Self-Neglect & Safeguarding Adults

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Case 1: Margaret, 78

Low-Medium Complexity

Referral Source: Housing Association

📋 Initial Referral

"Concerns raised about Margaret, 78, living alone. Housing officer reports strong odour from property, newspapers piled to ceiling in hallway, and Margaret refusing entry for gas safety check. Neighbours report not seeing her outside for weeks. Previous referral 18 months ago — NFA'd."

✍️ What are your immediate thoughts? What assumptions are you making?

🤔 Check any initial assumptions you're making:

She's hoarding and has mental health issues She's isolated and vulnerable because she's elderly Refusing entry means she's hiding something or lacks capacity The previous NFA decision was a mistake or failure Living in clutter/with strong odours = self-neglect

💡 Guidance: Generating Alternative Hypotheses

Before revealing more information, challenge yourself to think differently. Ask:

• What else could explain this behaviour?
• What haven't I been told?
• What would a different professional perspective reveal?
• What might this person's own explanation be?
• How might trauma, grief, or past experiences shape this situation?

💭 Aim for at least 3 different explanations — even ones that seem unlikely. This practice builds critical thinking muscles.

🔄 Generate 3+ Alternative Hypotheses (What else could explain this?)

📖 The Fuller Picture

• Margaret is a retired archivist; newspapers are her research collection on local history
• She has capacity and articulates clear reasons for her choices
• The "odour" is from her cats — she has 3, all registered and vaccinated
• She shops online and has regular phone contact with her daughter in Scotland
• Previous referral was similar — she declined intervention and situation remained stable
• She is managing her finances, attending medical appointments, and eating well

🎯 Common Assumptions Exposed

"Hoarding = mental illness" "Isolation = vulnerability" "Refusing services = lacking capacity" "Previous NFA = failure"

🌐 SOCIAL GRACES Analysis

Consider how these intersecting factors may have influenced your assumptions:

Age: Did ageism lead you to assume cognitive decline or vulnerability?

Gender: Would you have made the same assumptions about a 78-year-old man living similarly?

Class/Education: Her professional history as an archivist wasn't mentioned in the referral. How did this absence shape your thinking?

Living alone: Did you assume isolation equals loneliness or vulnerability?

⚡ Intersectionality Challenge

Critical Question: How do ageism and gendered assumptions about "appropriate" behaviour for older women intersect in this case?

• Are older women judged more harshly for unconventional living arrangements?
• Does the label "refusing" carry different weight when applied to an elderly woman versus a younger person?
• How do assumptions about "proper" femininity and domesticity influence professional judgement?

💭 After Reading the Fuller Picture

✍️ How did the additional context change your understanding?

🔄 Reflection Checklist

Now that you know the fuller picture, which of these apply?

I made assumptions based on limited information The language in the referral influenced my thinking I can see how Margaret's choices are valid for her I understand the difference between "unconventional" and "neglect" Ageism may have influenced my initial response

🎓 Key Questions for Practice

• How did ageism influence your initial assumptions?
• What is the difference between "unconventional lifestyle" and "self-neglect"?
• Under the Care Act 2014, what would "wellbeing" mean for Margaret?

👨

Case 2: James, 45

Medium Complexity

Referral Source: A&E Department

📋 Initial Referral

"James, 45, attended A&E with infected leg ulcers. Third presentation in 6 months. Discharged himself against medical advice. Staff describe him as 'aggressive' and 'non-compliant'. Notes indicate history of alcohol misuse. Address flagged for previous police callouts. Living conditions described as 'squalid' by paramedics."

✍️ What are your immediate thoughts? What assumptions are you making?

🤔 Check any initial assumptions you're making:

He's aggressive and difficult to work with He's non-compliant and doesn't want help Alcohol misuse is the primary problem Police callouts mean he's causing trouble He chooses to live this way

💡 Guidance: Generating Alternative Hypotheses

Before revealing more information, challenge yourself to think differently. Ask:

• What else could explain this behaviour?
• What haven't I been told?
• What would a different professional perspective reveal?
• What might this person's own explanation be?
How might trauma, grief, or past experiences shape this situation?

💭 Aim for at least 3 different explanations — even ones that seem unlikely. This practice builds critical thinking muscles.

🔄 Generate 3+ Alternative Hypotheses

📖 The Fuller Picture

• James served in Afghanistan; diagnosed with PTSD and chronic pain from injury
• His "aggression" occurs when feeling trapped — a trauma response, not hostility
• He stopped drinking 8 months ago but is not engaged with support services
• Police callouts were James calling about break-ins (he was the victim)
• He self-discharges because hospital environments trigger flashbacks
• His flat is cluttered with military memorabilia; he struggles to discard items
• He has no family contact after relationship breakdown linked to his PTSD

🎯 Common Assumptions Exposed

"Aggression = difficult person" "Non-compliance = choice" "Police involvement = perpetrator" "Alcohol history = current problem"

🌐 SOCIAL GRACES Analysis

Consider how these intersecting factors may have influenced your assumptions:

Gender: Did gendered expectations about male stoicism and "coping" influence your thinking?

Socioeconomic status: The referral mentions "squalid" conditions. How did class assumptions shape your response?

Appearance/Lifestyle: Did the combination of "alcohol history" + "police" + "aggressive" create a negative halo effect?

Occupation: His military service wasn't mentioned until the reveal. How might this have changed your initial assessment?

⚡ Intersectionality Challenge

Critical Question: How do class, gender, and mental health stigma intersect in this case?

• Are working-class men with mental health issues more readily labelled as "aggressive"?
• How does the "deserving/undeserving" narrative affect veterans with PTSD?
• Would a middle-class professional with PTSD be described using the same language?
• How do masculine norms about expressing emotion and seeking help compound vulnerability?

💭 After Reading the Fuller Picture

✍️ How did the additional context change your understanding?

🔄 Reflection Checklist

Now that you know the fuller picture, which of these apply?

I made assumptions based on limited information The language in the referral influenced my thinking I understand how trauma manifests as "non-compliance" I can see the importance of trauma-informed practice Class and gender bias may have influenced my response

🎓 Reflection Questions

• How might a trauma-informed approach change this intervention?
• What does "self-neglect" mean when someone is struggling with PTSD?
• How do we balance the Armed Forces Covenant with safeguarding duties?

👩

Case 3: Priya, 52

High Complexity

Referral Source: Adult Social Care (transfer)

📋 Initial Referral

"Transfer from neighbouring authority. Priya, 52, has care needs following stroke but consistently refuses carers. Family report she 'doesn't look after herself properly' and her diabetes is uncontrolled. Daughter states mother 'won't listen to anyone' and is 'in denial about her limitations'. Previous safeguarding referral for financial abuse by son (unsubstantiated). Described as 'culturally isolated' — limited English."

✍️ What are your immediate thoughts? What assumptions are you making?

🤔 Check any initial assumptions you're making:

Limited English means she lacks capacity to make decisions Her family knows what's best for her She's in denial about her health needs Refusing carers equals self-neglect Traditional approaches to health are problematic

💡 Guidance: Generating Alternative Hypotheses

Before revealing more information, challenge yourself to think differently. Ask:

• What else could explain this behaviour?
• What haven't I been told?
• What would a different professional perspective reveal?
• What might this person's own explanation be?
• How might trauma, grief, or past experiences shape this situation?

💭 Aim for at least 3 different explanations — even ones that seem unlikely. This practice builds critical thinking muscles.

🔄 Generate 3+ Alternative Hypotheses

📖 The Fuller Picture

• Priya speaks fluent English but previous assessments never used interpreters for her first language (Gujarati) — she has aphasia affecting her English more than Gujarati post-stroke
• She refuses carers because previous agency sent male carers without consultation, causing her distress due to cultural and personal preferences
• The "financial abuse" referral came from daughter during a family dispute; Priya had given money willingly to her son for his business
• Priya manages her diabetes differently using traditional foods — her HbA1c is actually stable
• Daughter has lasting power of attorney for finances but not health — yet has been making health decisions
• Priya has clearly expressed wishes to remain independent; these have not been recorded or respected

🎯 Common Assumptions Exposed

"Limited English = lacks capacity" "Family knows best" "Refusing care = self-neglect" "Medical model = only valid approach"

🌐 SOCIAL GRACES Analysis

Consider how these intersecting factors may have influenced your assumptions:

Culture/Ethnicity: Did assumptions about "traditional cultures" lead to stereotyping about family dynamics or health beliefs?

Language: Was "limited English" used as a proxy for limited capacity or intelligence?

Gender: Did assumptions about South Asian women and family hierarchies influence your thinking?

Age + Disability: How did the stroke diagnosis interact with assumptions about her ethnicity and language?

⚡ Intersectionality Challenge

Critical Question: How do racism, ableism, and linguistic discrimination intersect in this case?

• Are women of colour more readily seen as "passive" victims who need families to speak for them?
• How does the medical model's dominance erase valid alternative health practices from minoritized communities?
• Would a white British stroke survivor with aphasia be described as having "limited English"?
• How do professional assumptions about "cultural isolation" pathologize difference?

💭 After Reading the Fuller Picture

✍️ How did the additional context change your understanding?

🔄 Reflection Checklist

Now that you know the fuller picture, which of these apply?

I made assumptions based on limited information The language in the referral influenced my thinking I understand the difference between communication barriers and capacity I can see how cultural assumptions affected the assessment Racism and ableism may have influenced my response

🎓 Reflection Questions

• How did assumptions about culture and language affect previous assessments?
• What are the safeguarding implications of the daughter's actions?
• How does Making Safeguarding Personal apply here?
• What is the role of advocacy under the Care Act 2014?

👴

Case 4: David, 67

Very High Complexity

Referral Source: Multi-agency meeting

📋 Initial Referral

"Long-standing case. David, 67, severe self-neglect. Property condemned by Environmental Health. Diagnosed with 'Diogenes syndrome'. Multiple agencies involved over 5 years with no progress. Fire service report extreme fire risk. GP states David 'lacks insight'. Neighbours petitioning council for action. Mental health services discharged him as 'not meeting criteria'. Legal advice sought regarding inherent jurisdiction."

✍️ What are your immediate thoughts? What assumptions are you making?

🤔 Check any initial assumptions you're making:

This is a hopeless case with no solution The diagnosis explains everything Multiple agencies involved means everything has been tried He lacks insight/capacity Legal action is the only option left

💡 Guidance: Generating Alternative Hypotheses

Before revealing more information, challenge yourself to think differently. Ask:

• What else could explain this behaviour?
• What haven't I been told?
• What would a different professional perspective reveal?
• What might this person's own explanation be?
• How might trauma, grief, or past experiences shape this situation?

💭 Aim for at least 3 different explanations — even ones that seem unlikely. This practice builds critical thinking muscles.

🔄 Generate 3+ Alternative Hypotheses

📖 The Fuller Picture

David was a successful architect; his wife died 6 years ago, followed by both parents within a year
• "Diogenes syndrome" was diagnosed without psychiatric assessment — it's a description, not a diagnosis
• He has never had a Mental Capacity Act assessment specific to decisions about his living conditions
• His "lack of insight" conclusion came from a 10-minute GP consultation
• No one has explored what David wants or what would help him — all interventions have been enforcement-focused
• He has a brother he's estranged from; no one has attempted family mediation
• His hoarding began as preservation of his wife's belongings; now includes other items
• He engages well with his neighbour's dog — the only positive relationship documented

🎯 Common Assumptions Exposed

"Long-standing = hopeless" "Diagnosis = explanation" "Multiple agencies = everything tried" "No progress = person's fault" "Legal action = only solution"

🌐 SOCIAL GRACES Analysis

Consider how these intersecting factors may have influenced your assumptions:

Gender + Age: Did assumptions about older men being "stubborn" or "set in their ways" influence thinking?

Class/Education: His professional background wasn't mentioned until the reveal. How might this have affected initial assumptions?

Appearance: The focus on "condemned property" and "fire risk" may have obscured understanding of underlying grief

Loss: Experiencing multiple bereavements in quick succession — how does unresolved grief intersect with professional frustration?

⚡ Intersectionality Challenge

Critical Question: How do ageism, masculine norms about grief, and professional burnout intersect in this case?

• Are older men expected to "cope" with bereavement without emotional support?
• How does the narrative of "no progress" position David as the problem rather than examining system failures?
• Would a younger professional with grief-related hoarding be approached more empathetically?
• How does "professional frustration" with complex cases lead to punitive rather than compassionate responses?

💭 After Reading the Fuller Picture

✍️ How did the additional context change your understanding?

🔄 Reflection Checklist

Now that you know the fuller picture, which of these apply?

I made assumptions based on limited information The language in the referral influenced my thinking I understand how grief can manifest as self-neglect I can see how "no progress" may reflect system issues, not just individual resistance Ageism and gender norms may have influenced my response

🎓 Reflection Questions

• What might "no progress" actually mean? Whose definition of progress?
• How has grief been addressed (or not) in this case?
• What does the LGA/ADASS guidance say about complex self-neglect?
• How might a relationship-based approach look different?
• What are the ethical tensions between autonomy and duty of care?

How to Use This Activity

Select a Case to Begin

Case 1: Margaret, 78

Case 2: James, 45

Case 3: Priya, 52

Case 4: David, 67

Your Progress

Case 1: Margaret, 78

📋 Initial Referral

💡 Guidance: Generating Alternative Hypotheses

📖 The Fuller Picture

🎯 Common Assumptions Exposed

🌐 SOCIAL GRACES Analysis

⚡ Intersectionality Challenge

💭 After Reading the Fuller Picture

🔄 Reflection Checklist

🎓 Key Questions for Practice

Case 2: James, 45

📋 Initial Referral

💡 Guidance: Generating Alternative Hypotheses

📖 The Fuller Picture

🎯 Common Assumptions Exposed

🌐 SOCIAL GRACES Analysis

⚡ Intersectionality Challenge

💭 After Reading the Fuller Picture

🔄 Reflection Checklist

🎓 Reflection Questions

Case 3: Priya, 52

📋 Initial Referral

💡 Guidance: Generating Alternative Hypotheses

📖 The Fuller Picture

🎯 Common Assumptions Exposed

🌐 SOCIAL GRACES Analysis

⚡ Intersectionality Challenge

💭 After Reading the Fuller Picture

🔄 Reflection Checklist

🎓 Reflection Questions

Case 4: David, 67

📋 Initial Referral

💡 Guidance: Generating Alternative Hypotheses

📖 The Fuller Picture

🎯 Common Assumptions Exposed

🌐 SOCIAL GRACES Analysis

⚡ Intersectionality Challenge

💭 After Reading the Fuller Picture

🔄 Reflection Checklist

🎓 Reflection Questions

Activity Complete!

Case 1: Margaret, 78

💭 Your Initial Thoughts:

🔄 Your Alternative Hypotheses:

📖 Commentary:

Case 2: James, 45

💭 Your Initial Thoughts:

🔄 Your Alternative Hypotheses:

📖 Commentary:

Case 3: Priya, 52

💭 Your Initial Thoughts:

🔄 Your Alternative Hypotheses:

📖 Commentary:

Case 4: David, 67

💭 Your Initial Thoughts:

🔄 Your Alternative Hypotheses:

📖 Commentary:

🌟 Overall Reflection Questions

🧠 Key Learning Points

Respectful Uncertainty

Challenge Assumptions

Context Matters

Alternative Hypotheses