with vulnerable groups. Further vetting information is acquired from agencies to determine if the individual has any convictions, cautions, children’s hearing findings or if there is any other additional police information of interest. On receipt of this information, Disclosure Scotland decides on the suitability of the person to perform a role with at-risk groups. One of the benefits of this new disclosure system is that it will be continually updated. Thus any new information which may affect an individual’s position will be recorded and employers informed.

Adults with Incapacity Act

As users of health services we have an expectation that our choices in relation to the treatment we receive will be respected and honoured. Some people are unable to make decisions or communicate their decisions as a result of dementia, learning disability, acquired brain injury, mental illness or severe sensory impairment.

Yet, they still have a right to healthcare which ensures their wellbeing is protected. As a profession we must respect these basic human rights and utilise the existing processes which seek to protect vulnerable adults in relation to the provision of medical and dental treatment.

While this article cannot cover every aspect of the Adults with Incapacity Act nor its clinical applications, it must be touched upon to allow the reader to appreciate its role in the safeguarding of individuals who lack capacity.

The Adults with Incapacity Act was passed by Scottish Parliament with the intention of “safeguarding the welfare and managing the finances of adults who lack capacity due to mental disorder or inability to communicate due to a physical condition”.⁹ Part 5 of the Act specifically relates to medical treatment and research. It plays an essential role in the safeguarding of patients who lack the capacity to make decisions about healthcare and are reliant upon others to make a decision on their behalf.

For the purposes of the Act, incapacity is defined as being incapable of:

(a) Acting; or

(b) Making decisions; or

(d) Understanding decisions; or

(e) Retaining the memory of decisions,

It must be reinforced that capacity is not an all or nothing entity and each decision must be made on an individual basis. Equally, the stigmatisation of every person with a learning disability or other medical disease affecting cognitive ability being unable to consent is completely wrong; we must assume capacity until proven otherwise ensuring it is an active process. Each decision in relation to capacity is procedure specific. It may be that a patient is able to consent for certain procedures but not others – if a procedure were complex, or involved multiple risks, then a patient may not be able to consent despite the ability to do so for something more straightforward.

It is the responsibility of the dental practitioner to initially assess capacity. The process is not always black and white but can be established using a simple question and answer conversation. The patient must have the ability to understand what the procedure will involve, why it is required, the benefits and risks of that procedure, and the consequences of having no treatment. The patient must then be capable of making a decision based on the information they have been given, and communicate that decision (with aids if required). Asking your patient to explain to you in their own words their understanding of information you have given them about the procedure or treatment is one way of doing this. It is also worth remembering that some adults who lack capacity one day may not be in the same condition the next. Fluctuation in capacity necessitates continual reassessment.

If the person is deemed not to have capacity, and treatment is being considered, it is important that the principles of the Act are followed (Fig.1).

The next stage in the process would be for the practitioner to determine if the person without capacity has in place a welfare power of attorney, welfare guardian or person appointed by an intervention order (proxy) who should be consulted prior to the provision of any treatment. Where none of these individuals are in place a nearest relative should be consulted. Only if consent is given on the individual’s behalf should an Adults with Incapacity (Scotland) Act section 47 form be completed prior to the provision of treatment. An exception to this rule is the provision of essential emergency care, whereby as long as the principles are observed it may be correct to provide treatment without undertaking the capacity process described. These situations are few and far between in dentistry and should subsequent treatment be required an appropriate section 47 should be completed as required.

Only a few dental practitioners in Scotland have the training necessary to legally assess capacity and sign a section 47 form. However, every dentist must assess capacity before providing treatment. For the practitioner without this training there is a responsibility to contact the patient’s general medical practitioner, who is able to assess capacity in the eyes of the law and sign Section 47 forms. The dental practitioner can provide a treatment plan to the patient’s doctor listing the treatment intervention necessary and should the patient be deemed to lack capacity it can be signed off.

At present, dental treatment requires financial payment if an individual is not in receipt of exemption. A proxy involved in the consent process may also hold financial powers for an individual. If the proxy is refusing necessary treatment which is in the best interests of the person without capacity on financial grounds the intentions of that individual should be questioned. If the dental practitioner is certain that all the principles of the Act have been followed then it may be necessary to raise concerns with the local authority about the suitability of that legal guardian.

The importance of this Act to the safeguarding of vulnerable people should not be underestimated. Without education and training the profession cannot fully embrace the benefits of this Act and ensure the safety of those who lack capacity. There is a clear need for educators to disseminate their knowledge and skills at both undergraduate and postgraduate levels to improve the Profession’s use of the Act and ultimately the safety of our patients.

Until then there must be an opening of the channels of communication, to remove the barriers to care, between dental practitioners without the necessary training and general medical practitioners who can assess capacity on their behalf. Equally, dentists with expertise in this area are most numerous in the Public Dental Service and must be open to discussing such issues with colleagues as we throw away the compartmentalisation of services and work together as a team for the benefit of patients and practitioners alike.

The Adult Support and Protection (Scotland) Act 2007

The Adult Support and Protection (Scotland) Act 2007,¹⁰ is the core piece of legislation relating to the protection of potentially vulnerable adults in Scotland. Its role is to support and protect those members of society who are (or are likely to be) at risk of harm through their own conduct or that of others. The term harm when applied is specific to each individual but may include conduct which is physical or psychologically harmful, adversely affects property rights or interests and self-harm.

The Act defines adults at risk as persons aged 16 or over, who:

a) are unable to safeguard their own well-being, property, rights or other interests,

b) are at risk of harm

c) because they are affected by disability, mental disorder, illness or physical or mental infirmity, are vulnerable to being harmed than adults who are not so affected.

As a three-point test, all features must be present to say an adult is at risk. One of the fundamental themes of the Act is to ensure that where an individual is at risk any response should be multi-disciplinary necessitating the need for co-operation between bodies including health boards. Vulnerable individuals often interface with multiple services which may hold information of value in protecting that individual. When access to information is required during an investigation under the Act, the oral health practitioner has a duty to co-operate. In rarer instances the oral health physician may be asked to perform an examination and provide evidence in cases of neglect or physical harm which include traumatic injuries to the head and neck.

Table 1: Types of abuse and examples of possible indicators (adapted from Social Care Institute for
Excellence)¹²

Type of abuse	Definition	Example of possible indicators
Physical	The non-accidental infliction of physical force that results in bodily injury, pain or impairment	Multiple bruising and/or welts on the face, lips, mouth, torso, arms, back and thighs Cluster(s) of injuries or body marks including slap marks and finger marks
Sexual	The direct or indirect involvement of the adult at risk in sexual activity or relationships, which they: 1. Do not want or have not consented to 2. Cannot understand and lack the mental capacity to be able to give consent to 3.Have been coerced into because the other person is in a position of trust, power or authority (for example a care worker)	Pregnancy in a woman who is at risk or is unable to consent to sexual intercourse The uncharacteristic use of explicit sexual language Overt sexual behaviour/attitude Withdrawal (e.g. excessive fear/apprehension of, or withdrawal from, relationships) Reluctance of the adult at risk to be alone with an individual known to them
Psychological / Emotional	Actions or behaviour that have a harmful effect on the emotional health and/or development of an adult who is at risk	Alteration in the psychological state of the adult at risk (e.g. withdrawal or fear) Low self-esteem or unexplained paranoia Intimidation, use of threats, humiliation, bullying, swearing and other abuse
Financial	The use of a person’s property, assets, income, funds or any resources without their informed consent or authorisation.	Unexplained lack of money or inability to maintain lifestyle or withdrawal of funds from accounts, by any party The person managing the financial affairs of the adult at risk being evasive or uncooperative Abuse of position (e.g. exploitation of a person’s money or assets)
Neglect and Acts of Omission	The failure of any person, who has responsibility for the charge, care or custody of an adult at risk, to provide the amount and type of care that a reasonable person would be expected to provide. Neglect can be intentional or unintentional.	Poor physical environment or physical condition of the adult at risk (e.g. pressure sores or ulcers) Malnutrition or unexplained weight loss Untreated injuries and medical problems Poor personal hygiene or provision of reasonable personal care
Institutional	Is the mistreatment, abuse or neglect of an adult at risk by a regime or individuals.	Inadequate staffing levels or high turnover of staff People being hungry or dehydrated Poor standards of care with lack of personal clothing and possessions An ongoing absence of visitors Inappropriate use of restraints by staff Loss of or failure to provide dentures; failure to ensure that the person’s dentures are cleaned and reserved for their use

Protection of adults

The very essence of humanity must be questioned when we read of the events at Winterbourne View Hospital.¹¹ People with a learning disability and autism were cold-heartedly abused by those they were dependent upon for care. This report has been succeeded by further discoveries highlighting a shameful lack of care including the neglect witnessed at a Mid Staffordshire hospital. Francis, in his seminal report, gave a framework from which the NHS could move forward into a brighter dawn and regain the respect it once possessed as the shining beacon of the world’s healthcare services. As lessons are learned and grand plans are made to prevent further such instances, each and every dental practitioner has a role to play at the front line.

The dental practitioner may undertake domiciliary work visiting a patient’s own home, care home or supported housing whilst other dentists may work within a hospital setting. Privileged access to these environments should never be taken for granted as they provide a vantage point from which concerns about the safety of an individual or group may come to light. Equally, such signs may present in the patient who attends the surgery.

Empowerment is important, both for the adult at risk but also for the practitioner who has concerns. We must have the confidence to be able to report concerns to ensure safety and provide a vital link in the chain. We often interface with care environments more often than other healthcare colleagues and have built up trusting relationships with our patients for years such that they are able to disclose concerns to us.

The types of abuse and indicators vary but the dental practitioner must always remain vigilant and alert to potential signs. Table 1 provides some of the key types of abuse and the indicators which are most likely to be encountered.

Whilst being aware of the potential for abuse, we must appreciate that dental neglect, particularly in our older population, is complex. At face value there is no doubt that many older people resident in care homes have their oral health neglected and in no way can this be deemed acceptable. Yet, there are multiple barriers to the provision of oral care in this setting.

Work is currently being undertaken at The University of Glasgow Dental Hospital and School to gain a better understanding of these factors with the ultimate aim of improving oral health and quality of life for these people. At present, The Caring for Smiles Programme is being rolled out across the country as an intervention to improve the oral health for residents in care homes. The success of the programme is yet to be fully evaluated but the initial response appears promising, yet true success is dependent on high standards being maintained in the long term.

The Adult at Risk

The healthcare professional has a duty of care and a responsibility to report and record any concerns, suspicions or disclosures made by or about an adult who may need protection. Every dental practice and health board should have a protocol in place should such an event occur.

The role of the dental practitioner in adult protection is three-fold:

Recognise – Being able to identify an adult at risk
Respond – Manage the acute situation and inform other services as required
Record – Document and report in detail the information obtained and the actions taken

If concerns arise or a disclosure is made to the practitioner the following steps outline the initial management:

Remain calm and reassure the individual
Seek further information – obtaining who, what, when, where and why?
Record the information given
Inform person of the your next actions.

A non-judgemental approach is important while no attempt should be made to contact the alleged perpetrator nor should forensic evidence be removed. No promises should be made to the individual or assurances that you will keep any secrets.

Should there be concerns about the immediate safety of the individual the emergency services (police or ambulance services) should be contacted.

The capacity of the individual is not of primary importance in a life-or-limb situation and therefore, in an emergency, it is acceptable to contact services without the person’s consent. When contacting emergency help, the practitioner should never put themselves at risk and should always undertake appropriate risk assessment ensuring they are in a safe environment from which to communicate.

Responding to issues which are not of immediate urgency should involve a line manager in the first instance. This should facilitate discussion around the information available, the capacity of the person to consent and what action, if any, should be taken. If action is required contact with social services should be made within 24 hours.

If the individual lacks the capacity to consent then in those circumstances a referral to the local social work department should be undertaken. However, if the individual has capacity, the only instances where referral can be made without consent are if:

a person is, or may be, an adult at risk, and action needs to be taken in order to protect that person from harm;
there is an issue of public safety.
the person is/may be a service provider, and other people may also be at risk.

A referral should be made by telephone initially to the local social work department and followed up in writing by the practitioner. In such matters communication is essential, even if you are only seeking advice it is better to do so than neglect your duty. The process of actions undertaken by social services and associated agencies should an adult protection issue be raised are briefly outlined in Figure 2.

The recording of every aspect of adult protection is essential to ensure there is a contemporaneous record of events. The time taken to ensure these notes are of a high standard cannot be underplayed as they are important for services to establish if the adult is at risk but also for the dentist and their associated legal responsibilities.

Conclusion

The safeguarding of adults is a key area of practice for dental practitioners and is one of the few aspects of care which, if not acted upon correctly, could result in serious harm to an individual. Safeguarding affects many areas of practice which may not have been previously considered, including PVG and Adults with Incapacity. While this article provides an overview of safeguarding, further dedicated training is necessary for the dental community to ensure we are practicing safely and are able to promote welfare and protect vulnerable groups.

References:

1. Office for National Statistics. Population Ageing in the United Kingdom, its Constituent Countries and the European Union. March 2012. http://www.ons.gov.uk/ons/dcp171776_258607.pdf

2. The Scottish Government. Scotland’s National Dementia Strategy 2013-2016. http://www.gov.scot/Resource/0042/00423472.pdf

3. Boyle EM, Poulsen G, Field DJ, Kurinczuk JJ, Wolke D, Alfirevic Z, Quigley MA. Effects of gestational age at birth on health outcomes at 3 and 5 years of age: population based cohort study. BMJ. 2012 Mar 1;344:e896.

4. The Scottish Government .Living and Dying Well Living and Dying Well: A national action plan for palliative and end of life care in Scotland. 2008 .

5. Perala et al (2007) Lifetime prevalence of psychotic and bipolar I disorders in a general population Archives of general psychiatry, 64:19-28

6. Francis, R (Chair). Report of The Mid-Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013. http://www.midstaffspublicinquiry.com/report

7. Daly, B. Disability in Oral Health, Social Inequalities from evidence to action. ICOHIRP. Published: UCL. 2015

8. Disclosure Scotland. The Protection Vulnerable Groups Scheme. 2011. http://www.disclosurescotland.co.uk/disclosureinformation/pvgscheme.htm

9. Adults with Incapacity (Scotland) Act, 2000. http://www.legislation.gov.uk/asp/2000/4/contents

10. The Adult Support and Protection Act (Scotland), 2007. http://www.legislation.gov.uk/asp/2007/10/contents

11. The Department of Health, England. Transforming Care: A National Response to Winterbourne View Hospital. https://www.gov.uk/…/final-report.pdf

12. Social Care Institute for Excellence. Identifying the Signs of Abuse. http://www.scie.org.uk/…/Identifying-the-signs-of-abuse.pdf

About the Authors

Nicholas G. Beacher, BDS, MFDS (RCPSG) Clinical Lecturer and Honorary StR in Special Care Dentistry. University of Glasgow Dental School, School of Medicine, College of Medical, Veterinary & Life Sciences, Glasgow, UK

E-mail: Nicholas.Beacher@glasgow.ac.uk

M. Petrina. Sweeney, BDS, MSC(Med Sci), DDS, FDS (RCPSG) Senior Clinical Lecturer and Honorary Consultant in Special Care Dentistry. University of Glasgow Dental School, School of Medicine, College of Medical, Veterinary & Life Sciences, Glasgow, UK

Gillian C. Howie, BDS Longitudinal Dental Foundation Trainee, NHS Lothian.

Verifiable CPD Questions

Verifiable CPD questions

Aims and objectives

To gain an understanding of and be able to implement appropriate safeguarding practice for vulnerable adults
To review the legislation and requirements related to the safeguarding of vulnerable adults
To further develop the dental professional’s understanding of and ability to assess capacity and appropriately manage the patient who lacks capacity to ensure they are protected
To understand the importance of health promotion and prevention of harm in safeguarding
To recognise and appropriately manage abuse and neglect in vulnerable adults

Learning outcomes

The dentist should be able to describe the legislation related to safeguarding
The dentist should be able to understand the principles of the Adults with Incapacity Act, assess capacity and appropriately manage their patients who lack capacity
The dentist should be able to identify an adult at risk of/or is experiencing neglect or abuse and take appropriate actions