A simple Mental Capacity Assessment for Susan?

Susan was a 60 year old lady with a diagnosis of mixed cortical and subcortical dementia as a result of chronic alcohol misuse and also an ABI as a result a serious fall when intoxicated. When living at home her alcohol misuse was so severe that she didn’t eat for days on end, she had no running water or electricity and the house was filthy. She was often seen in town partially dressed and the LA safeguarding team were involved because of her vulnerability. Eventually Susan had a serious fall and ended up in a coma.

After her hospital admission, her deputy placed her in a dementia care home where she was very unhappy. She appealed her standard authorisation and I was asked to complete capacity assessments to support a decision in her future care arrangements.

When I first met Susan I thought I had the wrong lady! She presented so well; she was funny, orientated to time and place, recalled events from her past and had goals for the future.  She was a fierce advocate for herself and wouldn’t engage in any conversations with me unless it was about her returning home. However although Susan presented well; there were some clues that she may lack capacity; such as having very fixed views on her future that couldn’t be expanded upon and tending to have “scripts” when asked about difficult topics.

In preparation for the assessment, I considered the salient points required to make a decision and that a member of the public would not know necessarily know the details of some of the information and that this should be the baseline of my assessment. I wrote myself prompts to make sure I’d get everything I needed and also completed the assessment over two visits at a time and place of her choosing to maximise her capacity.

What was clear about Susan is that she could understand and retain the information needed and communicate her decision; but didn’t seem able to weigh the information up. For example; when discussing the risks of returning home she couldn’t make the link between her previous experiences and how this might help her think about her future. She could remember factually what life had been like but wasn’t able to use this information to assess why things could go wrong again. I considered whether this was her willful personality and refusal to accept that things could go wrong, or a consequence of her mental impairment. I decided that it was both! The latter being that her frontal lobe had been damaged and this had impacted her ability to evaluate memories in order to inform her decision making.

This case is particularly important to me because I assessed that Susan lacked capacity in relation to her care and accommodation needs, but that she had capacity to conduct court proceedings. This was a contentious decision and I was questioned as to why I thought she lacked capacity to make some serious decisions but had it for others. However, when this question is broken down it’s quite simple; the codes of practice are clear that we must assume capacity, meaning the burden is on the assessor to prove incapacity rather than the person proving that they have it. Also for people whose capacity is questionable; the assessor only has to believe that they have a borderline capacity and this can be as subtle as 51%.

I’m pleased to say that Susan did return home again, and although she initially returned with severe restrictions around access to money (to reduce the amount of alcohol she could purchase at once) these were gradually loosened and as far as I’m aware she remains at home to this day! 

Sarah Vaughan, Social Worker Case Manager, Expert Witness and Mental Capacity Assessor for Circle Case Management.