Safeguarding Adults

Including the Prevent Strategy

Study guide
Safeguarding adults
Regulations • CQC Outcome 7

Learning outcomes NHS.The lead agency for safeguarding adults is the

Local Authority.
Once you have read this information you will:
Each local authority must:
Have an understanding of the background to
Make enquires or ensure that others do so if it
adult safeguarding
believes an adult is subject to or at risk of abuse
Have some knowledge of national guidance and or neglect
legislation
Set up safeguarding adults boards
Be able to recognise different categories of abuse
Arrange for an independent advocate to
Be able to identify indicators of abuse
support a person who is the subject of a
Have an increased awareness of Barts Health safeguarding enquiry but has substantial
adult safeguarding procedures and how to difficulty being involved in the process.
report concerns and actual abuse
At Barts Health:
Understand the principles of safeguarding as
Safeguarding has the highest
outlined in the Care Act 2014. http://www.gov.
priority across our organisation
uk/government/publications/care-act-2014-
statutory- guidance-for-implementation. We must work closely with other agencies and
share relevant information in order to protect
For further information and reference please go
people or prevent them coming to harm.
to http://bartshealthintranet/Policies-and-
Guidelines/ Documents/Policies-Trust wide You are required to act swiftly and competently
when abuse or neglect is suspected or abuse is
COR/POL/045/2015-001
reported to someone
SAFEGUARDING ADULTS AT RISK OF HARM –
INCLUDES MENTAL CAPACITY ACT; DEPRIVATION Safeguarding adults at risk goes hand in hand with
OF LIBERTY AND PREVENT providing high quality dignified care and protecting
the rights of people who may not by able to claim
COR/POL/093/2013-001
those rights without support.
DOMESTIC ABUSE POLICY AND PROCEDURES

Guidance and legislation

Everyone has a role to play in safeguarding adults

from abuse and neglect and in ensuring they live a
life free from it.
Protecting vulnerable adults from abuse and neglect
is the responsibility of all staff at Barts Health.
In 2015 The Care Act (2014), came into force.
The Act requires all public organisations to have
processes and procedures in place that support staff
to protect adults at risk of abuse and neglect. It
sets out the duties of statutory bodies including the

1
Principles of safeguarding
The Care Act enshrines six principles for safeguarding:
Empowerment – Adults are encouraged to

make their own decisions and are provided with
support and information.
Prevention – Strategies are developed to
prevent abuse and neglect that promotes
resilience and self-determination
Proportionality – A proportionate and least

intrusive response is made balanced with the
level of risk
Partnerships – local solutions through services
working with their communities
Accountability – accountability and
 as sexual or emotional abuse as well as the
transparency in delivering safeguarding
Protection – Adults are offered ways to

protect themselves, and there is a co-ordinated
response to adult safeguarding.
The aims of Adult Safeguarding at
Barts are to:
Stop abuse or neglect from happening
Prevent harm and reduce the risk of abuse or
neglect to adults with care and support needs
Safeguard adults in a way that supports them in
making choices and having control about how they
want to live
Raise awareness so that patients relatives and the
public, alongside professionals, play their part in
preventing, identifying and responding to abuse
and neglect;
Provide information and support in accessible
ways to help adults understand how to stay safe
and what to do to raise a concern about the
safety or well-being of an adult; and
Address the causes abuse.
2
Who is an adult at risk?
An adult at risk is a person aged 18 or over who
has care and support needs and is unable to protect
themselves from abuse or neglect because of those
needs.
For Example, the person may have a:
Physical disability
Sensory impairment
Learning disability
Mental health problem
Age-associated frailty, illness or disability
Neglect and abuse includes ill treatment such
impairment of, or an avoidable deterioration in,
physical or mental health and the impairment
of physical, intellectual, emotional, social or
behavioural development.
Definition and categories of abuse
Abuse is a violation of an individual’s human and
civil rights by any other person or persons. Abuse
may consist of a single act or repeated acts. It may
be physical, verbal or psychological, it may be an
act of neglect or an omission to act, or it may occur
when a vulnerable person is persuaded to enter
into a financial or sexual transaction to which he
or she has not, or cannot consent to. Abuse
can occur in any relationship and may result in
significant harm to, or exploitation of, the person
subjected to it.
In healthcare settings failure to provide adequate
food and drink or failure to prevent injuries such as
pressure ulcers, may constitute abuse.
Categories of abuse include:
Physical abuse
Sexual abuse
Financial abuse
Neglect and acts of omission
Psychological abuse
Discriminatory abuse
Institutional abuse
Self-neglect or organisational

Domestic abuse
Modern day slavery
Human trafficking
Restraint
Indicators of harm/abuse
Abuse may come to light when a person who trusts
you and senses they are in a safe place, discloses
that they are being abused. However, there are other
situations or indications that you may observe that
will indicate all is not well.
The following list highlights situations or events
that should prompt you to make further enquiries
and report your concerns.
Physical abuse includes:
Hitting, pushing, pinching, shaking, kicking,
misusing medication, scalding, restraint or
hair pulling
Unexplained injuries including fractures
Cluster of injuries forming regular patterns or
reflecting shape of article
Lack of concern for a person’s dignity when
providing care
Rough handling
Sexual harm – may involve contact
or non-contact
Non-contact such as:
Showing of pornography against a
person’s will
Taking photographs of a sexual nature without
consent
Contact – may involve:
Inappropriate touching
Rape
Other sexual acts without consent
Psychological abuse includes:
Threats of harm or abandonment
Being deprived of social or other forms of
contact
Humiliation
Blaming
SAFEGUARDING ADULTS (LEVEL 1)
Controlling
Intimidation
Coercion
Harassment
Verbal abuse
Being prevented from receiving services
Financial harm – such as
Theft
Fraud or exploitation
Pressure in connection with bank accounts, wills
and misrepresentation of ‘power of attorney’
Property or inheritance fraud, possession or
benefits fraud
Neglect/acts of omission
Preventing access to health or social care or
educational services
Withholding the necessities of life such as food,
drink, lighting and heating
Inappropriate, old or shabby clothing, poor
personal hygiene
Sensory deprivation, not allowed to have
hearing aid, glasses or other aids to daily living
Physical condition is poor eg pressure damage,
untreated injuries or medical problems.
Self-neglect
This covers a wide range of behaviour such as
neglecting to care for one’s own personal hygiene,
health or surroundings and incorporates behaviour
such as hoarding.
Discriminatory abuse
Sometimes abuse may occur because of a
particular characteristic such as race, or disability.
The Equality Act 2010 deemed there were nine
protected characteristics — age; disability; gender
reassignment; marriage and civil partnership;
pregnancy and maternity; race; religious belief; sex;
and sexual orientation.
3
Institutional or organisational abuse
When people receive poor or inadequate care,
when care staff neglect and condone poor practice
that affects the whole service they can be judged to
have caused institutional harm. This has been found
in hospitals (Francis Report/Mid Staffs Enquiry) and
care homes (Winterbourne View TV Programme
(2012) that showed physical harm to adults with a
learning disability. This may range from a one off
incident to on-going ill-treatment and may be a
result of the structure, policies or processes within
an organisation.
Restraint
In extreme circumstances unlawful or inappropriate
use of restraint may constitute a criminal offence.
Someone is using restraint if they use force,
or threaten to use force, to make someone do
something they are resisting, or where an adult’s
freedom of movement is restricted, whether they
are resisting or not.
Risk factors
There are many factors that could increase the
risk of abuse. These include:
Dependency on others for assistance, especially
with personal care and finances
Difficulty understanding certain decisions or
transactions
Decreased mobility and disability
Social isolation
Lack of awareness regarding rights and
complaints
Low self-esteem and lacking power in
relationships
Victims of hate crimes
Limited life experience and sex education
Indifference to the standard of care they are
receiving
Lack of choice regarding accommodation and
people they live with
4
Perpetrators of abuse
Abuse of adults at risk may be perpetrated by a
wide range of people who are usually part of their
network. They may include:
Relatives
Informal carers Partners
Family members
Professional staff, including you and I
Paid care workers
Volunteers, befrienders
Other service users
Neighbours
Friends and other associates
Abuse of an adult at risk does not have to be a
deliberate act. Sometimes abuse happens when
people are trying to do their best, and do not
know they are doing the wrong thing. A person
who causes harm may do so because of frustration
even in the caring context. However, irrespective
of why the abuse might happen, any abuse of
an adult at risk is harmful. This makes it vitally
important to ensure that those involved with the
care and support of adults at risk have a clear sense
of what constitutes abuse and understand their
responsibility in relation to reporting suspected or
discovered abuse.
What to do if abuse is suspected or
disclosed
Take immediate action to protect the adult at
risk from danger. This may mean that a person
attending A&E cannot be discharged back to their
home or a care home until an assessment and
protection plan is put in place.
Inform your line manager.
Complete a Datix incident form and complete a
safeguarding alert form.

Preserving evidence
When dealing with any allegation of abuse, you
may suspect that a crime has been committed. If
you suspect a crime has been committed the police
should be informed.
It may be necessary to preserve evidence
relating to an incident and you should
consider the following:
Close off the room(s) until the police arrive to
obtain forensic evidence
Rape or sexual assault victims to be advised not
to change or wash clothes, consume drink/food
or wash themselves
In financial abuse cases act quickly to report
your concern as there may be some evidence eg
CCTV footage and leave any documents alone,
eg cheque books or bank books, so no one can
touch them.
When the person you are supporting tells you that
abuse has taken place you must record and report
that disclosure.
The following are useful do’s and don’ts to consider
when dealing with disclosures:
Stay calm and try not to show shock or disbelief
Listen carefully, supporting this with appropriate
non-verbal cues (nodding, open body posture,
leaning forward etc)
Be empathetic (I am sorry this has happened
to you)
Let the person speak at their own pace,
using their own words, don’t jump in with a
comment, judgement or correction
Record disclosure at earliest opportunity
Do not ignore it
Do not try and manage the situation on
your own
Do not promise to keep secrets
Do not contact/approach the alleged abuser
Do not sit on the information over the
weekend or until you are next on-duty, report
immediately to line manager or the site
manager out-of-hours
SAFEGUARDING ADULTS (LEVEL 1)
Do not assume that someone else will deal with
it – the responsibility lies with you
Remember to complete a Datix incident form
and a safeguarding alert. Sharing and storing
of confidential information must be in line with
data protection and Caldicott principles
Reporting abuse
Referrals to the Safeguarding Adult Team should be
made when there is a reason to believe that an adult at
risk is being abused or is known to have been abused.
The referral form that needs to be completed can be
found on the safeguarding pages on the Trust Intranet,
or here:
http://bartshealthintranet/Policies-and-
Guidelines/Documents/Policies-Trust wide
COR/POL/045/2015-001
SAFEGUARDING ADULTS AT RISK OF HARM –
INCLUDES MENTAL CAPACITY ACT; DEPRIVATION
OF LIBERTY AND PREVENT
Whistleblowing
Barts Health has a policy for whistleblowing. This
policy provides assurance that all paid and voluntary
staff working at the Trust can raise concerns about
the behaviour of others or about poor practice.
Barts Health is committed to the highest possible
standard of operation, probity and accountability.
In line with this commitment, employees and
others with serious concerns about any aspect
of their work, are encouraged to come forward
and voice those concerns. The whistleblowing
policy is designed to assist, encourage and enable
employees to make their concerns known.
Safeguarding adults
S: Suspect harm?
A: Act immediately to protect the person and
escalate your concerns to your line manager/site
manager
F: Fill in the Datix form completing safeguarding
section
E: Escalate to Safeguarding Team using details
below
5
G: Get the right people involved (consider police)
U: Utilize the policy
A: Abuse can be physical, sexual, psychological,
emotional or financial
R: Reporting any concerns about any form of abuse
is your responsibility
D: Document factually in all correspondence
relating to the incident
Your safeguarding team
There is a safeguarding page on the Intranet where
more information can be found. If you need advice
or support call the numbers below:
07507 413 609
07753 309 888
or
Email: safeguardingadults@bartshealth.nhs.uk
Mental Capacity Act (2005)
Capacity refers to the ability to make one’s own
decisions. People can lack this ability for many
reasons, either temporarily (eg because of acute
illness) or permanently (eg because of dementia or
learning disability). Most people are able to take
some decisions for themselves, even if there are
others that they cannot take.
The Mental Capacity Act sets out how decisions
have to be made in relation to people who are not
able to take their own decisions due to any kind of
disorder or disability.
Key principles of the Mental Capacity Act
The Act is underpinned by five key principles:
A presumption of capacity
The right for individuals to be supported to
make their own decisions
The right for individuals to make unwise
decisions
Decisions made on behalf of people who lack
capacity must be in their best interests
Best interest decisions should be least restrictive
of their the person’s rights and freedoms
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A presumption of capacity
The Mental Capacity Act requires us to presume
that a patient has capacity unless we have assessed
their capacity and established that they do not: it
is unlawful to decide that a patient lacks capacity
on the basis of factors such as their age, diagnosis
or appearance.
It is also important to understand that capacity
is specific to the decision being made – a patient
may be unable to make a really complex decision,
but still have capacity to make simple decisions,
or able to make decisions about some things, but
not others. If this is the case, the patient should be
supported to make all the decisions they can.
Capacity can also fluctuate. A patient may have
capacity to make decisions on one day, but not
another. If this is the case, any decision which can
safely be deferred until the patient is able to take it,
should be deferred.
Assessment of capacity
You will assess the patient’s capacity by talking with
them about the decision to be made, and listening
to their responses or observing their responses.
There isn’t a special ‘mental test’ that you can give
people to see if they have capacity. Any healthcare
professional can assess the capacity of a patient in
relation to the treatment or care that the healthcare
professional is proposing to give. Occasionally, if the
patient appears to be mentally ill or if their capacity
is particularly hard to assess, it may be helpful to
seek psychiatric advice, but this is very much the
exception. In all usual circumstances, those treating
the patient will be able to make this assessment.
To have capacity to take a decision, a person must
be able to do ALL of the following in relation to
that decision. If your assessment concludes that any
of these are missing, then the person does not have
capacity. The patient must be able to:
Understand the information necessary to take
the decision – for a decision about medical
treatment, this will include what the treatment
is, what the risks and benefits are, what will
happen if they don’t have the treatment etc.
They don’t have to understand the information
to the same level that a professional would:
 SAFEGUARDING ADULTS (LEVEL 1)

they just have to understand it well enough to difficulties, you must take all relevant steps to
take the decision support the patient’s communication, whether
this means getting an interpreter or using non-
Retain the information for long enough to
verbal means, such as pictures or gestures, to
take a decision – the patient does not have to
communicate with them
remember the information for very long, but
it has to be long enough for them to think A patient who is anxious or in pain may find it
through the decision hard to take a decision. Deferring the decision
until they are calmer or more comfortable, or
Weigh and use the information in order to
until they have someone with them whom they
take the decision – sometimes a patient with
trust, may allow them to take a decision which
a mental impairment will understand each
they initially find very found too difficult.
piece of information separately but won’t be
able to put all the pieces together to come to Unwise decisions
a meaningful decision. This doesn’t mean that
Lack of capacity can result in unwise decisions, but
they have to come to the same decision that
the fact that a patient makes an unwise decision
the healthcare professional would recommend:
doesn’t necessarily mean that the patient doesn’t
having weighed the information they may still
have capacity. People with capacity make unwise
decide to do something which is harmful or
decisions very frequently, and the Mental Capacity
foolish. But it does mean that they must have
Act is quite specific in making clear that they have
the ability to reason about the decision, and to
the right to do so.
see how the various factors relate to each other
Sometimes, for example, a patient with capacity
Communicate a decision – this doesn’t have to
decides to leave hospital or to refuse treatment
be in words or writing; it could be in gestures
when the healthcare professional believes that this
or signs or pictures. The important thing, if
will result in serious risks to them. If the patient
a person has difficulty in communicating,
has capacity, the Mental Capacity Act cannot be
is that you give them every opportunity to
used to force the patient to stay in hospital. This
communicate their decision in any way that
situation can be very stressful for staff who are
allows you to be sure what their decision is,
worried about the consequences if they allow the
and to be sure that they have capacity
patient to leave. If staff have any doubt about the
to make it. If a person is having difficulty
patient’s capacity in this situation, it is acceptable
communicating, a Speech and Language
to hold the patient for a short period to allow an
Therapist may be able to help.
expert assessment to take place – this is one of the
The right for individuals to be supported to occasions when it may be appropriate to ask for
make their own decisions a psychiatric assessment – or to take legal advice
about the situation.
You must never rush to the conclusion that a
patient doesn’t have capacity to take a decision
without giving them all reasonable support to Who makes decisions for people who lack
enable them to do so. There are many ways that capacity to do so?
you can give this support:
Sometimes communication aids, pictures etc. If a patient lacks capacity, decisions that they would
can allow someone with an impairment to otherwise have made themselves have to be made
understand a decision which they couldn’t by others. Who this is will depend on the decision
understand just from a verbal explanation to be made. In relation to healthcare decisions, it
could be:
Sometimes a more careful or slower explanation
will allow the patient to retain the information. A healthcare professional responsible for the
A patient who has cognitive difficulties of patient’s care
any kind may need more time to absorb
information and support to weigh up the
factors involved. If a patient has communication

7
 A person granted ‘power of attorney’ by the
patient whilst they still had capacity, or granted
this power by the Court of Protection on their
behalf
The Court of Protection as a result of a request
for an individual ruling in a difficult case
Unless they have been granted this right by a
court, relatives and family do NOT have any
right to take healthcare decisions on behalf of
a person without capacity, to dictate how they
should be treated or to refuse treatment on their
behalf. Usually, healthcare decisions on behalf of
people without capacity are the responsibility of
the person responsible for the treatment or care
concerned, who will sometimes need to take a
decision that the patient’s family or friends don’t
agree with.
If someone says that they have power of attorney
for a patient, or if you think that a decision may
need to be taken by a Court, you should contact
the legal services department.
Best interests decisions and consultation
If the person cannot make their own decisions, the
people who are looking after them – in hospital
this will be the clinical staff – have a duty to take
decisions on their behalf, in their best interests.
If there is more than one decision that would be
equally beneficial to the patient, the healthcare
professional should always choose the least
restrictive option, which usually means the decision
that will be most acceptable to the patient and
involve least limitation of their freedom.
‘Best interests’ doesn’t just mean the decision that
will keep the person in the best physical health or
keep them alive for longest. To work out what is in
the person’s best interests, you have to think about
the person in the round, taking account of what
matters most to them and what impact the risks and
benefits of the decision would have for the person,
in the context of their life and values.
In order to identify the patient’s best interests, there
is a duty to consult those who know the patient
best, in a non-professional capacity – their friends
and family. This isn’t so that these people can make
the decision for the patient, but so that the decisions
made by the clinical team are as well informed as
they can be, and take account of information which
only those close to the patient can give.
8
Independent Mental Capacity Advocates
(IMCAs)
Occasionally, a patient will not have any involved
family or friends, or it may be impossible to identify
or contact them. In these cases, most decisions will
be made by the clinical team, without the benefit of
consultation.
However, to ensure that these patients are not
disadvantaged when really important decisions
are at stake, the Mental Capacity Act requires an
Independent Mental Capacity Advocate (IMCA) must
be consulted if the patient is unsupported by relatives/
friends etc. and decisions have to be made about:
Serious medical treatment – this refers to things like
operations or treatment which is irreversible or has
serious side-effects
Place of residence (eg a move to a nursing home).
IMCAs may also be involved when there are
safeguarding procedures relating to a patient
and their family, or when the patient is subject to
an application under the Deprivation of Liberty
Safeguards (see below).
However, it is important to understand that IMCAs
will not get involved in other sorts of decisions about
the patient and cannot be called on to ‘arbitrate’
in circumstances where there are family or friends
appropriate to consult, but who do not agree with the
medical opinion or with each other.
A flowchart to help staff identify whether an IMCA
application is required for a particular patient is
available on the IMCA pages on the Trust Intranet
(See under adult safeguarding, which is available from
the “I want to…” link on the front page).
On the same pages you can find information about
how to contact the IMCA service and guidance on the
steps that need to be taken.
All IMCA referrals and correspondence relating
to IMCAs should be copied to the Safeguarding
Team, by Trust email (safeguardingadults@
bartshealth.nhs.uk)

Documentation
Whenever a person is admitted as an inpatient
there should be documentation of their consent to
come into hospital, or, if they do not have capacity
to consent to this, a documentation that treatment
is being given in their best interests. The Trust has a
standard form which is used for this, which can be
completed by any nurse or doctor.
If you conclude that the patient doesn’t have
capacity to make an important decision, whether
about admission, treatment or any other matter,
you should complete the Trust Mental Capacity
and Best Interests form. This can be found via the
Safeguarding Adults pages on the Intranet. You may
have to complete this form more than once during
an admission as new decisions have to be made or
as the patient’s capacity changes.
If you are giving any treatment or care to a patient
who lacks capacity to consent to that treatment, you
should always document in your continuous notes
the basis on which you are giving care and whether
this involves any particular restrictions. Generally
this will be just a brief note, such as “personal care
given with patient’s consent” or “personal care
given in patient’s best interests: patient not able to
understand, but compliant” or “personal care given
in patient’s best interests: necessary to hold patient
as resistant to intervention”.
You should also document your discussions
with family or friends, making clear that you are
consulting with them about what is in the patient’s
best interests.
Documenting the care in this way ensures that
there is clarity about the basis for your treatment,
and that, where relevant, you are protected by the
indemnities offered by the Mental Capacity Act
for people who are acting in the best interests of a
patient who lacks capacity.
Deprivation of Liberty Safeguards (DoLs)
Sections 4A/4B and Schedules A1 and 1A MCA
(2005)
When a patient is being treated in a hospital or care
home etc. but is not able to consent to this, there is
a risk that they may be subjected to unreasonable
restrictions. There is also a risk that a patient might
SAFEGUARDING ADULTS (LEVEL 1)
be treated in hospital on this basis when in fact
they had capacity or when hospital care wasn’t
in their best interests. The Deprivation of Liberty
Safeguards are a set of provisions designed to
protect these patients who cannot consent to their
admission by giving external oversight and ensuring
a regular review of their conditions of care.
The DoLS apply to all adult patients (over 18) who:
Lack capacity to consent to their admission and
care as a result of an illness, injury or inherent
condition such as learning disability
Are under continuous supervision and control
(this is likely to apply to all patients in hospital
without capacity)
Would not be allowed to leave against medical
advice (this is also likely to apply to most
patients in hospital without capacity)
The only adult patients being treated in hospital
without capacity to whom DoLS are not likely to
apply are those:
Whose lack of capacity is outside the scope of
the Mental Capacity Act (eg patients who are
simply intoxicated)
Who are already being held under the Mental
Health Act
Who lack capacity as a result of treatment that
they have validly consented to, having been
advised that a period without capacity is likely
to be a result of the treatment (this applies,
for example, to some patients following major
surgery)
Who are likely to regain capacity, leave hospital
or die within a period of three days or less, and
are not objecting to their treatment or subject to
any special restraints
9
DoLS applications
If you have an in-patient who lacks capacity,
you should complete the Mental Capacity and
Best Interests form which is available from the
safeguarding adults page. If the information you
give in this form indicates that the criteria for DoLS
are met, an application will then be generated by
the Safeguarding Adults team, and submitted to
the local authority. Completing this form provides
authorisation for the Trust to treat the patient until
they are assessed under DoLS by the local authority,
which has to take place within two weeks of our
application being made.
Members of the Safeguarding Adults Team will
handle the administrative processes involved
with DoLS, liaise with the local authority, copy all
paperwork to the ward manager for inclusion in the
patient’s record, and advise staff on actions that are
required. The Safeguarding Adults team will also
ensure that the requisite information is provided to
the patient, their relatives and the local authority.
Ward staff are responsible for ensuring that
the Mental Capacity and Best Interest Form
is completed when required, that relevant
paperwork is passed to patients when requested
by the Safeguarding Adults Team, and that the
Safeguarding Adults Team is notified immediately if:
The patient dies, is discharged, or transfers to a
different ward or hospital
The patient regains capacity
A relative is identified when previously none
was known
A new restriction is imposed, not mentioned in
the original form (eg use of hand restraints)
The patient or their relatives ‘persistently object’
to any part of the care being provided.
If you have any concerns or questions about
the DoLS process, the Safeguarding Adults Team
will be happy to advise or to provide training for
your team.
10
Restraint
Section 6(4) The MCA (2005) states that someone
is using restraint if they:
Use force or threaten to use force to make
someone do something they are resisting.
Restrict a person’s freedom of movement, whether
they are resisting or not.
It is rarely lawful to restrain a patient. Unlawful
restraint constitutes a common assault.
Circumstances where it MAY be lawful to
restrain a patient include cases where the
restraint of a patient is the least restrictive
option for safely managing a situation and at
least one of the following apply:
A patient (with or without capacity) is being
detained under the Mental Health Act and is
seeking to leave or resisting treatment essential
for their mental health
A patient without capacity is subject to DoLS
and is seeking to leave or resisting treatment
which is in their best interests
A patient without capacity is putting themselves
at risk and the policy relating to the use of hand
restraints applies (see policy below).
There is an emergency situation where we
have a duty of care and a patient is putting
themselves others at risk
Restraint has been approved by a court
This list is not exhaustive – if there are concerns
about whether a patient should be restrained, the
Legal Services Team or Safeguarding Team should
be contacted. The Trust has a Therapeutic Restraint
and Containment policy that sets out in more
detail the circumstances under which a patient may
be restrained.
Under carefully monitored circumstances, the
Trust allows hand restraint gloves to be used to
prevent an incapable person from interfering with
equipment, pulling out tubes etc. In ITU settings
only it also allows the use of forearm restraints for
the same purpose.
The provisions relating to this form of restraint
are set out in the Therapeutic Restraint and
Containment policy. Unless specifically authorised
as set out in that policy, no equipment, material

or device may be used to restrain a person – for
example, it is not acceptable to use cot-sides,
bandaging or tight bedclothes to prevent a patient
from getting out of bed, and any such action could
result in disciplinary procedures or even legal action.
Hand (or in ITU forearm) restraints can ONLY be
used where the patient lacks capacity and any
patient subject to these restraints will almost
certainly require DoLS. The Mental Capacity and
Best Interests form must ALWAYS be completed in
respect of a decision to use hand restraints.
The Mental Health Act 1983
The Mental Health Act 1983 (amended several
times since then) sets out the circumstances in
which patients with mental disorders can be
treated in hospital or the community, including
the circumstances in which they can be detained
and treated in hospital without their consent,
(such patients may be referred to as ‘formal’
or ‘sectioned’ patients, referring to the formal
sections of the Mental Health Act which allows this
detention and treatment).
It is unusual for patients to be detained
(“sectioned”) in acute hospitals, but this is
sometimes necessary in cases where a patient
already detained in a mental health hospital needs
treatment for a physical disorder, or when a patient
being treated for a physical disorder becomes
mentally unwell during their admission. Barts
Health is licensed by the Care Quality Commission
to detain patients under the Mental Health Act
when the need arises.
The Trust Mental Health Act policy sets out the
key circumstances under which patients may be
detained, and what the implications are for their
treatment and care. The Trust’s psychiatric liaison
services, which are provided by our partner mental
health trusts, will always be involved when a
patient is detained under the Mental Health Act,
and they are able to give advice on patients where
there are serious concerns about mental health.
SAFEGUARDING ADULTS (LEVEL 1)
All clinical staff need to understand the following
points about the Mental Health Act and its
application to our patients:
The Mental Health Act is different from the
Mental Capacity Act – the two acts apply to
different issues and often to different patients
Patients subject to the Mental Health Act may
have capacity, and if so they remain free to
make their own decisions about most physical
healthcare treatments – the Mental Health Act
only applies to mental health treatment
Patients may be detained under different sections
of the Act, with different implications for care and
treatment – details of each of these is given in the
Mental Health Act policy, which should always be
used as a resource.
In every case where a patient is being detained under
the Mental Health Act, or discharged, or transferred
to another hospital, the site manager must be
informed. Site managers are able to provide advice
on the issues that arise, and have to undertake
a number of actions following the detention of
a patient. There are complex legal requirements
relating to Mental Health Act documentation. Failure
to follow these may make the patient’s detention
and treatment in hospital unlawful. Original copies
of the (usually pink) statutory forms relating to
the Act must be immediately passed to the site
managers – only copies may be kept in the patient’s
notes. Advice relating to the Mental Health Act is
available from the psychiatric liaison teams, from the
Safeguarding Adults Team, or from the Trust legal
services managers.
Female Genital Mutilation
Children and young people are cared for across
health services within both children’s and adult
services, and in specialist areas such as gynaecology.
All health professionals must be aware of the issues
around Female Genital Mutilation (FGM) and be
able to recognise when girls or young women
may be at risk of FGM or have already had FGM
performed on them. All staff should, with other
agencies, act to protect girls and young women
who may be at risk.
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What is FGM?
FGM involves procedures that include the partial or
total removal of the external female genital organs
for cultural or other non-therapeutic reasons. The
practice is medically unnecessary, extremely painful
and has serious health consequences, both at the
time when the mutilation is carried out and in later
life. FGM is prevalent in 28 African countries as well
as in parts of the Middle East and Asia.
It has been estimated that over 20,000 girls under
the age of 15 are at high risk of FGM in the UK
each year and that 66,000 women in the UK are
living with the consequences, although its true
extent is unknown due to the hidden nature of
the crime.
FGM is practised by families for a variety of complex
reasons but often in the belief that it is beneficial
for the girl or woman.
FGM constitutes a form of child abuse and violence
against women and girls. It has severe short-
term and long-term physical and psychological
consequences. It should therefore be dealt with
as part of existing child and adult protection
structures, policies and procedures.
Key points for health staff to remember
It is illegal in the UK to subject a girl or woman to
FGM or to assist anyone to carry out FGM overseas.
Health professionals are key to providing support
to victims of FGM and intervening to prevent
girls and women from being harmed. However,
investigations and enquires about any criminal
offence are the responsibility of the police and
social care, and should not be conducted by
health professionals.
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While the overarching legal issue related to FGM
is its illegality, professionals must also ensure that
they provide care and support that is consistent
with safeguarding law and policy. If you suspect
that a woman or girl has been subjected to or is
at risk of FGM you should report this to your line
manager and seek advice from the safeguarding
children or adults teams.
Key points to remember
All staff must deal with FGM in a sensitive and
professional manner, and be sufficiently prepared so
that they do not exhibit signs of shock, confusion,
horror or revulsion when treating an individual
affected by FGM.
All girls or women who have undergone FGM
should be offered counselling and may not
want to make the arrangements for this while
her boyfriend, partner, husband or other family
members are present.
Professionals should be aware that there may be
coercion and control involved, which may have
repercussions for the girl or woman.
Professionals should be familiar with the full,
relevant clinical guidance when dealing with any
case of suspected FGM.
Professionals should inform/raise awareness among
their colleagues about the issues surrounding FGM,
including the guidelines referenced at the end of
this section. Always consider other girls and women
in the family who may be at risk of FGM when
dealing with a particular case.
Source
Multi-Agency Practice Guidelines: Female Genital
Mutilation. HM Government. Crown copyright
(2011)
Further reading
Barts Health staff should be familiar with the
following documents:
What to do if you’re worried a child is being abused
(HM Government, 2015)
Working together to safeguard children (HM
Government, 2015) and the appropriate sections
of the Children Acts of 1989 and 2004 in England
and Wales

Identifying and supporting victims of
human trafficking or modern day slavery
One of the newer elements of the safeguarding
portfolio, human trafficking, is perhaps one of the
most distressing, but one to which we can truly
provide positive support as a multi agency partner.
We can offer support to the wider prevention of
human trafficking by working with the police and
local authorities, to identify potential traffickers,
while providing compassionate care, help, advice
and understanding to victims of human trafficking
who are known to come through our doors for care
and treatment.
Admission to hospital, of trafficked people may
come as a result of physical harm from violence,
including sexual violence or neglect.
There are known trafficking rings in the local
community and you can play a vital role in supporting
the police to prevent these serious crimes.
All staff in every setting may identify a victim
of human trafficking and every staff member
has a duty of care and a legal obligation to take
appropriate action if we suspect a person is a victim
of trafficking.
What is human trafficking?
Human trafficking is the recruitment, movement,
harbouring or receiving of children, women or
men through the use of force, coercion, and abuse
of vulnerability, deception or other means for the
purpose of exploitation.
Who is trafficked?
British and foreign nationals can be trafficked into,
around and out of the UK. Children, women and
men can all be victims of human trafficking.
Why are people trafficked?
Children, women and men are trafficked for a wide
range of reasons including:
Sexual exploitation
Domestic servitude
Forced labour including in the agricultural,
construction, food processing, hospitality
industries and in factories
SAFEGUARDING ADULTS (LEVEL 1)
Criminal activity including cannabis cultivation,
street crime, forced begging and benefits fraud
Organ harvesting
How might you encounter a victim of human
trafficking?
A person may tell you about their experience
You detect signs that suggest a person may
have been trafficked
A trafficked person may be referred to you
Signs of trafficking for adults, children and
young people include
A person being accompanied by someone
who appears controlling, who insists on giving
information and coming to see the health
worker.
The person
May be withdrawn and submissive, seem
afraid to speak to a person in authority and the
accompanying person speaks for them
Gives a vague and inconsistent explanation of
where they live, their employment or schooling
Has old or serious injuries left untreated
Has delayed presentation and is vague and
reluctant to explain how the injury occurred or
to give a medical history
Is not registered with a GP, nursery or school
Has experienced being moved locally, regionally,
nationally or internationally
Appears to be moving location frequently
Has an appearance that suggests general physical
neglect
May struggle to speak English
Has no official means of identification or has
suspicious-looking documents.
Children and young people may
Have an unclear relationship with the
accompanying adult
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 Go missing (sometimes within 48 hours of
going into care) repeatedly from school, home
and care
Give inconsistent information about their age
What are the possible healthcare issues of
trafficked people?
Victims of trafficking may only come to your
attention when seriously ill or injured or with an
injury or illness that has been left untreated for a
while. Healthcare issues may include:
Evidence of long term multiple injuries
Indications of mental, physical and sexual
trauma
Sexually transmitted infections
Pregnant, or a late booking over 24 weeks for
maternity care
Disordered eating or poor nutrition
Evidence of self-harm
Dental pain
Fatigue
Non-specific symptoms of Post – Traumatic
Stress Disorder
Symptoms of psychiatric and psychological
distress
Back pain, stomach pain, skin problems;
headaches and dizzy spells
How might you suspect that a person is a
victim of trafficking and what should you do?
In all cases, trust and act on your professional
instinct that something is not quite right.
It is usually a combination of triggers, an
inconsistent story and a pattern of symptoms
that may cause you to suspect trafficking.
If you have any concerns about a child, young
person or adult take immediate action and
report your concerns to your line manager and
telephone the Safeguarding Adults Team for
further support and advice.
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Remember
Trafficked people may not identify themselves as
victims of trafficking
Trafficking victims can be prevented from
revealing their experience to healthcare staff
from fear, shame, language barriers or a lack
of opportunity to do so. It can take time for a
person to feel safe
Always seek independent language interpreters
if the person is unable to speak English
Err on the side of caution regarding age – if a
person tells you they are under 18 or if a person
says they are an adult, but you suspect they
are not, then take action as though they were
under 18 years old
Try to find out more about the situation and
speak to the person in private without anyone
who accompanied them
When speaking to the person reassure them
that it is safe for them to speak
Do not make promises you cannot keep
Only ask non-judgemental relevant questions
Allow the person time to tell you their
experiences
Do not let concerns you may have about
challenging cultural beliefs stand in the way of
making informed assessments about the safety
of a child, young person or adult.
For further information go to
https://www.gov.uk/government/publications/
identifying-and-supporting-victims-of-human-
trafficking-guidance-for-health-staff

Case scenario
Background
The extent of the human trafficking problem within
London is a significant cause for concern. Barts
Health is the main provider of acute healthcare
services to the local populations of three east
London boroughs. Working in partnership with
other agencies, Barts Health staff can support the
prevention of human trafficking and the protection
of its victims. The following scenario is based on a
real incident.
Scenario
A 23-year-old woman was brought to the Accident
and Emergency Department by ambulance with
traumatic injuries to her vagina.
The patient was from Eastern Europe and spoke
little English. She was accompanied by her partner
who gave a different account of how the symptoms
had occurred to the ambulance crew to the one he
gave hospital staff.
The patient was admitted to hospital, underwent
emergency surgery for her injuries. While the patient
was in the recovery area, her partner had tried to
gain entry to see her but was turned away by the
recovery nurse.
A number of attempts were made through a
telephone interpreting service, to communicate
with the patient but these were unsuccessful.
Staff were concerned about the patient’s social
circumstances and suspected that she may be a
victim of domestic violence. It was also noticed that
there were considerable communication barriers
between the patient and her partner as well as the
hospital team.
When the patient was fit for discharge, her doctor
called social services to discuss his concerns. The
nursing and medical staff decided not to discharge
the patient until the patient had been reviewed by
social services and they were sure she would not be
in danger. It was three days later that a face to face
interpreting service was contacted to translate for
the patient. Initially she stated that everything was
fine at home and that she was not being abused.
However, when she was asked how long she had
been in the UK, she told staff that she had arrived
in the last week for an arranged marriage. She
SAFEGUARDING ADULTS (LEVEL 1)
reported that a man had paid for her to come to
the UK to marry a man that she did not know. She
went on to say that she wanted to return to her
home country, but the man had her passport and
ID and that she would be beaten if she tried to
return home. Social services were contacted again
and the staff alerted the Safeguarding Team.
The Safeguarding Team, through an interpreter,
confirmed the information that had been given to
the ward staff. The patient had been trafficked but
was reluctant to discuss this with the police because
she was frightened of the consequences for herself
and her family. The patient was given assurances
that she could be protected and the police were
contacted. A specialist police unit were informed
and the patient was discharged to a safe place.
Key points
Always use, independent interpreting services
for people who cannot speak English
Do not rely on the patient’s friends or relatives
to do this particularly when there is a need to
gain informed consent or a suspicion about
how a person sustained injuries
Access to interpreting services, including a code
to gain access to language line is available in
your wards or department. If it is not, please ask
your line manager to supply it
If you are concerned or uncomfortable about a
patient’s circumstances or something does not
feel right, even if you are unsure why –
tell someone. Report it to social services,
complete a Datix incident form and let your line
manager know
It is very unusual for theatre staff to find
relatives trying to see patients in recovery
without being invited to. If you are suspicious
about how a patient’s visitor is behaving,
raise your concerns with your colleagues and
line manager
If your initial referrals do not result in a fast
response, escalate your concerns through
other channels. Seek advice from the
Safeguarding Team and raise your concerns
with senior managers.
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Remember
If you suspect trafficking or any violence
against women or girls, you should escalate this
immediately to the Safeguarding Team, who will
engage other multi-agency partners in directing a
swift and appropriate response.
Learning from Winterbourne View
Winterbourne View was a private hospital for the
assessment and treatment of people with learning
disabilities. Many of the patients also had autism,
mental health issues and/or behaviours that were
described as challenging.
Following concerns raised by ex-staff members,
an undercover investigation was carried out and
the findings from this were revealed through the
broadcast of a BBC Panorama documentary. The
documentary showed examples of criminal abuse
taking place in the hospital which resulted in the
hospital’s closure and the imprisonment of six
members of staff.
There were warning signs that something was
wrong, but these were not picked up or acted
upon and there is now a widespread transformation
of services underway to ensure that this is not
repeated.
The key learning points from this case are:
People with learning disabilities are at high risk
of abuse
Always listen carefully to what people with
learning disabilities are saying and/or revealing
through non-verbal means eg a lack of response
or negative response to care worker
Report any sign that might reveal abuse of
any patient. These must not be ignored. Act
immediately however uncertain you may be.
Contact the Safeguarding Team or the lead nurse
for learning disabilities for advice or discussion –
even if you are not sure what you are concerned
about. It may be a feeling or intuition. Give
people the opportunity to speak in private where
appropriate (many people may find being alone
with someone they don’t know too upsetting).
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The Prevent Strategy
The Prevent Strategy is part of the Government’s
counter-terrorism strategy CONTEST and its aim is
to stop people becoming terrorists or supporting
terrorism.
Prevent falls under the NHS safeguarding strategy,
because it seeks to identify and support people
at the point when they are coming under the
influence of people seeking to radicalise them
– either directly, through personal contact, or
indirectly, for example through the internet. People
who are vulnerable for other reasons – eg mental
health problems, learning disabilities or social
difficulties – are sometimes also vulnerable to
radicalisation, and may be particularly targeted for
radicalisation by terrorist groups.
There have been a number of cases where terrorist
actions have been undertaken or planned, involving
vulnerable people who have been cynically targeted
in this way. One of the key objectives of the Prevent
Strategy is to work with sectors and institutions
where there are risks of radicalisation which need
to be addressed.
The need for NHS providers to engage with the
Prevent Strategy is two-fold:
The NHS is one of the biggest employers
in the UK and therefore integrating the
Prevent Strategy across health will ensure its
implementation is widespread throughout
the country. Staff as well as patients may be
vulnerable to radicalisation.
Frontline staff working in health may, in the
course of carrying out their duties, come into
contact with people, who may exhibit signs
or behaviours of extremist activity or may
appear to be coming under the influence of
radical groups. This might be evident in various
ways, for example comments that they make,
the nature of injuries presented at A&E, or
comments from relatives etc. about worrying
changes in their behaviour or worrying contacts
with others.
 SAFEGUARDING ADULTS (LEVEL 1)

Reporting a concern via the Prevent Strategy will

result in a review of the information available about
the person, and possibly some further inquiries
about them. If it appears that they may be becoming
radicalised, they will be offered support via the
Prevent Strategy. They are not obliged to accept this
support, but the majority of people who are offered
this do accept it. Any staff member who feels that a
patient, colleague or other person appears to be at
risk of radicalisation should contact the Trust Prevent
Strategy lead, who is a member of the Safeguarding
Adults Team (safeguardingadults@bartshealth.nhs.
uk) Further information is also available via the
safeguarding adults pages on the Trust Intranet.
All clinical staff will also be offered a more detailed
training session in relation to Prevent.

MUST DO’s
Successfully complete Safeguarding Adults
level 1 quiz
Following successful completion your records
will be updated automatically

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