Practice Panel Older people team – Leeds primary care
trust and social services department.
Case Study :
The name of the service user has been
Situation: Enid Sullivan is 87 years old and
lives alone in an upstairs maisonette she has lived in for 46
years. She bought the home together with her husband Jeff – the
only family she had – who died in 1996. She has a volunteer to help
with shopping and trips out but refuses help from social services:
partly because she thinks they want to put her in a home. A worker
carried out an initial assessment and told her that stairs were
Problem: Despite the stairs Enid is determined
to soldier on and stay in the only home her and Jeff – whom she
profoundly misses – knew together. Indeed the house is as it was
when Jeff died. Enid has no central heating and relies on a small
gas fire – but forgets to put it on – and wraps herself in the
blanket that was on their bed when Jeff died from a heart attack
during his sleep. Since then she has often been in hospital with
pneumonia, chest infections and having both her hips and knees
replaced or operated on. Recently, worn out from the climb to her
door she suddenly felt dizzy and collapsed. After a few hours she
managed to get to her phone and call 999. She was taken to A&E,
where she is now well known. The hospital discharge team does not
think a referral home without support is feasible, but Enid will
hear of nothing else.
Once Enid had dialled 999 for an ambulance, the crew would
attend and assess Enid’s condition. If Enid lived in Leeds and an
acute hospital admission was not necessary, with her consent the
ambulance crew would refer to the community rapid response
A senior nurse from the team would respond within a maximum of
two hours to Enid’s home. The nurse would make a thorough
assessment and take a medical, social and physical history. Enid
can take control of her predicament and work closely with the rapid
response nurse to agree any further action; Enid’s reluctance to
receive help in the past may stem from a fear of losing control and
choice over her care.
The rapid response nurse would liaise closely with Enid’s own GP
and review possible causes of her collapse. In this case it might
mean a review of her medication and her long standing chest
A domiciliary assessment by the consultant for elderly medicine
linked to the rapid response team may be required thus avoiding
Enid having to go into hospital, and investigations into the
reasons for poor memory loss could be started.
Rapid assessment by the occupational therapist and
physiotherapist would help Enid to identify any help required to
improve her mobility problems and management of daily
The team could offer 24-hour support tailored to Enid’s needs as
appropriate for up to 72 hours. Building up a rapport and trust
will help to reassure Enid that there are services in her own
community to support her and help her to remain independent,
without the need of an acute hospital admission.
The team will work very closely with social services, and with
Enid’s consent the environmental problems can be addressed: that
is, heating, fitting the stair rail and any other aids and
adaptations tailored to her needs.
Once Enid’s condition is stable a referral to the community
matron will ensure that proactive and preventive assistance is in
place to enable Enid to be more involved in her care
Enid would probably be brought to the attention of the advanced
specialist practitioner (ASP) – the equivalent to a community
matron. Their role is to work with patients like Enid who are what
the government now describe as “very high intensity users” by
virtue of her hospital attendance.
The ASP, who is attached to the GP practice, would then review
Enid’s medical records held at the surgery and discuss Enid with
the family doctor before arranging to see Enid. She would be
thoroughly assessed when she is “well” and not in a crisis.
The role of the ASP would be to work with Enid to develop a plan
of care which should be based on Enid’s own goals. This may be, as
the case study shows, “to stay in her own home”. The ASP would
then work proactively with Enid towards achieving this goal.
The ASP would explore the possibility of either central heating
being fitted to reduce risk of hypothermia or fire – or possibly
alternative accommodation if this means Enid staying in the
community. Further risks would be negotiated with Enid: for
example, she may be offered a care alarm to call for help if she
The ASP would assess Enid’s blood pressure and review her
medication and her compliance with taking them, making sure she
knew and understood the reasons for taking them, and how.
It may be that a neighbourhood network or other voluntary group
may run exercise classes which Enid could attend to strengthen her
muscles, improve balance, reduce risk of falls, improve her ability
to walk up her stairs, as well as reducing social isolation.
It would als be very important to explore with Enid how she felt
about the death of her husband – and in doing so it might be
necessary to draw upon the resources of a counsellor.
One of the important aspects of the ASP’s involvement would be
about educating Enid about her illnesses such as chest infections
and pneumonia, explaining early warning signs and what to do and
who to call when they occur. The ASP would also act as a key
person in integrating all aspects of care for Enid drawing on
voluntary, health and social care services as necessary.
In an ideal world Enid would benefit from a place at a sheltered
accommodation complex, with access to 24-hour warden support or
Lifeline alarm facilities but this is a much more complex and
heart-rending situation, which requires skilful handling, write
members of Knowsley Older People’s Voice and other service
In light of the stalemate in which Enid could not return home
without support but is refusing help, it may be possible to offer
her an intermediate care bed for rehabilitation. This would allow
time for a care plan to be devised with Enid before her
A “worker” has advised that the stairs are too much for Enid but
we would question this assessment. An occupational therapist
should find out if Enid can cope adequately at home. This could
take place while Enid is still in hospital or an intermediate care
facility. She could then have the necessary adaptations provided to
help Enid remain independently in her own home.
During this time a grant could be applied for, with help from
the local council’s energy efficiency officer, to secure
improvements to her home including central heating and a gas safety
check to ensure that the accommodation is warm and safe.
Because of Enid’s perception of social services we would see a
volunteer as being the key to gaining trust and helping to explain
to Enid that she has choices available. They could suggest that
Enid puts her name forward for sheltered accommodation, as there
could be a long waiting list.
It could be explained that there is no commitment to accept the
accommodation, even if it is offered to her. In the meantime, she
could visit various types of accommodation to see what is
available in the area.
Bearing in mind that she is reluctant to accept input from
social services, Enid may accept involvement from other agencies
such as Age Concern, Red Cross, Pensioners Advocacy Services and
local church and community groups.
Enid does not seem to have recovered from the loss of her
husband and may be suffering from depression. She might benefit
from access to a bereavement counsellor to help her begin to regain
her confidence and independence.
By members of Knowsley Older People’s Voice – an older
people’s forum based in Knowsley, Merseyside – with help from
service users at St Mary’s Day Centre in Halewood and the Ageing
Well group from Kirkby.