Elder Abuse and Safeguarding — Viva

Long Case Viva Defence

Candidate's opening statement (model answer)

"Mrs Dorothy Chen is an 82-year-old woman with moderate Alzheimer disease, admitted with dehydration, malnutrition and a Stage 2 sacral pressure injury, who is the victim of suspected multiple types of elder abuse — neglect, psychological abuse, and financial exploitation — perpetrated by her daughter, who is her sole carer and her enduring power of attorney. The presentation raises an immediate safeguarding concern for a non-capacitous older person who cannot protect herself. [1]

Her main problems are:

1. Dehydration, malnutrition and a Stage 2 sacral pressure injury in a mobile patient — the acute presentation, and the evidence of neglect.
2. Moderate Alzheimer disease (MMSE 17) — the patient lacks capacity for decisions about her safety and her finances.
3. Suspected psychological abuse — the daughter's controlling behaviour, the patient's withdrawn and fearful demeanour, and the patient's disclosure that the daughter yells at her.
4. Suspected financial abuse — the recent transfer of the patient's house into joint names by the daughter, who holds the enduring power of attorney.
5. Carer dependency and social isolation — the daughter is the sole carer with no community support. [1]

My approach is, first, to ensure her immediate safety — she is admitted and must not be discharged home until a safeguarding plan is in place; second, to confirm her incapacity with a structured capacity assessment and document it; third, to document all findings meticulously, including photographs of the pressure injury and exact quotes of her disclosure; fourth, to involve social work and the hospital safeguarding team for a coordinated multidisciplinary response; fifth, to refer urgently to the state tribunal for review of the enduring power of attorney and the appointment of an independent guardian and financial manager; and sixth, to arrange long-term support services including residential or supported community care, counselling, and financial counselling. The overarching principle is that she lacks capacity and cannot protect herself, so the duty to protect overrides confidentiality — the safeguarding pathway is activated in her best interests, using the least restrictive intervention that ensures her safety." [1]

Examiner probing questions and model answers

Q1: "Walk me through how you would recognise and classify the types of abuse in this case." [1]

"I apply the WHO definition — a single or repeated act, or lack of appropriate action, within a relationship of expectation of trust, causing harm or distress to an older person [6]. Three types are suspected. First, neglect: the dehydration, the 8 kg weight loss over three months, and the Stage 2 sacral pressure injury in a patient who is still mobile with a frame are all evidence that basic care — nutrition, hydration, positioning, hygiene — has not been provided. A pressure injury in a mobile patient is a particularly strong marker of neglect, because the patient should be being repositioned and mobilised regularly. The delayed presentation — she has been allowed to become dehydrated and malnourished before medical attention was sought — is itself a red flag.

Second, psychological abuse: the daughter's controlling behaviour — refusing to leave the room, answering for the patient, becoming hostile when challenged — is a pattern of intimidation. The patient's withdrawn and fearful demeanour, her flinching, and her quiet disclosure that the daughter yells are the clinical features of an ongoing psychologically abusive relationship. [1]

Third, financial abuse: the recent transfer of the patient's house into joint names is a red flag for financial exploitation. In a patient with moderate dementia (MMSE 17), she cannot have meaningfully understood or consented to such a transaction. The daughter, as enduring power of attorney, is a fiduciary who must act in the patient's best interests — transferring the house into joint names is a breach of that duty. I would request the details of the transfer for the tribunal's investigation." [1]

Q2: "How would you formally assess this patient's capacity, and why is it central to the management?" [1]

"Capacity is the pivot of the entire management pathway [5]. I apply the two-stage test. Stage 1, the diagnostic stage: she has a clear impairment of mind or brain — moderate Alzheimer disease, with an MMSE of 17. Stage 2, the functional stage: I attempt to engage her in the decision about her safety and her living situation. Given her moderate dementia, she cannot understand the information about the abuse and the options for intervention, she cannot retain it, she cannot use or weigh it to reach a protective decision, and while she can communicate (she told me the daughter yells), that communication is an observation of her experience, not an integrated protective decision. She fails all four functional abilities. She lacks capacity.

Before finalising the assessment, I exclude reversible contributors — I treat the dehydration and any infection, I check her glucose, sodium, calcium and renal function, and I review her medications. Her moderate dementia is irreversible, so even after the acute issues resolve, her underlying incapacity for complex decisions about her safety and finances will persist. [1]

Why capacity is central: because she lacks capacity, the decision about her safety is made in her best interests, using substituted judgement, consulting the substitute decision-maker — but in this case the substitute decision-maker (the daughter) is the suspected perpetrator, so the decision must be referred to an independent guardian or the tribunal. The doctrine of necessity permits immediate protective action — admission, treatment, and prevention of discharge into the abusive environment — without her consent, because she lacks capacity and is at serious risk." [1]

Q3: "The daughter is the enduring power of attorney and is suspected of financial exploitation. What legal interventions are available, and how are they triggered?" [1]

"The state civil and administrative tribunal is the primary legal mechanism. In New South Wales this is NCAT, in Victoria VCAT, with equivalents in every state. The tribunal has several powers relevant to this case. First, it can review and, if warranted, revoke the enduring power of attorney on the grounds that the attorney is not acting in the principal's best interests — the house transfer into joint names is prima facie evidence of misuse. Second, it can appoint an independent financial manager — a professional or the State Trustee — to take over management of the patient's estate, ensuring her funds are used for her care and that any misappropriated property is investigated for recovery. Third, it can appoint a substitute guardian for personal and lifestyle decisions (where she lives, who provides care, what services she receives), if the enduring guardian (the daughter) is removed. [1]

The referral to the tribunal is made urgently given the evidence of ongoing harm. The application includes the clinical assessment, the evidence of abuse, the capacity assessment, and the recommended protective measures. An interim order may be sought to freeze the financial transactions pending the full hearing. In parallel, if the house transfer constitutes fraud, a police referral may be appropriate for criminal investigation. An Apprehended Violence Order may be sought to prohibit the daughter from contacting or approaching the patient if she is assessed as a continuing threat during the hospital admission." [1]

Q4: "What are the mandatory reporting obligations in your jurisdiction, and how do they interact with patient confidentiality?" [1]

"In Australia, mandatory reporting for elder abuse varies by setting. In residential aged care, the Aged Care Act 1997, as amended in 2024, requires approved providers to report serious incidents — including unexplained weight loss, pressure injuries, and suspected abuse — to the Aged Care Quality and Safety Commission, and to report criminal matters such as physical or sexual assault to the police. This patient lives in the community, and in most Australian jurisdictions there is no equivalent mandatory reporting obligation for a clinician treating a community-dwelling older person. [1]

However, the duty to protect a non-capacitous person at serious risk overrides patient confidentiality. This patient lacks capacity and is being harmed by the person who is supposed to protect her. The ethical and legal duty to act in her best interests justifies — indeed requires — disclosure to the safeguarding team, the tribunal, and potentially the police, even over the daughter's objections. The daughter is informed of the actions being taken, but her consent is not required because she is not the patient and the patient lacks capacity to consent. [1]

In New South Wales, a report could also be made to the Ageing and Disability Commission, which provides a community safeguarding pathway for older people and adults with disability. The guiding principle is that confidentiality is not absolute — it yields to the duty to protect a vulnerable person who cannot protect themselves." [1]

Q5: "Suppose this patient had intact cognition and full capacity, and she told you she understood the abuse but chose to remain at home with her daughter because she feared being alone. How would your management change?" [1]

"This fundamentally changes the management. If the patient has capacity for the specific decision — she understands the abuse, she can weigh the risks against her fear of isolation, and her decision is voluntary and consistent with her values — then her autonomy must be respected, however unwise the decision may seem to me. The legal and ethical principle is that a capacitous adult has the right to make unwise decisions, including the decision to remain in an abusive situation. [1]

My role shifts from protective intervention to support and harm reduction. I would provide accurate information about the abuse, the available services, and her legal options. I would offer harm-reduction measures — direct debits for essential bills, a community nurse or aged-care assessment team for regular visits, and a review of the enduring power of attorney. I would arrange regular follow-up to maintain the relationship and to monitor for escalation or cognitive decline. I would provide written information about elder abuse helplines and legal aid so she can access help independently if she changes her mind. And I would document her capacity assessment, the information provided, her decisions, and the follow-up plan. [1]

I would not override her autonomy by involving the tribunal or the police against her wishes, unless the situation escalated to a serious and imminent threat to her life. The hardest but most important ethical principle in elder safeguarding is that autonomy includes the right to make decisions others consider unwise, and the physician's duty is to inform and support, not to coerce." [1]

Short Case Discussion

A structured bedside assessment of suspected elder abuse

Examiner instruction: "You are asked to assess a 78-year-old woman in the outpatient clinic who has been referred by her GP with concerns about possible elder abuse. She lives with her son. Describe how you would conduct a structured assessment for suspected elder abuse." [1]

Candidate's model answer: [1]

"My assessment follows a structured framework: establish privacy, build trust, screen systematically, examine for physical evidence, assess capacity, and document meticulously. [1]

Step 1 — Establish privacy: I ensure the patient is seen alone. If the son has accompanied her, I frame it as routine: I always see my patients alone for part of the consultation. If he resists, I persist and document the resistance as a red flag. I do not proceed with the abuse assessment with a suspected perpetrator in the room.* [1]

Step 2 — Build trust and open with general questions: I start with open, non-judgemental questions to establish rapport: How are things at home? Who lives with you? Who helps you with things? I move to more specific questions only when trust is established: Do you feel safe at home? Has anyone hurt you, frightened you, or made you uncomfortable? Has anyone taken your money or belongings or asked you to sign things you did not understand? I use silence and patience — disclosure often comes after a pause.* [1]

Step 3 — Apply a screening tool if cognitively intact: If the patient is cognitively intact (MMSE 24 or above), I administer the EASI — the Elder Abuse Suspicion Index [2]. The first five items are asked of the patient: reliance on others for shopping, banking or finances; denial of food, clothes, medication, glasses, hearing aids or medical care; verbal or emotional cruelty or fright; being forced to do things against their will; and financial exploitation. The sixth item is completed by me based on clinical observation: is there evidence of poor compliance, missed appointments, or other signs of neglect? A yes to any of items 2 through 6 raises suspicion and prompts referral.*

Step 4 — Examine for physical evidence: I conduct a full examination, looking specifically for unexplained injuries, bruising in unusual distributions (upper inner arms, neck, axillae, trunk, inner thighs), grip-pattern bruising, injuries inconsistent with the stated mechanism, pressure injuries in a mobile patient, malnutrition, poor hygiene, over-sedation, and any signs of sexual abuse. I examine the medication chart for inappropriate sedatives or antipsychotics.* [1]

Step 5 — Assess capacity: I conduct a structured capacity assessment for the relevant decisions — about her safety, her finances, and her living situation — using the two-stage test and the four functional abilities [5]. This determines the management pathway.*

Step 6 — Document: I document the patient's history in her own words (verbatim quotes), the physical findings (with a body map and photographs of any injuries, with consent), the capacity assessment, the collateral history, the screening tool results, and the management plan. The documentation may become evidence in a tribunal hearing or criminal prosecution."* [1]

Examiner follow-up: "What if the patient has moderate dementia and the EASI cannot be used? How does your approach change?" [1]

"In moderate-to-severe dementia, the EASI is not validated and cannot be relied upon, because the patient cannot reliably self-report. The assessment shifts to three strategies. First, direct clinical observation — the physical signs (injuries, malnutrition, pressure injuries, over-sedation), the behavioural signs (fear, withdrawal, flinching), and the carer behaviours (controlling, speaking for the patient, refusing to leave). Second, collateral history — from the GP, community nurses, neighbours, other family members, and any previous hospital records, looking for patterns of injury, missed appointments, or carer concerns. Third, investigation of the environmental and financial context — are the bills paid, is the home maintained, have there been changes to legal documents? The threshold for safeguarding referral is lower in a non-capacitous patient, because they cannot disclose or protect themselves, and the index of suspicion must be acted upon more readily. The assessment still requires the patient to be seen alone, even if her capacity to report is impaired — her behavioural response to being separated from the carer (does she relax? does she try to communicate?) is itself diagnostic." [1]