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Case study
The names of service users  mentioned in this article have been changed

Situation: Edith McSweeney is an 82-year-old woman who lives alone in a high-rise flat. She suffers with poor mobility and is using a stick. Her husband died 30 years ago and she has not remarried.  Her daughter, Alison, who lived nearby, had become Edith's main carer even though their relationship had been somewhat fractious.  Edith has not seen a GP for many years.

Problem: Alison's husband was appointed to a job in Brussels which means they have now moved to live in Belgium. Alison was pleased to go - as it signalled a new and challenging start for them. However, it meant Edith would lose her carer. It was only when Alison had actually gone that it became apparent to Edith how much she relied on her. It seemed that Alison did everything for her, partly out of a sense of duty, but also because Edith expected it and ordered her about. This meant that Edith had lost all her independence skills: she'd never even used the microwave that she had owned for 12 years. Before long, Edith experienced a fall trying to get out of bed. At hospital she was assessed as being in danger of falling again and a community nurse was allocated the case. The community nurse also referred Edith onto social services. However, Edith has taken to ringing up the nurse and the community care worker demanding help and support with almost every task. She now rings each worker up to 25 times a day.

Panel responses
Christine Rawson (advanced specialist practitioner)

As an advanced specialist practitioner, I would talk to the members of the multi-disciplinary team already involved with Edith to identify what support she is receiving at present. I would do some detective work regarding medication prescribed, and information at hospital discharge, including any medical diagnoses.

Visiting Edith at home would enable me to form a relationship with her and explain my role. I would ask her to tell me how she is coping and identify any problems from her viewpoint. This may elicit her feelings about her daughter moving abroad and the impact this has had on her life. It would also be important to establish if she is happy taking her medication and if she is able to take it independently.

I would also liaise with her GP and ask for a general review including screening her mental health status and risk of depressive illness. It would be useful to have the views of Edith's daughter, and to establish whether or not any other family members are involved or would be willing to liaise with the care teams.

The number of phone calls she is making to the care staff daily suggests a high level of anxiety and loss of confidence; with her consent I would work with her to set goals to reduce this anxiety. Initially this may mean referring to the intermediate care team (ICT), enabling an intensive level of support for a short period. ICT would perform a multi-disciplinary assessment looking at Edith's potential for independence and mobility, plus an assessment of any aids and adaptations needed. It seems that she has not lived independently for many years and her motivation to do so needs to be established. Having had a recent fall, she would also be referred to the falls programme at a local hospital.

Having lost her main carer and frequent visitor, it is likely that Edith is socially isolated and lonely. As her confidence increases over time it would be prudent to try to involve her in some local activities: a local day centre or neighbourhood network would be a good starting point. Ongoing review would indicate if Edith is able to cope at home, perhaps with support from social services.

Jackie Dawson (district nurse)

Unfortunately, Edith has two main problems: falling and the loss of independence. Both these problems would require a referral to district nursing. As the scenario already mentions a community nurse, hopefully a rapport with Edith would have been established. This will enable a partnership between Edith and the district nursing team in resolving some of the issues highlighted.

The district nursing assessment would first examine the issue of Edith falling. Unfortunately, falls among older people are all too common. The government has identified this through the national service frameworks, aiming to reduce the number of falls. The assessment by the district nurse would examine the current medication Edith is taking, as certain types of medication increase the risk of falling. This would be done alongside a GP review. The district nurse would also discuss with the GP about any medical conditions that could be causing Edith to fall, in particular deteriorating eyesight could be considered.

Prevention of falls is an important aspect of Edith's management. This would involve an assessment of Edith's home environment to determine potential dangers; we would start by looking out for loose carpets and rugs. In certain parts of the country a handyman scheme is in place, where volunteers assist to repair unsteady stairs and other household problems. Edith's footwear would be examined as poor fitting slippers in particular can cause falls. Edith would be encouraged to use the "message in a bottle" scheme, whereby she can write her details and medication information and place it in the plastic bottle which is then stored in the fridge. A sticker can also be placed in the window of Edith's home, providing professionals with similar information should she fall.


The district nurse may refer Edith to the local falls prevention team, usually run by physiotherapists and occupational therapists, where a more in-depth assessment can take place. Regarding her loss of independence, the district nursing team would encourage her to gradually gain her confidence in tasks such as cooking. This would possibly require the involvement of the rehabilitation team. The district nursing team would encourage Edith to use local live-at-home schemes.

User view

It is obvious that Edith has become set in her ways and dependent on her daughter. She seems to have lost her communication skills and can only demand help, firstly from her daughter and then from the care workers, write members of Knowsley Older People's Voice.
There may be many reasons for her aggressive behaviour, such as fear and feelings of vulnerability. It is good that she has been assigned care workers and social care input but services now need to be put in place to help her regain her independence, if that is what she requires.

This case raises questions over community members being aware of the services that are available to help support carers. Alison may not have become the main carer for Edith if the support of other agencies were made available. This also would have ensured that when Alison moved away and was unable to continue to provide care for Edith then services could have been in place to support Edith.

It is apparent that she has not had any input from her GP and may well be suffering from illnesses or conditions, such as heart disease or blood pressure. She needs a complete medical review to ensure she is well and start any medication she may need.

It is vital that the causes of Edith's falls are established. Following the health review, services such as eye tests and podiatry care could be made available. Edith would benefit from a home falls assessment to see if she has any loose carpets or incorrect footwear causing her to fall.

In Knowsley we have a community independence team. This is a multi-disciplinary team and the initial assessment is carried out by an occupational therapist. Following this assessment and the falls assessment, any suitable aids or adaptations could be provided. In Knowsley, there are falls prevention groups in each area of the borough, and Edith could attend the appropriate group.

The possibility of more appropriate accommodation could be considered, with Edith's approval such as a bungalow or sheltered accommodation. When Edith is more confident in herself, a Senior Link phone could be provided for her which would give her peace of mind any time of the day or night.

A link into a befriending service would help to increase Edith's trust in other people and increase her independence. 

Knowsley Older People's Voice is an older people's forum based in Knowsley, Merseyside