A Case Study by Daniella Souris.
A Journey Through Complex Rehabilitation and Recovery
An Introduction to Daniella.
Daniella, being proudly South African-born and raised, gave her the insight, and highlighted the inequalities within society. This gave her the drive and determination to personally succeed and help people. She has worked as an occupational therapist and case manager in diverse settings, from rural villages in South Africa to working within the NHS and private sectors in London. She has extensive knowledge in the areas of cardio-thoracic, orthopaedics, general surgery, and neurology. Her passion lies within the area of neurology and this led her to furthering her studies in a master’s programme within Neurological Rehabilitation. She has developed a unique skill set which is transferrable to many circumstances. She works proactively, co-ordinating with professionals and services to ensure the most effective outcome for her clients.
An Introduction to the Case.
While attending a football match as a spectator, the client was inadvertently involved in a collision with a player, resulting in a fall to the ground. Following the incident, he was assisted by family members who transported him to A&E. He was subsequently diagnosed with a C4 incomplete spinal cord injury. The following day, he underwent a posterior cervical decompression spanning C3–C5.
Prior to the injury, he was fully independent and worked as a plumber. In addition to his vocational role, he volunteered regularly at sporting events supporting young people and contributed to the training of apprentice plumbers. He lived with his wife and maintained close family ties with his daughter, who lived in the UK, and his son, who lives abroad.
The Summary.
The incident occurred in July 2022 while the individual was attending a football match as a spectator. Following a collision with a player, he sustained a C4 incomplete spinal cord injury and was admitted to hospital immediately. During this acute phase, he underwent thoracic surgery and completed a six-month course of treatment for lymph node tuberculosis. The client’s ability to engage in rehabilitation was significantly limited due to periods of ill health and the need to prioritise medical management during this time.
In December 2022, he was transferred to a specialist spinal hospital—Stoke Mandeville Hospital—where his clinical trajectory remained complex. He experienced recurrent chest infections, resulting in ITU admissions and eventually resulted in a tracheostomy in March 2023. In addition to respiratory instability, the client developed pressure sores and experienced marked physical deterioration. This included reduced muscle strength, impaired continence, and an inability to weight bear due to his spinal injury, all of which significantly impacted his capacity to engage in and progress with rehabilitation.
By early 2024, he was discharged from hospital to a specialist nursing facility with a tracheostomy and was ventilated for up to 16 hours daily. At this stage, his tracheostomy care was managed under the NHS Respiratory Pathway. An Initial Needs Assessment (INA) was conducted in February 2024. At this time, Continuing Healthcare (CHC) funding supported the provision of physiotherapy, occupational therapy, and specialist care within the nursing home. To facilitate discharge home, CHC identified a private company to assess the feasibility of safe return. This provider completed a home visit in November 2024 and provided feedback in January 2025, concluding that the home environment was suitable for discharge with provision of 1:1 care and continued therapy input and had recommended private funding for a wheelchair accessible vehicle (WAV) to take him into the community for leisure social perspective.
Following the recommendation for discharge home, the case manager raised concerns regarding the safety and suitability of the proposed living environment. The room allocated for the client’s return was described as damp, posing a significant respiratory risk given his clinical history. Additional access barriers were identified: he was unable to reach the front door due to external steps and could not access the bathroom, toilet, or shower because of mobility limitations. In light of these concerns, it was advised that tracheostomy weaning be given thoughtful consideration, and an intermediate placement plan was initiated as a parallel pathway while the client’s safety and readiness for discharge could be assessed further.
The Case.
Due to ongoing disputes regarding liability, available funding for the client’s rehabilitation was limited, and the case manager was required to draw upon statutory services for treatment provision. Recognising the need for a review of the client’s neurological level and updated ASIA scoring was essential, particularly as the client has not been seen face to face by his NHS neurologist for over 18 months due to transport-related delays within NHS pathways. An updated assessment would provide a clearer diagnosis and prognosis, guide care planning, and support clinicians in setting realistic, goal-oriented rehabilitation targets.
In light of this, a referral was made to the Cleveland Clinic for a comprehensive rehabilitation review. This review was consultant led but also included reviews by an assessment by a Consultant in Rehabilitation Medicine, Occupational Therapist (OT), Physiotherapists, and Speech and Language Therapists (SaLT), allowing comparison of the client’s current presentation with the initial clinical benchmarks. These reviews offered a clearer picture of his diagnosis and prognosis, providing valuable insight into potential functional gains.
The outcome of this clinical assessment informed short- and long-term care planning and SMART goal setting. The report clarified the client’s rehabilitation trajectory, enabling instructing parties to better understand his prognosis and substantiate requests for further funding aimed at optimising recovery. In addition to supporting resource allocation, the recommendations within the report helped to identify necessary environmental adaptations to facilitate future discharge home, guiding further liaison with Continuing Healthcare (CHC) teams regarding long-term provision.
In addition, it was important to provide evidence to insurers that the client’s significant progress at his current placement is largely due to the intensity and consistency of the specialist rehabilitation he receives. While clinical reports and presentation support a positive prognosis and potential for further recovery, this progress is dependent on continued access to specialist therapy input to guide and support rehabilitation. This information also helped inform and motivate Continuing Healthcare (CHC) decision- makers regarding the level of therapy and specialist equipment required when planning the client’s transition to an intermediate placement.
“The aim was to avoid working in professional silos and instead build an integrated approach around the client”
– Danielle Souris (Case Manager)
Thoughts from the Case Manager about their role in this rehabilitation journey.
In this case, my role as the case manager was shaped significantly by the initial lack of private funding. This required a proactive and pragmatic approach to maximise the use of available statutory services. I focused on developing strong working relationships with statutory providers and fostering collaborative partnerships to ensure that the client’s needs were met as holistically and effectively as possible. The aim was to avoid working in professional silos and instead build an integrated approach around the client.
As the case progressed, I strategically engaged with private specialist services to refine our focus based on the client’s evolving diagnosis and prognosis. This targeted input helped guide the next stages of care and informed multidisciplinary decision-making. One of the key steps was facilitating a private neurological review, which became a pivotal foundation for a potential Continuing Healthcare (CHC) application. This contributed to a more robust clinical understanding of the client’s condition and informed long-term care planning.
From a medico-legal perspective, although liability has not yet been admitted, the early intervention and detailed clinical documentation laid important groundwork. The assessments and recommendations captured during this stage can support future heads of claim, including care, accommodation, rehabilitation, and specialist equipment. Additionally, this level of evidence will assist in the quantification of damages should liability be established.
Reflections and Learning.
A key learning from this case has been the value of professional advocacy, particularly when working with insurers who are cautious or limited in their approval of funding. I learned that even in situations where funding is tightly controlled, putting forward well- justified, clinically appropriate recommendations—despite higher associated costs— can result in approvals when supported by clear medical evidence.
This experience reinforced the importance of not pre-emptively dismissing potential interventions due to cost concerns. If the proposed support is in the client’s best interest and the clinical justification is robust, it is worth advocating for. Maintaining a client- centred, evidence-led approach can influence funding decisions more than anticipated, and ensures the client receives the care they need.