Facts:

20 yr old female, male partner 47 yrs

H/O Domestic Abuse within the family home, therefore entered foster care age 11.

Moderate learning disability and attended a specialist school. H/O bullying at school and smoked to fit in. Feelings of loneliness and being misunderstood/upset.

H/O self-harm
Attended 1:1 therapy but not completed. 
Met partner at a young age. No foster parent/friend contact.
Partner has physical disability.
Both now have baby Betty.
Sudden withdrawal, less engagement with services, dresses differently, Betty looks unkempt, less settled. Partner always present.
Appears anxious and on edge as reported by family nurse, as partner not present.

 My initial thought when reading this scenario include financial abuse, possible domestic abuse, Kirsty self-harming and feeling isolated. This scenario highlights just how much support from numerous professionals is required.

The age gap between Kirsty and David made me consider whether Kirsty was looking a father figure in her life and whether the age gap enable David to dominate within that relationship. Does Kirsty see this behaviour as caring? Due to many aspects in her past, Kirsty seems very vulnerable. She has been willing to do things to be ‘fit in’ and be accepted by others. She also appears to very isolated and has no contact with her foster carers, has no friends and no other support mechanisms other that David.

I initially considered financial abuse as neither Kirsty or her partner are working and the financial challenges of having a new baby maybe a factor within this. It appears David is much older than Kirsty and due to her learning disability, it may be very difficult for Kirsty to have control of her own finances/life.  The family nurse reported that Kirsty was dressing differently, Betty appeared unkempt and that Kirsty does not go out alone without David. It was also noted that although Betty was meeting her milestones, she was a little underweight. However, some of the details within this scenario could also point toward domestic abuse within Kirsty and David’s relationship.

Also reported by the family nurse was the fact that Kirsty appeared very anxious during a home visit and was touching her sleeves and looked very warm. Kirsty appeared to be very uneasy without David’s presence. Is this a sign Kirsty is self-harming again?

I feel the family nurse was right to encourage Kirsty to go to her GP, however, I don’t think she took into consideration Kirsty’s learning disability and how difficult this task may be for her. If I were that family nurse, I would have made the appointment for Kirsty whist I was with her and support her in accessing the care she requires.
Kirsty’s learning disability could be a strong factor in preventing her from being more independent and accessing the support services available. If Kirsty received the support she requires and deserves, it would enable her to feel more empowered to make her own decisions, feel she is being listened to and consequently happier within herself. She should also be encouraged to attend therapy again to help address personal issues, however, she would need support in order to access this and the therapy sessions themselves should be pitched at an appropriate level for Kirsty to understand and benefit from.

When providing care for Kirsty, a professional would need to be approachable, understanding, non-judgemental and experienced. It would be crucial to maintain good communication skills at a level suitable for Kirsty, these communication skills could be shown in numerous ways other than verbal communication such as drawing, photos, pictures. 
Continuity of carer would be vital in this situation in order to develop a trusting relationship with Kirsty and for the professional to really get to know her and know the best ways to communicate with her. They would need to know Kirsty well in order to read her body language. This one to one care would also benefit Kirsty due to her vulnerability and the fact that she is quite isolated. It would enable her to for a bond with professionals providing care/support and hopefully enable her to open up about her concerns.
As the professional, you would also need to be aware of the Laws and Acts surrounding disabilities and have a knowledge of support available and where/how to access these support services.

Questions for Kirsty:

Breaking down initial barriers – 
How are you feeling?
How’s baby Betty?
Are there any concerns
How’s David?/Where is David?
Do you feel well within yourself?

I would want to ask very basic questions at first, so not to make Kirsty feel stressed or uncomfortable, which would, in turn, run the risk of her becoming closed and non-compliant. I feel the information required would have to be obtained over time as the relationship with Kirsty further developed. I would then ask slightly more detailed questions but again at a level that is comfortable for Kirsty. 

I would want to discuss this scenario with the GP and Health Visitor initially as they would be the other professionals seeing Kirsty fairly regularly to provide 1:1 care. I would want to know where I could access further support for Kirsty that would be provided at an appropriate level to suit her specific needs.
Thanks Amy, thats great
Cath

- Kirsty is 20 year old first time mother, partner David 47 years

-  Kirsty was removed from parents aged 11 due to severe domestic abuse within her parent’s relationship

-  Kirsty had several foster placements and does not see foster parents or parents now

- Moderate learning disabilities 

-  Kirsty was bullied growing up and chose behaviours to fit in e.g. smoking

- Kirsty felt lonely, misunderstood, upset 

-  Kirsty has h/o of self-harm, social worker encouraged her to attend 1:1 talking therapy, Kirsty did not complete this course as she did not understand the therapist and felt she was ‘ok now anyway’. 
- At school they made reasonable adjustments to help Kirsty understand lessons 

-  Kirsty met David at age 17, lived with him at the age of 19 

-  Kirsty has no friends or family apart from David, she does feel well looked after by David 

-  David has a physical disability and does not work 

-  David has x2 children with x2 women who he does not have contact with 

-  Sarah is the family nurse, she has been involved throughout Kirsty’s pregnancy and following birth, Betty is now 6 months old

-  There has been input from various services, Betty has been meeting milestones however is underweight 

Current situation:

-  Recently Kirsty has appeared withdrawn, less engaging in services, dressing differently, unkempt, less settled than usual

-  David plays a bigger role in caring for Kirsty and Betty, attends all appointments and goes out in community with them, Kirsty no longer goes out alone

- Sarah did an unannounced visit, David was not home Kirsty was nervous to let Sarah in, rushed the visit and appeared anxious and on edge that David was not present. Sarah encouraged Kirsty to book appointment with GP as expressed health concerns about Kirsty. 

What are the main issues in this case?
 - Kirsty is a vulnerable adult. She has had social services involvement as a child, has lived with various foster carers who she no longer is in contact with, has a learning disability, has never felt like she has fitted in so has chosen unhealthy behaviours to fit in, has experienced domestic abuse, has no friends and family other than David and did not complete the course with her therapist. 

-       Kirsty is now only attending appointments or going out the house with David present. She has appeared nervous, withdrawn and on edge whereas David appears to have more involvement in Kirsty and Betty’s care and activities.  Kirsty is a vulnerable isolated adult, who has already experienced domestic abuse therefore is at higher risk, could the presentation of Kirsty above be signs that David is abusing Kirsty? Could Kirsty feel dependant on David and feel she is unable to have her own independence? Could she be viewing him as a father figure and allowing him to take control as she has a fear of losing him and feeling even more isolated? The routine enquiry needs to be asked when Kirsty is alone but in a way that she can understand due to her learning disability.  Betty is underweight is she being fed appropriately, check this is not a sign of abuse towards her too?

-   David has two children with two different women, and he has no contact with these children. I would want to do a lateral check on David to check that there are no concerns with him being around children or vulnerable adults e.g. previous domestic abuse, safe-guarding concerns leading to him not able to have contact. I think this is important not only for him caring for Betty but also him caring for Kirsty who has a moderate learning disability 

-       Kirsty did not complete her 1:1 therapy sessions one reason was because she did not understand the therapist, I think it is important when offering referral to Kirsty and during the treatment it is important to explain everything at a level that Kirsty can understand and feels comfortable at.  When the nurse offered Kirsty a GP appointment she could have supported with making the appointment while David was not present and also could research into professional advocates for Kirsty who may be present at appointments to support her in explaining how she is feeling and to support her to make informed decisions 

-       Kirsty has a limited support network, as the nurse is aware Kirsty often feels lonely and misunderstood could she look into local support groups and peer support groups for Kirsty

- Neither of the parents work, are they coping ok financially and what are they doing to keep themselves busy during the week, are they taking part in activities in the community to support healthy mental health, self-caring for themselves. 

· SKILLS REQUIRED: 
- I feel I need to learn more about the different levels of disability and learn more about what reasonable adjustments can be made. Adjustments could include using visual aids to support verbal communication, using terminology that can be understood, ensuring written information is adjusted to meet the needs of the reader, e.g. terminology, font size, colour. Advocate services that can be present during appointments and can give the person another form of support other than their family members so the support is impartial. 

-       Skills needed: communication skills, approachable, non-judgemental, able to judge a situation and ask questions in an appropriate and sensitive manner e.g. only doing a routine enquiry when David is not present and asking it in a way that Kirsty can understand without feeling uncomfortable 

Develop some questions that you want to ask Kirsty:
 - How are you feeling lately? Explore Kirsty’s mental health and explore why she might be feeling more anxious and on edge lately? Explore management options and explore why she did not complete the course last time and what may be different about the treatment this time e.g. the therapist could adjust her communication to meet the needs of Kirsty 
 - Explore the relationship with David, ask the routine enquiry, explore how she feels about David attending every appointment and her not going out the house alone. Is this a confidence issue that needs addressing or is it that David insists on this? 

·         Explore what support networks Kirsty has in place and what peer groups she could attend. What does Kirsty want?

- Regular MDT meeting to discuss how the family’s needs are being met and opportunity to raise any concerns or further support required. This can include: HV, family nurse, social worker, GP and any other support professionals.