Indicators of harmful behaviour

These can leave clear impressions of the teeth.

• Black eyes are particularly suspicious if, both eyes are black (most accidents cause only one), there is no bruise to the forehead or nose or suspicion of skull fracture (black eyes can be caused by blood seeping down from an injury above).
• Bruising in or around the mouth
• Grasps marks arms – or chest
• Finger marks (e.g. you may see three or four bruises on one side of the face and one on the other)
• Symmetrical bruising (especially on the ears)
• Outline bruising (e.g. belt marks, hand prints)
• Linear bruising ( particularly on the buttocks or back)
• Bruising on soft tissue with no obvious explanation
• Different age bruising ( especially in the same area)
• Abrasions, especially around wrists and /or ankles

NB Most falls or accidents produce one bruise on an area of the body - usually on a bony protuberance. An adult who falls downstairs generally has only one or two bruises. Bruising in accidents is usually on the front of the body as most people generally fall forwards. In addition, there may be marks on their hands if they have tried to break their fall.

The following are uncommon areas for accidental bruising: back of legs, buttocks (except, occasionally, along the bony protuberance of the spine), neck, mouth, cheeks, behind the ear, stomach, chest, underarm, genital and rectal area.

It can be very difficult to distinguish between accidental and non-accidental burns, but as a general rule burns or scalds with clear outlines are suspicious. So are burns of uniform depth over a large area. Also slash marks about the main burn area (caused by hot liquid being thrown).

NB: Concerns should be raised where a carer responsible for an adult at risk of harm has not checked the temperature of the bath.

Cuckooing is a form of crime in which drug dealers take over the home of a vulnerable person in order to use it as a base for drug dealing. The crime is named for the cuckoo's practice of taking over other birds' nests for its young. Victims of ‘cuckooing’ can include older people, those suffering from mental or physical health problems and those living in poverty. The victim is at risk of domestic abuse, sexual exploitation and violence from the gang. It is common for gangs to have access to several addresses. They move quickly between vulnerable people's homes for just a few hours, a couple of days or sometimes longer. This helps gangs evade detection.

Signs that 'cuckooing' may be going on at a property include:

• An increase in people entering and leaving
• An increase in cars or bikes outside  
• Possible increase in anti-social behaviour  
• Signs of drugs use

• Unequal treatment based on age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex or sexual orientation (known as 'protected characteristics' under the Equality Act 2010) 
• Verbal abuse, derogatory remarks or inappropriate use of language related to a protected characteristic
• Denying access to communication aids, not allowing access to an interpreter, signer or lip-reader
• Harassment or deliberate exclusion on the grounds of a protected characteristic
• Denying basic rights to healthcare, education, employment and criminal justice relating to a protected characteristic
• Substandard service provision relating to a protected characteristic

Violence against women is wrong and women should be offered support and protection, but the key factor in relation to activating adult protection procedures in such situations is dependent on an assessment of “adults at risk” as defined earlier.

The Police define domestic violence as “any form of physical, non-physical or sexual harm which takes place within the context of a close relationship committed either in the home or elsewhere”. In most cases this relationship will be between partners (married, cohabiting or otherwise) or ex-partners. The similarity between the above acts of harm in relation to adult protection is recognised.

Violence Against Women Safer Lives: Changing Lives

For the purposes of this approach, Scottish Government define violence against women as actions which harm or cause suffering or indignity to women and children, where those carrying out the actions are mainly men and where women and children are predominantly the victims. The different forms of violence against women - including emotional, psychological, sexual and physical harm, coercion and constraints - are interlinked. They have their roots in gender inequality and are therefore understood as gender-based violence.

Scottish Government’s approach is informed by the definition developed by the National Group to Address Violence Against Women based on the United Nations Declaration on the Elimination of Violence Against Women (1993) which follows:

In recognising this definition, there is no denying or minimising the fact that women may use violence, including violence against a male or female partner. Although less common this is no less serious and requires to be addressed.

Scottish Government note that the definition they offer differs from the dictionary definition of violence which generally requires some form of exertion of physical force. Inclusion of these behaviours or activities as part of the spectrum of violence against women, and indeed the use of this term itself, is accepted internationally as evidenced by a number of definitions developed by the UN and EU, and, where necessary, Scottish Government will make clear the distinction between this definition and normal and legal usage of the term 'violence'.

Coercive Control

The 2019 Domestic Abuse Act criminalises psychological domestic abuse and coercive and controlling behaviour.

Forced marriage

Forced marriage is when someone uses physical or emotional pressure to try to force another person into a marriage without their consent. Forced Marriage Protection Orders (FMPOs) aim to protect people threatened with, or already in, a forced marriage. The individual at risk can apply for the FMPO, or a third party can do so on their behalf. FMPOs were introduced by the Forced Marriage etc. (Protection and Jurisdiction)(Scotland) Act 2011.

Resulting in mental distress to the adult at risk e.g.

• Excessive shouting, bullying, humiliation
• Manipulation or the prevention of access to services that would enhance life experience
• Isolation or sensory deprivation
• Denigration of culture or religion, sex, gender status, sexuality and disability.
• Exploitation through prostitution

The following indicators should be considered by workers when concerns regarding emotional harm arise.  In some situations the following will be applicable:

• Carers’ behaviour
• Carers’ history
• Pressure exerted by family or professional to have someone committed to care
• Weight change - loss of appetite or overeating
• Withdrawal confusion (could be caused by dehydration which produces toxic confusion)
• Loss of confidence
• Extreme submissiveness or dependence in contrast with known capacity
• demonstration of fear of another person by the vulnerable adult
• Sudden changes in behaviour in the presence of certain persons
• Rejection
• Denigration
• Scapegoating
• Denial of opportunities for appropriate socialisation
• Under stimulation
• Sensory deprivation
• Isolation from normal social experiences, preventing the adult at risk from forming friendships
• Marked difference in material provision in relation to others in the household
• Unrealistic expectations of the vulnerable adult
• Asking for an adult at risk to be removed from home, or indicating difficulties in coping with an adult at risk, about whose care there are already doubts
• Fear of carers
• Refusal to speak
• Severe hostility/aggression towards other adults.

Involving the exploitation of resources and belongings of the adult at risk e.g.:

• Theft or fraud
• Misuse of money, property or resources without informed consent
• Important documents are reported to be missing
• Unexplained or sudden withdrawal of money from accounts
• Contradiction between known income and capital and unnecessary poor living conditions especially where this has developed recently
• Personal possessions of valuables going missing from the home  without satisfactory explanation
• Someone has taken responsibility for paying rent, bills, buying food etc. – but this is not happening
• Unusual interest taken by relative, friend, neighbour or other in financial assets, especially if little real concern shown in other matters
• Next of kin refuse to follow advice regarding control of property via continuing/welfare power of attorney
• Where care services, including residential care, are refused under clear pressure from or other potential inheritors
• Unusual purchases unrelated to the known interests of the adult at risk

Should be suspected if there is pain, swelling, discolouration over a bone or a joint.

The most common non accidental fractures are the long bones i.e. arms, legs, ribs.

• Human trafficking
• Forced labour
• Domestic servitude
• Sexual exploitation, such as escort work, prostitution and pornography
• Debt bondage – being forced to work to pay off debts that realistically they never will be able to

This may occur in an ongoing relationship or service setting or to more than one person at a time. It is important therefore to look beyond single incidents and consider underlying dynamics and patterns of harm.

This includes ignoring medical or physical care needs. 

Part 3 -"Ill-treatment and wilful neglect" of the Health (Tobacco, Nicotine etc. and Care)(Scptland) Act 2016) identifies as criminal offences ill-treatment or wilful neglect in health and social care settings. One offence applies to individual health and social care workers, managers and supervisors, and another applies  to organisations.

Part 2 of the same Act places a duty of candour on health and social care organisations. This creates a legal requirement for health and social care organisations to inform people when they have been harmed as a result of the care and treatment they have received.

It is recognised from many recent reports that harm in care homes is an issue that should be recognised and that age discrimination by professionals and staff can contribute to risk and harm not being recognised.

Age discrimination is also a risk factor that may contribute to harmful conduct, and institutional harm can take many forms and the recent English report Inquiry into Home Care published in 2012 provides considers this in further detail.

The following indicators, singly or in combination, should alert workers to the possibility that adult at risk needs are being neglected:

• Failure to provide access to appropriate health, social care, or educational services
• Withholding necessities such as nutrition, appropriate heating etc
• lack of appropriate food or poor quality food
• lack of adequate clothing
• circulation disorders
• unhygienic home conditions
• lack of protection or exposure to dangers including moral danger, or a lack of supervision appropriate to the adults ability to manage harm
• Failure or delay in seeking medical attention
• A adult at risk is found at home or in a care setting in a situation of serious but avoidable risk
• Unnecessary delay in staff responses to residents requests
• Serious or persistent failure to meet the needs of the adult at risk
• Non-attendance at arranged care service
• Isolation
• Staff regularly change and/or poor management

Involving actual or attempted injury to an adult defined as at risk e.g.

• Physical assault of punching, pushing, slapping, tying down, giving food or medication forcibly, denial of medication.
• Use of medication other than as prescribed
• Inappropriate restraint

An attack by a stranger on an adult defined as at risk is an assault, a criminal matter, and should be reported to the police. However where there is the possibility that the violence may be part of a pattern of victimisation in a community or neighbourhood, Adult Protection Procedures may apply in respect of effective multi-agency intervention.

Many adults have scars, but notice should be taken of exceptionally large numbers of differing aged scars (especially if coupled with current bruising), unusually shaped scars e.g. round ones from possible cigarette burns or large scars from burns or lacerations that did not receive medical treatment.

This may be observed during regular contact with the adult but is not always easy to identify if the adult hides their actions or is isolated. Self-neglect is often reported as occurring in older people or is associated with mental ill health such as failure to east a proper diet or carry out personal care tasks. Acts of omission may include failure to take prescribed medication or ignoring medical needs.    

Involving activity of a sexual nature where the adult at risk cannot or does not give consent e.g.

• Incest
• Rape
• Acts of gross indecency
• Sexual Harm can occur when adults at risk of harm are involved in sexual relationships or activities which they have not consented to or are pressured into consenting to or they cannot understand.
• Such activities could include unwanted sexual contact such as rape or incest, inappropriate touching including sexual harassment either verbal or physical, indecent exposure, displaying pornographic material and inappropriate sexual material.
• Exploitation through prostitution. This includes women with a learning disability who may be subject to exploitation through prostitution.

Physical indicators of sexual harm:

The possibility that the following behaviour or injury could be as a result of the Adult at Risk of Harm normal observed behaviour over a substantial period of time should always be taken into account. It is noted changes in an adult at risk of harms out with their normal behaviour that is significant not the presence of the following in isolation:

• Adult aversion to being touched.
• Tendency to withdraw and spend time in isolation
• Deliberate self-harm
• Depression and withdrawal
• Wetting or soiling, day or night
• Sleep disturbances or nightmares
• Anorexia or bulimia
• Unexplained pregnancy
• Phobias or panic attacks

The following are more specific indicators:

• Recurrent illnesses, especially venereal disease
• Injuries in genital area
• Infections or abnormal discharge in the genital area
• Complaints of genital itching or pain
• Presence of sexually transmitted diseases
• Excessive washing

Not all people with substance dependencies will be considered at risk of harm under the Act. However, many such people will find themselves leading difficult and at times chaotic lives. The long term and cumulative nature of these problems can include periods when the person would not be regarded as being able to take authentic decisions affecting their health and wellbeing, and this can have serious consequences for their health and safety. They may then be more vulnerable to harm than others without such issues.

The problematic use of drugs or alcohol may take place alongside (and on occasions contribute to) a physical or mental illness, mental disorder or a condition such as alcohol related brain damage. If this is the case, an adult may be considered an adult at risk under the Act. It may also be that the impact of a person’s dependency renders them subject to physical or mental infirmity, and places them at risk of harm. It is essential to move from a position of looking at substance dependency in isolation and, instead, to see it in terms of relational causation and connection, i.e. a shift from the view that dependency causes self-neglect, to one that understands such dependency as an outward symptom or sign of deeper challenges and of self-neglect itself. As above, considerations of the impact of trauma on the individual’s ability to safeguard should be a thread throughout ASP activity.

People who are homeless are increasingly being recognised as likely to be considered as adults at risk under the terms of the Act, as many homeless people will be affected by disability, mental and/or physical illness or infirmity, or may have substance dependency issues.

In the years since the inception of the Act, hoarding has been recognised as a classified disorder in its own right, often alongside other conditions. In extreme cases, it can lead to some people living in dangerous and/or unhealthy conditions, resulting in a risk of harm.

It is not appropriate to use the existence of any of the circumstances outlined above to conclude that a person would not fall within the scope of the Act. All the circumstances in a person’s life must be considered together when applying the three-point criteria.