The Ripple Effect

Kim ChamberlainNovum Law

www.novumlaw.com

The Ripple Effect

Tom Parker

Background • Aged 38.• HR Manager in a large Hotel Group earning £45k pa. • He has a wife, Kate and two children. She is currently caring for the

children and her mother with a view to returning to work.

Hobbies• Rugby fan and liked going to the pub occasionally.• Keen cyclist, part of a local club and took part in cycling events.

Care• Wife provided limited care to her elderly mother on a daily basis. • The closest family members were a 2 hour drive away.

The Accident and Emergency Services

4

Police Ambulance

A&E

Police

Officers first to the scene

Collision Investigation Unit

Family Liaison Officer

Ambulance

• Immediate treatment from the attending paramedics.

• Vital information for treatment at the scene and transfer to A&E.

• Glasgow Coma Score - a tool used to assess the severity of the head injury (Tom Parker 7/15 at the scene).

• Liaising with the police to enable them to contact the family.

Accident and Emergency

Initial Investigations/assessment of patient dependent on level of trauma • Assess condition, scans and x-rays• Observations• Administering pain medication Transfer to: • Intensive Care Unit/High Dependency Unit• Surgery • The most appropriate ward • Discharge Head Injury What do the scans/x rays show? Possible outcome:• Observation and/or discharge • Surgery - depending on severity of head injury• Referral for follow up with neurosurgeons or other treating consultants

Case Study

• Tom Parker had a GCS of 7/15 at the scene indicating a severe brain injury.

• Scans revealed a severe brain injury and fractures of the skull.

• He was intubated* and taken straight into theatre for an insertion of a pressure bolt and underwent a craniotomy* 2 days later.

• He required orthopaedic surgery, involving internal fixation of his pelvic fractures and his stable spinal fractures treated conservatively with a back brace.

• He was then transferred to the high dependency unit (HDU).

*Intubation is the placement of a flexible plastic tube into the trachea (windpipe) to maintain an open airway or to serve as a conduit through which to administer certain drugs. * Craniotomy, a surgical operation in which a bone flap is temporarily removed from the skull to access the brain.

The Ripple Effect

9

Emergency Services

Police

Ambulance

A&E

Tom

Inpatient Team

• Multidisciplinary Team in the high dependency unit dealing with surgical needs and high dependency care.

• Tom has required neurosurgery and orthopaedic surgery. Kate attending daily, with members of close family and possibly short visits with the children.

• Transfer to neurosurgical ward for monitoring and continuing care.

• Transfer for inpatient rehabilitation.

Ongoing Difficulties

Head injury - Concentration- Memory- Difficulties remembering words- Problem solving- Planning- Wife describes personality change - Difficulties controlling temper- Disinhibition- Impatience- Depression- PTSD and adjustment disorder

Orthopaedic Injuries- Recovery from surgery and pain- Restricted mobility.

Inpatient Rehabilitation Team Physiotherapist assessment to review: Mobility (transfer, sitting & wheelchair, standing)Programme of mobility, balance and strengthening exercises (recommend outpatient physiotherapy through GP).

Tom was initially reliant upon a wheelchair and mobility aids.

Occupational Therapist assessment: Assess personal care (grooming, washing, dressing)Cooking and shopping (on discharge)Cognitive screening.

Tom’s main area of deficits were memory, speed of attention and executive functioning, fluency and language skills resulting in referral to Neuropsychologist. Suggestion that he also receives vocational rehabilitation following recovery from surgery.

Nursing reportMedication continence personal care nutrition wound care pressure care

Inpatient Rehabilitation Team

Clinical Neuropsychology • Neuropsychological assessment to identify areas to focus cognitive

rehabilitation following discharge.• Consider personal history, extent of post traumatic and retrograde

amnesia, level of consciousness following the accident.• Consider neuropsychological test results. • Tom displays global cognitive impairment resulting in difficulties involving

language, memory, attention, executive functions and impulsivity.• Degree of recovery unknown.• Referral to Clinical psychologist to evaluate difficulties once out in the

community• Potential referral to mental health team to recommend to assist with

depression.

The Ripple Effect

14

Emergency Services

Police

Ambulance

A&E

Inpatient treatment and care

Trauma high dependency

Neuro ward

Tom

Inpatient rehabilitation

Discharge

Discharge

• Staged Discharge : – organised visits for a few hours a day, then over the weekend before final

discharge.

• Occupational Therapy: – a member of the rehabilitation team to arrange a home visit, to assess Tom’s

immediate needs(aids and equipment and adaptations etc.)before discharge home.

• Home adaptations/ aids and equipment that may be required: – widen doors and install ramps– improve access to rooms and facilities e.g. stair lifts or a downstairs

bathroom/bedroom– provide a heating system suitable for needs– adapt heating or lighting controls to make them easier to use– Provision of wheelchair, walking frame, crutches, hand rails etc.

The Ripple Effect

17

Emergency Services

Police

Ambulance

A&E

Inpatient treatment and care

Trauma high

dependency

Neuro ward

Inpatient rehabilitation

Tom

Discharge

Care at Home

• District nurses provide care in the community.

• Immediate care at home often provided by spouse and family.

• Support workers (agency or directly employed), either funded by compensation claim, if there is the opportunity to secure interim payments, or via local authority/NHS provision which would require assessment and likely to be more limited.

• In the case study the immediate care is provided by Tom’s wife, Kate, in addition to caring for their 2 young children and caring for her mother, until a potential claim has been investigated.

Tom’s Immediate Needs

• Mobility• Personal Hygiene• Administer Medication • Food/drink preparation • Adapting property • Emotional support• Managing fatigue• Night time support • Planning and organising (daily routine and activities) • Additional household tasks and childcare• Liaison with previous employer on his behalf • Household administration • Continuing contact with GP

Outpatient Rehabilitation

• Possible referral to outpatient brain injury rehabilitation via NHS referral, for assessment and treatment from multi-disciplinary team to implement strategies to assist with day to day function.

• A potential move to community services. May be appointed a social worker through social services, to co-ordinate discharge planning and services in community depending on needs.

• Access to treatment and referrals via GP (would have been notified of discharge planning meeting).

• Follow up appointments with treating consultants (neurosurgeons, orthopaedic consultants/fracture clinics, psychologists/psychiatrists, outpatient physiotherapy).

• Referral to Pain Clinic if required.

The Ripple Effect

21

Emergency Services

Police

Ambulance

A&E

Inpatient treatment and care

Trauma high

dependencyNeuro ward

Inpatient rehabilitation Outpatient

rehab team

Care providers

Tom

Discharge

Impact on the Family

Tom• Loss of employment

• Loss of independence

• Limited mobility

• Pain

• Cognitive deficits

• Frustration

• Fatigue

• Personality change/disinhibition

• Feelings of isolation

• Lack of insight

Kate

• Fundamental change in the relationship as a carer. • Co-ordinating medical appointments.• Loss of support with their children and household tasks.• Loss of control.• Financial pressures. • More socially isolated.• Potentially unable to return to work as planned.• Feelings that life is on hold/ loss of her own independent

life.• Feelings of bereavement. • Managing emerging difficulties.• Pressure of keeping the family together and meeting needs

of Tom.

Children

Children

• Feelings of shock.• Extra care from relatives and friends.• Away from home environment. May miss school.• Feelings of isolation or being left out.• Confused and upset.• Difficulty seeing parents experience the trauma.• May require careful management at school.• Change in routine.• Hospital environment strange and unfamiliar.• Do not recognise Tom’s change in behaviour – confused/upset. • Importance of sharing information to prevent feeling of isolation

and uninvolved.

Children Discharge home: • Not as much attention.• Anxiety – feeling parents worry and upset.• Huge change requiring adaption.• Most of the attention is on Tom.• Confused/upset if dad is showing unpleasant.

changes in behaviour.• Anger, jealousy depression.• Forced to grow up a little bit quicker and perhaps

given extra responsibilities/chores.

Support• Short breaks/respite care provided by Local Authority.

Allows the family to have a break from caring which can be vital for the whole family.

• Liaising with schools to make them aware of need of changes in behaviour, extra support required.

• Brake - 24 hour helpline, support guides, events, resources and training for support professionals.

• Brain injury support groups – providing support for the individuals who have suffered the injury and their families. Meeting face to face or via social media support groups.

• Headway - UK Charity who focus on improving quality of life to those who have suffered a brain injury. 125 groups and branches across the UK. Wide ranging services to include brain injury rehabilitation programmes, carer support, social re-integration, community outreach and respite care.

• Silverlining Charity - providing community based activities, events and challenges for service users. A number of groups nationwide.

• Carers Trusts - grants for carers who need respite.

The Ripple Effect

29

Emergency Services

Police

Ambulance

A&E

Inpatient treatment and care

Trauma high

dependencyNeuro ward

Inpatient Rehabilitation

Outpatient rehab team

Care providers

Spouse

ChildrenFamily and

friends

Brain Injury Support Groups

Support at School

Voluntary organisations

Tom

Discharge

Financial Consequences

Tom was the major earner within his family and Kate cannot plan a return to work. Consequences:

• Loss of earnings - potential impact on quality of life• Cost of treatment/ rehabilitation (over and above NHS provision)• Cost of care.• Accommodation - Adaptations and/or relocation• Aids and Equipment• Therapies• Medical Costs• Holidays • Additional costs of transport (attending appointments and need for an adapted

vehicle)• Professional deputy if there is a lack of capacity• Miscellaneous (clothing etc.)

Claim for Compensation

Legal Team build the case and support the family:• Liability investigations to establish negligence. • Quantum investigations - gathering expert/witness evidence.• Instruct team of medico-legal experts.• Drafting Schedule of Loss detailing all financial losses, past and

future, potentially over a lifetime.• Appoint a professional Deputy (if the injured person lacks capacity

to litigate and/or manage finances).* • Obtain Interim payments to assist the family with day to day living

expenses, fund case management, appoint multi-disciplinary team of treatment experts and to implement their recommendations .

• Appoint Case Manager *

*Speakers Christine Bunting and Anita Pascoe to follow

Claim for Compensation

Lega

l tea

m Medico-legal

experts

Non Medical experts

Multi-disciplinary team

Claim for Compensation

NeurosurgeonNeurologistNeuro-radiologistNeuropsychologistNeuropsychiatristNeuro-physiotherapist Vestibular PhysicianENT Surgeon

Medico-legal experts

Orthopaedic ConsultantSpinal SurgeonPhysiotherapistOrthotic ExpertOccupational Therapist

Claim for Compensation

Claim for Compensation

• Treating Psychologist

• Case Manger

• Lead Support Worker

• Occupational Therapist

• Physiotherapist

• Client and/ or wife and/or parent

• Vocational rehabilitation expert

Treating experts (Multi-disciplinary team)

What assistance is available to Kate and Tom to support them financially ?

Lost Earnings

Application for State Benefits

- Council tax reduction

- Housing benefit

- ESA/JSA

- Tax Credits

- Personal Independence Payments(replace DLA)

- Carers Allowance

- Direct Payments

Lost Earnings

Residual earnings capacity

No residual earnings capacity

• Retraining (college courses, open learning, training on the job)

• Vocational assistance

• Voluntary work (vocational assistance and contacting organisations that will offer voluntary work)

• Brain injury groups/social activities

Rehabilitation

Claim for compensation

No Claim

• Interim payments from insurers to fund private rehabilitation, facilitated by a Case Manager.

• Liaising with rehabilitation experts via the NHS.

• Waiting times. • Brain Injury rehabilitation units.• Pain Clinics.• Therapists . • Community rehabilitation

services .

Care and Case Management

Claim for compensation

No Claim

• Case manager appointed to employ services of support workers, to implement recommended care and rehabilitation through a multi-disciplinary team. Liaise with family, legal and treating team.

• Costs met by family over and above local authority provision.

• Liaise with NHS, local authorities who will carry out an assessment for provision of care.

• Tom may need to pay a contribution towards the cost, depending on his financial situation.

Accommodation

Claim for compensation

No claim

• Adaptations and/or move to suitable accommodation to meet Tom’s needs.

• Liaising with Solicitor who will seek interim payments, to fund recommendations.. May require liaison with estate agents, builders ,architects etc.

• Private funding• Disabled Facilities Grant which

is means tested (earnings and savings) and limited to £30,000k.

The Ripple Effect

42

Emergency Services:

Police

Ambulance

A&E:

Inpatient treatment and care

Trauma high

dependencyNeuro ward

Inpatient rehabilitation

Outpatient rehab team

Care providers

Spouse

ChildrenFamily and

friend

Brain Injury Support Groups

SchoolVocational

rehab

Voluntary organisations

MDT

Medico-legal team

Legal team

DWP

Deputyship team

Local authority

Team of support workers

Tom

Discharge

Thank you

Questions

Kim Chamberlain

Senior Associate Solicitor

t: 01793 412591

m: 07917834538

e:kchamberlain@novumlaw.com

www.novumlaw.com

@novumlaw

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