1. Scenario Ethel is a 78-year-old widow with no children who lives alone in a two bedroomed semi-detached house with three concrete steps from the pavement to the doorstep, an internal staircase and an upstairs loo. She has a bath but no walk-in shower. Until now she has been fully self caring and attends the practice once or twice a year for a medication review and for blood tests. She suffers from high blood pressure and has been on bone protection therapy since she broke her wrist four years ago. At 10.15am one Thursday morning in May she stumbles on a step in her back garden whilst hanging up the washing. She is found by a neighbour after 15 minutes who manages to help her up and get her into her sitting room chair. She suggests an ambulance is called but Ethel refuses. The GP is called and a visit request is made. The GP on call rings her back after half an hour and offers a GP visit later.

2. GP access GP has access to complete GP record and can assess her recent state from this. Implied consent for this to be seen by all in the practice They can quickly scan the problem list, the current medication, glance at the lab results for last blood count and kidney function, why she last attended and look at recent correspondence This takes about 1 minute to do

4. The visit On visiting her at 12.30 the GP finds her sitting in her arm chair, sipping a cup of tea. She is well oriented and shows no sign of a head injury, but has a sore back and a small cut on her shin. Her legs have mild pitting oedema (swelling). She’s able to get up out of the chair and walk across the room holding on to furniture. Overall she seems stable, but needs her leg dressing. GP has with her a paper summary sheet with problem list, recent consultations, medication and latest lab data The GP decides to refer her to the community nursing team (ICT)

5. How the Community Nurse finds out… The GP returns to base and can: Walk into another room and ask the nurse Ring the nurse Write a message in the message book Send a referral fax via SPA Task the nurse on systmOne Econsult the nursing team via systmOne

6. The referral-form Faxed to SPA, the agreed mechanism for contacting the community nursing service /ICT ( Integrated Care Team) based at another health centre 3 miles away. Apart from the demographics, the GP ignores all this and the information completed on the form is the following: “Ethel has had a fall and injured her shin. Her legs are a bit oedematous but she is mobilising. Can you dress her legs and monitor the wounds until you're happy. Could you check her bloods please? FBC U&E LFT TSH glucose” The form is passed on to the local ICT who arrange to visit later that afternoon. Implied consent

7. The Community Nurse At 2.30 the nurse makes an assessment and dresses the wound. Ethel’s neighbour is there making a sandwich and tea, Ethel seems comfortable and it seems Ethel is stable and will get the help she needs overnight. The nurse asks Ethel if it is ok for her to share her records with the GP. Ethel says yes. Expressed consent

8. The Admission At 10 that night Ethel falls over getting out of bed to get to the toilet. Her neighbour has been kindly popping in, finds her on the floor and phones an ambulance. A paramedic suspects a broken hip She arrives at A&E unaccompanied, without any information other than the bag of pills and the history this tired woman can give herself Summary care record may be available (expressed dissent) She is later found to be mildly anaemic and her potassium is very low