# data[].attributes.body
ABCDE Assessment – to assess immediate life-threatening conditions in A&E.

FAST Tool – for rapid identification of stroke symptoms (Face, Arms, Speech, Time) (NICE, 2019)

NEWS2 (National Early Warning Score 2) – to monitor and escalate clinical deterioration (RCN, 2023)

Assess the level of consciousness using the Glasgow Coma Scale.

CT Head Scan (non-contrast) – the gold standard for identifying ischaemic vs haemorrhagic stroke; NICE (2019) recommends within 1 hour of arrival in A&E.

CT Angiography or MRI (if needed) – may follow to assess vascular abnormalities or more subtle brain damage.

Medication Review & Reconciliation – necessary due to unintentional non-compliance and polypharmacy (Ramipril, Simvastatin, Amitriptyline) (BNF, 2024)

Why these tools matter:

Alan’s stroke risk is high due to hypertension, smoking history, and hypercholesterolemia.

Presenting symptoms (confusion, anxiety) may overlap with stroke, delirium, or cognitive decline.

Ensuring a holistic and structured approach can improve early recognition and referral (NMC, 2018)

# data[].attributes.body
National Institute for Health and Care Excellence (NICE), 2019. Stroke and transient ischaemic attack in over 16s: diagnosis and initial management (NG128). [online] NICE. Available at: https://www.nice.org.uk/guidance/ng128 [Accessed 24 Jun. 2025].

Royal College of Nursing (RCN), 2023. National Early Warning Score 2 (NEWS2): RCN Position Statement. [online] Available at: https://www.rcn.org.uk/professional-development/publications/rcn-news2-position-statement-uk-pub-010-127 [Accessed 24 Jun. 2025].

BNF, 2024. British National Formulary. [online] London: BMJ Group and Pharmaceutical Press. Available at: https://bnf.nice.org.uk [Accessed 24 Jun. 2025].

# data[].attributes.body
Alan Hughes presents with several safeguarding concerns that must be addressed holistically within the framework of UK legislation and clinical best practice. One significant concern is self-neglect, demonstrated by his unkempt appearance, poor diet, and non-compliance with prescribed medications. Self-neglect is a recognised safeguarding issue under the Care Act 2014 and has been linked to increased mortality and hospital admissions in older adults living alone (Braye et al., 2015). A referral to adult social care under Section 42 of the Care Act is therefore warranted, alongside a comprehensive needs assessment. This would enable the development of a multi-agency support plan tailored to his needs, involving social workers, nurses, and potentially mental health services.

Alan’s mental health and cognitive status also require attention. His anxiety, forgetfulness about medications, and excessive worry may indicate depressive symptoms or emerging cognitive impairment. Under the Mental Capacity Act 2005, a formal assessment of his decision-making capacity regarding his health and treatment is legally required if there is reason to doubt it (Bartlett, 2020). Cognitive screening tools such as the MoCA or MMSE should be employed in a clinical setting to evaluate his needs accurately. If capacity is impaired, best interest decisions must be made in line with statutory guidance.

Another pressing issue is medication non-compliance, which significantly increases Alan’s risk of further vascular events given his history of hypertension and hypercholesterolemia. NICE guidance on medicines optimisation (NICE, 2015) recommends person-centred reviews and support systems to improve adherence. In Alan’s case, involving hospital pharmacy staff and considering post-discharge support—such as dosette boxes or community pharmacy follow-up—can help manage and monitor medication use effectively.

Social isolation is also a key safeguarding concern. Since the death of his wife, Alan has become increasingly withdrawn, which correlates with poorer health outcomes and increased hospital readmission rates in older adults (Victor & Bowling, 2012). Research shows that loneliness and isolation are associated with functional decline, particularly when compounded by bereavement and limited social support (Cattan et al., 2005). Social prescribing or referral to local support services via primary care may help address these issues in a non-stigmatising way.

Finally, Alan’s acute stroke symptoms, such as facial droop, highlight immediate safeguarding needs related to hospital discharge. NICE guidelines on stroke rehabilitation (NICE, 2019) recommend early involvement of multidisciplinary teams (MDTs) to assess post-stroke needs, including physical and cognitive rehabilitation. Given that Alan lives alone, discharge planning must involve occupational therapy assessments and possibly a temporary care package to ensure a safe return home. Without appropriate intervention, Alan faces a significant risk of further deterioration or rehospitalisation.

Together, these factors represent a complex safeguarding situation that requires legal, clinical, and social input. Intervening early and in a person-centred manner is crucial not only for Alan’s recovery but also to uphold his rights, dignity, and autonomy.

# data[].attributes.body
Bartlett, P., 2020. Mental Capacity Law and Policy. Oxford: Oxford University Press.

Braye, S., Orr, D. and Preston-Shoot, M., 2015. Serious case review findings on the challenges of self-neglect: Indicators for good practice. The Journal of Adult Protection, 17(2), pp.75–87. https://doi.org/10.1108/JAP-03-2015-0009

Cattan, M., White, M., Bond, J. and Learmouth, A., 2005. Preventing social isolation and loneliness among older people: A systematic review of health promotion interventions. Ageing and Society, 25(1), pp.41–67. https://doi.org/10.1017/S0144686X04002594

National Institute for Health and Care Excellence (NICE), 2015. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes (NG5). London: NICE.

National Institute for Health and Care Excellence (NICE), 2019. Stroke rehabilitation in adults (NG128). London: NICE.

Victor, C.R. and Bowling, A., 2012. A longitudinal analysis of loneliness among older people in Great Britain. The Journal of Psychology, 146(3), pp.313–331. https://doi.org/10.1080/00223980.2011.609572

# data[].attributes.body
Given Alan Hughes’ clinical presentation and background, several multidisciplinary referrals are essential to ensure holistic, safe, and person-centred care. As he is presenting with possible stroke symptoms, the first and most urgent referral should be made to the specialist stroke team for immediate neuroimaging and evaluation for thrombolysis or thrombectomy, as per NICE guideline NG128.

# data[].attributes.attachment_link.title
Overview | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE

# data[].attributes.attachment_link.description
Evidence-based recommendations on diagnosis and management in the acute stage of a stroke or transient ischaemic attack (TIA or 'mini-stroke') in over 16s

# data[].attributes.body
A referral to the Speech and Language Therapy (SALT) team is also necessary to conduct a swallow screen within four hours of admission to prevent aspiration, which is a common complication post-stroke.

# data[].attributes.body
Alan’s forgetfulness, anxiety, and distress raise concerns about possible delirium or cognitive impairment. The NICE Delirium Guideline (CG103) provides guidance on how to assess and manage these symptoms effectively, ensuring that any acute confusion is identified and treated promptly.

# data[].attributes.body
Alan’s social isolation, poor self-care, and medication non-compliance also raise safeguarding concerns. The NICE Social Care Guideline (NG150) and the Care Act 2014 provide a framework for protecting vulnerable adults and arranging appropriate social support services, ensuring his safety and wellbeing.

# data[].attributes.body
1. Stroke Management Guidelines

Relevant guidance:

• NICE NG128 – Stroke and transient ischaemic attack in over 16s: diagnosis and initial management

2. NICE CG90 – Depression in adults: recognition and management

NICE QS50 – Mental wellbeing in older people in care homes (relevant for social care interface)

Key Points:

• Alan is on Amitriptyline, which is not first-line due to:

• Anticholinergic burden (risk of confusion, falls, cognitive issues post-stroke)

• Poor tolerability in older adults

• Switch to SSRI (e.g. sertraline or citalopram) under supervision

• Psychological therapies should be offered in conjunction: CBT, bereavement support, or referral to IAPT

# data[].attributes.body
Condition
Stroke
Patient Demographics
Alan Hughes is a 72-year-old Black Caribbean gentleman. He is retired and now lives
alone since the recent death of his wife. He used to work as a long-distance lorry driver
and is largely independent in all aspects of his Activities of Daily Living (ADL’s). He has
had a poor diet since the loss of his wife, with a pack history of around 40 pack years – He is an occasional drinker. He has become more socially isolated, and looks slightly unkempt upon his arrival in A&E. He is now (unintentionally) non-compliant with taking his medication.
Setting
A&E
Background
On receipt of a handover, you have the following information: Alan has said that he was diagnosed with high blood pressure 5 years ago, but he can’t remember his other
medications that he takes - he has also said that he feels anxious and hates needles and is worried that he left the front door unlocked.
Past Medical History
• Blood pressure medication for 10-years
• Antidepressants since the loss of his wife
• Hypercholesterolemia
Current medication
• Blood pressure medication (Ramipril – ACE inhibitor)
• Statin for Hypercholesterolemia (Simvastatin)
• Antidepressants (Amytriptyline)