IMCA Case Study

1
IMCA Case Study Jean
2
You received a referral from a ward matron of
an acute trust where Jean, age 67 has been
recovering from injuries sustained in a fall
after a mild stroke. The ward manager of the
hospital states that Jean generally lacks
capacity but sometimes communicates using
gestures and some speech. They tell you that
Jeans hearing aid went missing on her admission
but they are a busy ward and can only attend to
her physical needs.   The matron tells you
Jean needs hip replacement surgery and they have
scheduled her for theatre in two months time. In
the meantime they plan to send her to a nursing
care home, as she no longer needs a bed in
hospital.   Jean had lived independently for
16 years after her husband died and had enjoyed
her independence. She frequently went to Bingo
with her neighbours. She has a sister in New
Zealand but contact with her is limited to a
telephone call at Christmas and an exchange of
birthday cards.    
3
1. Who is/are the decision maker(s)?   2. Is this
an appropriate IMCA referral? Why/why not?   3.
What is/are the issues that the IMCA may be
involved in?   4. Outline the steps you would
take as an IMCA to support Jean.
4
The Decision Makers are 1. Social worker
regarding moving Jean to a care
home. 2. Consultant/Surgeon regarding
surgery.   Possibly not an appropriate referral.
  Have the decision makers presumed incapacity
based on the nursing staffs views rather than
presuming capacity and taking all reasonable
steps to communicate with Jean?   What about
capacity regarding each of these two different
specific decisions? Capacity regarding moving
from an NHS hospital to a care home. Will Jean
stay in the care home longer than 8
Weeks? Capacity regarding having serious medical
treatment.
5
Lets revisit the two-stage test for
capacity   Does Jean have a temporary or
permanent impairment of the mind or brain, or is
there some sort of disturbance affecting the way
her mind or brain works? If so, does that
impairment or disturbance mean that Jean is
unable to make the decision in question at the
time it needs to be made?   If Jeans
incapacity is temporary could these decisions be
deferred? It appears the ward staff have failed
to apply this test. Also
6
Does Jean have a general understanding of what
decisions they need to make and why they need to
make them? Does Jean have a general understanding
of the likely consequences of making, or not
making, these decisions? Is Jean able to
understand, retain, use and weigh up the
information relevant to these decisions? Can Jean
communicate their decisions (by talking, using
sign language or any other means)? Would the
services of a professional (such as a speech and
language therapist) be helpful?   Finally Maybe
they should have looked for Jeans hearing aid or
called in an audiologist.   The IMCA should be
asking the decision makers questions on these
issues just like a concerned family member might.
We are not MCA police but will highlight the
possible need for MCA training in our reports as
well as in our quarterly monitoring meetings.
7
IMCAs Role   Receive the referral. This may be
from the decision maker or someone else such as a
nurse or ward manager. The referral could come
from a secretary. Review the referral and ask
appropriate questions. In this case the IMCA
would question the validity of the capacity
assessment and may not take any further action
until capacity has been determined according to
the Act. If the IMCA is then satisfied that the
tests for capacity have been correctly applied to
make these particular decisions they will attempt
to communicate, in private, with Jean using
alternative, non-verbal techniques where
possible. Try to find out what Jeans wishes
and feelings would likely be and beliefs and
values that would likely influence her if she had
capacity and make the decision makers aware of
any relevant information. The advocate may
consult with Jeans bingo friends as they might
have the best understanding of Jeans wishes,
feelings, beliefs and values.
8
If the advocate is unable to discern the Jeans
wishes, the advocate would act only to protect
Jeans rights and entitlements to good quality
care.   The advocate may wish to examine and take
copies of any relevant Health or Local Authority
records.   Ask the decision makers what
alternative or less restrictive courses of action
are available in relation to Jean.   Obtain a
further medical opinion where treatment is
proposed if the advocate thinks that one should
be obtained.   The IMCA then evaluates all the
relevant information and submits a report to the
authorities who must take it into consideration.
9
And We do all this in 8 hours!