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Substantial danger
What amounts to substantial danger (PADP regs, regs 5(2)(b), 5(3)(b) and 7(2)(b)(ii)) is a question of fact in each case. ‘Substantial’ should be given its ordinary, everyday meaning. Substantial danger could result from a fall, exposure or neglect. Case managers should consider the circumstances of each individual in deciding whether the danger is substantial.
Individuals with certain mental conditions, or conditions that affect memory or thinking, may create danger for others without being aware of the consequences of their actions. For example, they may:
- lash out at others, potentially causing injury
- turn on a gas appliance without lighting it
This list is not exhaustive.
Individuals may be a substantial risk to themselves if there is a risk of suicide. Continual supervision may be required to reduce the risk of self-harm, although this may not eliminate all the substantial danger.
People without certain disabilities can generally recognise everyday dangers. Individuals with mental health conditions, or conditions that impact memory, may:
- be unaware of these dangers
- put themselves at risk of serious injury.
For example, an older person with dementia may have substantially less awareness of the dangers of unattended cooking appliances than other older people.
Example: an individual is at substantial danger from falling and seizures
Emira is 78 years old and has epilepsy. She loses consciousness during frequent seizure and can fall if her carer is not there to prevent it. If she falls and loses consciousness, she is unlikely to be able to do anything to prevent injury or harm to herself. This is more likely to be a ‘substantial danger’ compared to falling more generally, as Emira will not be unable to take preventive steps or communicate that she requires assistance when she is unconscious.
Example: an individual requires another person to be awake at frequent intervals to avoid substantial danger to themselves
Mary is 85 years old and has obstructive sleep apnoea. Over the past 8 months, Mary has also started to become forgetful and regularly distressed. Mary’s obstructive sleep apnoea alongside her other symptoms have been confirmed by her medical professional through supporting information.
Mary uses a continuous positive airway machine (CPAP) overnight to improve her breathing. Mary lives with her daughter who has been trained to use the CPAP machine.
Since Mary started to become forgetful, she has been unable to use the CPAP machine independently. Mary’s daughter assists her to put on the CPAP mask before bed and ensures that this is correctly and securely in place. She regularly wakes up during the night feeling distressed and will remove the CPAP mask. This has led to regular instances of Mary getting out of bed while feeling disorientated and upset, and has led to her injuring herself regularly.
Throughout the night, Mary’s daughter checks in on her to monitor if she has removed the mask in her sleep and will wake her up to replace the mask securely. Mary tends to become disorientated when this occurs, and requires to be settled back into bed. Mary regularly calls out for support when she wakes up feeling distressed due to the CPAP mask, causing her daughter to wake up and tend to her.
Although Mary’s application states that she has started to become forgetful and disorientated, she does not currently require help during the day. The case manager has determined that Mary is at risk of substantial danger, as she may become entangled in the tubes of the CPAP machine when she removes the mask while sleeping, and is at risk due to her injuries when getting up during the night.
Therefore, as Mary reasonably requires her daughter to be awake at frequent intervals to watch over her to avoid substantial danger, the case manager has determined that Mary satisfies the night-time condition and is entitled to the lower rate of PADP.
The case manager considers that Mary’s needs may change in the future due to her becoming regularly forgetful and distressed. Therefore, a three year review period has been set for Mary’s award. This will allow for a review to take place to consider whether Mary’s needs have changed.
Falls
An individual may be at risk of substantial danger because of a physical condition. For example, certain disabilities may put a person at risk of falling. These falls should be distinguished from accidental falls which could happen to anyone.
Further guidance is available in the Medical Guidance and advice can be sought from a practitioner through a case discussion.
Where an individual is at risk of falling as a result of a condition or illness, the case manager should consider if the falling is:
Predictable
If the falling is predictable, case managers should consider whether the individual can reasonably be expected to avoid the risk unless supervised.
Unpredictable
If the falling is unpredictable, case managers should consider:
- whether the falling may result in substantial danger to the individual
- whether the risk of substantial danger is too remote.
Example: the risk of substantial danger is too remote
Leo is 69 years old and has seizures. During seizures, Leo would briefly lose consciousness. If he was standing, this means he would fall with a danger of injuring himself.
Leo was prescribed lamotrigine to help manage his seizures. It has been very successful. Leo has not had a seizure now for 12 months. As long as Leo continues to take his medication, his seizures are manageable. This means that the risk of substantial danger is remote.
Example: there is a risk of substantial danger
Kristof is 75 years old and has had a stroke. Kristof needs long-term support due to weakness on one side of his body. He is no longer able to walk on his own and requires the use of aids to stand and walk very short distances. He is not able to climb stairs using the aids and needs help to stand and sit down.
Kristof needs to be supervised because there is a risk that he could fall and injure himself, even with the use of aids. Kristof has not fallen yet, but without supervision and attention from another person, it is likely that he would. It is also likely that he would injure himself when this happens.
It is important to appreciate that the key issue is the likelihood of serious injury, and not the frequency of falls. Serious injury can arise due to a fall itself or as a consequence of an inability to get up after a fall.
Some conditions can increase the risks of injuries and potential issues arising due to being unable to get up after a fall. The individual does not need to have experienced a serious injury in order to be at risk of substantial danger from falls.