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Background: The Mental Capacity Act (2005) states an Independent Medical Capacity Advocate (IMCA) should be arranged for any unbefriended adult who lacks capacity and is in need of serious medical treatment, is in need of a change in accommodation or who has been in hospital for 28 days.

Concern had been raised from the Safeguarding Team at the local county council about low referral rates compared to government estimates.

We wanted to establish whether we were failing to refer people who meet IMCA referral criteria, and how we could efficiently audit this on a hospital-wide scale.

Sampling methods: Two geriatricians systematically reviewed hospital notes from all discharges over a two-week period in September 2011 (one surgical ward, two medical). We identified from the notes whether patients had a diagnosis of dementia/delirium during that admission, which may have caused them to lack capacity. For those who did, documented next of kin/friend details were sought.

Full hospital coding for these admissions was reviewed, to establish its potential for identifying all patients with dementia/delirium. Our designated “gold-standard” was the two-doctor agreement on dementia/delirium being present during that admission.

Results: 92 sets of notes were obtained. 11/92 (12%) patients were considered to have had dementia/ delirium. All 11 (100%) had a clearly documented next of kin/friend.

Regarding coding, 0/92 patients were considered to have been inappropriately coded as having dementia/delirium. Only 6/11 (55%) were correctly identified as having dementia/delirium on coding.

Conclusions: Systematic notes review is a preferable method for auditing whether IMCA referrals are made when appropriate, as 45% patients with dementia/delirium were missed on coding. Further education on dementia, delirium recognition and importance of documentation is being given to medical and coding staff, and mandatory fields in discharge summaries introduced. IMCA referrals and coding accuracy will be re-reviewed.

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