Safeguarding Older and Vulnerable People in Italy: Risk, Abuse and Protection

An older woman living at home may depend on the same relative for meals, money, transport and communication with professionals. A resident of an RSA may rely on staff for almost every aspect of daily life. A person with dementia may be unable to explain why they have become frightened around a particular worker. In each situation, protection depends on somebody recognising that vulnerability, dependency and power have combined to create risk.

Italy does not organise this protection through one national adult safeguarding system equivalent to those found in some other countries. Instead, responsibility is distributed across criminal and civil law, the Servizio Sanitario Nazionale, regional and local health structures, municipalities and social services, judicial authorities, law enforcement, professional responsibilities, provider governance and the wider framework protecting dignity, health and autonomy. The Italy Ageing, Long-Term Care & Community Support Knowledge Hub shows why that distributed architecture matters: long-term care itself crosses health, social, residential, household and family boundaries.

Safeguarding therefore cannot be reduced to investigating extreme abuse after it becomes visible. It includes preventing neglect, recognising coercion and exploitation, responding to unsafe care, protecting rights without unnecessarily removing autonomy and ensuring that concerns do not disappear between organisations. Italy's ageing population, reliance on family caregiving and privately arranged domestic care, regional variation and expanding community-based support make that preventive dimension increasingly important.

Italy protects people through several overlapping systems

The Italian framework is better understood as a network of protections than as a single safeguarding pathway.

The Constitution establishes fundamental protections around human dignity, equality and health. Criminal law applies where conduct amounts to offences such as mistreatment, violence, threats, unlawful restraint, fraud or other forms of exploitation. Judicial authorities and law-enforcement bodies become relevant where criminal conduct is suspected. Civil-law mechanisms can support people who have difficulty managing important aspects of their interests, including through the amministrazione di sostegno, or support administration, where legally appropriate.

Alongside these legal protections sit health and social-care responsibilities. Regions and Autonomous Provinces organise healthcare and social-health services within the national framework. Aziende Sanitarie Locali or equivalent regional structures have responsibilities within territorial healthcare and oversight arrangements. Municipalities and Ambiti Territoriali Sociali are important within social assistance. Residential and home-care organisations have their own professional, organisational and contractual responsibilities.

The result is necessarily multi-agency, although Italy does not use that term as one universal statutory adult-protection procedure.

A concern may therefore require action from several directions at once. Immediate healthcare may be necessary. Social circumstances may need reassessment. A provider may need to protect the person from a worker. Law enforcement may need to investigate suspected criminal conduct. Judicial intervention may be relevant to financial or decision-making issues.

This is why coordination between agencies is more than administrative good practice. Where responsibility is distributed, coordination becomes part of the protection itself.

Abuse is broader than visible physical harm

Physical mistreatment is among the most recognisable forms of abuse, but long-term care creates other risks that can be less visible.

Older people can experience psychological intimidation, humiliation, financial exploitation, neglect, inappropriate restriction, sexual abuse, coercive relationships or systematic failures in care. Harm may occur within a formal service, a family relationship, a privately arranged care relationship or through criminal exploitation from outside the care network.

Some risks emerge gradually rather than through one dramatic event.

A relative may begin using an older person's pension for household costs and progressively take control of all financial decisions. A care worker may speak harshly to residents without leaving physical evidence. A person living alone may receive insufficient food or hygiene support because everyone assumes another family member is providing it. An overstretched service may normalise delayed continence care or inadequate repositioning.

The distinction between intentional abuse and unsafe care can matter for investigation, but it does not remove the need to protect the person.

A useful operational framework therefore considers several possible forms of harm:

• physical, psychological or sexual mistreatment;
• financial exploitation, theft, fraud or coercive control over money;
• neglect or serious omissions in essential care;
• inappropriate restriction of movement, choice, contact or privacy;
• organisational practices that repeatedly expose people to avoidable harm; and
• self-neglect or severe deterioration where the appropriate response requires careful assessment rather than automatic coercion.

Understanding different forms of abuse matters because recognition determines whether concerns are noticed early enough to prevent escalation.

Dependency can increase risk without removing autonomy

Many people receiving long-term care depend heavily on other people. That dependence can create an imbalance of power.

An 88-year-old who cannot transfer independently may be unable to leave a room without assistance. Someone with advanced dementia may depend on others to interpret communication. A person whose badante manages shopping, appointments and medication collection may have few alternative sources of support.

Dependency does not mean that abuse is inevitable, nor does age itself remove a person's right to make decisions.

This distinction is central to rights-based safeguarding. Protection should not become a justification for taking control of every aspect of an older person's life.

A person may choose to continue a relationship that professionals consider difficult. They may accept some risk in order to remain at home. They may prefer privacy to intensive monitoring. They may reject an option that appears safer but would significantly reduce independence.

Safeguarding therefore requires attention to the person's wishes, ability to understand relevant decisions, communication needs and the seriousness of the risk. Where cognitive impairment or other circumstances affect decision-making, appropriate legal and clinical frameworks need to be followed rather than assuming incapacity because somebody is old, frail or disabled.

The wider principles of safeguarding, decision-making and human rights are especially relevant where protection and autonomy appear to pull in different directions.

Operational scenario: bruising reveals a wider dependency problem

An 84-year-old woman in Piemonte receives help at home from her adult son. He manages shopping, transport and most household finances. A privately employed care worker attends several times each week.

During a home visit, a healthcare professional notices bruising on the woman's upper arm. She initially says that she bumped into furniture. Later, when her son leaves the room, she becomes anxious and says that he sometimes grabs her when he is angry. She also says she does not want him to get into trouble because she has nobody else who can help her.

The situation cannot be resolved simply by asking whether she wants to make a complaint.

The immediate risk needs assessment. Her injuries may require clinical attention. Her communication and decision-making need to be understood without her son controlling the conversation. Social services may need to examine what practical support would be available if his involvement changed. If suspected conduct may constitute a criminal offence, the appropriate authorities need to be involved.

Her wishes remain important throughout. But genuine choice requires alternatives. Telling her that she can refuse her son's help means little if the consequence is being left without food, transport or personal support.

The protective response therefore includes rebuilding the care arrangement as well as responding to the suspected harm. This is an important principle: safeguarding is stronger when it reduces the dependency that allows abuse to continue.

Residential care creates concentrated safeguarding responsibilities

RSA services and other residential settings concentrate vulnerability, workforce responsibility and organisational power in one place.

Residents may have dementia, significant physical dependency, communication difficulties or complex clinical needs. Some cannot easily leave the service or explain what happens when relatives are absent.

Italy's regional authorisation and accreditation systems provide important structural controls, while health authorities, other competent public bodies and provider governance contribute to oversight. Inspections and investigations can also involve the Carabinieri's Nuclei Antisofisticazioni e Sanità, particularly where serious health, safety or suspected criminal concerns arise.

Recent Italian enforcement activity has continued to demonstrate why external scrutiny remains necessary. Investigations involving facilities for older people have included allegations of repeated mistreatment and other serious exploitation of vulnerable people. Such cases should not be used to characterise the residential sector as a whole, but they show that formal service status does not eliminate abuse risk.

The strongest protection therefore combines external oversight with internal cultures in which staff can challenge poor practice before it becomes systemic.

A service that relies exclusively on inspection is already too dependent on outsiders discovering what its own governance should be able to see.

Organisational abuse can develop through normalised practice

Not all institutional harm begins with an individual deliberately deciding to abuse somebody.

Unsafe routines can gradually become normal.

Residents may be put to bed early because evening staffing is limited. Call bells may be answered slowly because teams have accepted chronic understaffing. People who walk at night may be routinely discouraged from moving because restriction is easier than adapting the environment. Continence care may follow a timetable rather than individual need.

Each practice can acquire an operational explanation. Together, they can substantially diminish dignity, autonomy and safety.

This is where safeguarding intersects with quality governance.

Leaders need evidence capable of detecting patterns before an extreme incident occurs. Complaints, staff concerns, sickness, turnover, medication events, falls, unexplained injuries, weight loss and changes in resident behaviour may become more significant when viewed together.

The Governance Maturity Assessment can help organisations examining comparable issues test whether responsibility, challenge and escalation are sufficiently embedded in their own governance arrangements. It is not an Italian safeguarding or regulatory instrument, but the underlying question is relevant: can leadership distinguish isolated operational pressure from an emerging pattern of unsafe care?

A strong safeguarding culture also gives workers permission to challenge colleagues and managers. Policies are of limited value if staff believe reporting poor practice will damage their employment or relationships.

Operational scenario: distress is initially treated as dementia

An 81-year-old man with dementia lives in an RSA in Lazio. Staff begin recording increased resistance during morning personal care. He pushes workers away, shouts and becomes visibly distressed when one particular member of staff approaches.

The initial explanation is that his dementia is progressing.

A newly appointed worker notices that his distress is much less pronounced on the staff member's days off. She also hears impatient language during one care interaction and raises the concern with her supervisor.

A safeguarding response changes the question from “How do we manage his behaviour?” to “What might his behaviour be communicating?”

The provider protects the resident while the concern is examined, reviews relevant care records and staff accounts, informs the appropriate organisational leadership and follows the applicable regional, professional and legal reporting routes. Family information is also important because relatives can help describe the man's normal communication and responses.

The review identifies rough handling and repeated intimidating communication during personal care.

The response cannot end with action concerning one employee. Governance needs to ask whether colleagues witnessed earlier warning signs, whether staffing pressure contributed, whether supervision was effective and whether other residents may have been affected.

This connects safeguarding with root-cause and thematic learning. Removing an individual risk may protect one person today; understanding how unsafe practice remained undetected helps protect everybody tomorrow.

Home care distributes risk across less visible environments

Home is often the preferred place to receive long-term support, but it changes the visibility of safeguarding.

Formal workers may be present for only short periods. Family members may provide most support. Neighbours and professionals see fragments of daily life rather than the whole arrangement.

ADI professionals may focus primarily on health needs while municipal support addresses social needs. A privately employed domestic worker may provide extensive day-to-day care outside the organisational structure of a home-care provider. Family relationships can simultaneously provide protection and create dependency.

This makes professional curiosity particularly important.

A missed appointment, sudden withdrawal, unexplained financial anxiety, repeated bruising or deterioration in hygiene may have innocent explanations. They may also be signals that require further exploration.

Workers need routes for raising concerns even when they cannot prove abuse. Requiring certainty before escalation places too much investigative responsibility on the first person who notices something unusual.

The same principle applies to risk and safeguarding in home-based support: frontline workers need to recognise changes, record observations objectively and know who should receive the information.

The badante model creates distinctive safeguarding questions

Italy's extensive reliance on privately employed badanti creates a safeguarding environment that differs from provider-organised care.

A live-in worker can offer extraordinary continuity. They may know the older person better than any visiting professional and may be the first person to notice deterioration.

But a household employment relationship can also create mutual vulnerability.

The older person may depend almost completely on one worker. The worker may depend on the household for income and, in some circumstances, accommodation. Family members may live elsewhere and assume that constant presence guarantees safe care.

Neither assumption is reliable.

Potential risks include neglect, financial exploitation, inappropriate control and isolation of the older person. Conversely, domestic workers can experience exploitation, excessive working expectations, unsafe employment conditions or abuse from the person receiving care or relatives.

A sustainable safeguarding approach therefore avoids depicting migrant care workers as either inherently risky or automatically protective. It examines the quality of the care arrangement.

Questions include whether duties are realistic, whether the worker has adequate rest, whether clinical tasks exceed competence, whether relatives maintain appropriate oversight, whether the older person retains private communication with others and whether there is a route for either party to raise concerns.

This is also a workforce issue. A care model that depends on one person being continuously available can create conditions in which exhaustion becomes a safety risk even without malicious intent.

Financial abuse can hide inside ordinary family arrangements

Money is particularly sensitive because Italian long-term care frequently combines public benefits, pensions, household resources and privately purchased support.

Family members often manage finances for entirely legitimate reasons. An older person may willingly ask a son or daughter to pay bills, organise a domestic worker or withdraw cash.

The safeguarding challenge is recognising when assistance becomes exploitation or coercive control.

Warning signs can include unexplained withdrawals, sudden changes in spending, unpaid care bills despite adequate income, pressure around property or inheritance, or an older person appearing frightened to discuss money.

The Indennità di Accompagnamento also illustrates the wider governance issue. The benefit gives recipients flexibility rather than prescribing one standard package of care. That flexibility can support autonomy, but receipt of cash does not demonstrate that adequate care is actually being purchased or provided.

Financial protection therefore cannot depend on surveillance of every household transaction. It requires proportionate professional awareness, appropriate legal mechanisms where a person needs support with their affairs and effective investigation where exploitation is suspected.

Operational scenario: financial protection creates its own governance risk

An 89-year-old widower near Rome has increasing cognitive impairment. His niece helps with bills and appointments. As his ability to manage finances declines, a formal support arrangement is established to assist with his affairs.

Several months later, irregular payments begin appearing. Care fees are unpaid despite sufficient resources, while substantial sums leave his account for purposes unrelated to his needs.

The existence of a formal support mechanism cannot itself be treated as evidence that the person is protected.

Concerns about misuse require independent scrutiny and, depending on the facts, judicial and law-enforcement involvement. His immediate care also needs attention because unpaid support may place him at risk even before the financial investigation is complete.

The case illustrates an important governance principle: protective authority creates accountability as well as power.

Recent Italian investigations involving alleged misuse of vulnerable people's resources have reinforced that financial exploitation can involve individuals occupying positions that ostensibly exist to provide assistance. Safeguarding systems therefore need checks around the exercise of authority rather than assuming that formal appointment removes risk.

The principle is wider than any individual legal mechanism. Wherever one person controls another person's money, access, information or care, accountability should be proportionate to the power being exercised.

Information sharing is essential when responsibility is fragmented

Safeguarding concerns rarely arrive as complete cases.

A hospital may see repeated injuries. A general practitioner may notice family tension. Municipal social services may know that a carer is exhausted. An ADI nurse may observe deteriorating living conditions. Individually, each piece of information may appear inconclusive.

Connecting them can change the risk assessment.

Information sharing therefore has to balance privacy with legitimate protection. Professionals need to understand the legal basis and purpose for sharing information rather than treating confidentiality as either an absolute barrier or a reason to circulate personal information indiscriminately.

This is particularly relevant to safeguarding information sharing and confidentiality. The quality of a decision depends not on maximising information but on ensuring that relevant information reaches the people responsible for acting on it.

Digital interoperability can help where systems permit appropriate information exchange, but technology does not resolve uncertainty about responsibility. An alert that everybody can see but nobody owns remains an unmanaged risk.

Organisations considering those digital interfaces can use the Digital Transformation Readiness Assessment to examine whether technology, governance and workforce capability support reliable information flow. Any use in Italy would need adaptation to Italian privacy, health-information and organisational requirements.

Workforce competence determines whether policy reaches the person

Most safeguarding systems ultimately depend on somebody noticing something and deciding to act.

That makes workforce competence central.

Staff need more than awareness of extreme physical abuse. They need to recognise neglect, coercion, financial exploitation, inappropriate restriction and subtle behavioural changes. They need confidence to challenge senior colleagues and to document facts without turning suspicion into unsupported conclusions.

Competence also includes knowing the limits of one's role.

A frontline worker should not be expected to conduct a criminal investigation. Their responsibility is to recognise, respond to immediate risk, preserve relevant information, record accurately and escalate through the appropriate route.

Supervision matters because ambiguous concerns require judgement. A worker who repeatedly raises subtle observations should encounter curiosity rather than dismissal simply because no single event crosses an obvious threshold.

This places safeguarding training and practice competence within the operational architecture of protection.

Workforce conditions matter as well. Chronic understaffing, excessive workload, poor supervision and high turnover can weaken observation and continuity. They can also create environments in which rushed or depersonalised care becomes normalised.

These pressures do not excuse abusive behaviour. They do, however, belong within prevention because governance should identify conditions that increase the likelihood of unsafe practice.

Operational scenario: carer exhaustion changes the safeguarding response

A 78-year-old woman with advanced Parkinson's disease lives in Campania with her 80-year-old husband. He provides most personal support between periodic professional visits.

A visiting worker notices that the woman has lost weight and has developed skin damage. Her husband appears exhausted and becomes defensive when asked about care routines.

The evidence does not immediately establish deliberate neglect.

A purely punitive response could discourage both people from accepting help. Ignoring the situation because the husband is an unpaid family carer would be equally unsafe.

The assessment needs to consider the woman's immediate health, nutrition and skin integrity alongside her husband's capacity to continue caring. The couple's wishes matter, but so does whether the current arrangement can meet essential needs.

Additional home support, equipment, clinical review, respite or a broader reassessment may be required. If evidence subsequently indicates deliberate harm or serious neglect, the response must escalate accordingly.

The important distinction is that safeguarding should respond to risk rather than begin with assumptions about intent.

Family care is one of Italy's greatest long-term care resources, but family partnership and carer support are also preventive safeguards. Supporting a carer before exhaustion becomes dangerous can protect both people while preserving a valued relationship.

Technology can protect and intrude at the same time

Remote monitoring, sensors, location technology and telecare can increase safety for older people living alone or experiencing cognitive impairment.

They can detect falls, support medication routines or enable earlier response to deterioration. In residential settings, digital systems can help analyse incidents and identify recurring patterns.

But technology can also create new safeguarding questions.

Continuous monitoring can reduce privacy. Location tracking can become routine rather than proportionate. Families may install cameras without adequately considering the dignity of the person receiving intimate care or the privacy of workers. Automated alerts may create false reassurance if nobody can respond promptly.

Technology should therefore be governed around purpose.

Leaders need to understand what risk the technology addresses, who receives the information, what happens when an alert occurs, how long information is retained and whether less intrusive alternatives could achieve the same objective.

This is particularly important where the person has dementia or difficulty expressing preferences. Protection should not become permanent surveillance merely because technology makes surveillance possible.

The same balance underpins technology and digital support for older people: useful innovation strengthens human care when it is proportionate, understood and connected to a reliable response pathway.

Safeguarding governance needs to see patterns, not just cases

An individual concern requires an individual response, but organisational learning requires aggregation.

A provider may record several unexplained injuries across different units. A territorial service may receive repeated concerns involving financially dependent older people living alone. A municipality may see increasing numbers of family carers reaching exhaustion before support is arranged.

Those patterns should influence more than case management.

They can inform workforce training, service capacity, inspection priorities, prevention programmes and future resource decisions.

A mature safeguarding evidence set might therefore consider:

• the nature and source of concerns rather than only their total number;
• time between recognition, protective action and appropriate escalation;
• recurring locations, relationships or service pressures;
• whether people and families understand what happened and what will change;
• whether actions arising from investigations are completed and tested; and
• whether similar concerns reduce or recur after intervention.

The Quality Dashboard Builder offers organisations a practical way to structure comparable quality intelligence. It does not provide an Italian safeguarding reporting framework, but it can help leaders avoid treating incident numbers as self-explanatory measures of safety.

An increase in reports, for example, may initially indicate a healthier reporting culture. Governance needs enough contextual evidence to distinguish improved visibility from deteriorating care.

Prevention begins before somebody becomes a safeguarding case

The most effective protection does not start with an investigation.

Social isolation, frailty, cognitive impairment, financial dependency, inadequate housing and carer exhaustion can all increase vulnerability. Preventive policy therefore overlaps with wider ageing policy.

Law 33/2023 and Legislative Decree 29/2024 are significant because they place dignity, autonomy, social inclusion, active ageing, prevention of frailty and reduction of relational isolation within Italy's developing national approach to older people.

Those objectives are not labelled as one national adult safeguarding system, but they affect the conditions in which harm becomes more or less likely.

An older person who has several trusted relationships, accessible services and control over their own decisions may be better able to disclose mistreatment. A family receiving timely support may be less likely to reach an unsafe level of exhaustion. A person receiving regular professional contact is less invisible than somebody entirely dependent on one isolated care relationship.

This gives prevention and early intervention a safeguarding dimension.

It also connects protection with Italy's wider long-term care reforms. Better multidimensional assessment, more coherent home support and stronger territorial coordination can create earlier opportunities to identify vulnerability before serious harm occurs.

Regional variation requires clear escalation routes

Because Italy's health and social-care organisation is decentralised, detailed procedures and responsible bodies can vary by territory and service type.

That variation makes it especially important for organisations to define local escalation routes accurately.

Staff working in an RSA need to know the applicable regional and organisational requirements. Home-care professionals need clarity about the health and social structures operating in their territory. Managers need to understand when a matter requires internal action, notification to competent authorities, professional escalation, judicial involvement or law-enforcement referral.

A generic policy copied across Regions without mapping those responsibilities can create dangerous ambiguity.

National principles can still be consistent: protect the person, respond to immediate danger, record facts accurately, respect rights, involve appropriate authorities and learn from what happened. But the institutional pathway must reflect the territory in which the service operates.

This is another reason safeguarding cannot be separated from quality assurance and governance. Leaders need evidence that procedures describe the real system around the service rather than an abstract model of how protection ought to work.

Protection is becoming more explicitly rights-based

Italian policy for older and vulnerable people is increasingly framed around dignity, autonomy, inclusion and the ability to remain connected with ordinary life.

This matters because safeguarding can become overly restrictive when safety is treated as the only outcome.

The emerging rights-based direction is also visible beyond older-person policy. From late 2025, collaboration between the national Authority responsible for the rights of persons with disabilities and the Carabinieri Command for Health Protection created arrangements for joint visits to residential settings including RSA, care homes and family homes within the Authority's remit. The focus includes fundamental rights, social-health assistance and opportunities for social and relational life.

That development should not be misrepresented as a new universal older-person safeguarding regulator. Its statutory remit is disability rights. However, many people living in long-term care have disabilities, and the initiative illustrates a wider shift in oversight: protection is not confined to the absence of physical abuse.

A person can be physically safe yet deprived of privacy, relationships, autonomy or meaningful participation.

The stronger safeguarding model therefore asks both whether people are protected from harm and whether the protective response respects the life they are entitled to live.

What Italy's experience offers internationally

Italy illustrates a challenge shared by many long-term care systems: responsibility for protection often crosses the same institutional boundaries that divide care itself.

The transferable lesson is not that every country needs the same national safeguarding institution. Legal traditions, administrative structures and professional responsibilities differ too greatly for that.

The stronger lesson concerns interfaces.

Where health services, social services, municipalities, providers, families, domestic workers, judicial authorities and law enforcement can all hold relevant information or responsibilities, protection depends on knowing when those interfaces must activate.

Italy's extensive family and household care also highlights another international issue. Safeguarding cannot be designed only around regulated institutions. As countries seek to support more people at home, protection increasingly has to operate in private environments where formal oversight is lighter and relationships are more complex.

Finally, Italy demonstrates why safeguarding and autonomy should not be treated as opposites. Preventing abuse is essential, but long-term care exists to support people to live, not simply to eliminate every possible risk.

Other systems can adapt that principle without replicating Italy's legal or administrative mechanisms: protection is strongest when it reduces harmful dependency, preserves meaningful choice and creates enough visibility for concerns to be recognised before they become severe.

Conclusion

Safeguarding older and vulnerable people in Italy operates through a distributed network rather than one national adult-protection system. Health and social services, Regions, municipalities, providers, professionals, judicial authorities, law enforcement, families and community relationships can all contribute to protection. That breadth is necessary because abuse and neglect can occur in equally diverse environments, from accredited residential facilities to private homes and family financial arrangements.

The central challenge is ensuring that distributed responsibility does not become fragmented responsibility. Concerns need clear routes for escalation, workers need practical competence, organisations need cultures that welcome challenge, and information needs to cross boundaries when protection legitimately requires it. Governance must also look beyond individual incidents to the patterns created by workforce pressure, isolation, carer exhaustion, financial dependency and repeated unsafe practice.

Italy's developing emphasis on dignity, autonomy, prevention, integrated assessment and community support creates an opportunity to make safeguarding more preventive as well as responsive. Stronger protection will not come only from investigating more cases. It will also come from reducing isolation, supporting families, strengthening care relationships and identifying vulnerability earlier.

The most credible measure of progress is therefore not a system in which risk disappears. It is one in which older people remain visible, their rights remain central, concerns can be raised safely and every part of the care system knows when responsibility for protection has become its responsibility to act.