The Law, The Facts & Life Back on Track

Rehabilitation Challenges: recovering from brain injury

• Boyes Turner

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Every brain injury survivor's journey is as unique as their fingerprint, and navigating the road to recovery requires a map we're constantly redrawing. In this episode, Claire Roantree, Partner in the Personal Injury team, talks to Case Manager Dan Whitlock, as about the complexities of rehabilitating individuals like David*, whose life was upended by a brain injury. 

Listen in as they discuss critical early steps of legal and case management intervention that pave the way for a seamless transition from hospital to specialized care. Through David's story, we come to understand the monumental role played by multidisciplinary teams and the lifeline that family support becomes in steering a survivor towards reclaiming their independence. 

You'll hear about the triumphs and trials, and ultimately the independence that defines David's story, culminating in his incredible achievement of homeownership without the need for a care team. 

*names have been changed

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Claire Roantree Host 00:03

Hello, I'm Claire Roantree and I'm a partner in the personal injury team at Boys Turner. I've represented brain injury survivors and their families for over 15 years to claim compensation for their injuries and financial losses and to access funds to help with their ongoing rehabilitation needs after a brain injury. I was also a trustee for a local branch of the Brain Injury Charity Headway. Today I'm joined by Dan Whitlock, who's a case manager and works with solicitors to support brain injury survivors and their family through their rehabilitation journey. Dan and I are going to be discussing some of the issues we experienced when working with brain injury survivors, particularly clients who have neurobehavioural symptoms after a brain injury. 

Hi, Dan. 

Dan Whitlock Guest 00:45

Hi Claire. So just following on for a little bit, I'm Daniel Whitlock, case manager at Bush Co. I've been a case manager for seven years working with clients with complex brain injury and a specialist area of neurobehavioural rehabilitation. 

Claire Roantree Host 00:58

So just to give you a little bit of background regarding the case Dan and I worked on recently. We're going to call this client David*. It involved a 20-year-old male who suffered a severe brain injury. Now, prior to his accident, he was working hard to build a career in construction, he was saving to buy his first home, he loved spending time with friends at the gym and with his family and he really enjoyed sports and going to festivals, and he lived independently in a rented flat. 

01:26

Following his accident, whilst he recovered fairly well from his physical brain injury, he was left with severe neurocognitive and neuropsychiatric impairments. So, for example, he had difficulties with short-term memory, attention and concentration, processing information, decision-making, planning and organising all the things that you and I take for granted. He also suffered from personality changes which really affected how he behaved and how he interacted with others. So he was really irritable and easily agitated. He became impulsive and disinhibited, he had really rigid thinking and displayed verbal and physical aggression. On top of that, David suffered from fatigue and that really impacted on his cognitive impairments and on his behaviour, and he lacked insight into his difficulties, which meant he was at risk when he was in the community and he was at risk of exploitation and he required a really high level of supervision and support from a multidisciplinary team of clinicians and therapists. Dan was appointed to act as a case manager to support David and his family whilst he was still in an acute hospital setting. Dan, can you tell me about when you first met David? 

Dan Whitlock Guest 02:40

Yeah, I first met David when he was in a major trauma centre. At that time he was very unwell and his immediate future was very uncertain. So initially he'd made a pretty good recovery from his brain injury. So he also had hydrocephalus, which is inflammation of the brain, and this set him back in his recovery and he was back to sort of acute setting in a major trauma centre. Very uncertain time for the client David and his family, very worrying time and it was timely instruction from Claire to come in and support the family and help them understand brain injury. 

Claire Roantree Host 03:16

And it was a really stressful and frightening time for the family, as you say, Dan, because suddenly they were in this world that they'd never been in before. They were surrounded by people that weren't in their life before, such as the police, medical and healthcare professionals, a case manager, a lawyer, social services, the defendant, insurers and solicitors, medical experts and barristers and care agencies and carers. Medical experts and barristers and care agencies and carers. 

 

So the first thing we want to talk about today is the safe and appropriate discharge of David from hospital to a neurorehabilitation unit for his ongoing care, and, from a legal perspective, it's really important to be involved as early as possible, and ideally whilst the client's still in hospital and before their discharge, so that you can work with the hospital and your case manager to make sure that that discharge is to an appropriate and safe environment for ongoing rehabilitation. Dan, do you want to just talk a little bit about those early days? 

Dan Whitlock Guest 04:25

Yes, as David made a recovery and progressed through his rehab journey, it was time to look at discharge destinations and appropriate placements for David. My opinions differed to that of the major trauma centre. They were looking at a discharge to a travel lodge with other vulnerable people. We felt that this was wrong, the family felt this was wrong and this ultimately culminated in a best interest meeting for the client, for David. At that meeting we discussed various different options for discharge. 

04:59

Unfortunately, the provision for male brain injury clients with neurobehavioral disability is quite limited. There aren't that many specialist centres around. At this this point it was really crucial to get the local authority involved and the brain the local brain injury team. So we had a best interest meeting for David. At this time, everybody around the one table discussed all the possible options and we looked at a step down unit into a community-based neurorehabilitation unit as the least restrictive option a much better option than a travel lodge opportunity for more rehabilitation because we could see that David had potential for further rehabilitation, a stable environment and hopefully, a safe environment as well. 

Claire Roantree Host 05:45

So, Dan, can you talk about the next placement that David attended? 

Dan Whitlock Guest 05:51

So, with David's presentation at that time being quite challenging, we needed to look for a specialist neurobehavioural rehabilitation unit that could manage his difficulties and challenges and all of those challenging behaviours. The options are limited so we went with the least restrictive option, which was a community-based neurobehavioral unit that was registered as a care home rather than a hospital, so David could be managed under adults. Within this this setting he could have some specialist psychology, OT, physiotherapy to help work on some of the deficits that he had. 

Claire Roantree Host 06:29

And there were ongoing issues there as well, weren't there, Dan? 

Dan Whitlock Guest 06:33

So as David went through his rehabilitation journey, some of these difficulties and behaviours that he had became more and more apparent Within this unit. He saw it as a challenge. So he worked out that he could kick the doors open and just leave whenever he wanted to. He team split with the staff. So he would go and talk to one member of staff, get an answer, go and talk to another member of staff, get a different answer, then use that information to his advantage to negotiate for what he wanted, which was a real, real challenge for the staff. 

07:12

There was issues with targeting other residents as well. Within that setting they couldn't manage David and the unit themselves. We had a meeting with them and they said that they weren't robust enough to manage his difficulties. So he was going out into the community and then, not knowing where he was effectively absconding, having to be brought back by the police at times. So we sat down and looked at different options, and it was decided that a more robust hospital setting was more suitable for David, where the doors could be locked. It's a bit more secure and his neurobehavioral presentation could be better managed. 

Claire Roantree Host 07:48

So the intention was to move David to a new setting, wasn't it Dan? And the plan was for him to go to the new setting in March but unfortunately COVID hit so that delayed the opening of the centre and he was kind of left for several months, wasn't he in the old setting until he could move into the new centre? 

Dan Whitlock Guest 08:10

Yeah, it was a difficult time for David and his family and the provider at that time to manage his presentation in a setting that wasn't robust enough. I think they did a good job. They kept him safe and then it just gave us enough time to wait for the new setting to be open. 

Claire Roantree Host 08:27

I just wanted to add something in there that you know, during that period of isolation he was really isolated, you know. His family couldn't visit him and he was surviving, really, on his Xbox, wasn't he which broke down and you drove over at one point, didn't you, to grab his Xbox out of his window, so you can fix it for him. I think, in terms of a case manager, you kind of went above and beyond your role as a case manager there. So, um, he then moved into his new setting, didn't he? 

Dan Whitlock Guest 09:03

Yeah, so it was a brand new hospital that specializes in neurobehavioral rehabilitation, so it was a lot more robust setting. There was locked doors, the perimeter had a high fence that you shouldn't be able to abscond from. But that was a challenge for David, something that he could work towards. He was transitioned from his community-based setting into a semi-independent living flat within the ward at the hospital, and this was a great environment because it gave him a taste of independence and to show what he could do and demonstrate some of his skills whilst keeping him safe and managing his risks. So at this time we had a really good understanding of what David's risks were and the challenges of his presentation. So it was clear that there were some big issues with frontal lobe paradox. So what David said he would do and what he did were often two completely different things. 

Claire Roantree Host 09:56

Dan, can you give us a couple of examples of what you mean by frontal lobe paradox? 

Dan Whitlock Guest 10:00

Yeah, sure, Claire. So he would say that he's absolutely fine. He can go out on his own, go out into the community, do all his own shopping, he's cooking and just manage his day-to-day life. He's very, very convincing of this as well, and very persuasive, but when it actually came to following through with this, he couldn't. The vulnerabilities were there, the difficulties were there, memory being a significant difficulty. So going shopping, he would go to the supermarket and he would spend so much time in there, hours walking up and down the aisle, forgetting what he was looking for, but going back up and down the aisle, but he wouldn't admit that he had those difficulties. So rather than asking for help, he would just keep walking up and down, forgetting what he was looking for, and just doing laps up and around the supermarket.

Claire Roantree Host 10:51

He refused to make a list, didn't he? He didn't want to. It was so difficult for david because he wanted to present that he was normal and he, you know, there was absolutely nothing wrong with him. Um, which is something we see time and time again with the clients.

Dan Whitlock Guest 11:05

If, if staff tried to intervene and help David and give him some and advice, this was a big issue for David and he would verbally attack the staff. He could storm off and abscond. So it's really difficult and had to really carefully manage to support him in a way that he was being supported and kept safe, but without him feeling like the staff were overbearing and keep an eye on him. 

Claire Roantree Host 11:29

And he would disengage, wouldn't he, from rehab. And so they had a real job on building trust with David, which I think they definitely got to within a few months of him being there. 

Dan Whitlock Guest 11:43

Yeah, so there was some particular issues with concrete thinking In his own mind. He believed that he could go out in the community for a whole day, do whatever he wanted to do and come back at a certain time and he had no vulnerabilities, no risks and not vulnerable at all to the members of the public. This wasn't the case, but it's really difficult to get him to see these vulnerabilities and to accept support and help with managing these vulnerabilities. 

Claire Roantree Host 12:11

Rehab was also extended, wasn't it as well, because of various COVID restrictions preventing him from going out into the community. So he was there probably, safe to say, six months longer than he should have been, because of because of COVID as well, so that that sort of had an impact on his rehab journey as well and it made it really difficult for him and his family. 

Dan Whitlock Guest 12:38

With David's concrete thinking as well and the challenges that he was presenting with. He almost saw that inpatient setting and the staff as a bit of a challenge and there was a sort of vigilante personality where the really vulnerable patients in the setting. He would sort of side with them and then he would target other other patients within that setting as well to, in his mind, protect the more vulnerable patients. Rather than letting the staff deal with these issues, he would take it upon himself to intervene and this got him into some situations where he went into another patient's room, trashed the room through his belongings on the roof of the unit, graffitied doors, stole fire extinguishers, barricaded rooms to stop staff coming in. 

13:30

Some really challenging behaviours at times within that unit. He was restrained, sometimes he bit a member of staff. There were some altercations with other patients as well. There was some abscondsions where he would go on to the ground, leave within the unit, but he'd climb over the fence and just run away and abscond and had to be brought back by the police. So really difficult, challenging time within that unit. But also at the same time there was some really good progress with some elements of rehabilitation and independence. So it was really difficult to find that balance manage the risks and also promote independence and take some positive risks. 

Claire Roantree Host 14:11

And there was a turning point, wasn't there, Dan? 

Dan Whitlock Guest 14:18

Yeah, so David was sectioned under Mental Health Act, section 3, and this was really a line in the sand at that point where he realised that there was consequences to his behaviours and actions and we saw a big change in his presentation and progress in his rehabilitation. 

Claire Roantree Host 14:31

And that meant that we could then start to look at planning his discharge home and back into the community, didn't it? 

Dan Whitlock Guest 14:39

Yeah, there's a lot of planning went into discharging to community. 

So, with the risks that David presents with, he's a robust, really robust experienced care team but also a really experienced TDT, so transdisciplinary team, who are experiencing neurobehavioral rehabilitation, managing risks of a vulnerable client in the community.

Claire Roantree Host 15:00

From a legal perspective and all my medical legal experts and the team at the unit all agreed that in order to provide that scaffolding and that support network for him moving into the community, he would need 24/7, 2-1 waking night care following the initial discharge. That was right, wasn't it? 

Dan Whitlock Guest 15:22

Yep, I think, with with the risks that David presents with, if they're not managed, any incident could have been catastrophic for him in his future and he could have gone down a very different path to the way he did go. 

15:35

So he needed that structure, which he didn't necessarily agree with going into community. But we had to take a really cautious approach, robust, intense structure, really meticulously care-planned, risk-ass assessed and managed. And he underwent a long transition process of spending days in the community, overnights and two nights, three nights and so on, and any point during that process, if there are any incidents, we could scale back and start that process again once he's stabilized.

Claire Roantree Host 16:09

And, from his perspective and his families, they were extremely worried about that huge change from leaving a hospital environment where he'd been for really over three years, taking into account his time in hospital and how he would then cope with living in the community and he was deeply scared and anxious about that wasn’t he. 

Dan Whitlock Guest 16:34

Although he wouldn't admit it and you wouldn't, you wouldn't see it from him, but you know he'd put up a bit of a front to say, yeah, I can't wait, really looking forward to it, I want to go now I can live on my own independently. 

16:44

We all knew that wasn't the case and underneath that there was, there was some anxiety around going into community um as well from David and his family. I think a really good move that we did was involving David as much as we could, and particularly his father, in the transition. So in terms of selecting a property, interviewing potential members of the care team, meeting with the TDT and just helping, helping improve their confidence in what we were doing and the transition and making them believe that what we were doing was going to work. So, as well as all of those practical elements of the discharge, we also need to consider the legal framework and keeping the client safe within a legal framework. 

Claire Roantree Host 17:24

And from a legal perspective that meant working with our Court of Protection team and the community care team and the local authority to apply for a community DOLO, which is a deprivation of liberty order.

And, of course, once in the community. It was an extremely exciting time for David, but also it was a challenge. There were some teething issues and there were some ongoing issues with his behaviour that required some careful management.

Dan Whitlock Guest 17:50

Yeah, I think on that point, my advice for any case managers was that you need that experienced TDT and managing neurobehavioral disability. The client presented with manipulative behaviour, team splitting, aggression, trust, paranoia and refusal to take medication. So, you need that TDT to be able to put together a really thorough risk assessment and care plan but ultimately acknowledge, no matter how robust and carefully planned and meticulous details within that care plan, things are going to go wrong and you need a tdt who can be responsive and experienced in managing those difficulties and when things do go wrong, they don't panic they support the client and make some decisions in their best interest.

Claire Roantree Host 18:37

I think, from my perspective, having those regular MDT meetings that we had so that we could regroup, look at the ongoing challenges, rewrite or add to the risk planning and and the care assessment, um, and and also having a team around us that weren't working a 9-5 Monday to Friday approach. They were flexible and they went out of their way to deal with crises as and when they occurred, which is bound to happen.

Dan Whitlock Guest 19:03

Yeah, it's clear the TDT genuinely wanted the best for the client, for david, and wanted him to succeed in the community and it's fair to say they all went above and beyond and worked really hard to support him and keep him safe within the community. 

Claire Roantree Host 19:23

And, I'm pleased to say, the case is settled. David now is in the process of buying his own house and he's hoping to complete shortly. He's still crazy about the gym and he's managing to live independently without a care team. 

Dan Whitlock Guest 19:41

Yes, great, great success. He's done really really well. 

I think some of that personality of David, where he was so concrete in his thinking, has actually worked really well for him, because he's pushed and pushed, and pushed to reach the goals that he wanted to achieve and he's absolutely thriving in the community, which is great to see.

Claire Roantree 20:02

I just wanted to finish with something that the father fed back about having a case manager on board who has experience in these types of injuries. 

20:12

He said what can I say? “It's been a fantastic support for us over the years and I could not have gone through this journey without Dan's support, friendship and advice. This has been a new world for me and my family and, without doubt, having Dan to guide us through it has been invaluable. He listens, understands, and thinks differently to me. He's very calm and patient. When countless issues have arisen, he has the ability to stop you from reacting in a certain way and to think about how to resolve issues. His role in overseeing rehabilitation, care and support is pivotal to my son being able to stay in the community”.

And I think that's a really poignant and positive way to end this episode. Thanks, Dan, for your time today. 

Dan Whitlock Guest 20:57

Thank you, Claire. It was great working with you on this case. 

Claire Roantree Host 21:00

If you have any questions based on what we've discussed in this episode, then please do get in touch with the team. Find our details on the Boys Turner website. Thanks for listening and goodbye. 

 

*names have been changed