MCA case study - 89 year elderly lady

Produced by: NHS London Purchased Healthcare Team
Supplied by: NELFT NHS Foundation Trust

ER is an 89 year elderly lady with progressive Alzheimer’s disease whose capacity was in question in regard to choosing whether to remain at her home or to go into residential care. The situation was complicated by the following safeguarding concern being raised whereby her youngest daughter and her adult children had moved into her home and were accused by the two older daughters of exploiting her financially and neglecting her care needs. Police were called by the eldest daughter to visit their mother at home stating that she was being abused there. Police conducted a welfare check and concluded that because ER was able to say she was “alright” when asked, that there were no grounds to intervene. They did however, note that the home was dirty, sparsely and shabbily furnished and that ER was in a filthy nightgown with matted hair and long fingernails and therefore informed the Local Authority (LA) via a Safeguarding Adults Alert. The extended family had already made multiple and ever increasingly, what appeared to be, vexatious complaints against the LA for their perceived lack of action against each other in respect of their mother. (All three daughters plus spouses and several grandchildren made on-going multiple allegations against each other). For these reasons a senior safeguarding nurse in the local mental health provider trust, was approached to conduct the mental capacity assessment and lead the best interest decision making, in order to ensure impartiality.

On meeting with all of the various family members it became apparent that this extended family had been in conflict for many years with unresolved and ingrained grievances against each other. ER herself was able to discuss her current situation and how she felt very protective of her youngest daughter who was herself in her late 40’s. She cited this as the reason why she did not wish to go into care as this would effectively make her and the adult grandchildren homeless as they were “destitute” and living off of her pension. However, ER admitted that none of the adults who lived with her looked after her and was adamant she could look after herself. It was evident that this was not the case as ER presented as dehydrated and with a high level of unmet hygiene needs thus showing limited insight into her own care needs. As it was, the daughter and her adult children had previously refused to allow a care package on ER’s behalf. Additionally ER seemed to be quite fixed in her belief that her youngest daughter was far less able than was actually the case and treated her, as if she were still a teenager needing care. It was this final facet that was impacting on her decision making; ER did not accept her daughter was not acting her best interest, stating she (the daughter) would not behave as such.

These aspects, together with a level of their undue influence that prevented ER accepting the help she needed, resulted in the assessing nurse to conclude that with regard to the decision in hand, ER lacked capacity at this time. The principle reason for this was that ER was assessed as unable to fully understand the situation in order to process it; essential steps when applying the assessment for capacity under the 2005 Act.

ER agreed to a short stay in a residential care home where a Deprivation of Liberty Safeguards (DoLS) urgent authorisation was applied whilst a Standard application was made and an Independent Mental Capacity Advocate (IMCA) engaged. ER cooperated fully with the care on offer at the home and her presentation dramatically improved quite rapidly including weight gain; she seemed happy in the company of the other residents and made friends. She made no solo attempts to leave, did not ask to go home but when any of her family visited she would try to leave with them. ER’s family would not agree to attend any meetings where they all were in the room at the same time, making it difficult to try and resolve their conflict of opinion as to what was in ER’s best interest. The eldest daughter wanted ER to move into her house, the middle one wanted ER to remain in the care home and the youngest wanted ER returned to her own house where she was continuing to reside together with her adult children.

The assessing nurse then moved into the role of Best Interest Assessor (BIA) and together with the medical assessor completed the required six assessments under the DoLS procedures and in conjunction with the IMCA concluded ER lacked capacity to consent to her stay at the care home at that time, ought to remain in her best interest for up to 6 months and should eventually be supported to move in with her eldest daughter who was having a ground floor extension built to accommodate her. This decision was made because whilst ER seemed happy at the care home her implied wishes, evidenced by her trying to leave, was to live with family. One must always try to take into account the preferences of the adult in question even when they do not have the ability to make an informed choice regarding the decision. It is often the view that residential care cannot compete with family life, and ‘what use is making someone safe if you make them unhappy’, a view endorsed by Sir James Munby President of the Family Division of the High Court in Re MM (an adult) [2007] EWHC 2003 (Fam). This decision is in line with Article 8 of the European Convention on Human Rights which provides a right to respect for one's "private and family life, his home and his correspondence", subject to certain restrictions that are "in accordance with law" and "necessary in a democratic society".

About this case study collection

Purpose: The purpose of this document is to share MCA cases that have taken place within London for NHS staff to refer to when dealing with difficult MCA cases.

Audience: Commissioner and Provider staff involved with MCA decision making.

Background: The London NHS Commissioner MCA Board identified a number of tools/documents to support them to gain MCA assurance. One of the requests was to share MCA case studies. This document outlines a number of MCA cases which has been shared by CCG and provider MCA leads across London.

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