CLINICAL FEATURE
KEYWORDS Safeguarding / Vulnerable adults / Abuse
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication September 2014.
Safeguarding adults
by V Richardson
Correspondence address: Theatres, Rotherham General Hospital, Moorgate Road, Rotherham, S60 2UD.
The safeguarding of patients is a key concern for all health and care professionals. Research
shows that more instances of unacceptable care are likely to occur due to an increase in
population of those deemed to be vulnerable. Increasing professionals’ awareness, knowledge
and understanding of safeguarding and of the systems in place for reporting concerns is
essential for best practice and for protecting patients and their families.
Introduction
Safeguarding vulnerable people is
a professional responsibility. When
opportunities to protect are missed by
individual professionals and agencies,
resulting in the unfortunate death of a
victim, for example Victoria Climbie or
Baby P a lot of negative media attention is
generated. These high profile cases have
led to a much greater awareness of child
protection and improvements in the service
across all professional groups as a result.
But what about the following names: Steven
Hoskin, Gemma Hayter, Michael Gilbert,
or Margaret Panting? These are all equally
serious cases, but involve vulnerable adults
rather than children. There is comparatively
little research on the protection of adults
(Ramsey 2009) and staff remain confused
over the frameworks in place for their
protection (Manthorpe et al 2012).
This article aims to define safeguarding,
raise awareness, and discuss our
responsibilities to address the needs of a
growing vulnerable population with regard
to current legislation.
What is safeguarding?
Safeguarding is the protection of
vulnerable groups from abuse and/or
neglect and forms a key responsibility
not just of healthcare professionals, but
of all people working with these groups.
This responsibility is encompassed in the
Department of Health’s NHS Constitution
(DH 2012a) in its principle of ‘…provides
a comprehensive service to all’. The
service we provide as professionals should
seek to address any concerns regarding
safeguarding that we may have about a
patient. This is reiterated by the Health
and Care Professions Council (HCPC) in
their Standards of conduct, performance
and ethics (2008a) as ‘You must act in
118
the best interests of service users’. The
issue of responsibility is also addressed in
the Standards of proficiency for operating
department practitioners (HCPC 2008b),
and the Nursing and Midwifery Council’s
code of conduct (NMC 2008). Keeping
our patients and other service users safe
from avoidable harm, abuse, or anything
else detrimental to their wellbeing is
fundamental to acting in their best interests
and providing an optimal service of care (DH
2011). Failure to do this and to follow the
principles of the Mental Capacity Act 2005
can itself be deemed to be abuse and can
result in prosecution (Phair & Heath 2012).
Abuse of an individual can take many forms
and its definition is open to interpretation,
but it can be defined as the violation of
an individual’s human and civil rights by
any other person or persons (DH 2000).
Government guidance in ‘No secrets’ (DH
2000) categorised abuse in the following
groups: physical, sexual, psychological,
financial/material, neglect/acts of omission,
discriminatory; these may be perpetrated as
a result of deliberate intent, negligence or
ignorance. It is also explained that neglect
and poor professional practice creates a
further category of institutional abuse. This
would include cases such as the problems
at Mid Staffordshire NHS Foundation Trust
detailed in the Francis report (Mid Staffs
2010), and the events at Winterbourne
View Hospital which were exposed by a
BBC Panorama programme in 2011 (DH
2012b). The latter resulted in the criminal
prosecution of some members of staff, and
demonstrated that, despite the effective
disclosure and barring for working with
vulnerable adults and children introduced
in the Safeguarding Vulnerable Groups Act
2006, some perpetrators of abuse avoid
detection and still work in a professional
capacity (Griffith & Tengnah 2009a,b). We
need to be aware that such things exist
May 2014 / Volume 24 / Issue 5 / ISSN 1750-4589
and not ignore our suspicions as that itself
creates an act of omission.
Vulnerable adults using the
theatre service
Most practitioners working in theatres will
come into contact with a huge variety of
patients over the length of their career, and
in areas such as obstetrics and paediatrics
will also have contact with family or carers
of the patient. Patients could be children,
people with mental health problems, people
with disabilities (both physical and/or
learning), and the elderly. Whilst the main
responsibilities are towards the patient, and
those over 18 with capacity have a right
to make choices about their own safety,
there is also a professional responsibility to
consider the risk, and to safeguard those in
contact with the patient. This can include,
for example, dependent children or adults
in the same household that they may be
caring for who may be at risk of neglect or
abuse from the patient (DH 2011, Phair &
Heath 2012).
A vulnerable adult is defined by the
Department of Health (DH 2000) as:
‘... who is or may be in need of community
care services by reason of mental or
other disability, age or illness; and who
is or may be unable to take care of him
or herself, or unable to protect him or
herself against harm or exploitation.’
Statistics show that vulnerable adults are
abused as often as children (O’Keefe et al
2007). Yet, although there is a wealth of
evidence on the protection of children, there
is comparatively little on the protection
of adults (Ramsey 2009) and staff seek
clearer frameworks for understanding and
dealing with such cases (Manthorpe et al
2012).

Like many policies, safeguarding policies are often lengthy documents and this
can make it difficult for staff to extract the information they need
It should be noted that neither a person’s
age nor disability by itself makes the person
vulnerable. Their vulnerability is affected
by their personal circumstances, the risks
to them from the environment, and by the
presence of resilience factors such as their
personal strengths and social supports (DH
2011). However, due to better treatments
and advances in care, there is a growth
in the elderly population with multiple co-
morbidities (disability, mobility and cognitive
problems), and therefore with increased
vulnerability. The risk for the abuse and
neglect of these vulnerable elderly patients
will also therefore increase (O’Keefe et al
2007, Day et al 2010).
In 2007 a report prepared by O’Keefe et
al for Comic Relief and the Department of
Health into the abuse and neglect of elder
people showed that 4% of those over the
age of 66 (equating to 342,400 people)
had suffered abuse and that this was
likely to be under-reported due to fear and
embarrassment of those taking part in the
survey. The survey also acknowledged it did
not include those with severe dementia or
living in residential care, which make up a
significant vulnerable group, and could have
led to further under reporting. The increase
in the elderly population, along with the
under reporting of abuse and/or neglect
highlights why healthcare professionals
need to be vigilant and open to concerns
when dealing with this group of vulnerable
adults and effective strategies need to be
put in place to protect both patients and
staff (Ramsey 2009). The increase in this
patient demographic in turn leads to an
increase in how often we encounter the
elderly due to the number of procedures
strongly related to age, for example, hip and
knee replacements, carotid endarterectomy,
and cataract surgery. Therefore, we in
theatre departments need to increase our
knowledge and awareness of these issues.
Roles and responsibilities
towards vulnerable adults
Our basic roles and responsibilities towards
the safeguarding of vulnerable adults,
or indeed any vulnerable group, are the
same as those of any other professional
working with these groups. Namely, these
responsibilities are: to report any suspicions
appropriately, document discussions
May 2014 / Volume 24 / Issue 5 / ISSN 1750-4589
and any action taken accurately, follow
local and national policies as required,
but underpinning all of these, to have an
awareness and knowledge of this area
of work (Manthorpe et al 2012). Without
maintaining knowledge in this area we fail
in our role as a professional, and in our
duty to patients as described in the HCPC
standard ‘You must keep your professional
knowledge and skills up to date’ (2008a).
It is the employer’s responsibility to provide
basic induction training on policy and
procedures, awareness of abuse and the
duty to report, and to provide updates
(DH 2000). Safeguarding training should
provide the opportunity to discuss and
share experiences that will help others to
gain valuable knowledge (Day et al 2010),
especially those new to their profession
who have little direct experience and so rely
on the experience of others to inform their
practice.
Like many policies, safeguarding policies
are often lengthy documents and this can
make it difficult for staff to extract the
information they need. Phair and Heath
(2012) raised the point that it is not always
clear which system to use when reporting
concerns and incidents. This issue needs
to be addressed as such confusion over
reporting is detrimental to our patients
and can delay action and cause poor
collaboration when relevant information not
being shared appropriately with the correct
agencies. Employers and trainers need
to find a way of simplifying information so
that it is readily available to frontline staff
in a clear format which does not involve
reading pages and pages of literature to
find the most basic actions to take. Systems
must provide a simple way of reporting any
concern staff may have.
In our daily work in the theatre environment
there are several actions that we can take
to ensure the safeguarding of patients.
Team briefings before the start of lists,
as well as covering information relating
to equipment etc provide an opportunity
to share information regarding existing
safeguarding issues. To respect patient
confidentiality, information can be shared
only on a need to know basis, and if it
directly affects what we may be doing with
the patient (DH 2000, HCPC 2008a,b).
CLINICAL FEATURE
Disclosure of abuse
Due to the nature of our roles in theatre
we are rarely alone with a patient for
any significant amount of time. In the
anaesthetic room an anaesthetist would
normally be present, and in theatre
itself there would be numerous other
staff present. For most of this time the
patient will be under the influence of a
general anaesthetic or possibly sedation
if undergoing a procedure under regional
or local anaesthesia. Patient disclosure
of abuse is therefore rare to practitioners
in our role due to the preference of most
people to disclose to someone with whom
they have built up a rapport, and during
one-to-one contact. Our role and working
environment does not allow for this due
to the number of staff present and the
short time available before induction of
anaesthesia. However, this may not be the
best care for the patients. An anaesthetic
room is a closed, private environment and
could provide an ideal opportunity for a
disclosure to be made. It may also be the
only time that a patient is away from a
perpetrator of abuse who, for example, may
be influencing their behaviour on a ward
environment. Unless we are informed of any
concerns at team briefing, we are pressured
into moving to induction of anaesthesia
without delay, and so an opportunity to
initiate safeguarding procedures is missed.
During surgical procedures we are in a
unique position for identifying marks or
injuries left by physical abuse as the patient
is often exposed in areas that they could
otherwise hide. Perpetrators of physical
abuse are known to concentrate on those
areas not normally visible to others (Bertolli
et al 2011), yet due to the rolling of patients
for us to carry out skin assessments
for pressure area management we may
discover suspicious markings. These need
to be referred to safeguarding teams, in
line with local policy, so that appropriate
safeguarding responses can be initiated.
Documentation on perioperative care plans
is essential and must be relevant, accurate,
legible and complete (HCPC 2008a,b) to
provide evidence for future reference.
Following up concerns and feedback
Many places adopt a hierarchical approach
to dealing with safeguarding issues, with
a senior staff member being responsible
119
CLINICAL FEATURE
Safeguarding adults
Continued
for reporting and following up concerns.
Whilst this has advantages there is also
a significant disadvantage. Research
shows that the abuse of vulnerable adults
is currently under-reported and that the
risk of abuse is likely to increase because
of a growing aging population (Griffith
& Tengnah 2009a), but some staff are
not gaining familiarity with safeguarding
strategies and procedures from actually
applying their knowledge from training (DH
2009).
This drawback needs to be addressed
otherwise it will lead to a largely
inexperienced staff group and a lack of
engagement in safeguarding activity, which
in turn impacts patient care. This concern
was raised by the review of the No secrets
document (DH 2009). Whilst it makes
sense to have a senior member of staff
responsible for dealing with safeguarding,
perhaps it would be beneficial for them
to supervise and advise junior staff in
dealing with a concern rather than take
sole responsibility themselves. Some
workplaces already adopt this approach,
however this highlights another problem
with regards to safeguarding adults: there
is relatively little research and literature on
adult safeguarding procedures and the best
methods for handling concerns in practice.
Another way in which safeguarding
procedures could improve is with the
provision of feedback on referrals. Whilst
confidentiality for the patient must take
priority, feedback on what was done
correctly, what could be improved, whether
suspicions were justified and appropriate
actions are now being taken, would
help to build practitioners’ confidence in
reporting, would inform future practice and
acknowledge their contribution to a much
wider team of professions and agencies.
The report into Mid Staffordshire NHS Trust
(2013) states in recommendation 12:
‘…reporting of incidents of concern
relevant to patient safety, compliance with
fundamental standards or some higher
requirements of the employer, need to be
not only encouraged but insisted upon.
Staff are entitled to receive feedback in
relation to any report they make, including
information about any action taken or
reasons for not acting.’
Although this refers mainly to the neglect
and poor standards which could be deemed
as institutional abuse, safeguarding is a
120
key part of patient safety and so it could be
applied to other safeguarding procedures
too.
Conclusion
Safeguarding vulnerable adults is equally
as important as safeguarding children,
especially as this population group is
increasing due to an aging population.
Greater familiarity with safeguarding adults,
especially the elderly, is needed in the
theatre department as our work is likely to
see an increase in the elderly attending for
procedures. Adequate training, increased
awareness, and effective collaboration
between different professions must exist
within the healthcare environment for
effective safeguarding to take place and to
address the potential growth of the problem
in the vulnerable adult group.
References
Bertolli ER, Brown CD, Pannone DR, Bartles TW 2011
Physical abuse Forensic Examiner 20 (3) 60-5
Day MR, Bantry-White E, Glavin P 2010 Protection
of vulnerable adults: an interdisciplinaray workshop
Community Practitioner 83 (9) 29-32
Department for Constitutional Affairs 2005 Mental
Capacity Act 2005 London
Department of Health 2000 No secrets: Guidance
on developing and implementing multi-agency
policies and procedures to protect vulnerable
adults from abuse Available from: www.gov.uk/
government/publications/no-secrets-guidance-
on-protecting-vulnerable-adults-in-care [Accessed
November 2013]
Department of Health 2009 Safeguarding adults:
Report on the consultation on the review of
‘No secrets’ Available from: http://webarchive.
nationalarchives.gov.uk/20130107105354/http://
www.dh.gov.uk/prod_consum_dh/groups/dh_
digitalassets/documents/digitalasset/dh_102981.
pdf [Accessed November 2013]
Department of Health 2011 Safeguarding adults:
The role of health services Available from:
http://webarchive.nationalarchives.gov.uk/+/
www.dh.gov.uk/en/publicationsandstatistics/
publications/publicationspolicyandguidance/
dh_124882 [Accessed November 2013]
Department of Health 2012a The NHS Constitution
for England Updated March 2013 Available from:
www.gov.uk/government/publications/the-nhs-
constitution-for-england [Accessed November 2013]
Department of Health 2012b Transforming care: A
national response to Winterbourne View Hospital.
Final Report Available from: www.gov.uk/
government/uploads/system/uploads/attachment_
data/file/127310/final-report.pdf.pdf [Accessed
November 2013]
May 2014 / Volume 24 / Issue 5 / ISSN 1750-4589
Griffith R, Tengnah C 2009a The protection of
vulnerable adults and the law British Journal of
Community Nursing 14 (6) 262-6
Griffith R,Tengnah C 2009b Understanding the
Safeguarding Vulnerable Groups Act 2006 British
Journal of Community Nursing 14 (7) 309-13
Health & Care Professions Council 2008a Standards
of conduct, performance and ethics London, HCPC
Health & Care Professions Council 2008b
Standards of proficiency: operating department
practitioners London, HCPC
Manthorpe J, Wilkinson A, Chinn D, Coopamah
V 2012 Changes and sticking points in adult
safeguarding: a discussion British Journal of
Community Nursing 17 (7) 334-9
Mid Staffordshire NHS Trust Public Inquiry
2010 Robert Francis inquiry report into Mid-
Staffordshire NHS Foundation Trust Available
from: www.midstaffspublicinquiry.com/key-
documents [Accessed November 2013]
Mid Staffordshire NHS Trust Public Inquiry 2013
Report of the Mid Staffordshire NHS Foundation
Trust public inquiry: Executive summary Available
from: www.midstaffspublicinquiry.com/report
[Accessed November 2013]
Nursing and Midwifery Council 2008 The code:
Standards of conduct, performance and ethics for
nurses and midwives London, NMC
O’Keefe M, Hills A, Doyle M et al 2007 UK Study of
abuse and neglect of older people: Prevalence
survey report Available from: www.warwickshire.
gov.uk/Web/corporate/wccweb.nsf/Links/6EA9
19F805F3B54180257885002E4C6B/$file/Full+
Report_UK+Study+of+Abuse+and+Neglect+of+
Older+People+v2.pdf [Accessed November 2013]
Phair L, Heath H 2012 Safeguarding vulnerable older
people in hospital Nursing Standard 27 (4) 50-5
Ramsey J 2009 Safeguarding vulnerable adults
Nursing Management 16 (4) 24-9
About the author
Victoria Richardson
BSc (Dual Hons), PGCE, DipHE
Operating Department Practitioner, Theatres,
Rotherham General Hospital
No competing interests declared
Members can search all issues of the BJPN/JPP
published since 1998 and download articles free of
charge at www.afpp.org.uk.
Access is also available to non-members who pay a
small fee for each article download.
 Disclaimer The views expressed in articles published by the
Association for Perioperative Practice are those of the writers and do not
necessarily reflect the policy, opinions or beliefs of AfPP.

Manuscripts submitted to the editor for consideration must be the

original work of the author(s).

© 2014 The Association for Perioperative Practice

All legal and moral rights reserved.

The Association for Perioperative Practice

Daisy Ayris House
42 Freemans Way
Harrogate
HG3 1DH
United Kingdom

Email: hq@afpp.org.uk
Telephone: 01423 881300
Fax: 01423 880997
www.afpp.org.uk