The Vulnerable and you
Exploring the role of DCPs in identifying and dealing with victims of abuse in general dental practice
As dental care professionals (DCPs), we should take appropriate action if worried about possible abuse of children or vulnerable adults 1. However, we must not discriminate against patients or groups of patients 1. We should look for signs of abuse in all patients and not just those who are easily perceived as vulnerable.
The term vulnerable adult encompasses people over 18 who are at a higher risk of abuse, who may receive community care due to disability, age or illness and are unable to protect themselves from harm. Elderly people who are isolated, have memory problems, don’t get along with their carer or have a carer who lives with them and/or has drug/alcohol problems are one example. Other vulnerable groups include those with learning difficulties, physical disabilities or mental illness 2.
The Protecting Vulnerable Groups (PVG) scheme was introduced in February 2011 in response to the 2002 Soham murders. This was established by the Protection of Vulnerable Groups in (Scotland) Act 2007. The PVG scheme is excellent, but we shouldn’t solely rely on it to ensure patient safety. Harold Shipman was a trusted doctor who murdered at least 215 patients. He would probably have been allowed to join this scheme as no one suspected him of his crimes. This shows why we can’t link trust with occupation 3.
Obtaining valid consent is difficult if the patient is under the control of their abuser
We will have an increasing role in the prevention of elderly abuse as the geriatric population increases. Neglect is the most common form of elder abuse 4. It’s important to raise a concern about suspected abuse or neglect of vulnerable adults 1.
Care of people suffering from dementia should be co-ordinated by a multidisciplinary team 4. As therapists, we should work effectively as part of this team, keep accurate patient records of intra/extra oral findings and obtain valid consent for treatment and release of confidential information 1.
This may involve collaborating with the dentist and doctor in order to obtain a section 47 certificate of incapacity to ensure that the patient receives treatment to meet their needs. The Adult Support and Protection in Highland guidance details inter-agency procedures for the implementation of the Adult Support and Protection (Scotland) Act 2007 14.
Two thirds of abused older people are harmed by family members acting as carers. Therefore, many victims are reluctant to report abuse due to a fear of escalation of abuse, embarrassment or worry that nobody will look after them if the abuser is removed 5.
If we suspect a carer may be the perpetrator of abuse it would be best to talk to the patient individually. We have to be careful not to place ourselves at risk of blame and there should always be a chaperone present when treating patients 1.
In situations where we are unsure of appropriate action to take, then we should contact our defence union for advice. We may be asked to be a professional witness in court for a victim of abuse and should seek dento-legal advice. As GDC registrants, we are responsible for ensuring that we have professional indemnity cover 6.
We all recognise the importance of recording positive clinical findings of abuse in patient notes – it’s also important to document negative findings 7. More recently, dental professionals’ roles have broadened from recognising and reporting child abuse to include domestic violence relating to spouse/partner, the disabled and elderly 8. Kenney’s paper provides guidance (RADAR see below) on screening patients for domestic violence:
- Routinely screen
- Ask direct questions
- Document your findings
- Assess patient safety
- Review options and referrals. 8
It also supports talking to the patient alone, promotes use of bathrooms for the display of helpline numbers and advises literature should not be placed on a victim as it could become a trigger for abuse.
A study of registered hygienists who attended CPD on the recognition and reporting of abuse found that the cohort was more aware of child abuse than elder abuse and CPD increased self-perceived knowledge and likelihood to report abuse.
It identified areas of knowledge deficits such as how to date bruising; reinforced the need for adequate training in dental and hygiene curricula, and for practising hygienists to seek CPD in recognition and reporting of abuse 9.
Reporting abuse in patients who withhold consent for the release of their records is challenging for the clinician. We should encourage patients to release information and document efforts to obtain consent. If they put their own safety or that of others at risk, we may be justified in releasing confidential information 1.
Control is emotional abuse 10 and valid consent must be voluntary – not due to pressure from family members 11. Obtaining valid consent is difficult if the patient is under the control of their abuser. Victims may develop strong emotional ties with abusers, leading to confusion of pain and love interfering with good judgement about relationships allowing longing for attachment to override realistic fears 12.
Understanding and empathy are required – we can report concerns from a safe place, unlike victims who may be unable to think logically due to fear or misplaced loyalty. We screen for signs of abuse, work as part of a multidisciplinary team treating oral trauma by taking radiographs, clinical photos, repairing broken teeth and providing holistic care by referring to specialists such as oral surgeons or psychologists.
Our role in reporting and prevention is paramount to protect against neglect, exploitation, discrimination, and physical, sexual and emotional abuse.
“Everyone has the right to life, liberty and security of person.” 13
About the author
Jodie started her career within dentistry as a dental nurse before going on to study the BSc Oral Health Science course at the University of the Highlands and Islands. She graduated as a dental hygienist/therapist in June 2014 and is now employed in both private and NHS practices based in Speyside and Grampian.
- Department of Health (2014). No Secrets: Guidance on Developing and Implementing multi-agency policy and procedures to protect vulnerable adults from abuse. Available from http://www.elderabuse.org.uk/Documents/Other%20Orgs/No%20Secrets.pdf [1 May 2014]
- Mental Welfare Commission for Scotland (2014). Medical treatment under the Adults with Incapacity Act [online]. Available from www.mwcscot.org.uk/the-law/adults-with-incapacity-act/medical-treatment/ [24 April 2014]
- Moore R and Newton JT. The Role of the General Dental Practitioner (GDP) in the Management of Abuse of Vulnerable Adults. Dental Update. 2012, 39(1), 555-564
- General Dental Council (2013) Standards for the Dental Team [online]. Available from www.gdc-uk.org/Dentalprofessionals/Standards/Documents/Standards%20for%20the%20Dental%20Team.pdf [21 April 2014]
- NHS (2013) Vulnerable People [online]. Available from www.nhs.uk/CarersDirect/guide/vulnerable-people/Pages/vulnerable-adults.aspx [21 April 2014]
- Baker R. Implications of Harold Shipman for general practice. Postgraduate Medical Journal. 2004, 80(1), 303-306
- Hansberry M, Chen E and Gorbien M. Dementia and Elder Abuse. Clinics in Geriatric Medicine. 2005, 21, 315-332
- Juggins K, Panesar J, Sinha S, Acharya P, Jafar H, Bower E, Harrison V and Newton T. The Management of Abuse: 4. Abuse of Vulnerable Adults. Dental Update, 2006. 33(1), 555-559
- General Dental Council (2010). Advice for those who employ dental professionals [online]. Available from http://www.gdc-uk.org/Newsandpublications/Publications/Publications/Employer%20Information%20leaflet%20Sep10.pdf [26 April 2014]
- The Dental Defence Union (2014). The Professional Witness [online]. Available from http://www.theddu.com/guidance-and-advice/guides/reports-and-court-appearances/the-professional-witness [26 April 2014]
- Kenney J. Domestic Violence: A complex health care issue for dentistry today. Forensic Science International. 2006,165S, S121-S125
- Harmer-Beem M. The Perceived Likelihood of Dental Hygienists to Report Abuse Before and After a Training Programme. Journal of Dental Hygiene. 2005, 79(1), 1-12
- Office on Women’s Health (2012). Emotional Abuse [online]. Available from www.womenshealth.gov/violence-against-women/types-of-violence/emotional-abuse.html [1 May 2014]
- NHS Choices (2012). Consent to Treatment [online]. Available from www.nhs.uk/conditions/consent-to-treatment/pages/introduction.aspx [1 May 2014]
- Kolk B. (1989) The Compulsion to Repeat the Trauma [online]. Available from weavertargetrecoverymodel.com/documents/Compulsionto RepeattheTrauma.pdf [1 May 2014]
- United Nations (1948). The Universal Declaration of Human Rights [online]. Available from www.un.org/en/documents/udhr/ [1 May 2014]
- NHS Highland (2010). Adult Support and Protection in Highland [online]. Available from http://www.highland.gov.uk/download/downloads/id/6118/adult_support_and_protection_inter_agency_procedures [24 April 2014]