1. A good death: we did it his way… Denise Souter

2. Trevor’s Story

3. Contents Trevor’s Story Role of the CTPLD Referral
Trevor’s Like and Dislikes
Plan of Action
Support Network
Good Practice which made a difference
Challenges and Reflections
Questions

4. Role of the community team for people with learning disabilities
Multi-disciplinary team specialising in learning disability
Assessment of health and social needs
Care co-ordination
Risk management
Staff training
Communication and learning disability awareness and promotion
Assessment
Health management strategies
Education
Enabling access to primary and secondary services
Partnership working

5. Initial referral to CTPLD
Referral source: GP
Initially requested learning disability nurse involvement
Input requested:
Guidance for Trevor’s supported living accommodation
Education and staff training
Guidance around capacity and best interest decisions
Family and access to appropriate support
Liaison with health professionals
Education around the needs of individuals with Learning Disabilities
Providing accessible materials to enhance communication

6. Trevors likes

7. Trevors dislikes

8. Plan of action Reflection on self-knowledge and educational needs
Build rapport and liaise with Trevor, family and professionals
Start of advanced care planning and risk management
Shared consensus and understanding of aims of ‘A good death’
Educate with specialist learning disability knowledge
Develop appropriate accessible materials
Point of contact and co-ordination

9. Trevor’s support network
Liaison nurse
Hospice staff/ counselling
Residential placement
Family GP
Denise Souter
Professionals
Consultant
Kings College Hospital
MacMillan community nurses
Care management

10. The Little things that made a BIG difference

11. Early referral by GP Enabled time to build rapport
Liaise with relevant professionals
Personal training and education
Enabled insight of health challenges
Ensure stable network of care
Robust care plan and strategy
More TIME!!!

12. Pain recognition

13. ‘Pottery’ at St. Catherine’s

14. Towards ‘a good death’? Trevor and family at the centre
Keeping mindful of:
Client’s personal preferences
Life goals and interests
Respect for family
Maintaining communication networks
Professionals
Clinicians
Family
Individually tailored and advanced care planning
Providing family support
Shared knowledge

15. Reflections Communication Co-ordinating professionals
Forming a structure of support
Establishing procedures and guidance
Consistency of care
Multi-professional involvement – sharing information
Capacity and Best interests
Awareness
Assessment
Practical logistics
Emotional resilience
Roles and remits
Resistance

16. Denise Souter Community Nurse Learning Disabilities Surrey and Borders Partnership Trust
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