Adult abuse is defined as a single or repeated act or lack of appropriate actions, occurring within any relationship where there is an expectation of trust, which causes harm or distress to a vulnerable person.
Safeguarding adults is about protecting those at risk of harm. It involves identifying abuse and acting whenever someone is being harmed. The Department of Health defines a vulnerable adult as a person aged 18 years 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.
Safeguarding is the responsibility of everyone, including all health workers. Anyone can raise a safeguarding concern. All allegations of abuse need to be taken seriously whether made by a patient, carer, healthcare professional, or other service provider. Any concerns reported to a healthcare worker should be followed up by inquiries about the nature and circumstances of the allegation. It is very important to ask about the safety of the person when the allegation is raised and any support the person is already receiving.
Abuse of adults can take place in various environments, including their homes, hospitals, assisted living arrangements and nursing homes.
- Because of issues about identification, stigma, and institutional systems, concerns about allegations of abuse are known to be under-reported. Only a small proportion of adult abuse is currently detected.
- People with health needs make up a large proportion of the referrals for adult abuse, including people with physical disabilites, mental health difficulties, learning disabilities and people with substance misuse.
- One systematic review of studies of elder abuse has found that about a quarter of vulnerable elderly people are at risk of abuse, with only a small proportion of these currently detected.
- In the UK a cross-sectional survey of family carers for people with dementia found around a third reported important levels of abuse.
Risk factors for abuse
- Lack of mental capacity.
- Increasing age.
- Being physically dependent on others.
- Low self-esteem.
- Previous history of abuse.
- Negative experiences of disclosing abuse.
- Social isolation.
- Lack of access to health and social services or high-quality information.
Main types of abuse
- Physical abuse may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
- Sexual abuse.
- Psychological abuse, including emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment, verbal abuse.
- Financial or material abuse, including theft, fraud, exploitation, pressure in connection with wills, property, inheritance, or financial transactions, misuse or misappropriation of property, possessions, or benefits.
- Neglect and acts of omission, including ignoring medical or physical care needs, failure to provide access to appropriate health, social care, or educational services, withholding medication, adequate nutrition, and heating.
- Discriminatory abuse, including racist, sexist or abuse based on a person’s disability.
Other categories of abuse as listed in the Care Act (2014) include:
- Domestic abuse - including psychological, physical, sexual, financial, emotional abuse, so-called ‘honour’-based violence.
- Modern slavery - includes slavery, human trafficking, and forced labour and domestic servitude.
- Organisational abuse - including neglect and poor care practice within an institution or specific care setting such as a hospital or care home.
- Self-neglect - includes a wide range of behaviour neglecting to care for personal hygiene, health or surroundings and includes behaviour such as hoarding.
Safeguarding vulnerable adults
The primary aim of safeguarding is to keep an individual safe and prevent further abuse from occurring. The Department of Health for England and Wales states six principles of good safeguarding practice:
- Empowerment: presumption of person-led decisions and informed consent.
- Protection: support and representation for those in greatest need.
- Prevention: it is better to take action before harm occurs.
- Proportionality: proportionate and least intrusive response appropriate to the risk presented.
- Partnership: local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse.
- Accountability: accountability and transparency in delivering safeguarding.
Interventions should be aimed at making life easier, such as providing mobility aids or treating physical and mental illness to help individuals maintain independence. Such actions reduce barriers to patients making their own choices and reduce their reliance on others.
In England and Wales, the Care Act 2014 sets out a legal framework for how local authorities and other parts of the health and care system should protect adults at risk of abuse or neglect.
In Scotland, the Adult Support and Protection (Scotland) Act 2007 describes the function of adult protection committees and sets out the requirements for multi-agency working. For Northern Ireland, procedures are described by the Department of Health, Social Services and Public Safety.
Serious case reviews often identify lack of information sharing between agencies as an issue. Doctors must therefore ensure that they share information about their concerns while respecting an individual's right to confidentiality.
If a person retains capacity under the Mental Capacity Act (2005), doctors have no legal authority to make best interest decisions on their behalf. However, balancing a respect for the choices of adults who retain capacity, against the desire to promote their welfare, can present genuine dilemmas.
Patients and carers need to be informed that their right to confidentiality is not absolute and that information may be shared in some circumstances where there is a significant risk of harm to others and in cases where it is in the public interest.
Potential or actual abuse is not always obvious and often goes unnoticed for long periods of time. The wider context of the person's life, such as family support, social networks and culture, must be considered.
When assessing abuse, doctors should seek to establish the circumstances surrounding the concerns. The abused person may have difficulty in reporting abuse. The person may be frightened that the abuse will become worse if it is revealed and may be worried that it may leave them even more vulnerable.
An abused adult may seem withdrawn, unkempt, lose weight, and have poor skin care. This may be due to illness or may be due to neglect. It is important to establish whether the person can reach a drink, can feed him or herself and is able to ask for help.
Unexplained injuries may be discovered on examination or reported. These should be followed up and the cause of injury clarified to understand whether abuse may have occurred.
The distress caused by abuse may cause the person to have behavioural change, such as becoming withdrawn, aggressive, irritable or emotionally labile.
Factors to consider when inquiring about abuse include:
- The vulnerability of the individual.
- The nature and extent of the abuse.
- The length of time it has been occurring.
- The impact on the individual.
- The risk of repeated or increasingly serious acts.
Managing the conversation with an individual when abuse is suspected:
- Make sure the alleged abuser is not present.
- It may be helpful for the potentially abused person to be accompanied by a trusted person.
- Ensure they have appropriate support to express themselves clearly, including an interpreter if necessary.
- Be clear what will happen with the information that the victim discloses.
- Establish the facts of the allegation of abuse and acknowledge the impact of the abuse on the victim.
Making sure the potential abuser is not present when asking about concerns should help the abused person to talk openly. Being accompanied by a trusted person may help a vulnerable adult feel supported and more confident in sharing information.
In all cases of possible abuse, doctors must assess the risk to the individuals and whether there is a need for immediate intervention. Circumstances that would require immediate action would include when someone’s life is in immediate danger or there is significant risk of serious harm. Then you should ring 999/112/911.
Doctors assessing risk should also think about any risk posed to adults at risk other than the patient, to members of the public, or to children.
All concerns regarding significant risk of abuse should be reported to the local services responsible for safeguarding. If unsure, doctors should always make a referral for investigation. All responses depend on the circumstances of the case.
In England and Wales the local services responsible for safeguarding are the local safeguarding investigating team. The lead agency for safeguarding is the local authority. The local authority is now able to delegate this authority to other statutory organisations such as NHS partnerships.
Doctors need to be aware of how and where to report in their local area. Most safeguarding boards have contact details and information on their websites.
Further reading and references
Domestic violence and abuse: how health services, social care and the organisations they work with can respond effectively; NICE Public Health Guidance (February 2014)
Safeguarding adults; Social Care Institute for Excellence
Adult Safeguarding Network; NHS England
Safeguarding vulnerable adults – a tool kit for general practitioners; British Medical Association, October 2011
Reader TW, Gillespie A; Patient neglect in healthcare institutions: a systematic review and conceptual model. BMC Health Serv Res. 2013 Apr 3013:156. doi: 10.1186/1472-6963-13-156.
Safeguarding Vulnerable Older People (Abuse and Neglect) - Good Practice Guide; British Geriatrics Society (2009)
Boland B, Burnage J, Chowhan H; Safeguarding adults at risk of harm. BMJ. 2013 May 14346:f2716. doi: 10.1136/bmj.f2716.
Lachs MS, Pillemer K; Elder abuse. Lancet. 2004 Oct 2-8364(9441):1263-72.
Cooper C, Selwood A, Livingston G; The prevalence of elder abuse and neglect: a systematic review. Age Ageing. 2008 Mar37(2):151-60. doi: 10.1093/ageing/afm194.
Gibson J, Nicol B, Ronayne E, et al; Safeguarding adults in primary care: making a safeguarding adults referral. Br J Gen Pract. 2016 Jun66(647):e454-6. doi: 10.3399/bjgp16X685525.
Vulnerable adults and confidentiality; British Medical Association (BMA)
Safeguarding Adults: The role of health services; Dept of Health, March 2011