Thursday 8 November 2007


I've a gentleman with dementia. Properly, he's got ICD-10 F00.12 Alzheimer's disease, late onset, severe.

He couldn't manage at home, had support, progressed, had respite care and now is in permanent care within an EMI Residential Home.

He is happy.

Within the meaning of the Mental Capacity Act 2005, with regard to decisions on his placement and future care, he's an incapacitated adult.

I have seen him many times at this care home, he always has been settled, cared for and content. My nursing colleagues see him and find him equally well. An Occupational Therapist assessed him. A Physiotherapist has looked at his mobility of late, as it's deteriorated. A Dietician saw him 2 weeks ago to give advice on dietetic input. A Modern Matron from the PCT saw him recently to look at pressure care and prevention of sacral sores (which he's never had, but he's increasingly sedentary). His GP reviews him episodically to consider physical health concerns (episodic joint pain and cramps, mostly). An external Independent Mental Capacity Advocate (IMCA) reviewed care and felt it would be in his best interests to remain in that care home receiving the care he was receiving.

His mental health has been stable, he's on no medication at all and hasn't needed any.

The EMI Residential care home has had two unannounced visits from the regulatory body CSCI this year and found to be absolutely fine. With so many professionals going in, often unannounced when we're in the area, we've also found everything to be fine. Scrutiny of the care plans show care to be fine. No families or residents have complaints/issues.

So, my patient's in a good care home receiving good care that oodles of professionals over a many months consistently see to be the case.

The home feels they may have to serve notice on him. They do not want to, they feel great warmth for him and enjoy caring for him (which they do well). They're very patient centred, if he has sleep disruption (as he does) and wants a bath at 2.00am (as he did) then he has one. When he was offered food at meal times but declined then was hungry later on he ate pizza just before midnight. They're sensitive to his care and are very accomodating.

My patient has 2 daughters. One thinks he's getting great care. She told me today that every time she visits dad,"He's happy, and that's the most important thing." She thinks he's well cared for. She wants him to stay there.

Another daughter wants him moved. She has no formal mental illness diagnosed but in the couple years I've (endlessly) seen her I'd wager good coin she's got a personality disorder. Maybe this is kinder than her sister who says she's a "vile woman" who's been "thinking of herself all her life" and "is wicked."

This daughter concedes that all major care is delivered (he is fed, washed, toileted, mobilised and so on) but that the quality of care falls short of what she wants. So she harasses staff. Daily. And generates prolific pages of complaints. Endlessly.

Protection of Vulnerable Adults (POVA) was initiated but hasn't had helpful outcomes since the daughter's malign influence hasn't been sufficient to enable police or agencies to be involved. The POVA meeting recognised she lied and mislead people and misrepresented people's views.

My patient's happy. He's happy to stay there. The care home want him to stay there. The professionals feel he's best placed there. The independent IMCA feels he should stay there. One daughter wants him to stay there. The other daughter (who's the nearest relative) makes it untenable for the staff to look after him (and has moved him 3 times already).

The evidence base is that if he were to move at this stage in his illness he'll be dead within 12 months.

Is there any lawful way we can prevent the nearest relative from visiting her father when she's impacting so negatively on the home that her father's best interests are not being served?


Elaine said...

....short of locking her up...

R said...

Strewth. Good luck with that one.

I would imagine that it would be possible to obtain an injunction against her by court order, or insist on all communications from her being passed through a third party... the father's legal advocate or the care home staff could instigate this, possibly both.

It sounds like a wonderful home, and I wish the father many more happy years there.

Kelly said...

Can she not be displaced as nearest relative? That way maybe her endless complaints etc could be filed in the bin and she could be prevented from visiting as she causes unnecessary disruption to the running of the home and to her father's needs.

I guess in an ideal world this could happen but in reality it isn't so simple. Tis a truly sad situation :-(

Vicky Pollard said...

You've got excellent grounds for displacing her as nearest relative. I would look into that with all haste.

PhD scientist said...

Yes... surely there must be a legal mechanism for the other sister to petition to become the guardian / "nearest relative" of record based on the Evil Sister's behaviour, which is clearly not in the patient's interest?

The Shrink said...

She's thwarted care plans (e.g. not letting peope feed him, mobilising him on her own when he drops and needs 2 to mobilise safely), lied (e.g. saying other sister wants him moved when she said the opposite) sat saying things are broken and inappropriate when they're not (e.g. 'phoned the CPN saying his sensor on the mattress was broken and beeping then the matron walked in to see her bouncing her hand up and down on it to activate it when it was fine) and been far more intimate than anyone we know is with their father (but police feel there's not yet quite enough evidence of incestuous behaviour to act yet).

Problem is, "nearest relative" is a term that's used with meaning in the Mental Health Act 1983 but he's an informal patient in a care home. A social worker looked at having her displaced only to be told, what would that do for our patient's care, how would it change his care plan? And as an informal patient, it really shouldn't.

I'm scared since she's packed his stuff and moved him from a home all in one afternoon before, so she's likely to just "abduct" him in a similar fashion again if she can.

It seems harsh to detain him, and to date social workers (acting in keeping with the Code of Practice to manage him in the least restrictive setting) haven't entertained thoughts to detain him since he's not at immediate risk to health or safety of self/others and is happy to stay informally with no active attempts to leave, ever. thus, section 7 (Guardianship) seems tricky to implement. But I asked for it since section 7 would mean he's got to live there, and that's that.

Anonymous said...

I wish I had an answer, because your telling of this history is one of the most positive Ive heard.. this gentleman is getting 1st rate care.

Anyways get her (bad sister)assessed... fit for making decisions, turn the table on her ?...hmm some ideas

Or change his status ? ( I dont know the laws in the States... but this sounds like thinking outside the box)

Ive seen stuff thwarted, but only because the health care providers didn't know their rights and are scared to push them.

Hmmm.. if section 7 was good, and you were really comfortable with his care there, they want him, the other sis wants him, he wants it & there is room to move to a LTC or CCH if need be... maybe its worth it... and way do design the move to higher care later on

just thoughts