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A Polish man who served with the RAF in the second world war has become a recluse and is struggling on everyday tasks

Case study
The name of the service user has been changed

Situation: Jan Cerowski is an 87-year-old man who lives alone in a council house but has no surviving family. His twin sons died at birth and a daughter was killed by polio in the 1950s aged seven. Mr Cerowski's wife died eight years ago and he has been somewhat of a recluse since. A neighbour helps with shopping and errands. He sought refuge in England in 1939 as a Polish airman and joined the Royal Air Force Volunteer Reserve - and has remained since.

Problem: Because of his poor mobility, the SSAFA, the national charity helping serving and ex-service men, women and their families, referred Mr Cerowski to his GP. He had repeatedly fallen while trying to get out of bed. He had not engaged with health care services since his wife's funeral. A district nurse from the GP's surgery visited and found Mr Cerowski's mobility was poor - he used a broken broom handle to get around - reinforcing his social isolation (he used to regularly attend the local Catholic church). He had not bathed for some time as climbing the stairs and getting in and out of the bath were too much. He would wash in the kitchen sink. He often eats standing up in the kitchen because he struggles to carry his food, hold his stick and walk at the same time. He likes to deep fry his food and uses a thick saucepan to do so.

Practice Panel - Leeds social services department and primary care trust

Panel responses
Mick Ryan
Jan Cerowski has both health and social care needs. A multi-disciplinary assessment is required to find out what these needs are and how they might be best met.

He is struggling with day-to-day living and the primary focus of any intervention should be to promote his independence rather than simply undertake all the tasks for him. Outcomes need to be agreed with him as an integral part of the assessment process.

This places his views at the centre of the process and also means that any success can be measured against his improved satisfaction with services provided and, it is hoped, his improved functioning.

To facilitate this, a range of professional opinion should be sought. Mobility difficulties appear to be at the heart of Mr Cerowski's reduced independence and increased isolation. They make it difficult for him to access basic needs: for example, being able to prepare and eat food, and they represent a major risk in his life because of his falling.

An occupational therapy assessment is vital to look at the home environment. Equipment and adaptations could be used to help him attempt to fulfil care tasks. Specific items, such as perching stools, trolleys and more efficient walking aids, may help. A microwave oven with financial help from the SSAFA if necessary would be less risky than the saucepan and may also enable a more varied and healthy diet.

The falls clinic could provide a specific focus on the falls but would also examine Mr Cerowski's environment and safety. Health staff could assess any medical conditions and whether these could be reduced through further investigation and treatment. An alternative intervention could be care and rehabilitation through intermediate care services.

Finally, because the situation worsened after Mr Cerowski's wife died, bereavement counselling may be helpful.

Overall, home care-type services may be needed to undertake tasks directly and provide ongoing maintenance, but I feel the care management task should focus initially on outcomes that rigorously explore Mr Cerowski's strengths and potential to improve his quality of life.

Sue Orchard
If Mr Cerowski were our client the visiting district nurse would make a referral to intermediate care services for a multi-disciplinary assessment and a period of rehabilitation to determine whether continuing care is needed.

At the initial assessment it may be decided that Mr Cerowski would benefit from rehabilitation in one of our intermediate care beds and, with his permission, would be transferred to a residential care setting. This would be for a short time and he would return home once his mobility had improved.

An occupational therapist would assess his ability to undertake personal aids to daily living, which would include his ability to wash and dress himself and to prepare meals. Reasons as to why he falls getting out of bed would be determined and we would look at ways to prevent these.

A kitchen assessment would be undertaken to assess his ability and safety when preparing meals. Equipment, such as a perching stool and a trolley could be tried in the kitchen to improve his safety. Use of a microwave and ready-made meals could be suggested.

A physiotherapy assessment would help to determine the reasons for his poor mobility and assess whether a mobility aid, such as a Zimmer frame or walking stick, and an exercise programme to improve his mobility, would be required. The assessment would include his ability to climb stairs and would determine whether rails are required. These could be put in place as soon as possible using the Care and Repair scheme.

If he is not admitted to an intermediate care bed and once assessments have been done and care plans are in place, intermediate care staff will work with him, in his own home, to improve his mobility and his ability to look after himself.

After a period of rehabilitation it will be discussed with him as to whether he needs, and would accept, any ongoing care, such as home care. If this is required a referral will be made to social services for provision. A referral could also be made to the voluntary sector for him to attend luncheon clubs, to be taken shopping and to be taken to church which he used to attend regularly.

User view
It seems clear that if the SSAFA had not been in contact with Mr Cerowski then he was in danger of slipping through the net, as it is doubtful whether he would have sought help for himself, write members of Knowsley Older People's Voice.

This case is a perfect example of the need for joined-up services to support people in the community. We would suggest that, with Mr Cerowski's agreement, contact be made with the Polish Associations Council for support. We are concerned over communication and cultural barriers that may exist - this could be one of the underlying reasons for his not engaging with services.

Mr Cerowski has experienced loss of family members throughout his life and more recently with the loss of his wife. We acknowledge that bereavement can affect people in different ways and it may be the case that access to counselling services would be needed to help.

The desire for independence or lack of knowledge of what support is available is highlighted by his choice to use a makeshift walking stick. In this case the choice for independence is counteractive and threatening his health. Also, the choice to deep fry food using a pan raises serious concerns over fire safety. The local fire brigade could provide a home safety assessment.

If Mr Cerowski chooses to accept help many people will have a key role to play. The neighbour seems to have his trust and could be part of the solution in helping him to retain his independence. Now that the district nurse is involved they should co-ordinate the approach to helping Mr Cerowski.

It would be necessary to investigate the reason why Mr Cerowski falls within the home so often. He may need blood pressure checks and input from falls assessment teams to identify any underlying issues in his health or home environment and management of his personal care.

We are concerned at the absence of annual health checks for older people. We feel that Mr Cerowski's deterioration would have been picked up much sooner if these took place. Opportunities such as annual flu jabs could be used more effectively by GPs.

His withdrawal from the church is reinforcing his social isolation. The church as a community itself could see itself as part of the wider support network and provision needs to be in place to help people like Mr Cerowski stay active and involved.

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