Mrs Murray is 76 years old and has been chair-bound and aphasic since having a stroke four years ago. She lives with her divorced daughter.
For the past 18 months, the daughter has refused social services involvement and respite care, and will not let the district nurses visit, although she accepts supplies of incontinence pads.
When I visited last week, Mrs Murray looked thin and unhappy, and I noticed bruising on her upper arms and chest. I checked her blood clotting function and it was normal. The next day I saw her daughter coming out of the bank hand-in-hand with a man who has a long criminal record. I contacted social services with my concerns, but they said that there was nothing they could do if the daughter would not give them access. I am still not happy. What should I do?
A GP'S VIEW - DR PETER ILVES, A GP IN SOUTH-WEST LONDON
You must have been thinking that there was active abuse with physical harm and/or neglect occurring for you to have contacted social services.
An alternative is that Mrs Murray's daughter is delivering care to her mother in the best way she knows how and she is too proud to accept help.
However, with the observational evidence available at this stage there remains a duty of care to the mother. The daughter's relationship with a known criminal, although notable, should not be used to jump to a conclusion.
As you have managed to gain access to the home, there might still be a modicum of trust in your services. You should collate all the information available from the district nurses and any other community services that have been involved to date. You should also urge social services to attempt access to the home.
Failing this, and particularly if there is unwillingness or downright refusal by the daughter to allow any further contact, you should discuss the matter with the police.
Alternatively, you could contact the local domestic violence unit and thus ensure legal access to the mother and the home on the grounds that abuse and neglect are a possibility. In these cases it is better to do something than nothing.
A MEDICO-LEGAL OPINION - DR RICHARD STACEY, MEDICO-LEGAL ADVISER, MEDICAL PROTECTION SOCIETY
This is a difficult scenario where, although it is not explicitly stated, there appears to have been a change over the past 18 months in that the daughter is refusing additional support services.
You are concerned that Mrs Murray is at best not being cared for properly and at worst being abused or suffering from another pathology.
Given that your duty of care is to Mrs Murray, it might be worthwhile seeing her on your own, if possible, in order to try to establish her capacity and see if she can communicate her wishes and/or concerns to you. If, however, Mrs Murray is not in a position to give you her view, either through lack of capacity or pure practicalities, then you must try to act in her best interests.
I would suggest that you obtain a second opinion, either from a colleague, a home visit from a consultant geriatrician or, ideally, by admission for assessment, probably in association with a local specialist in medicine for the elderly.
I think it is also important that you explore with the patient, and certainly with her daughter, further input from the district nurses and other members of the primary care team. If the daughter refuses to allow such input and you have continued concerns, then you must insist social services assess the situation.
A PATIENT'S VIEW - TREVOR SEEMANN, A MEMBER OF THE PATIENT PARTNERSHIP GROUP
It seems that Mrs Murray's medical conditions make any comprehensible communication with her virtually impossible.
I would like to know if you have had any opportunity to discuss Mrs Murray's health with her daughter and, if the daughter is also your patient, whether there has been any impact of stress on her health.
However, the bruises are an incontrovertible fact and, taken with the other indicators, you do have a duty to act on any concern of abuse. Your first priority should always be to ensure the safety and protection of vulnerable adults.
I believe you were correct to report this case to social services. Their lack of action surprises me as I thought that their duty was to give any concern of abuse high priority. I would be inclined to remind them of their responsibilities.
You could find it beneficial to contact Action on Elder Abuse. This organisation has been very effective in raising awareness of elder abuse and in assisting people in dealing with its realities. They also run a highly effective telephone lifeline service.