safeguarding – Bradford VTS

Safeguarding Adults for GPs: Your Survival Guide

Shield the vulnerable without losing your sanity - lighthouse keeper skills included

☕ Tea-Friendly Learning ⏰ For GP Trainees Short on Time 🚩 Red Flag Focused

Date Updated: January 2026

Executive Summary: What You'll Master Today

Because you have 47 other things to do before lunch, and that's just the morning list

Quick Facts at a Glance:

1 in 6

Adults aged ≥65 experience some form of abuse

1 in 30

People aged 60-74 experience domestic abuse

50%

Of elder abuse occurs in their own home

1 in 4

Care home residents experience neglect

Quick Navigation

🧠 Essential Wisdom ⚖️ Legal Framework 🏥 Care Home Abuse 👴 Elderly Domestic Violence 💬 Screening Questions 🌍 Cultural Considerations 🧠 Capacity Assessment ⛓️ Modern Slavery

📥 Downloads

path: SAFEGUARDING ADULTS

🌐 Web Resources

Brainy Bites: Essential Safeguarding Wisdom

The Care Act 2014 - 6 Golden Rules

Accountability: We have a statutory duty and responsibility

Proportionality: Response matches the risk level

Empowerment: Enable adults to make their own decisions

Protection: Safeguard the person from harm

Prevention: Stop it happening again

Partnership: Work together to resolve problems

Red Flags - What Not to Miss!

Unexplained injuries or frequent "accidents"

Sudden behavioural changes or withdrawal

Fear of specific individuals or situations

Poor hygiene, malnutrition, or neglect

Always accompanied, never alone

No documentation or inconsistent information

Care Home & Nursing Home Abuse

Spotting Abuse in Care Settings

NICE NG189 guidance on indicators and immediate actions

Updated NICE Guidance (NG189): New evidence-based indicators for individual and organisational abuse in care homes. GPs have a crucial role in identifying concerns during visits and assessments.

UK Care Home Abuse Statistics

5-10%

Physical abuse annually

20-30%

Neglect & psychological abuse

<10%

Formal safeguarding referrals

Key Insight: Physical abuse affects around 1 in 10 residents at most, but neglect and psychological abuse affect closer to 1 in 4 — and that's where most harm lies. GP visits are one of the few external safety nets.

The Reality Check

What We Look For vs What Happens Most

• Families/professionals look for: Bruises, obvious injuries
• What actually happens most: Poor hydration, missed medications, humiliating care
• Reporting distortion: <10% of safeguarding referrals cite physical abuse, >60% relate to neglect

Home vs Institution Myth

• Up to 50% of elder abuse occurs in the person's own home
• Family carers (not institutions) are the most common perpetrators
• Teaching point: Safeguarding ≠ "care home problem"

Physical Signs to Look For

Unexplained Injuries

• Bruises in unusual locations (inner arms, back, buttocks)
• Multiple bruises at different healing stages
• Finger-tip bruising (grip marks)
• Fractures inconsistent with explanation
• Burns or scalds in unusual patterns
• Rope marks or restraint injuries

Signs of Neglect

• Poor hygiene, body odour, dirty clothing
• Malnutrition, dehydration, weight loss
• Untreated pressure sores (bed sores)
• Medication errors or omissions
• Lack of appropriate aids (glasses, hearing aids, dentures)
• Inappropriate clothing for weather

Documentation Tip: Always photograph injuries (with consent) and document exact measurements, colours, and patterns. Note any explanations given and whether they seem plausible.

Domestic Violence in the Elderly

The Hidden Epidemic

Age UK data reveals the shocking scale of domestic abuse in older people

Breaking News (2022): ONS data shows 1 in 30 people aged 60-74 and 1 in 50 people aged 75+ experience domestic abuse annually. That's over 400,000 older people in England and Wales alone.

Key Differences in Older Adults

• Perpetrators: Equally likely to be adult children/grandchildren as spouses
• Gender: Men at increased risk as they age (family abuse)
• Duration: Many have endured abuse for decades
• Dependency: Often rely on abuser for care and support
• Health conditions: Disability increases vulnerability
• Financial: Cost of living crisis increases isolation

Barriers to Seeking Help

• Professional awareness: Health/social care staff miss signs
• Assessment tools: Designed for younger women, not older adults
• Service gaps: Lack of age-appropriate support services
• Shame/stigma: Protecting family reputation
• Normalisation: Abuse becomes accepted over time
• Discrimination: Additional barriers for LGBTQ+, ethnic minorities

When and How to Screen Older Adults

Opportunistic Screening Moments

• Hospital discharge: "How do you feel about going home?"
• Care assessments: "Who helps you at home? How do they treat you?"
• GP appointments: "Do you feel safe at home?"
• Medication reviews: "Does anyone control your medications?"
• Falls assessments: "How did this injury really happen?"
• Mental health consultations: "What's making you feel this way?"

Age-Appropriate Screening Questions

• "Are you afraid of anyone in your family or household?"

• "Has anyone ever hurt you, threatened you, or made you do things you didn't want to do?"

• "Does anyone control what you do, where you go, or who you see?"

• "Has anyone taken your money or belongings without permission?"

• "Do you feel safe where you live?"

• "Is there anyone you would like us to contact or not contact?"

Age-Specific Indicators of Domestic Abuse

Physical Indicators

• Injuries inconsistent with explanation
• Delay in seeking medical treatment
• Repeated "accidents" or falls
• Malnutrition or dehydration
• Poor medication compliance
• Untreated medical conditions
• Signs of restraint use

Behavioural Indicators

• Withdrawal from social activities
• Depression, anxiety, or fearfulness
• Reluctance to speak in front of carer
• Excessive gratitude or compliance
• Sleep disturbances or nightmares
• Confusion about finances
• Mentions of being "punished"

Carer Behaviour

• Overly controlling or possessive
• Prevents private conversations
• Speaks for the older person
• Shows little concern for wellbeing
• History of substance abuse
• Financial dependence on older person
• Aggressive or impatient manner

Risk Assessment for Older Adults

High-Risk Factors in Older Adults

Victim Factors

• Cognitive impairment or dementia
• Physical disability or frailty
• Social isolation
• Financial dependence
• Multiple health conditions
• Communication difficulties

Perpetrator Factors

• Substance abuse problems
• Mental health issues
• Financial dependence on victim
• History of violence
• Caregiver stress
• Social isolation

Modified DASH for Older Adults

Additional considerations for older victims:

• Threats to withdraw care or support
• Threats to put in care home
• Control of medication or medical care
• Isolation from family and friends
• Financial exploitation or control
• Threats involving grandchildren

Support Services for Older Victims

Specialist Services

• Hourglass: 0808 808 8141 (24-hour helpline)
• Age UK: Partnership with Hourglass for complex cases
• SafeLives: Safe Later Lives programme
• Local Age UK: Community support and advocacy
• Adult Social Care: Care assessments and protection

Practical Support

• Safety planning adapted for older adults
• Alternative care arrangements
• Financial protection and advice
• Legal support and advocacy
• Accessible accommodation options
• Health and social care coordination

Age UK Partnership Model

Age UK now works with Hourglass to provide:

• Specialist case workers for complex abuse cases
• Community response networks
• Independent Domestic Violence Advocates (IDVAs) trained in elder abuse
• Tailored safety plans considering age-related factors
• Support to rebuild confidence and recover from trauma

Screening Questions & Disclosure

The Power of the Right Question

GPs identify domestic abuse in <10% of affected patients, but a single direct question increases disclosure 3-4 fold

Key Teaching Point: "If I only ask women, I miss half the problem. If I only ask about violence, I miss most of it."

The Single Safeguarding Question (Older Adults)

"Sometimes, as people get older, others start making decisions for them or helping in ways that don't always feel right. Has anyone ever made you feel uncomfortable, unsafe, or not in control at home or where you live?"

Why this works clinically:

• Normalises the issue ("sometimes, as people get older...")
• Does not say "abuse" or "violence"
• Captures neglect, financial abuse, coercion, carer stress harm
• Allows a yes/no/hesitant response

Universal Screening Question

"Because abuse can happen in any relationship, I ask everyone this: has anyone you're close to ever made you feel frightened, controlled, or hurt — emotionally, physically, or sexually?"

Why this wording is powerful:

• Explicitly inclusive ("any relationship")
• Avoids assumptions about gender, sexuality, perpetrator
• Includes coercive control, emotional abuse
• Signals routine practice, not suspicion

Key Statistics on Disclosure

<10%

GPs identify domestic abuse in affected patients

3-4x

Increase in disclosure with direct questioning

~20%

Male victims ever disclose to professionals

Gender Differences in Disclosure

Women (1 in 4 lifetime prevalence)

• ~40% disclose to professionals
• More likely to present with obvious injuries
• Better access to specialist services

Men (1 in 6 lifetime prevalence)

• Only ~20% ever disclose to professionals
• Twice as likely to present with somatic symptoms
• More likely to disclose after repeated GP visits
• Red flag: Frequent attenders + vague symptoms

Financial Abuse - The Hidden Epidemic

Key Facts

• 40-50% of elder abuse cases
• Most common form in older adults
• Often involves adult children
• Power of attorney misuse
• Coercion without visible injury

Clinical Teaching Point

"Looks fine" ≠ "is safe"

Most elder abuse is invisible unless the GP asks directly

Cultural Considerations in Safeguarding

Ethnicity, Disclosure & Help-Seeking

Understanding cultural barriers while avoiding stereotypes

Key Principle: Domestic abuse prevalence is broadly similar across ethnic groups. Ethnicity does not predict abuse.

Similar Prevalence Across Groups

Large UK surveys show no major difference in overall prevalence between:

• White British
• South Asian
• African / Caribbean
• Eastern European groups

👉 Ethnicity does not predict abuse

Reporting Differences

But reporting and help-seeking differ dramatically by culture:

• Some migrant and minority groups are 30-50% less likely to disclose
• Fear drivers include:
- Immigration status concerns
- Shame and stigma
- Community retaliation
- Language barriers

👉 Lower disclosure ≠ lower abuse

LGBTQ+ Considerations

Similar Risk, Fewer Exits

• Domestic abuse rates in same-sex couples are similar to heterosexual couples
• UK data show ~25-30% lifetime prevalence in:
- Lesbian couples
- Gay male couples
- Heterosexual couples

Barriers to Support

• Less likely to be believed
• Less likely to access specialist services
• Fear of discrimination
• Lack of LGBTQ+-specific resources

👉 "Same risk, fewer exits"

Practical GP Approach

Use Universal Screening

Ask the same questions of everyone, regardless of background

Provide Interpreter Services

Never use family members as interpreters for safeguarding concerns

Understand Additional Barriers

Be aware of immigration status fears, but don't let this prevent safeguarding

Build Trust Over Time

Multiple appointments may be needed before disclosure occurs

Legal & Ethical Frameworks

GMC Guidance & Professional Duties

Your professional obligations under GMC guidance

Core Professional Duties

• Demonstrate broad knowledge of safeguarding procedures for vulnerable adults
• Understand how safeguarding must shape clinical decisions and behaviour
• Apply statutory legislation for vulnerable adults in clinical practice
• Coordinate care with other agencies (Social Workers, Police)

Remember: You have a professional duty to act when you suspect abuse or neglect, even if the patient doesn't want you to.

Balancing Confidentiality with Safeguarding

The core challenge: when can you break confidentiality?

You CAN share information without consent when:

• It's necessary to prevent serious harm to the patient or others
• Required by law or court order
• In the public interest (serious crime prevention)
• Patient lacks capacity and sharing is in their best interests

Always document your decision-making process and seek advice from your defence union if unsure.

Mental Capacity Considerations

Understanding when adults can make their own safeguarding decisions

Adults WITH Capacity

• Can refuse help or intervention
• Can make "unwise" decisions
• Must be supported to make informed choices
• Information sharing requires consent

Adults WITHOUT Capacity

• Decisions made in their best interests
• Information can be shared appropriately
• Involve family/carers in decision-making
• Consider Lasting Power of Attorney

GP as Advocate

Your role in promoting empowerment and equity

Promote Empowerment

Help patients with disabilities make their own decisions and access services

Coordinate Care

Work with multidisciplinary teams, social services, and police

Ensure Equity

Tailor resources and facilities to communication and relationship difficulties

Mental Capacity Assessment

The Mental Capacity Act 2005

Understanding capacity assessment and decision-making

Golden Rule: Don't automatically assume a person lacks capacity just because they have a disability, stroke, or learning difficulty. Always start with the assumption they HAVE capacity.

Key Principles

• Assume capacity unless proven otherwise
• Decision-specific - capacity varies by decision
• Can fluctuate - especially in dementia
• Unwise decisions don't mean lack of capacity
• Least restrictive pathway always

The 3 Tests for Capacity

RETAIN

Can they hold the information in their mind?

WEIGH UP

Can they consider pros and cons?

COMMUNICATE

Can they express their decision?

Optimising Capacity Assessment

Try to talk to the patient when they're most likely to have capacity:

• Familiar environment: Home visit rather than surgery
• Best time of day: Daylight hours, not evening
• Minimal people: Reduce anxiety and confusion
• Familiar faces: Include trusted family member
• Clear communication: Simple language, visual aids

Lasting Power of Attorney (LPA)

• Must be made when patient HAS capacity - cannot be done retrospectively

• Doesn't stop patient making decisions while they still have capacity

• Two types: Health & Welfare, Property & Financial Affairs

• Attorney must act in patient's best interests

Domestic Abuse & Violence

Recognition & Response

Systematic approach to domestic violence screening and management

When to Screen

Routine Screening

• All maternity patients
• Sexual health consultations
• Mental health presentations
• Contraception consultations
• Annual health checks

Opportunistic Screening

• Unexplained injuries
• Frequent attendance
• Depression, anxiety
• Substance misuse
• Partner always present

Safe Environment: Always screen when patient is alone. Use "I need to examine you privately" to separate from partner.

Recording Domestic Abuse - RCGP 2021

Language Matters

❌ Don't use: "Patient alleges Mr X assaulted her"

✅ Do use: "Patient says Mr X assaulted her"

Why? "Alleges" implies disbelief - use neutral language

Documentation Best Practice

• Code as "History of Domestic Abuse"
• Use patient's own words in quotes
• Hide from patient online access
• Major active problem until resolved
• Link perpetrator's EMR to victim's
• Redact DA references from children's records if given to perpetrator

DASH Risk Assessment

Use the DASH toolkit to assess risk in Domestic Abuse, Stalking and Honour-based Violence

High Risk Indicators

• Escalating frequency/severity
• Threats to kill
• Strangulation/choking
• Sexual violence
• Controlling behaviour
• Stalking behaviours
• Pregnancy/recent birth
• Separation/divorce proceedings

Immediate Safety Planning

• Safe place to go in emergency
• Important documents location
• Emergency contact numbers
• Safety code word with family/friends
• National Domestic Violence Helpline: 0808 2000 247

Modern Slavery & Trafficking

Recognition & Response

40+ million people are slaves globally - more British slaves in the UK than any other country

Shocking Fact: More modern slavery victims IN THE UK are BRITISH than any other nationality. 1 in 4 victims are children.

Vulnerable Groups

• Mental health problems
• Alcohol and drug issues
• Homeless individuals
• People with disabilities
• Children (25% of victims)
• Migrants and asylum seekers
• Care leavers

Common Countries of Origin

• Albania - highest numbers
• Vietnam - cannabis farms, nail bars
• UK - yes, British citizens!
• China - restaurants, factories
• India - domestic servitude

Clinical Indicators - What to Look For

Physical Signs

• Non-specific trauma
• Old untreated injuries
• Sexual trauma, STIs
• Poor nutrition, dental hygiene
• Stomach/back pain
• Tired all the time

Psychological Signs

• Depression, anxiety
• Self-harm behaviours
• Withdrawn, submissive
• Looks distressed
• Fearful, hypervigilant
• PTSD symptoms

Social Signs

• Always accompanied
• Moves frequently
• Language barriers
• No documentation
• Not registered with GP
• Emergency appointments only

What Should You Do?

Immediate Actions

• Ensure immediate safety
• Treat medical needs
• Document everything
• Don't confront suspected traffickers
• Consider interpreter needs

Referral Pathways

• National Referral Mechanism (NRM)
• Salvation Army: 0300 303 8151
• Hope for Justice: 0300 008 8000
• Modern Slavery Helpline: 08000 121 700
• Police: 101 or 999 if immediate danger

PREVENT & Radicalisation

Counter-Terrorism Strategy

PREVENT is about safeguarding vulnerable people from radicalisation

Key Principle: PREVENT is all about safeguarding. It's often the vulnerable who become radicalised - homeless, learning disabilities, financial struggles, children.

Vulnerable Groups

• Homeless individuals
• People with learning disabilities
• Those struggling financially
• Children and young people
• Mental health problems
• Social isolation
• Identity crisis
• Grievance against society

Warning Signs

• Sudden behavioural changes
• Expressing extremist views
• Isolation from family/friends
• New social circle/online activity
• Travel to conflict areas
• Possession of extremist material
• Secretive behaviour
• Glorifying violence

How Radicalisation Works

Extremists move vulnerable people from a non-criminal space to a criminal one by:

• Offering belonging and purpose
• Exploiting grievances
• Providing simple answers to complex problems
• Creating us vs them mentality
• Gradually normalising extreme views

Your Role as a GP

• Strengthen the wall: Help protect vulnerable patients from exploitation

• Report concerns: Contact police if you suspect radicalisation

• Don't investigate: Never challenge suspected extremists yourself

• Consider safety: Your safety and your family's safety comes first

• Document concerns: Keep detailed records of your observations

Reporting Pathways

Emergency

• Police: 999 (immediate threat)
• Anti-terrorist hotline: 0800 789 321

Non-Emergency

• Police: 101
• Local safeguarding team
• Channel programme referral

You've Got This! 🌟

Remember: You don't need to be a safeguarding specialist to provide excellent protection for vulnerable adults. You just need to know when to worry, when to act, and when to refer.

Safeguarding is like being a lighthouse keeper - scan the horizon for signals of distress, shine a light on hidden dangers, and guide the vulnerable safely to shore. Trust your instincts, document everything, and never hesitate to seek help.

Now go reward yourself with that well-deserved coffee ☕

DON’T FORGET, YOU CAN ALSO CONTACT YOUR LOCAL POLICE DEPARTMENT

101/Modern Slavery Helpline is 08000 121 700