Why is it so easy to fall through the cracks?

A few months ago I had been called to a situation where a 93 year old was dying. The staff called me because they were concerned about the woman’s daughter. She appeared to be in her 50’s but had an obvious learning difficulty and/or a mental health problem. 

This became very apparent when I had the unenviable job of trying to explain to the daughter that her mum was about to die. It was clear to me that the daughter wasn’t taking it all in despite my best efforts. I stayed with them both till mum died. The daughter without showing that she understood the significance of what had just happened then said she wanted to go home. 

Earlier I had spoken to an elderly aunt and cousin who lived some distance away and were the only living relatives. They told me the daughter had always been simple and that the mum had done everything for her. The daughter could go shopping and could cook but they were worried how she would cope in the long term. They told me they would come up. I kept the daughter occupied until they arrived and took her away. I then asked the nurse in charge to refer the daughter to our social workers as a vulnerable adult. She told me that the ward staff were planning to do this.

Two months later I bumped into this woman wandering around the hospital corridors. She was dirty and smelly. People were giving her a really wide birth. I asked her if she remembered me. She told me she did. I asked if anyone had been to see her at home since mum had died and she told me no-one had been around. I asked her why she was at the hospital and she told me that she was a bit depressed and liked to come here for a walk. I asked her if she’d been eating and drinking ok and managing to get to the shops and she told me she had. I then said it must be hard since mum had died and that it seemed to me that she wasn’t looking after herself. I told her that she needed to have a bath and wash her clothes. I also told her to could come and talk to me or one of the other chaplains any time she wanted. I then offered to take her for a cuppa but she decided to go.

It was a tough conversation and not one that I wanted in full public view in a hospital corridor. The woman obviously took comfort from being back at the last place she had seen her mum.

When I got back to the office I checked the vulnerable adults policy and realised it wasn’t any good for these circumstances as the woman wasn’t a patient. I decided to talk it over with a colleague but wasn’t successful in meeting up due to being so busy. While I was wandering the hospital carrying out my usual duties I kept thinking about the situation and wandering what was the best thing to do. I eventually hit upon the idea of looking up the mothers details and finding out who the GP was. I then rang the GP. They told me that a referral had been made in November. I explained that the mum had been dead 6 weeks by then and that the woman needed an urgent assessment. The GP asked me what was wrong with her as they had no records. I said I wasn’t medically qualified to answer but it was clear there were significant problems and she was very vulnerable. The GP assured me she would take action so therefore I felt I’d done the right thing and handed her over to someone who could make a difference.

It never ceases to amaze me how easy it is for people to slip through the net, even in a supposedly civilised world. How many thinking and feeling people walked passed that woman as she wandered the hospital corridors or the local community and did nothing? I hope I never get to the point where I am so intimidated by a situation that I turn into a bystander!