I’ll say this is hypothetical.
But, a service user with dementia in a care home, call him Z. Care plan identifies aggression and care workers to work in pairs when administering care intervention.
Z has a fall and needs an X-Ray.
Due to the pain, Z is more agitated and aggressive.
Z’s son can’t take Z to hospital and accepts that if Z is too aggressive then he can’t be taken.
Paramedics called and attend in a two man team.
Z continues to be aggressive but is fastened into a wheelchair and taken in the ambulance.
Z is accompanied by X, a fully trained senior carer from the home.
At triage, Z continues to be aggressive and A&E refuse to treat him.
As part of the attempt to treat him, Z assaults (punches) X.
X calls the home, and is told to follow training and keep Z at arms length.

The crux is, is it, that when Z is checked in, does he become the care and responsibility of the hospital?

Could the home have simply let the paramedics take him without X being there?

I appreciate this is a little vague but I can’t regale the whole story on here, just curious about when, if at all, the burden of care moves from one party to the other.

I have no idea regarding the actual legalities of this, but can answer from a healthcare professional point of view.

It’s very difficult to assess and accurately treat a care home patient with dementia who hasn’t come with a carer (whether that’s a nurse from the care home or a family member). I’ve admitted patients like this when the carer has dropped the patient off at the front door and left – it’s often impossible to get any information from the patient in this situation e.g. how the fall happened, what has been injured, past medical history, medications, allergies, usual functional status etc.

In my experience, some nursing homes do send their patients to hospital without anybody accompanying them, but it’s a PITA and dangerous for the patient IMO. Even more nursing homes send them with the most junior member of staff, who didn’t see the fall, has never met the patient, and doesn’t know the first thing about their medical history.

EDIT: the ideal scenario would be that the carer stays until the patient is assessed by the medics and can give all the relevant information. I would hope that the patient would be triaged to be seen as a priority, not least because treating the pain will help to alleviate the patient’s anxiety/aggression and lead to an all-round better outcome.

EDIT 2: I’ve only ever refused to treat aggressive patients when they were fully compus mentis and are kicking off because of alcohol etc (even then, I’ve only ever seen one patient chucked out of A+E because of violent behaviour, and that was because he gave a nurse a black eye and threw a pair of crutches at the policeman who was attempting to reason with him). I don’t think any A+E department would refuse to treat a patient with dementia even if they were being aggressive.

Ambo bod here. We try our level best to get R/H to send an escort, for reasons eloquently set out above. Some don’t, citing staffing or whatever. We/the hospital can and do manage without a carer who knows the patient, but it’s much harder. Understanding what is ‘normal’ for the patient when the patient is in no position to explain means that the patient would often have a longer stay and receive more invasive assessments as a result.

As for who is ‘responsible’ for care; when the ambo takes over in the home, they are. When the patient is handed over at hospital, the hospital becomes responsible. This doesn’t mean that sending a carer is not the right thing to do, though.

Thanks, both great comments.
This is something going round and round in my mind, and not being in any of these industries, I keep coming up with differant answers!

Quite a can of worms but am I right in assuming that Z is lacking in capacity due to the dementia and is therefore a vulnerable adult.
In which case “refuse to treat” doesn’t compute.
Make decisions in best interest of patient, ie, no need for X-ray, can be safely managed back in care home etc is not same as refusing to treat.
And yes. Someone from care home or family should go with patient to a&e to assist in giving history, this will help those in a&e make best decisions about what they do.

I would think that the care home owe a duty of care until he is either formally admitted to hospital or his next of kin can take over, especially if dementia may mean there are questions over z’s capacity to consent to medical treatment.

Also surprised that A&E might refuse to treat him, and would suggest that combined aggression and dementia should have seen involvement of AMHP at that stage.

A&E refused on the basis they operate a zero tolerance policy towards aggressive behaviour.
I thought that was a bit harsh given the reason for the aggression, it’s not like he’s a drunken brawler.

Would someone need to go with him to A&E if the necessary history had been relayed to the paramedics. The home also complete and send a history form with him, and surely if the son had gone, he would probably know less than a carer?

How do you know if the necessary history has been relayed to the paramedics (or is on the form)? What one person deems important information may not necessarily be the same as the next person, so it’s often useful to speak directly to the carer/family to answer specific questions.

In an ideal world, the medical team looking after the patient would be able to talk directly to both the carer who knows the patient well, and the family (either in person or by phone).

A&E refused on the basis they operate a zero tolerance policy towards aggressive behaviour.
I thought that was a bit harsh given the reason for the aggression, it’s not like he’s a drunken brawler.

From what you have described this is not ‘violence and aggression’ but ‘clinically related challenging behaviour’ and should have been dealt with as such. Is it not mentioned in his core care plan?

As a care worker, I’ve been in this situation on several occasions.

The welfare of the service user is paramount.
We know them very well and can interpret, judge mood, offer advice, help with moving and handling, ensure all relevant history is noted etc.

Where I work, we send the most experienced carer, or the person who knows that service user best.
We stay and help until we’re not needed anymore.
Someone else takes over when if we finish shift, wherever the client is – our duty of care doesn’t end just because someone is in hospital.

For example, trying to clean up a doubly incontinent, violent person, in great pain because he’s pulled out his catheter, whilst he’s stuck on a trolley in A&E is my responsibility.
I need help, to protect the service user from hurting himself, but don’t expect the nurses or paramedics to drop everything, they can be better employed elsewhere.
We’re used to dodging the odd punch and stopping someone from hurting themselves – cot sides are hard and we need to ensure the hospital provides a cot with adequate padding, somewhere quiet, for example.

legolam’s post above reflects my experience almost exactly.

Would someone need to go with him to A&E if the necessary history had been relayed to the paramedics.

this is what happens, frequently, but is suboptimal. It lets errors creep into the history (see; Chinese whispers) and it is not good practice to base clinical decisions on a handover, however competent. You’ve not mentioned a son before; where does he fit in to the story? (We shall call him ‘Y’ 😉 )

Edit; yes you did; apologies. Post night fug

Edit; sounds like Rusty Spanner is an EXCELLENT care worker from a decent R/H. He is a rarity, cherish him, nurture him, pay him moar!

It’s interesting you mention dodging the odd punch as that is what the Manager said to me, it’s almost taken as a given that physical attracts are to be expected, an occupational hazard if you must.

Rusty, I doff my virtual cap to you as that must be as challenging as it is a rewarding role and you stating their care even on a trolley is your responsibility perhaps reflects your attitude and kindness rather than the strict legal position?
As evidence above, some will be dropped at the door.

It strikes me that the legal position is one thing, but the reality is somewhat more clouded as we are dealing here with people who, for no fault of their own, need support.

/remains confused/

As far as I’m aware, our legal obligation is towards the local authority – we have a duty to provide a set level of care on a 24 hour basis.
This varies for each service user.

The home in your OP sound like they did the right thing.

But, as stated above, primary responsibility is a different matter, v8ninety has it above, as far as I know.
Where I work, it’s the Registered Nurse.
The Paramedics assume primary responsibilty from them when they arrive etc.

As to physical attacks, it’s just another part of the job.
In my environment, for 99% of the time it’s involuntary, a consequence of a brain injury.
The other 1% would be dealt with by the police, as in any other environment.

It’s something that is always shocking when it happens, but we do receive excellent training. The company I work for are mostly top notch, the Directors are hands on and try to provide solutions to minimize unnecessary stress for all involved.
Every day is a school day.
Pay IS crap though.

Thank you for the kind comments, hope all ok.

🙂

Rusty: I know you will say that you are just doing your job, but people like you are solid gold. 🙂

When I worked in a care home we waited with them till they were admitted to a ward/discharged back to the home.

Now working on a ward the patient is put onto the ward in a bay for enhanced care usually 1-2 staff to 4 patients.

Can I just ask, what was the reason for admitting him into A &E what was the concern? what did you think they had broken that required an x-ray?

I am a careworker too and agree the best practice would be for the care worker to attend the hospital to try to reassure the patient /service user and to provide medical staff with information they may need and to assist where appropriate . They should wait until the person is on a ward. This can be a loooooong time 9hrs for me in one case.

noteeth – Member
Rusty: I know you will say that you are just doing your job, but people like you are solid gold.

Pete is one of life’s good guy’s. I sadly have to use the care of people like him for my wife (30+ years of secondary progressive MS) so I can go to work.

The dedication & empathy of her carer’s humbles me given the shit money they are paid.

I struggle with the care the rest of the time & it breaks my heart seeing someone unable to do the most basic of life’s tasks.

Perhaps its harder for me as its the woman I love 🙁

There are a variety complexities to who holds a duty of care to an individual at what times, as many agencies and organisations have found to their cost. But if you are a body that holds a ‘duty of care to your clients/ patients’, if that client or patient’s feet enter your ground they are your responsibility at that moment in time, whatever arguments there are to be had about that subsequently. What I can’t work work out, is if the OP’s point mainly relates to A&E’s refusal to treat or did something else occur whilst the the chap was in A&E or being conveyed from A&E to where ever he ended up, so don’t know what failing of which aspect of a duty of care was the issue in this case. Since one agencies duty of care can differ in terms of actions and reasonableness of those actions taken, to another, I’ll shut up now.

rockhoper , so where did the patient go to for treatment, or was he returned to the home without an xray, and did they see a dr while he was in the care of the hospital.

Like my original question? What was the reasoning for him being taken to A&E. In my experience a lot of care homes are simply passing the buck and covering their backsides by referring the patient for an A&E attendance, the ‘ambulance crew’ ( not always paramedics) turn up and they do the same.Now this is obviously not always the case.

And to that extent not all people who attend A&E need to be there, and with appropriate on scene assessment could be left at home with more suitable referral pathways.

I know this as it’s what I do day in day out as a paramedic practitioner.

I know this as it’s what I do day in day out as a paramedic practitioner.

Then you’d know that assessing an uncooperative and aggressive patient with dementia for injuries is fraught with pitfalls; there’s really not many patients with advanced dementia that I would leave at home. Depends on available alternative pathways of course, but the OP stated ‘needs an X-ray’, which is kind of indicative of some difficult to assess potential trauma.

‘Covering backsides’ can be a disparaging way of saying ensuring safest care.

Yes I know all of the pitfalls you mention – thank you.

I’m not going to get in to an argument with you about this, but I do see a lot of dementia patients during my twelve hour shift. With varying degrees of dementia.

I don’t send all patients in to hospital who happen to have ‘advanced dementia’ just because their chronic condition dictates I ought to do so’, irrespective of their injuries and mechanism of injuries…why would I if they don’t need to go in and if their attendance is going to be both upsetting and counter productive to their overall well being !?

It’s a complex topic for sure. But I do see an awful lot of dementia patients in A&E who really could have stayed at home and are discharged promptly, but with more confusion and distress than was actually necessary.

Oh and I’m not adverse to covering my own backside, crikey I wouldn’t have survived in this role for as long as I have were I not aware of safe/best practice.

Gawd Almighty…. currently we’re nursing my MIL who is sick with cancer, incontinent and beginning to go downhill fast but I thank God she’s placid, sleepy and mostly lucid, even that is enough of a strain on the family. Can’t imagine how bad it would be if she was aggressive.