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.
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.
Evidence of any one indicator from the following lists should not be taken on its own as proof that abuse is occurring. However, it should alert practitioners to make further assessments and to consider other associated factors. The lists of possible indicators and examples of behaviour are not exhaustive and people may be subject to a number of abuse types at the same time.
Types of physical abuse
- Assault, hitting, slapping, punching, kicking, hair-pulling, biting, pushing
- Rough handling
- Scalding and burning
- Physical punishments
- Inappropriate or unlawful use of restraint
- Making someone purposefully uncomfortable (e.g. opening a window and removing blankets)
- Involuntary isolation or confinement
- Misuse of medication (e.g. over-sedation)
- Forcible feeding or withholding food
- Unauthorised restraint, restricting movement (e.g. tying someone to a chair)
Possible indicators of physical abuse
- No explanation for injuries or inconsistency with the account of what happened
- Injuries are inconsistent with the person’s lifestyle
- Bruising, cuts, welts, burns and/or marks on the body or loss of hair in clumps
- Frequent injuries
- Unexplained falls
- Subdued or changed behaviour in the presence of a particular person
- Signs of malnutrition
- Failure to seek medical treatment or frequent changes of GP
Domestic violence or abuse
Types of domestic violence or abuse
Domestic violence or abuse can be characterised by any of the indicators of abuse outlined in this briefing relating to:
Domestic violence and abuse includes any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been, intimate partners or family members regardless of gender or sexuality. It also includes so called ‘honour’ -based violence, female genital mutilation and forced marriage.
Coercive or controlling behaviour is a core part of domestic violence. Coercive behaviour can include:
- acts of assault, threats, humiliation and intimidation
- harming, punishing, or frightening the person
- isolating the person from sources of support
- exploitation of resources or money
- preventing the person from escaping abuse
- regulating everyday behaviour.
Possible indicators of domestic violence or abuse
- Low self-esteem
- Feeling that the abuse is their fault when it is not
- Physical evidence of violence such as bruising, cuts, broken bones
- Verbal abuse and humiliation in front of others
- Fear of outside intervention
- Damage to home or property
- Isolation – not seeing friends and family
- Limited access to money
Types of sexual abuse
- Rape, attempted rape or sexual assault
- Inappropriate touch anywhere
- Non- consensual masturbation of either or both persons
- Non- consensual sexual penetration or attempted penetration of the vagina, anus or mouth
- Any sexual activity that the person lacks the capacity to consent to
- Inappropriate looking, sexual teasing or innuendo or sexual harassment
- Sexual photography or forced use of pornography or witnessing of sexual acts
- Indecent exposure
Possible indicators of sexual abuse
- Bruising, particularly to the thighs, buttocks and upper arms and marks on the neck
- Torn, stained or bloody underclothing
- Bleeding, pain or itching in the genital area
- Unusual difficulty in walking or sitting
- Foreign bodies in genital or rectal openings
- Infections, unexplained genital discharge, or sexually transmitted diseases
- Pregnancy in a woman who is unable to consent to sexual intercourse
- The uncharacteristic use of explicit sexual language or significant changes in sexual behaviour or attitude
- Incontinence not related to any medical diagnosis
- Poor concentration, withdrawal, sleep disturbance
- Excessive fear/apprehension of, or withdrawal from, relationships
- Fear of receiving help with personal care
- Reluctance to be alone with a particular person
Psychological or emotional abuse
Types of psychological or emotional abuse
- Enforced social isolation – preventing someone accessing services, educational and social opportunities and seeing friends
- Removing mobility or communication aids or intentionally leaving someone unattended when they need assistance
- Preventing someone from meeting their religious and cultural needs
- Preventing the expression of choice and opinion
- Failure to respect privacy
- Preventing stimulation, meaningful occupation or activities
- Intimidation, coercion, harassment, use of threats, humiliation, bullying, swearing or verbal abuse
- Addressing a person in a patronising or infantilising way
- Threats of harm or abandonment
- Cyber bullying
Possible indicators of psychological or emotional abuse
- An air of silence when a particular person is present
- Withdrawal or change in the psychological state of the person
- Low self-esteem
- Uncooperative and aggressive behaviour
- A change of appetite, weight loss/gain
- Signs of distress: tearfulness, anger
- Apparent false claims, by someone involved with the person, to attract unnecessary treatment
Financial or material abuse
Types of financial or material abuse
- Theft of money or possessions
- Fraud, scamming
- Preventing a person from accessing their own money, benefits or assets
- Employees taking a loan from a person using the service
- Undue pressure, duress, threat or undue influence put on the person in connection with loans, wills, property, inheritance or financial transactions
- Arranging less care than is needed to save money to maximise inheritance
- Denying assistance to manage/monitor financial affairs
- Denying assistance to access benefits
- Misuse of personal allowance in a care home
- Misuse of benefits or direct payments in a family home
- Someone moving into a person’s home and living rent free without agreement or under duress
- False representation, using another person’s bank account, cards or documents
- Exploitation of a person’s money or assets, e.g. unauthorised use of a car
- Misuse of a power of attorney, deputy, appointeeship or other legal authority
- Rogue trading – eg. unnecessary or overpriced property repairs and failure to carry out agreed repairs or poor workmanship
Possible indicators of financial or material abuse
- Missing personal possessions
- Unexplained lack of money or inability to maintain lifestyle
- Unexplained withdrawal of funds from accounts
- Power of attorney or lasting power of attorney (LPA) being obtained after the person has ceased to have mental capacity
- Failure to register an LPA after the person has ceased to have mental capacity to manage their finances, so that it appears that they are continuing to do so
- The person allocated to manage financial affairs is evasive or uncooperative
- The family or others show unusual interest in the assets of the person
- Signs of financial hardship in cases where the person’s financial affairs are being managed by a court appointed deputy, attorney or LPA
- Recent changes in deeds or title to property
- Rent arrears and eviction notices
- A lack of clear financial accounts held by a care home or service
- Failure to provide receipts for shopping or other financial transactions carried out on behalf of the person
- Disparity between the person’s living conditions and their financial resources, e.g. insufficient food in the house
- Unnecessary property repairs
Types of modern slavery
- Human trafficking
- Forced labour
- Domestic servitude
- Sexual exploitation, such as escort work, prostitution and pornography
- Debt bondage – being forced to work to pay off debts that realistically they never will be able to
Possible indicators of modern slavery
- Signs of physical or emotional abuse
- Appearing to be malnourished, unkempt or withdrawn
- Isolation from the community, seeming under the control or influence of others
- Living in dirty, cramped or overcrowded accommodation and or living and working at the same address
- Lack of personal effects or identification documents
- Always wearing the same clothes
- Avoidance of eye contact, appearing frightened or hesitant to talk to strangers
- Fear of law enforcers
Types of discriminatory abuse
- Unequal treatment based on age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex or sexual orientation (known as ‘protected characteristics’ under the Equality Act 2010)
- Verbal abuse, derogatory remarks or inappropriate use of language related to a protected characteristic
- Denying access to communication aids, not allowing access to an interpreter, signer or lip-reader
- Harassment or deliberate exclusion on the grounds of a protected characteristic
- Denying basic rights to healthcare, education, employment and criminal justice relating to a protected characteristic
- Substandard service provision relating to a protected characteristic
Possible indicators of discriminatory abuse
- The person appears withdrawn and isolated
- Expressions of anger, frustration, fear or anxiety
- The support on offer does not take account of the person’s individual needs in terms of a protected characteristic
Organisational or institutional abuse
Types of organisational or institutional abuse
- Discouraging visits or the involvement of relatives or friends
- Run-down or overcrowded establishment
- Authoritarian management or rigid regimes
- Lack of leadership and supervision
- Insufficient staff or high turnover resulting in poor quality care
- Abusive and disrespectful attitudes towards people using the service
- Inappropriate use of restraints
- Lack of respect for dignity and privacy
- Failure to manage residents with abusive behaviour
- Not providing adequate food and drink, or assistance with eating
- Not offering choice or promoting independence
- Misuse of medication
- Failure to provide care with dentures, spectacles or hearing aids
- Not taking account of individuals’ cultural, religious or ethnic needs
- Failure to respond to abuse appropriately
- Interference with personal correspondence or communication
- Failure to respond to complaints
Possible indicators of organisational or institutional abuse
- Lack of flexibility and choice for people using the service
- Inadequate staffing levels
- People being hungry or dehydrated
- Poor standards of care
- Lack of personal clothing and possessions and communal use of personal items
- Lack of adequate procedures
- Poor record-keeping and missing documents
- Absence of visitors
- Few social, recreational and educational activities
- Public discussion of personal matters
- Unnecessary exposure during bathing or using the toilet
- Absence of individual care plans
- Lack of management overview and support
Neglect and acts of omission
Types of neglect and acts of omission
- Failure to provide or allow access to food, shelter, clothing, heating, stimulation and activity, personal or medical care
- Providing care in a way that the person dislikes
- Failure to administer medication as prescribed
- Refusal of access to visitors
- Not taking account of individuals’ cultural, religious or ethnic needs
- Not taking account of educational, social and recreational needs
- Ignoring or isolating the person
- Preventing the person from making their own decisions
- Preventing access to glasses, hearing aids, dentures, etc.
- Failure to ensure privacy and dignity
Possible indicators of neglect and acts of omission
- Poor environment – dirty or unhygienic
- Poor physical condition and/or personal hygiene
- Pressure sores or ulcers
- Malnutrition or unexplained weight loss
- Untreated injuries and medical problems
- Inconsistent or reluctant contact with medical and social care organisations
- Accumulation of untaken medication
- Uncharacteristic failure to engage in social interaction
- Inappropriate or inadequate clothing
Types of self-neglect
- Lack of self-care to an extent that it threatens personal health and safety
- Neglecting to care for one’s personal hygiene, health or surroundings
- Inability to avoid self-harm
- Failure to seek help or access services to meet health and social care needs
- Inability or unwillingness to manage one’s personal affairs
Indicators of self-neglect
- Very poor personal hygiene
- Unkempt appearance
- Lack of essential food, clothing or shelter
- Malnutrition and/or dehydration
- Living in squalid or unsanitary conditions
- Neglecting household maintenance
- Collecting a large number of animals in inappropriate conditions
- Non-compliance with health or care services
- Inability or unwillingness to take medication or treat illness or injury
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.