Chapter 2 Safeguarding vulnerable adults Summarised from The Management of Abuse: A Resource Manual For The Dental Team, By Elizabeth Bower et al.
There has been a growing awareness in recent years of the abuse of vulnerable adults, perhaps as a result of the similar exposure given to child abuse and corresponding child protection. Who is a vulnerable adult? A vulnerable adult is defined as a person aged 18 or over “who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation” (Department of Health, 2000). This where community care services includes all care services provided in any setting or context. The weakness of this definition rests in its exclusion of a number of individuals who have mild or moderate learning disabilities and who manage their lives relatively independently but remain very vulnerable to exploitation within their local communities.
Defining abuse of vulnerable adults Abuse is defined as “the violation of an individual’s human and civil rights by any other person or persons”. Like the abuse of children, it can take the form of a single or repeated harmful act, or a failure to prevent harm. Abuse can be physical, sexual, psychological, or financial, and/or take the form of neglect. Examples of abuse are given in Table 1. The definition also encompasses discrimination, particularly in regards to the person’s age or disability, and institutional abuse, where the ethos, culture, management, and organisation of an institution lead to abusive practices at a corporate level. Examples of institutional abuse include poor care standards, inadequate staffing, a lack of responses to complex needs, rigid routines, a lack of training on antidiscriminatory practice, and an insufficient knowledge base within the service. Abuse can occur over a long period, such as in ongoing family problems where domestic violence between spouses or generations is a long term feature of family life. Alternatively, it may be situational, where abuse arises in a previously satisfactory relationship due to deterioration in the health or behaviour of the vulnerable adult or
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deterioration in the health and social situation of the carer. Difficulties due to debt, alcohol or mental health problems in the carer may contribute to the neglect of the vulnerable adult. Abuse may also be opportunistic, such as theft occurring because money has been left around. Serial abuse, in which the perpetrator seeks out and ‘grooms’ vulnerable adults, usually involves financial or sexual abuse. It is important to note that the definition does not include self-neglect, which usually occurs due to the inability of an independently living, mentally competent elderly or disabled person to meet the needs necessary for their own physical and mental wellbeing. Such an adult is able to refuse care unless they are at severe risk of harm.
Who abuses vulnerable adults and in what circumstances? Vulnerable adults are usually abused by people with whom they are in regular contact rather than strangers. Such people can be relatives, professional staff, paid care workers, volunteers, other service users, neighbours, and friends. It is estimated that two-thirds of abused older people are harmed by family members who act as carers. Sexual abuse by other service users accounts for up to half of the reported incidents of sexual abuse in adults with learning disabilities. Abuse can take place in any context, including places previously assumed to be safe. It may occur in a vulnerable adult’s home, whether the adult is living alone or with a relative. It can also occur within residential or day care settings, nursing homes, hospitals and in public places (Department of Health, 2000).
Barriers to reporting abuse Vulnerable adults are often reluctant to report abuse. A fear of retaliation and escalation of the abuse may prevent disclosure. Victims may be ashamed and embarrassed to admit that they are being abused or even feel that they deserve the abuse. They may fear that if the abuser is removed or punished, no one will take care of them. Many vulnerable adults, particularly elderly people, are socially isolated and powerless. The only person in contact with the victim may be the abuser on whom the victim is totally dependent for personal care, making it difficult for the vulnerable adult to access support services. Severe cognitive and physical disabilities may prevent the victim from communicating the abuse to others. Vulnerable adults with severe cognitive disabilities may not know that they are being abused. Table 2 lists the potential indicators of abuse that the dental team might see in the domiciliary setting.
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The management of the abuse of vulnerable adults The management of the abuse of vulnerable adults revolves around early detection, appropriate referral, and provision of ongoing treatment and support. It is the responsibility of the dentist who has examined the vulnerable adult to ensure that appropriate action is taken with the help of team members. It is important to focus on the needs of the vulnerable adult, rather than the needs of the carer, related family problems and potential solutions to those problems. Whilst the other issues may have to be addressed by various agencies in the medium and long term, the dental team’s responsibility is always to the health and wellbeing of the vulnerable adult. Whilst it is important to be sensitive to the cultural background of the patient in managing the case, there are no circumstances in which the abuse of vulnerable adults is acceptable. The Department of Health state that cultural factors cannot be used as justification for abuse, and that anxiety about being accused of racism should not prevent a dentists and the dental team from taking action to safeguard the welfare of a patient. This will include:
• Recognising the signs of abuse
• Respecting what the victim says and being sympathetic
• Providing treatment for oro-facial injuries and referral for treatment if necessary
• Assessment of risk to victim
• Making appropriate referrals
• Giving helpful information not advice
• Keeping comprehensive records
• Supporting and following-up
Further reading Department of Health (2000). No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. London, HMSO. Department of Health (2001) Valuing People: a New Strategy for Learning Disability for the 21st Century. London, HMSO.
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Table 1 Examples of abuse of vulnerable adults
• Failing to arrange for a dentist to examine an elderly person with broken or ill-
• Leaving a housebound person alone for days on end
• Hitting a vulnerable adult when s/he doesn’t do what you ask her/him to
• Opportunistic theft of an elderly person’s purse whilst providing care in
fitting dentures
the home
• Failing to ensure a vulnerable person is kept clean
• Swearing at an elderly relative when he/she asks for help to go to the toilet
• Preventing an elderly relative from seeing her friends
• Coercing an elderly person into changing his/her will
• Failing to help a physically disabled person to clean their teeth
Table 2 Potential indicators of abuse in the general dental practice or domiciliary visit setting. • Appointments often missed • Difficulties in arranging appointments/frequent cancellations • Poor compliance with treatment regimens • Injuries are inconsistent with explanation given • Explanations of injuries are conflicting or vague • Delay in presentation for treatment of dental problems/injuries
Patient • Appears passive or afraid of carer • Remains quiet while carer responds to questions • Withdrawn/detached • Anxious • Poor eye contact
Carer • Attitudes of indifference or anger to the vulnerable adult • Ignores vulnerable adult • Doesn’t allow vulnerable adult to speak for him/herself • Inappropriate displays of affection by caregiver • Blames vulnerable adult (e.g. for bad behaviour, incontinence, or forgetfulness)
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