1. Sarah 18 years old. Lives at home with her Mum, Dad and brother. ? Mild learning disability She arrives at A&E, ‘burns’ on the tops of her legs, can’t get an appt with her own GP. Examination ? Urine burns. No story given as to what has happened. Decision to treat and discharge home She comments that she’s going to be cold tonight and doesn’t like the rain as she can’t sleep.

2. David 50 years of age. Has a terminal diagnosis. Admitted via Ambulance at weekend – stomach pains Decision to admit for observation Tells Nurse that his cousin is his carer and she ‘looks after me’. Jokes that she might not for long though as she was angry at him for buying a new tv, bed and bedroom carpet and that ‘there would be nothing left for the funeral’ and ‘her inheritance’.

3. Mary 60 year old grandmother. Sold her house to move in with her son, daughter in law and two teenage grandchildren. Family report that she can’t be left on her own and doesn’t manage to look after herself. Ambulance called by family as Mary was feeling unwell and was distressed. SAS reported to A&E Nurse that when they arrived to collect Mary, they noticed that the rest of the house was comfortable and warm whereas her bedroom was noticeably colder and untidy. There are some concerns re personal hygiene. Mary herself showed some agitation around the Daughter in law in particular.

4. George George lives in a care home. His only son, Brian, lives in England. He phones regularly but can only visit a few times a year. George is brought to A&E by ambulance, having fallen. A care assistant comes with him but can only give basic information about what happened. George is malnourished, complains of having a sore mouth, appears dehydrated. The care assistant doesn’t think that he eats very much of what’s given to him and tells the Nurse in A&E that he can be ‘difficult’. On examination, there are a number of sore, red patches on his skin and some bruising around his upper arms. George does not know how he got these or what happened to make him fall.

5. Betty An elderly woman brought to A&E by ambulance following a fall at home. Patient sustained a fracture to her upper arm and clavicle as well as suffering a head injury. Just prior to her transfer to the orthopaedic ward patient divulged that her elderly husband had pushed her then hit her in the chest causing her to fall and hit her shoulder and head.

6. Wilma Resident in care home brought into ED by ambulance accompanied by care assistant. She has advanced dementia and unable to give history. It was noted Wilma has a fracture 5th metacarpal in left hand and bruising of the left wrist. Jodie, the care assistant was unable to give explanation for injury. On further examination patient noted to have evidence of old bruising to both upper arms.

7. Irene 85 year old patient who is recently bereaved, brought to ED by SAS – generally unwell. Accompanied by daughter, Grace, who lives in south of England. Irene’s son lives nearby and he has a drink problem. Grace expresses concern that her brother, Bob, is stealing from the Irene and she lives in fear of her son’s mood swings, although Irene is denying this is the case.

8. Gordon Resident in care home brought to ED by ambulance. Gordon was found by care workers this morning with facial swelling and emerging bruising, patient unable to give any history due to cognitive impairment

9. Iain Phone call received by ED nurse from granddaughter of Iain who is currently in the ED, expressing concern that another family member was subjecting Iain to financial and possibly physical and mental harm. Iain has no cognitive impairment and is not disclosing any of this to nursing staff.

10. Alex Alex is a resident in nursing home brought to ED following collapse. On examination he is noted to have tears to both lower legs which are actively bleeding Pressure damage is present on both heels, thoracic area of back and sacrum. Alex is recently discharged from hospital. No mention on the transfer letter to the nursing home of the presence of sores or skin tears.

11. Alice Arrived by ambulance without escort, following an unwitnessed fall and was obviously confused and constantly requesting to be taken to toilet. Alice repeatedly asked various members of staff and other patients in the waiting room for assistance to go to toilet. A&E staff telephoned the nursing home to query why no escort was with patient and was advised that they did not have the staff available. Also questioned why she was repeatedly asking for the toilet and was informed “this was part of her condition”

12. Andy Admitted to A&E ward, no fixed abode, complaining of auditory hallucinations. via police to place of safety prior to admission to learning disability ward. Andy was unkempt and frightened, terrified of police. Brenda reports to nursing staff Andy is being financially exploited by "friends" who have her bank card and his pin number and these "friends" take £80/week from his bank account for digs and food.,

13. Sheila Sheila was admitted to ward via emergency department from care home. It was discovered on admission to ward that patient was quite unkempt, evidence of faeces on legs and feet, odouress and necrotic sacral area and necrotic heels.

14. Tom Tom is 53 and was admitted to A&E via an ambulance with smoke inhalation following a small house fire This is his second admission over the past year. Tom has a long term history of alcohol misuse. He also smokes. The SAS staff report that the second floor flat has a lot of rubbish being stored in the hallway.

15. Joyce 85 year old who is recently bereaved, living in her own home, family concerned as she appears to show signs of dementia. SAS called a workman who was repairing guttering on her house fell and has broken ankle “Chance” conversation with Joyce highlights that workman was charging £20,000 for the work on the house.

16. Case Studies 1.Is the patient an “adult at risk” in terms of the legislation? 2.Do you have adult protection concerns? 3.What support could be given to the patient following discharge from A&E? 4.Would you report your concerns to the Council? If so, how (please be very specific ie how would you refer eg what paperwork would you complete, who would you phone, what phone number.)