Case Studies

Case study 1

Mrs Smith is aged 85, she is well known to her GP. She had a fall a week ago and now has a pain in her leg.

Mrs Smith’s daughter Claire visits her mother on a Saturday afternoon and is concerned that her mum is in terrible pain and worries she may have broken her leg in the fall. She decides to take her mother to A&E.  The doctor at A&E diagnoses an infection in her leg, so he wants to give Mrs Smith antibiotics to treat the infection. The doctor asks Mrs Smith whether she has had any allergies to antibiotics in the past, she says “no.” However Mrs Smith has forgotten that she had an allergic reaction to antibiotics 5 years ago. The doctor views Mrs Smith’s Wirral Care Record and notices that her GP records state that she is allergic to penicillin. If the A&E doctor had given this it would have made her very ill. He was able to choose a different antibiotic that was suitable for her.


Case Study 2

Mr Stevens, age 68 has a history of heart disease. His health began to deteriorate and he was admitted to hospital on Friday; his medication was altered to help improve his condition and he was discharged from hospital on Saturday evening. Unfortunately since leaving hospital Mr Stevens has developed an itchy rash. He phones his practice on Monday morning and is given an appointment the same morning to see his GP, Dr Knowles.

After examining the rash, Dr Knowles suggests that it is likely to be a reaction to the new medication started whilst in hospital. Mr Stevens has not brought the medication with him, cannot remember what it is called and the practice have not yet received the information from the hospital. Dr Knowles accesses Mr Steven’s WCR, can see the new medication started and replaces it with a suitable alternative to look after Mr Steven’s heart, allowing him safely to stop the tablet which has caused a rash.


Case Study 3

Miss Patel is 26 and has been rushed to A&E as she was found unconscious but with no visible signs of injury. The first instinct of the doctor who is caring for Miss Patel is to order a CT scan to check for any head trauma. Before proceeding with the scan he accesses Miss Patel’s WCR. Miss Patel’s Care Record shows that she suffers from epilepsy; the doctor concludes she has likely suffered a seizure. The doctor views what anti-epileptic drugs Miss Patel takes and is able to administer the correct drugs immediately, saving valuable time.


Case Study 4

Mr Bennett is 75 years old; he struggles with his emphysema and also has dementia. He lives in Birkenhead with his wife who is 70 and has arthritis. Their nearest relative is their daughter who lives in Sheffield. Mr Bennett is deteriorating, and they are struggling to manage.

Dr Cairns, their GP, refers Mr Bennett to the Integrated Care Coordination Team (a team of social workers and other care professionals who work together to provide care.) Mr Bennett has a Wirral Care Record.

From this the District Nurse can see details of his recent stay with a flare up of emphysema and also what tablets he is currently taking. The Nurse visits and helps Mr Bennett to use his inhalers better and arranges to visit regularly to monitor his health.

The social worker in the team can see from the Wirral Care Record the problems that Mr and Mrs Bennett are struggling with. The social worker visits Mr Bennett and his wife and after discussion arranges carers to visit twice a day to assist with washing, dressing and meals. Mrs Bennett says how pleased she was that it was all arranged smoothly and they did not have to keep repeating their information which both of them would have found difficult.

Their daughter is relieved that care for her parents was arranged efficiently and they sound a lot happier when she phones.