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Is he guilty of elder abuse against his diabetic wife?

Case history

Mr and Mrs C are an elderly, wealthy couple. Mrs C is a brittle type 2 diabetic on insulin, which her husband supervises.

His expectations are high and he is often in conflict with practice and district nurses. When he attends with his wife he has a very authoritarian attitude with the receptionists, although he is polite to the GPs.

Today's home visit is as a result of Mrs C falling in the garden. Her husband, who usually does all the talking, is out. Her injuries are mild and involve grazing to her knee and palm.

She then asks you to look at her back, saying it was where her husband had 'thumped' her, causing her to fall. You see an early but definite bruise on her shoulder.

With perfect timing her husband reappears and is concerned, covering his wife's shoulder and telling you she is falling a lot.

Dr Liz Bowen

'I must somehow get rid of Mr C so she can talk to me openly'

Either Mrs C is genuinely falling and, for reasons of dementia or malice, is falsely stating her husband pushed her, or this is domestic violence. I could explore the situation further even though Mr C has returned. Some open-ended questions about the difficulty of living with Mrs C's condition, and the restrictions it puts on their lives, might elicit some obvious frustrations and aggression from Mr C.

I would encourage Mrs C to give her account and ask Mr C to allow her to talk. I would suggest that if Mrs C has been falling I should make a full assessment in the surgery. She might be willing to talk if I could get her by herself.

There may be other family members known to the team who could shed light on Mrs C's mental state and her relationship with Mr C. And the district and surgery nurses may have comments too.

When they do attend, I could take Mrs C to another room to examine her away from her husband, to allow us to chat. If Mrs C disclosed regular abuse, and I felt her to be compos mentis, I would discuss with her what approach to take. I would make her aware that this behaviour was not acceptable or legal and that she could involve the police. I think she would decline, and I would have to decide if the situation was serious enough for me to breach confidentiality to contact the domestic violence unit. Either way, a needs assessment by social services would be appropriate.

Dr Michael Crawford

'This ''abuse'' may be an ongoing problem or a one-off episode'

I need to attend initially to the medical needs of Mrs C who has requested the home visit and, second, address her frank and open allegation.

Her injuries appear consistent with a blow to the shoulder, which has unbalanced her, causing a fall. It seems unlikely that hypoglycaemia would have caused confusion and confabulation, leading to a visit request in the absence of Mr C. Mr C is probably unaware that his wife has divulged his actions and is obviously keen to escort me off-side as promptly as possible.

However, even though Mr C has returned, I cannot ignore his wife's allegation. Perhaps this has been an ongoing problem and due to Mr C's persistent presence has never come to light in a consultation or maybe this is a one-off 'spur of the moment' action.

I would ask Mrs C if she would mind me discussing our conversation with her husband and if she agreed I would ask him to explain what had happened.

My further actions would depend on his response. If, as is most likely, he dismisses this sequence of events out of hand I will explain to him that following any incident of this nature social services would be informed and may visit the home.

Given the last thing I wish to be in this situation is confrontational, I would ask Mrs C to see me the following week at the surgery to be reviewed after her falls.

If Mrs C declines to allow me to discuss our conversation then I would complete my examination and leave to make a detailed record, inform my partners of the alleged incident and discuss ongoing supervision with social services.

I would also briefly discuss the case with my medical indemnity society.

Dr Lorna Gold

'Confronting Mr C will have only a very limited benefit for Mrs C'

Unless the practice has a system at management level for dealing with difficult patients, Mr C and I are unlikely to have anything more than a mutually civil but silently antagonistic working relationship.

If the receptionists or nurses had complained I would not have hesitated to spell out to him, in Anglo-Saxon monosyllables and in his wife's presence, that his behaviour was unacceptable.

If I perceive Mr C to be an unpleasant bully who feels the need to be dominant when dealing with women, I will find it all too easy to believe he has been battering his hapless wife throughout their marriage and will have to make a conscious effort to avoid responding to this instinctive conclusion because there are other, equally likely, explanations.

Confronting Mr C with the fact that his wife has told a very different story about how she came by her injuries would have a very limited upside and a huge downside for Mrs C. Even if my inclination to believe her is correct, I have enough experience of dealing with couples in abusive relationships to realise that if I accuse Mr C of assaulting his wife, he is likely to deny the fact and make a formal complaint, and Mrs C will almost certainly back him up even if this means lying about what she has told me.

Mr C's comment that his wife has been falling a lot is a perfect springboard for a detailed examination. Her risk of Alzheimer's and vascular dementia is higher in the presence of type 2 diabetes, or she may have developed an incidental condition.

I would also review her insulin regime and her home glucose monitoring results in case she is having hypoglycaemic episodes, and check whether she is on medication that could cause sedation or postural hypotension. I would also be watching Mr C's behaviour very closely during my visit.

Before leaving I would arrange follow-up and ask the couple whether they felt they needed any help at home and whether they would like me to make arrangements or speak to other family members. On returning to surgery I would seek out the local policy on dealing with suspected elder abuse. I still think I might need to use it.

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