Elderly people exploited, neglected and abused in the UK.
I would like to thank you and your colleagues for the kindness shown to myself and my wife. I class myself as very fortunate to have met such kind and caring people.
Raymond, HertfordshireRegrettably not a week goes by without reports of elderly people being exploited, neglected and abused in the UK. The current controversies surrounding elderly care continue to appear in the national and local press because this raises important ethical issues that can no longer be ignored by government, the medical and nursing professions, or state authorities empowered to protect people from harm.
The recent case of the Maypole Nursing Home, which was registered to care for the elderly mentally ill, is a startling example of the inadequacies in elderly care. It is also an example of how legislation has failed to protect vulnerable adults repeatedly over many years.
In January 2006 the GMC removed Dr Jamalapuram Hari Gopal and his wife, Dr Pratury Samrajya Lakshmi from the medical register for behaviour which was held to be "inappropriate, irresponsible and in adequate" in their running of the Maypole Nursing Home which they owned and also managed as the residents' GPs. The matter remains under review by the Nursing and Midwifery Council.
Despite the GMC findings and the numerous investigations by statutory authorities, the unexpected death of Leslie Vines at the Maypole Nursing Home on 7 September 2002 remains unresolved. At the time the cause of his death was recorded by one of the GP owners to be bronchial pneumonia and neither a post mortem nor an inquest was held. Evidence indicates that Mr Vines received an excessive dose of sedative medication and was restrained in a bucket chair in which he may have died.
Died in nursing homes
In the absence of any formal inquiry into the circumstances of the death of Mr Vines, the family have spent the last 3 years attempting to find out how their father died in the Maypole Nursing Home. The only avenues now left to the family are a judicial review of the coroner's recent decision not to hold an inquest, or a full public enquiry.
Maypole Failings
Sadly good practice was not evident at the Maypole where there were a catalogue of failings reported over the years where according to the evidence presented to the GMC vulnerable residents lived and died in unacceptable conditions.
Among a number of failings, it was reported that there were poor standards of medical and nursing care. There was insufficient staffing, no awareness of nutritional needs, dirty equipment and hazardous storage, no interaction between staff and residents and no respect for dignity. Cramped living conditions were found in addition to the excessive use of restraint without documented justification where residents were also receiving significant medication. There were a significant number of accidents which should have been reported some of which could be considered under Adult Protection procedures.
It may be argued by some that there may well have been aspects of the home the management got right, but unfortunately, this was overshadowed by the many serious failings that were all too obvious to those using the service and those paying for the service. The reality was an under-resourced service which was inadequately managed by staff who failed to do their utmost to initiate remedial action or to set appropriate standards for themselves or others. The conditions at the home were reported to be "appalling" and the overall impression according to inspectors prior to the closure was of an old style mental institution.
It was reported that health officials had conducted 17 inspections of the Maypole Nursing Home before it was finally closed in March 2003. In just one year 28 residents died. 16 of those deaths were identified as cause for serious concern. It was unacceptable that it took until 2006 to formally address the problem and remove the doctor and wife team from medical practice.
Whilst the GMC decision is to be applauded, it brings cold comfort to those families whose relatives have suffered in that care home over the years. Blame not only attaches to those professionals who had responsibility to care for the residents, but it also attaches to those authorities empowered to monitor the quality of care and regulate service provision, but which allowed such a state of affairs to continue for so long.
Following the recent BBC documentary 'Dying for the Truth' it appears that complaints have been raised with the authorities as long ago as 1991. It has been revealed that the management of the home had failed to ensure that changes to practices had been embedded in the everyday practice of the home. Despite the numerous inspections and recommendations for improvement, poor and deficient practice was evident up until the time the home was voluntarily closed in March 2003.
Underlying Problems
The underlying cause for these failings, the large number of unexplained deaths at the home and the delay in taking the necessary action are threefold:
Firstly, the differences in certification procedures for burial and cremation are inconsistent which leads to confusion in the system. Also there is no systematic procedure for auditing the death rate in nursing homes as the current system relies upon self-reporting. The problem of how Shipman-style abuse of the system might be prevented remains unresolved as the system depends upon only one doctor to certify a death certificate.
Secondly, whilst the GMC may frown upon doctors owning and practicing in nursing homes, there is no outright ban. Whilst doctors may be deemed best placed to run a nursing home because they understand the complex needs of the elderly who often suffer from a combined number of physical and mental conditions, many would consider this dual role to be a conflict of interest which may undermine the doctor-patient relationship. It follows, therefore, that a presumption of wrongdoing is bound to be raised where there have been gross failings in care in circumstances where a doctor has a financial interest in a home, transferred the residents on to the list of their GP practice (where there is a financial gain), treats the residents, certifies their death certificates without the medical evidence or an independent second opinion and then fails to report the death to the authorities.
Thirdly, and most importantly, the 13 principle agencies involved in preventing such occurrences at the Maypole Nursing Home failed to do so because the legislative scope of their individual inquiries does not provide for collaborative action to be taken to prevent harm.
The Solution
Attempts to deal with the potential problems in isolation or without legislation are likely to fail.
The issue of death certification requires reform alongside reform of the coronial system. The draft Coroner's Bill is a golden opportunity to rectify the current system, which is considered to be unsafe and unsatisfactory. However, any suggestion of having 2 doctors certify a death certificate is unlikely to resolve the problem. This would give rise to delays in establishing the cause of death. It would also require the involvement of doctors who would be unknown to one another and who had no knowledge of the deceased's medical history.
Regarding the issue of doctors owning nursing homes, any suggestion that the GP should register his combined nursing home ownership and GP practice with the Primary Care Trust will not provide the requisite safeguards. The administrative burden on already overloaded GPs and the authorities would only serve to complicate matters further. The simplest way forward would be to legislate to prevent doctors from practicing as GPs in nursing homes in which they have a financial interest.
Finally, there must be a statutory duty placed on authorities to communicate adverse findings to other agencies to prevent cases such as the Maypole deaths from falling through the cracks in the current system.
The future
One way or another, care of the elderly and sick can no longer be compromised as it has been in the Maypole case. Regardless of the recent GMC decision to strike the doctors at the Maypole off the register, it is time that legislation was put into place now to prevent such occurrences in the future. One way or another, with an ever increasing elderly population the public needs reassurance that systems are in place to protect the elderly in homes like the Maypole.
Victoria Blankstone, Irwin Mitchell Clinical Negligence Solicitor, Birmingham
Back to case studies