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Domestic Safeguarding Abuse Violence Topics for Challenging Breaking Bad Sick Notes Workplace News today Situations Organ DonationCase 1 • 78F with limited mobility presents to A&E after having accidentally fallen down the stairs. • She says she lost balance. On examination, you see multiple bruises at different stages of healing. • unkempt. She lives with her husband who hass dementia and their son. Neglect is defined as the failure to provide needed care. Which of the following are examples on neglect: 1 2 3 4 Coercing Restricting Failure to Hitting, them to access to provide slapping, transfer family adequate food kicking or finances members or clothing punchingElder Abuse • Abuse of the elderly is common (one in four vulnerable older people are at risk of abuse) • Safeguarding aims to uphold an adults fundamental right to be safe. • It is a criminal offence under the mental capacity act to willfully neglect a person without capacity.https://safelives.org.uk/spotlight-1-older-people-and-domestic-abusehttps://www.helpage.org/silo/files/elde r-abuse-what-is-it.pdfPhysical Abuse • Attempts can be made to hidden physical injuries • Cuts, lacerations, puncture wounds, open wounds, bruises, black eyes, burns, broken bones, skull fractures • Untreated injuries at different stages of healing • Poor skin condition or hygiene • Dehydration / malnourished • Loss of weight • Signs of being restrained • Property damage • Inappropriate dosing of medication (over or under)Psychological abuse • Most common • Hard to recognize • Usually involves threats about something they care about (access to grandchildren) • Often linked to financial abuse • Often has impact on persons mental health • Helplessness, hesitation to talk openly, anger without apparent cause • Unusual behavior (sucking, biting or rocking) • Unexplained fear • Extreme withdrawalFinancial abuse • Sudden cash withdrawals • Family excessively concerned about care spending • Lack of processions • Sudden appearance of previously uninvolved relatives • Deliberate isolation of the elderly person by othersSexual Abuse • Distress / fear • Physical signs • Bruising around breast or genital areal • Unexplained STIs • Unexplained vaginal or anal bleeding • Difficulty in walking or standing • Torn, stained or bloody underclothing • If you suspect sexual abuse do NOT wash the older person or their clothing. Call the police immediately so expert services can be consultedNeglect • Dirt, faecal or urine smell, • Rashes, sores or lice on him/her • Inadequately clothed • Untreated medical conditions • Poor personal hygiene • Lack of assistance with eating or drinking • Sometimes this could be by personal choice. If in doubt apply the tests from the Mental Capacity Act • People are allowed to make unwise decisionsWhat to do? • Who’s responsibility is it? • What to do immediately? • What if you’re not sure? • Who needs to be notified?Safeguarding of Adults • Every hospital will have arrangements with local social services, police and other agencies about how to notify • It is everyone’s responsibility to act on safeguarding concerns. • Hospitals have safeguarding teams who’s assist with the referrals / assessments. • Attend to their immediate medical needs • If a crime has been committed – report to the police • If medically to be discharged but you are concerned admit them to a place of safety until more assessments can be carried out. Actions • Record thoroughly and accurately all concerns and assessments in medical notes. • Perform a capacity assessment on adult patientsActions Adult without capacity or Children Adult with capacity If the risk is posed to a child (<18 years) or a explain to them the risks as you perceive them, and vulnerable adult without capacity, you must break what help is available. You must encourage them to confidentiality (even if they object) and inform social accept help from you and/or allow you to refer them services on. However, if they have capacity and do not give consent, you cannot disclose their situation to anyone Admit if not safe to discharge else or make a referral Refer to Safeguarding team who will refer to social Admit if not safe to discharge and they agree services (out of hours contact usually available) Must refer to safeguarding team if children or vulnerable adults are affectedSummary SuspectCumbria social services Decision making tool •insomnia.old female presents to GP with • She states that she thinks it is due to Case 2 troubles in her relationship but doesn’t want to give any more details • She is reluctant to allow a physical exam. • After reassuring the patient about confidentiality she agrees to be examined • patient has multiple bruises on Case 2 examination • patient confides that her long term Continued boyfriend has been hitting her • They don’t live together or have any childrenWhich statement is most correct about this situation? 1 2 3 4 abuse as it is notic the police regardless of with patient about what at risk it does not meet happening within the patient’s wishes help is available and the threshold for a home. what she would like to referral to domestic happen next abuse services.Domestic ViolenceApproach to scenario • Offer supportive environment (reassure of confidentiality, privacy and safety) • Don’t be afraid to ask about abuse • Ensure potential abuser is not around • Perform a risk assessment for patient and any children involved • Offer formal support • Don’t assume they want to leave their partner. DASH risk checklist https://safelives.org.uk/sites/default/files/resources/Dash%20 without%20guidance.pdfIf more than 14 ‘yes’ answers this generally meets the criteria for MARAC referralMARAC • MARACs are Multi Agency Risk Assessment Conferences. They are regular meetings of professionals who discuss how to help individuals who are most at risk of serious harm due to domestic violence and abuse. • You should make a MARAC referral if your client: • comes out as 'visible high risk' on the DASH risk assessment • is at high risk based on your own professional judgement (for example if you do not have enough information for a DASH risk assessment) • has reported 3 crimes from a perpetrator in a 12 month period https://www.leeds.gov.uk/antisocial-behaviour-and-crime/domestic-violence-and-abuse/making-a-marac- referral-for-domestic-violence-and-abuse • 24 M re-attends with a complaint of ankle injury and requests that their medical notes be altered. • After further questioning the patient Case 3 reveals they initially said that they got the injury while playing football and would like to change the history to sustaining the injury while at work. • They put this down to being in pain at the time of initial assessment What is the next best course of action? 1 2 3 4 notes and complete notes leaving themial documentation and are lying and youthey a new assessment. still visible and add a new entry can not document complete a new stating what the anything they are assessment patient is telling you. telling you.Medical Documentation • Medical notes are a legal document • If a mistake is made you need to cross it out with a clear line and date and sign the amendment • You can not give misleading information in the notes • You can add an entry to reflect what the patient is now telling you • Extremely important for medico-legal casesRCP Approved ‘Generic Medical Record Keeping Standards’Fit Form • Needs to be completed by medical professional • Not Job specific • A person can self certify for 7 days without a fit note • Recommend allowances if just certain type of work is not possible • Statutory sick pay is available to zero-hour contract workers as long as they: • They're ill for four days or more in a row (including days off). • They follow your rules about reporting sickness—or tell you within seven days. • They earned on average at least £123 per week (before tax) in the past 8 weeks. • Scenario: You are working in a medical specialty ward alongside a FY1 doctor. A medically fit patient is very angry and has recently complained that they have been awaiting discharge documentation Case 4 and take home medication for several hours and is delaying them going home. Discuss the situation with the FY1 doctor • (Hidden agenda: FY1 is burnt out and suffering from depression and is struggling to cope with their clinical duties)Difficult discussions with colleagues • If able – offer to help them with there duties for the day • If unsafe to continue working escalate immediately • Listen to their concerns • Try and encourage them to seek the help they need • Unless absolutely necessary don’t escalate for them • Signpost for support • Occupational health department of wellbeing • Educational supervisor • Clinical supervisorDifficult discussions with colleagues • GMC good clinical practice: Domain 3 Communication partnership and teamwork • You must work collaboratively with colleagues, respecting their skills and contributions. • You must treat colleagues fairly and with respect. • You must be aware of how your behaviour may influence others within and outside the team. • Patient safety may be affected if there is not enough medical cover. So you must take up any post you have formally accepted, and work your contractual notice period before leaving a job, unless the employer has reasonable time to make other arrangements.NACT UKFor most professional situations which is the most appropriate escalation path 1 2 3 Another junior colleagueonsultant on duty Educational supervisor ↓ ↓ ↓ Clinical supervisor Consultant on duty Training program Director ↓ ↓ ↓ Educational supervisoClinical supervisor ↓ ↓ Clinical supervisorTraining program directHead of school • 58 male presents with sudden loss of consciousness at home and was found to have a massive intracranial haemorrhage. Case 5 • He was previously fit and healthy and has a guarded prognosis (unlikely to wake up) • How would you discuss this with the Next of Kin?At what point is it most appropriate to refer to the organ donation team? 1 2 3 4 has been declared ast given consent for organ has been withdrawn patient has likely brain brain dead donation death (absent cough fixed dilated pupils)/Breaking Bad News • SPIKES • Perception • Invitation • Knowledge • Emotions and Pathway • Strategy and SummaryBreaking Bad News Setting • comfortable, quiet and private room. • Make sure to have some tissues available. • Ensure both you and the patient/relative are sitting down. • Other people who may be helpful to have in the room when breaking bad news: • “Would you prefer to have a family member or friend here?”.Breaking Bad News Perception • Establish what the patient already knows or is expecting, the patient may or may not have been made aware of the possible diagnoses. • Invitation • “I have the result here today, would you like me to explain it to you now?”.Breaking Bad News • Invitation • Most patients will indicate that they want full information • Check if the patient wants to receive their results today • “I have the result here today, would you like me to explain it to you now?”. • Be sensitive to how the patient is reacting, and provide information at an appropriate pace.Breaking Bad News • Knowledge • Use a warning shot • “As you know we took a biopsy/did a scan, and unfortunately the results were not as we hoped”. • Then provide the diagnosis using simple language: “I’m sorry to tell you this, but the results from the investigations show you have cancer”. • Deliver information in chunks, pausing between each piece of information.Breaking Bad News Emotions and pathway • Recognize and respond to emotions with acceptance, empathy and concern. • Do not lie or give false hope. • If you do not know information, tell them that, and suggest that you can refer their case to a specialist or that more information is needed.Breaking Bad News Strategy and summary • Make a plan together and inform them of what the next steps are including specialist referrals. • Check the patient’s understanding of the bad news you have delivered.Organ Donation • England has an opt out system • If over 18, not opted out, had capacity to opt out if wished – They are a registered organ doner • Anyone can potentially be an organ doner except • Creutzfeldt-Jakob Disease (CJD) • Ebola virus disease • Active cancer • HIV • Organ donation should be considered as a usual part of end-of-life care planning. • Most frequent situations where organ donation should be considered • patients who have had a catastrophic brain injury with absence of one or more cranial nerve reflexes and a GCS of 4 not explained by sedation • the intention to withdraw life-sustaining treatment in patients with a life- threatening or life-limiting condition which will, or is expected to, result in circulatory death. • Organ donation team • Approach topic sensitively with the family – explore what the wishes of the patient would likely be