This page is the first of a two part case-study

Read the second part of this case-study

Capacity to manage care - part 1

Background

James Green is 22 years old. He has a moderate learning disability and type 1 diabetes. 

Until a month ago he lived with his mother, Linda Green, and relied on her for practical support such as monitoring his diabetic control and reminding him to attend appointments.  After a series of arguments with his mother, James moved out into shared accommodation with new friends. 

James is under the care of his GP, Dr Praed.

Scenario

Dr Praed receives a phone call from Linda. She tells him that James has been regularly binge-drinking.  She doubts he is monitoring his diabetes and she is worried the people he has moved in with are having a bad influence on him.

The next day, James arrives for an appointment with Dr Praed looking dishevelled and smelling of alcohol. While Dr Praed is testing his blood sugar, James tells Dr Praed he is upset because his friends have ‘borrowed’ money from him several times and have not paid it back.  James’s blood sugars are high.

Dr Praed tells James about his high blood sugars, and suggests that he should let his mother help him manage his health. Dr Praed goes on to say he is concerned about his new friends, and suggests James should consider involving the police if they have been stealing from him.

James is confused about whether he wants his mother’s to help. When the police are mentioned, he becomes agitated and says he is afraid his friend, Paul will get into trouble.

James describes his new friend to Dr Praed, who realises he is another patient, who he knows has a long history of illicit drug use and several convictions for theft and burglary.

What the doctor did

Dr Praed does not contact the police because he decides that, despite his concern that James's friends may be stealing from him, the evidence is limited and, at this stage, he thinks it is more important to focus on providing support to James, to improve and stabilise his health.

Dr Praed explores further with James the risks of binge drinking and poor diet for a person with diabetes. James says he understands these risks, but it is clear from his answers that he thinks they can be easily managed by having more insulin injections. 

Dr Praed is concerned that James does not have the capacity to understand and weigh up the risks of serious harm as a result of poor management of his diabetes. He is also worried that James is too trusting of his new friends, and that he is unable to assess the risk they might pose to him.

Dr Praed tells James that he is very worried about his health and that he thinks James would benefit from some help. He explains to James that he intends to call the local adult safeguarding team to ask them to provide some support to him.

James becomes very angry at what he sees as Dr Praed's interference and leaves the consultation.

What the doctor had to consider

  • If the patient lacks capacity, he should not disclose relevant information to an appropriate responsible person or authority unless he believes it is not of overall benefit to the individual to do so (Confidentiality, paragraphs 55 and 56). 
  • The local adult safeguarding processes that should be followed and that the patient should be informed  of what he intends to do, and why, and document these discussions in the patient’s records (Confidentiality, paragraphs 48 and 49).
  • Even if the patient is not at risk of serious harm he should still explore with the patient whether he could benefit from additional support, for example from social services, a local charity, or an independent advocate.
  • If the patient is judged to have capacity to make the decision then as a general principle, adults who have capacity are entitled to make decisions in their own interests even if others consider those decisions to be irrational or unwise or leaves them at risk of serious harm, unless the disclosure is required by law (Confidentiality, paragraph 57& 59). 
  • If the adult has capacity it may be appropriate for him  to encourage the patient to consent to a disclosure if he considers it necessary for the patient’s protection, to explore his reasons for refusing, and warn him of the risks if the information is not shared (Confidentiality, paragraphs 57 to 58). 
  • If patient is judged to have capacity to make the decision, he should abide by the patient’s wishes and not involve anyone the patient has not asked to be involved in his or her care.  He should however explore with the patient whether there are other sources of support that could be helpful to him. 
  • Separate to considering the patient’s capacity, he should also consider whether the patient’s friends may be a risk to other vulnerable people. If so, disclosure of information about the reported theft might also be justified in the wider public interest (Confidentiality, paragraphs 63 to 70).
  • Doctors working in Scotland and Wales doctors should be aware that there are some legal requirements for health boards and other bodies to disclose information about adults who are known or considered to be at risk of, or to have suffered, abuse or neglect, whether or not they have capacity. See the adult safeguarding section of our key legislation factsheet for more information about relevant legislation.