The Law, The Facts & Life Back on Track

Rehabilitation after amputation: how a case manager assists recovery

• Boyes Turner

Share episode

Julie Marsh, Partner in our Medical Negligence team, is joined by Kate Gibbons, Senior Rehabilitation Case Manager, to discuss the critical role of rehabilitation case managers in helping amputees rebuild their lives after catastrophic injury.

Their conversation reveals how case managers support recovery by coordinating multidisciplinary support teams that address everything from medical needs to accommodation, psychological wellbeing, and social reintegration.

The conversation highlights how effective rehabilitation continues beyond legal settlement, with many clients initially distancing themselves from interventions, only to return when facing new challenges. Throughout this journey, the most successful outcomes stem from strong multidisciplinary teams centered on the client's evolving needs and aspirations, creating a support network that remains accessible long after the litigation concludes.

If you or a loved one have recently had an amputation, contact our medical negligence team to understand how early intervention through case management can significantly improve recovery outcomes and how we can help.

Episode links:

 Julie Marsh Host 

00:04 

Hello and welcome to this latest podcast in the series the Law, the Facts and Life. Back on Track. I'm Julie Marsh, a partner in the medical negligence team at Boys Turner Solicitors. For those of you who have listened before, you'll know that I act on behalf of severely injured people who have suffered their injury as a result of medical negligence. If you've not listened before, well now you know who I am. Welcome and thanks for listening. 

00:29 

Today I'm talking to Kate Gibbons, Senior Rehabilitation Case Manager from MLA Associates. Welcome, Kate, and thank you for joining me. Thanks for inviting me. So today I've invited Kate to join me to talk about her role as a case manager working with and supporting people who have suffered an amputation. 

00:48 

The injury might have been sustained as a result of poor medical treatment, but might also have been sustained as a result of a road traffic accident or an injury at work. Kate and I met a few years ago when we were working with a young female client who had sustained bilateral midfoot amputations as a result of a delay in diagnosis and treatment of meningitis. It was as a result of working with her on that case that I've invited her today to share with me her experience of working as a case manager with clients who've suffered amputation, but also to talk about how a case manager can help in practical ways that, sadly, as a lawyer, I never can. So to start today, Kate, perhaps I can ask you to introduce yourself. Tell us a bit about your training and background and how you came to work in your current case manager role. 

Kate Gibbons 

01:34 

Well, I trained as a physio at the Uni of Manchester and then, after a short break to go travelling, I worked across several of the London teaching hospitals as a basic grade physi physiotherapist and then stayed there to go on to my senior rotations. Towards the end of that period I started to do some private work in the community and it was during that that I probably stumbled across what I now know to be the case manager role. I was treating an elderly lady in her home. She'd had a stroke and on one occasion that really sticks in my mind. I arrived at her house. She was alone. 

 

02:04 

She'd had a stroke and on one occasion it really sticks in my mind I arrived at her house, she was alone, she'd not had anything to eat or drink that day and had all the symptoms of a UTI and feeling quite desperate, and I just stood there thinking this is pointless, there's no point in me treating her hand function, it's not really important today, and instead I spent the time getting a GP review and sorting out some help for the following days. Once I realised that role existed in reality, I went on to work at the London Centre for Spinal Cord Injuries at Stanmore in their case management team and loved it. 

Julie Marsh Host 

02:35 

Great, thank you. That's really interesting that you were within that kind of setting and then realised that you had to step outside of your role in order to kind of help somebody and make progress for them. 

Kate Gibbons 

02:44 

Just to say on that. I think it's quite. At that time it was probably quite new for physios to be working as a case manager, so I did feel, you know, I was a bit alone. But now, more and more, you know, it's probably even Stevens across physios, OTs and social workers and some nurses. So yeah, it's been quite an interesting development. 

Julie Marsh 

03:04 

Yeah, that's really interesting. So perhaps that's a good time for us to explain a little bit about what a case manager is, what they do and what the job kind of broadly entails and involves. 

Kate Gibbons 

03:14 

I suppose the formal answer is that we coordinate a programme of rehabilitation to restore an injured individual, as far as money allows, to how they were prior to the accident or index event. When I've tried to explain my job to friends before now, they reply with ah so you project manage an injured individual and I suppose in a way that's quite a good description. But our roles are really broad. As case managers we cover various areas, focusing on care and support, accommodation, medical and therapy interventions, looking at how you know transport modes, how a person is getting around, social and leisure, as well as you know their education or employment situation. We'll create a team of people to work with each individual to manage their needs. We then monitor the progress and keep reviewing and updating that plan and changing what's happening to make sure that we're meeting those needs. 

Julie Marsh 

04:09 

That's really interesting. I quite like the image of a project manager because you do often have so many different moving parts to control Different hats. 

Kate Gibbons 

04:16 

Different hats, lots of different hats, yeah. 

Julie Marsh 

04:18 

And I know we've had a conversation in the past about all the different hats that I quite often wear as a litigator, so I can imagine there are many more hats as a case manager but always working towards that one kind of overarching aim of getting that person to the best position they can possibly be within the environment. 

04:32 

Exactly so in cases involving medical negligence, a case manager does not typically get involved until liability has been admitted and then interim funds are available to meet the cost of the case manager and the therapy equipment and other recommendations that are then made. The situation is a bit different when a case involves personal injury, maybe arising from a road traffic accident or accident at work, where the rehab code generally means rehabilitation support can be accessed earlier. This means that it can be some significant time following the index event or injury in a medical negligence case before someone can access rehab and get the right support. So what are the key issues with coming on board as a case manager later down the line, for example in an amputation injury, that are kind of important to consider and that are different? 

Kate Gibbons 

05:27 

Yeah, well, I think often the delay can mean that that injured person has had a period of trying to cope and just putting up with, you know, issues that have arisen, and in some instances I think that can become so normal that they just accept it and they don't realise how hard they're having to work just to manage the processes of daily life. Often after an amputation, what we see is that the NHS don't want to provide prosthetic input until the stump volume fluctuation has settled, and again, following that, the input isn't always available in as timely a manner as we'd like it to be, nor offering the best possible options, and this means that by the time a case manager gets involved, the treating team that we put in place have to spend time undoing bad habits or dealing with issues before they can actually progress forwards. We've also got you know, deconditioning can be quite a big factor. It's likely that an individual will have become weaker and less fit from that immediate period after the accident or event, and then in lots of cases people are dealing with psychological trauma and they've not got the insight or motivation to engage in the brief bit of home exercises that may have been recommended, and without proper, decent support, so that just becomes even more of an issue. 

06:45 

That lack of access to support for mental health conditions post-amputation can really lead to some significant longer-term issues and I think that really means for us that when the some good therapy gets put in, it can't progress in the same way and you're dealing with an awful lot more than just the trauma of the injury or event that led to the amputation and, of course, grief. You know these people are dealing with so much. It's such a catastrophic thing to have happened in their life and that needs careful handling by a suitable professional. When that's not in place, the impact can be wider than just on the individual. Their ability will have changed, their mobility level and then, if their psychological wellbeing is also impacted, other members of the family are also then, you know, equally impacted and I think in some circumstances, sadly, that leads to relationship breakdowns. So without that quick, suitable, you know appropriate support, it can spiral very quickly. So I do strongly believe and see evidence of regularly that that early intervention leads to better functional outcomes. 

Julie Marsh 

07:53 

And that's certainly what we saw in the case that we worked on together. 

07:57 

Absolutely, there was a real mental block around the help and support that was out there and about the benefits of certain therapy and actually, even though you come from a position of educated and knowing what benefit that support can really bring to that individual, you've got to convince them of that to start with, because they haven't had that input at the outset yeah, yeah and certainly a lot of the clients that I work with are still grieving for what they've lost and still struggling to come to terms with what the new normal life looks like and are having to battle through and all of a sudden to be told oh well, actually you can have physiotherapy and hydrotherapy and there's this aids and equipment that might help and all the rest of it. That's a real mind shift for clients to have to kind of deal with as well. 

Kate Gibbons 

08:52 

And such a big impact in their life as well. You know it takes an awful lot of their time on a day to day basis and if they've found a way to just manage and crack on, that might not be doing them good. In in some respects they may be walking really badly or moving really badly and you know, longer term that's just not going to last and it's certainly not going to put them back into the best situation they can be in. But they just manage it and so to stop doing that, to take a step off that and then re-engage in a program is quite hard. 

Julie Marsh 

09:25 

And it takes a lot of energy, a lot of commitment and a lot of positive motivation, whereas it's sometimes just easier to revert to oh well, I was managing before. So what's the problem? Yeah, so when you're coming in as a new case manager with a new amputation client, what are the kind of key issues that you're often looking at? 

Kate Gibbons 

09:46 

I think primarily it's key to find out what their life looked like prior to the amputation, an event that led to that. You know how they functioned personally, on a day-to-day basis, professionally, within their family and the wider community. And then the key issues really are all those covered in an immediate needs assessment. So, history of input to date, what's in place in terms of care, medical and therapy provision, any changes that have been done to their home school work situation, how they're accessing the community and the impact on their leisure pursuits. I've had occasions where there is an issue of critical importance and this really might need immediate, immediate input. For example, it might be psychological support, even prior to the INR being completed and reviewed by by. You know all the legal teams and I've had times where I've made requests and it's been funded before they've even seen the INR, which has been really positive. And I think it's always important to consider what I, as a case manager, would recommend and what is going to make a big difference. 

Julie Marsh 

10:49 

But it's critical to think about that person's priorities as well which leads me on to my next question, which was really how do you prioritize with a person the next steps in their rehab journey and identify which direction to go in first? Because you, as a professional, will have a view. 

11:08 

But obviously they as an individual will also have a view, and they're suddenly being presented with this whole range of opinions and advice which sometimes can be really difficult to take on board. So how do you go through having those kind of preliminary discussions with somebody? 

Kate Gibbons 

11:22 

Yeah. Well, what I try and do is outline, if I can, at the end of the face-to-face assessment with an individual, what I'm going to recommend in my reports. You're sort of scribbling notes all the time, thinking, okay, yes, we've talked about that, so that's going to go in my recommendations. So if I can outline that and give them an idea of what I'm going to say, once the funds are hopefully agreed I meet with them again and go through those recommendations and sort of ask them what their three main priorities are, and I think it's then useful for a case manager to offer advice on that of what you know we might feel might make the biggest difference and be the best way to approach those recommendations. But consider together that order and agree the focus, because you know it is about them, it's all for them, so they've got to be on board with it. 

12:12 

I think often accommodation is up there, but sometimes it can be really different. I can remember working as a physio once with a young mum and the entire team had sort of agreed that the best immediate input would be to work on transfers and seating. Her focus was purely about how she was going to cuddle her newborn baby, so that was put as her number one goal. So I think you know, having those those thoughts and considerations, that everyone is different. Everyone is an individual. You can't just blanket treat everyone the same way, assuming that their injury might look the same. You know it's it's important to go in and review with that person how the process is going to work that's great and so important. 

Julie Marsh 

12:58 

I think that the person's on board with what those recommendations are and can identify from those recommendations. Well, actually, this is my real priority and, as you say, remembering that the heart of all of this is the injured person and what they really want to achieve as their priority, should be front and centre. Yes, and you mentioned there about accommodation, and I remember having conversations with you about our mutual clients accommodation needs and sometimes accommodation is a real big ticket item for a client. Sometimes it's their absolute priority. They're really struggling, but sometimes it's not, is it? It's sometimes much further down the list, as it were in terms of priority. 

13:38 

So when you're talking to a new amputation client, how does accommodation factor into your assessment? 

Kate Gibbons 

13:47 

So I'll always ask if I can have a look around the property and if you know, if they're allowing me to take some photographs so that will go into my report and provide an outline of you know where it's located, how many bedrooms there are, what's on the ground floor, what might be upstairs, what changes have been made, what can and can't be accessed and and therefore you're sort of identifying any issues that they're having. I'm not an OT by background, so I will always want to get a further OT assessment to consider issues arising and recommendations moving forward. I think having a conversation at that early stage it can can be quite hard. You know, you often might be meeting someone who's lived in that house for 50 years or longer and they don't want to leave it. It was never their intention to leave it and although life is hard there, they're torn. 

 

14:44 

So perhaps just you know, looking carefully at the situation that that person's, in taking on board some of their comments that they've said, but highlighting at that early stage that it's just your comment from a professional's point of view, that perhaps that home isn't enabling them as much as it could, and that might take a period of time. You know, as we saw in that case that we needed a period of time for them to understand how much easier life could be in a different property. But I think early conversations are important and honesty, but honesty from both parties. So I think you know, taking on board how they're feeling at that point in time and you know, if it's not not immediate, it may be further down the line but for some people, as you say, it might be a high priority and something that we've got to make a difference to straight away and I think it is a conversation that has to be revisited, isn't it over and over? 

Julie Marsh 

15:42 

because it evolves and changes and, as a person maybe becomes slightly more capable, actually that accommodation might then be more of a hindrance or life might, as you say, just be a bit easier. So there's a period of adjustment. So, having the early conversation floating the idea that some changes might be needed, but also the way those changes can be accommodated, those changes can be accommodated in the case we worked on. 

 

16:12 

We looked at, you know, airbnb, didn't we? As a short term trial period in different accommodation and on your own, which is a whole different ball game to being in a house that you're familiar with and with family around you to support you in that accommodation. So it can be kind of looking and thinking outside the box in terms of meeting accommodation need. 

Kate Gibbons 

16:33 

Absolutely, and I think amputation clients are quite interesting really, because they are hopefully and in many cases going to be walking for a significant period of their day, each day, but it's likely that each day, and at other times maybe for longer periods, they're going to require the use of a wheelchair. So you're sort of managing two different situations. You know that then they're not fully ambulance and they're not a full-time wheelchair user, so you're trying to work to two different requirements and make sure that both are equally good yes, and that's interesting because as a litigator I'm looking at a accommodation claim and future proofing it, so inevitably there'll be a recommendation for single-story accommodation. 

Julie Marsh 

17:25 

But of course, a young client who is hoping to be active, with good prosthetic support and things, will never want to be looking at a bungalow and living in an area with an older population because they see themselves as kind of that pulls them out and marks them as having a disability absolutely and if they're, I think sometimes the younger they are and and it can be the more newly injured they are, if the process has been fairly smooth for them in terms of they've not had issues well for that period. 

 

18:00 

When you meet them trying to have a discussion, that there may be times when they're not going to be like that isn't always well received no, and also highlighting situations where you think this is absolutely a situation where you probably would want to be in single story accommodation, because you've seen the range of issues that occur. So in that situation, we had a client who was thinking about having children and we were trying to think about well, do you really want to be in a property which is two stories when you're going to have to be mobilizing up and down stairs on prosthetics? What if there is an emergency? You can't sprint up and down the stairs like a normal, non-injured person. 

Kate Gibbons 

18:53 

And that was a difficult conversation to have and something that they struggled to come to terms with, I think to think about yes, absolutely, and I think you know three floor lifts can be good, but they're not quick, they're not easy, they're not always in the right place in the property. As you say, they're not going to be as quick as running down the stairs. 

Julie Marsh 

19:19 

So how does your role change and evolve during the life of the claim, and then post-settlement as well, which is another real step change, isn't it? 

Kate Gibbons 

19:28 

Absolutely. I think I probably often find that people want their lives back for a while. They've had enough of the claims process, you know, people poking into their lives or feeling watched and monitored, I think in a way. And many individuals I think it's probably fair to say you know find the litigation process tiring and can be quite traumatising in some cases. So they want to retreat, enjoy just being them for a while and having their life back and hopefully, if that person has got to a stage in the lifetime of the claim where they've got good supporting team, they know who to reach out to and, importantly, when to reach out. They can manage quite well. I can stay on hand for calls and advice as and when they need me. 

20:13 

Some people do want to continue with the same level of case management input, which I can also do, and I think what we do find is those that want that break initially come back 12 months down the line or even later and ask for assistance again because perhaps something's gone wrong or is not working as well as it was, and that can sometimes be because simply, they've just not kept up with the rehab program as much as they had been, you know, because they want to break from everything and things have just deteriorated a little and they need that encouragement, motivation or just this pure suggestion to re-engage in that, have another burst and get back on track again. 

20:51 

Sometimes, if they've left it for a longer period, it can be almost like having a new client again and we need to do a sort of full assessment to get them back on track. And what we see in a few cases is that I think people still look to a case manager for reassurance on costs. So whilst they've got their settlement, I think they do worry about what's a reasonable cost and they like to chat through, you know, a therapy suggestion or equipment costs, and certainly on accommodation. Again, it varies person to person and I think if a case manager can be flexible to that, that can work really well. 

Julie Marsh 

21:25 

Yes, I can totally understand how brutal people can find the litigation process and how intrusive, and I'm often talking to my clients about expert assessments from both parties, a number of expert assessments people, as you say, poking into their lives, judging to a degree, offering recommendations almost in a vacuum. And, as a case manager, I suspect you have to diffuse some of what the litigation creates around those issues. 

Kate Gibbons 

21:56 

That's certainly a tough one, you know. I think you can. That would almost require a separate little rehab programme on its own, sometimes that you're managing the impact of the injury and then quite separately managing the impact of litigation, and that might not be on the injured person. We find, certainly with youngsters, parents take on that stress and strain, often with an injured person for whatever reason. Their spouse might take that on, and so you've then got two people that are being massively impacted then. 

Julie Marsh 

22:30 

So yeah, lots to deal, deal with and I think that's a particular issue with the litigation process is that the claimant, the injured person, is always at the centre of it and the focus is always on them, but we have to try and remember the impact that it has on the wider family and those that are providing the care and support and often have provided that care and support for such a significant period of time before then, further intervention and help is available. 

Kate Gibbons 

22:56 

For sure. I had one case a teenager and I didn't get involved, or case manager didn't get involved for quite some time, by which point the parents have done such a fabulous job, you know, to the best that they can do and using their knowledge, but then that's quite hard for them to hand over. So that took time to build a relationship not just with the client but with the parents as well, to allow me to support all of them and to take on things that they just desperately held on to, as any parent would, I think, to you know, fight for their child. So I think the longer that goes on, the harder it is sometimes for case managers to get involved and really get a good handle on the case, because you've got to build a rapport first. 

Julie Marsh 

23:44 

I mean you do in every case, but certainly the longer they coped, for you know you're dealing with that as well- yes, and I think we find as litigators, sometimes the hardest part is actually handing over the relationship to the case manager, because we play case manager for a period of time before a case manager is instructed and then, because you've been involved in that person's life or the family's life for so long, they then have to start over with somebody new and they sometimes feel like you're kind of washing your hands of them. 

Kate Gibbons 

24:14 

yeah, yeah, I can see that but I think they know, you know if you, if, if a case manager comes in and talks all the team about that support network, you know, when I said earlier about once someone's finished, that you settled their claim, finished with the litigation, that as long as they know the right people and the right time to make contact with for whatever their needs are, and I think at any stage if you just say, look, this is that person, they're still within your support network so they're always there. Don't ever feel you can't ask them. You know, it's not that you've got to come to me, it's just that I can help you with these things. And hopefully, if you form a good MDT, you know if an individual is reaching out to one person about something that's perhaps not quite their role, they will then pass it on and that's. You know the benefits of a strong MDT. 

Julie Marsh 

25:03 

Yeah, and that's so important. We see that time and again, how important it is to have that MDT around the injured person. Thank you so much for joining me today, kate, to discuss such an interesting topic and what I think must be a very complex and often very challenging role. It's been great to understand the issues and talk generally about the benefit of a case manager and what they can bring to an injured person. 

Kate Gibbons 

25:26 

Thanks for having me, julie, always happy to chat about case management. 

Julie Marsh 

25:30 

Thank you for tuning in. I do hope that you've enjoyed listening to this podcast and if you or anyone you know has experienced an injury or amputation as a result of poor medical care, or want to inquire about making a complaint or bringing a claim, please contact us at boyesturnerclaims.com