An excerpt from Chapter 6 of Social Work, Cats and Rocket Science.
‘Find me somebody to love’, a lyric from the band Queen. A lyric which has endured over 40 years. It conveys the aching, human desire for connection with another human. To love and be loved. There can be nothing greater. ‘Someone to safeguard’ was originally written as a reflective piece about social work we have been involved with where we made the person’s life worse. Our involvement focused on our own power, and not on listening to what Elsie really needed and not hearing and respecting what she was telling us about what was important to her. The blog about our experience supporting (or failing to support) Elsie has been our most successful ever and continues to be so, with around a hundred new people every month finding it. ‘Someone to safeguard’ asks us to consider what the cost is to the person when we allow the protection imperative to take hold of us. As professionals we have the power to displace people’s autonomy and impose a host of restrictions on their freedom. We have to be continually alert to this risk. The trick to being powerful is to know how and when to exercise that power and when to exercise restraint.
Someone to Safeguard
By ROB MITCHELL
The referral was pretty bog standard these days. The neighbours didn’t get Elsie’s permission for any of her details to be referred to social services. In truth, it had never crossed their minds they’d be asked for this. When pushed by the call centre about the issue of consent they said that they didn’t think they needed her consent and that this was a matter that ‘the Council must take seriously for everyone’s sake’. And then behind the thinly veiled threat to act, the neighbour stumbled upon four little words. Magic words. Words that suddenly change the meaning of everything and words that seemingly come with their own legislation, procedures, judges and juries. ‘It’s a safeguarding issue.’ And boom, there it is. Elsie, aged 87, never having failed to pay for council services or any other tax that funded the welfare state she chose not to use, was known. Consent overridden. Case opened. Within moments Elsie had an electronic file. Elsie had a reference number. And Elsie would receive an automated letter thanking her for contacting the Council and she would receive a call within the next seven days. All done within five short minutes from the start of the phone conversation. Within ten minutes Elsie was on a waiting list of other reference numbers waiting to be allocated to a social worker and sitting on the computer screen of the manager. Whether Elsie used services or not, from that moment on to the day of her death, nothing was clearer – Elsie was now a service user and there was a record to prove it. There was, as far as everyone was concerned, someone to safeguard.
The social workers went in twos to the address. No one was quite sure why. The referral mentioned that Elsie had got cats but there was not any belief that the cats were dangerous. Perhaps the second social worker was there because social workers love cats. The referral said the house was ‘dirty’, ‘things everywhere’, ‘cluttered’, ‘soiled pads in the garden’ and Elsie, although not seen for some weeks, was wholeheartedly felt by the neighbours to be dirty herself. ‘She’s self-neglecting.’
Having knocked at the door and got no response, the social workers pushed slightly at it and the door opened. A cat ran out and then back in again. No sign of Elsie in the hallway. The social workers called her name, walking gingerly through the hallway, past a sideboard with some framed pictures of a moustachioed man with ‘Geraldo, King of Swing’ emblazoned on them. Calling out her name and holding out their ID badges the social workers continued inward.
Elsie was in the kitchen. She smiled when she saw the social workers and beckoned them in still further. The social workers introduced themselves and whilst doing so Elsie kept on smiling before raising her hand as if to stop the second social worker saying their name. Elsie bent forward and placed her right ear up against what looked like an old radio from footage used to show listening to the broadcasts of Prime Minster Churchill telling them they wouldn’t surrender to the Nazis. Almost trance like Elsie’s smile remained fixed as she listened to the radio. Elsie probably listened to the radio for a full three minutes; to the social workers, observing the cats, the newspapers (one from May 1991 with a picture of Paul Gascoigne on it) and moving their feet on the sticky floor tiles, the three minutes felt like a lifetime.
When Elsie moved away from the radio, she asked the social workers, ‘Who are you again, love?’ The social workers explained who they were and said that they were there to see if ‘she was alright, you know, see how things are’. Elsie said she was fine and asked if the neighbour had asked for them to visit. ‘She’s lovely, like that. Looks out for me.’ Elsie explained that she had lived in the house all her life. Her parents, who she told the social workers ‘died recently, in 1971 and 1975’, had left the house to her. The social workers listened. They wanted to be respectful, they had questions of course (and they had lots of boxes to tick) and had already decided that things ‘weren’t right’ but they listened nevertheless. Halfway through talking Elsie’s eyes suddenly lit up. ‘John!’ she said. Within moments Elsie was back to the other side of the kitchen, head propped up against the radio, same expression on her face, which now to the social workers seemed almost rapturous. This time a longer wait. Five minutes. Elsie broke her concentration just once, to beckon the social workers to sit down. Neither did. Elsie didn’t notice or care.
Elsie said that John worked for the radio. He was in his late 40s and his job was a ‘broadcaster’ and that each day John ‘either announced the news or introduced big bands…sometimes both’. Elsie said that John was based in London and he still lived there. She said John sometimes slept in the radio station and sometimes broadcast during the night, but not usually. The social workers continued to listen but really wanted to talk about the cats and Elsie’s ‘daily routine and keeping clean’. More in an effort to wrap the conversation up about John and move on to the matter at hand, the self-neglect, one of the social workers asked a question. ‘John sounds lovely. Is he someone you have actually met and know?’ And with that the tone of the conversation changed. Elsie explained that John had spoken to her on the radio for over 60 years. He was her man friend and he was engaged to marry her. Her betrothed. John had promised Elsie that one day he would drive up from London in a white Bentley car and marry her. Their plan was to live in London and take Elsie away from all this, including the cats. Elsie said the social workers could have the cats if they wanted them. On walking to the door with the social workers Elsie thanked them for coming but they had to go now as John liked to ‘talk to her alone’. Elsie smiled as she shut the door behind them. The last thing the social workers heard Elsie say as the door closed was that John was her man and ‘was not for sharing, goodbye’.
The social workers weren’t inexperienced. One had just become an AMHP and the other had worked with older people for years. But as they walked to their car and drove back to the office the silence between them spoke more than any words of completed boxes on the safeguarding form. ‘What was all that about?’
Safeguarding referrals can be complex. The social workers knew that. They also knew that to ‘help’ Elsie they had to get to know her, build up trust, etc. So, the visits continued throughout the next week. On no occasion did it occur to the social workers to contact and arrange for an advocate to be there. Elsie was on her own. They were the professionals. They would be able to work out how to protect her. On each occasion Elsie spoke to the social workers but continued to ignore any questions about her health, her wellbeing, her cats and the state of her house. Most questions were met with ‘I know love. John will see to it.’ All conversations were interspersed with long periods of Elsie listening to the radio and smiling with occasional, knowing nods and some ‘yes love’ aimed at the social workers as if ‘John’ was further confirming plans that would need to be relayed to the social workers. For the most part, the social workers just heard the hiss of the untuned radio. For them there was no voice, no programme and without doubt there was no John. However, what bothered the social workers more than this was that there was no progress. No getting Elsie to see what state she was in. No getting Elsie to consent to sorting the house. No getting Elsie to realise the safeguarding issue. The self-neglect. The abuse.
Safeguarding doesn’t allow for stalemate or for someone to continue to be abused. It identifies the abuse and through a list of ‘outcomes’ it makes the social workers do something. For the social workers things needed fixing for Elsie. She had a choice. Either Elsie worked with them to ‘improve the situation’ or they would ‘refer to other agencies’. The case notes were clear. Elsie wouldn’t engage. She lacked capacity to make the decision. It was all in her best interests. The risks were unmanageable. The hoarding was a fire risk. The cats were underfed and the RSPCA would be cross. She needed safeguarding. If only she could see it! She was a problem. The problem needed fixing.
The social workers didn’t seek Elsie’s consent to refer to other professional agencies. In Elsie’s case, the ‘other agencies’ was the Community Mental Health Team. Elsie was visited by a community psychiatric nurse, who within hours visited again but this time with the psychiatrist. The social workers received a call: ‘How has this gone on so long?’ and ‘she’s in a terrible way, totally delusional, paranoid ideation’ and is ‘refusing all treatment because of this bloody John thing.’ The next call was to the AMHP. Pink papers in the bag, the Mental Health Act assessment was to take place that evening. No one thought to ring for an Independent Mental Health Advocate.
The ambulance couldn’t stay and eventually the police were called. Eighty-seven-year-old Elsie was escorted out of her property by two young police officers. One of the police officers had to switch the radio off during ‘the incident’ in the house. He at least had the foresight to give the radio to Elsie and reassured her that she ‘could hold it’ in the back of the car. It was the only bit of humanity Elsie ever witnessed either that evening or throughout her entire dealings with the ‘support’ agencies. Section 2 completed. Safeguarding outcome achieved. No more self-neglect. Someone had been safeguarded.
The first thing Elsie did on the ward was to find a plug for the radio. John was there. Reassuring her and helping her to stop crying. And that’s how things stayed for a number of weeks. The medication was taken, Elsie complied. The nurses moved on to the next person, Elsie listened to John. There were no more worries being reported about Elsie from the neighbours; the problem had been fixed. No more self-neglect; no more self to neglect. Elsie’s care plan said ‘needs all cares’. And that’s what she had. All cares attended to and a continued love affair with John.
The discharge planning never once considered home. Home was where the ‘multi-disciplinary team’ had felt that the bad thing happened. Home was where the cats had had to be removed and where the social workers had found Elsie’s love letters to John, which had ensured merriment on the ward due to the details that she went into about her feelings for him. The self-neglect would re-start at home and why risk things? Elsie was happy enough. Everything was fixed, apart from the John thing.
The care home never fully read the care plan about Elsie and the new social worker had not really written much up about John and what had happened at home. The radio didn’t go with Elsie to the care home. Elsie noticed this on her first day at the home. However instead of asking for the radio Elsie screamed for eight hours. In the end she was given medication. The care home didn’t call the hospital or speak to the psychiatrist about how distressed Elsie was. They made one phone call that day, which was to the social worker requesting more funding ‘due to the screaming’ and the impact this was having on other patients and staff.
Over the next three months Elsie moved into two different care homes and was returned to hospital following a fall. The radio was never switched back on.
Elsie died in a care home. It was four months, five days and six hours after the phone call from the neighbour.
In the main, people working in social care choose to do so because they want to be caring. But sometimes they do not support people to live the lives they want to lead. Perhaps it’s the surprisingly ordinary, possibly even dull nature of an ordinary life which leads to workers talking up worries. This can lead to a reframing of the ordinary act of asking another person for advice or help being turned around and becoming a problem to worry about, evidence of a dependency, a vulnerability the person needs protecting from.
Under intense pressure, good people can behave badly and poor organisational culture, usually hidden, can be exposed. In the midst of heightened anxiety, consideration of human rights, issues of consent and evidence of compassion can be the first things to go. Issues of choice and control, foremost in social work values, are at risk of being overridden and drowned out, replaced by the dehumanising language of the day: ‘patient’, ‘green cross’, ‘system block’, ‘the admission’, anything but people like Elsie being known by their name. Massive pressure can be transferred onto social workers, to shunt poorly people in need of care, compassion, support and access to therapy and nursing into care homes without any consideration of their capacity to be involved in decisions about how their care needs are met or their right to advocacy. As the case of London Borough of Hillingdon v Neary & Anor EWHC 1377 (2011) made clear, there is an obligation on you as a social worker to arrange for a suitable person to provide advocacy and safeguard the person’s rights where a person lacks the capacity to make the decision about moving into a care home for the purposes of care and treatment (Section 7 DoLS CoP).
To read on about the risks to good safeguarding practice, the case of Neary and Anor, and the rest of the gems of wisdom in Social Work, Cats and Rocket Science, buy the book! Out on September 19th.
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