Working together for a dementia patient in Leighton Buzzard

“D”, from Leighton Buzzard, suffered with dementia. Enabling her to remain at home was very important. However, her respiratory condition had deteriorated and she was unable to climb the stairs to get to bed. Her main carer, her husband, was elderly and unable to assist. 

D’s situation was brought to the attention of the Working Together Leighton Buzzard team (WTLB) via a referral from a Nurse at her GP Practice. WTLB is a programme that brings together GP practices, mental health services and social care to better coordinate care across organisations.

Various professionals within the WTLB team reviewed D’s case and, following discussion, a joint visit was arranged with the district nurse and social worker for the following day. They undertook a holistic assessment of D and created a care plan with input from her husband. They also made an occupational therapist referral and ordered a new bed so that she could comfortably and safely remain sleeping downstairs.

The husband was also assessed as the main carer and he was offered any necessary support. A review of D’s medications was undertaken by the community pharmacy technician and, following liaison with her GP, further medications were prescribed in order to improve her respiratory function.

By working together across organisations, the WTLB team managed to co-ordinate a timely and appropriate response for this patient and prevented what would otherwise have been a hospital admission.