Ryan, 23, is living with a severe brain injury following a fall from height at work. Prior to the accident, Ryan was a fit and active builder working for a small local construction firm. He was known for being reliable and for having a strong work ethic, often working long hours on-site.
He enjoyed the physicality of the job and socialising with his colleagues; they were a tight-knit team.
Before the injury, Ryan rented a one-bedroom house in the city centre, close to friends and work. He was independent, proud that he had saved up and moved out of the family home, but remained close with his parents and siblings whom he visited often.
Ryan also had a close friendship group, where he was known as ‘the practical one’. He was always on hand to help friends and family with DIY, which he enjoyed.
Motivated and determined, Ryan was focused on his future; he aspired to one day own his own construction firm.
Ryan’s initial condition was complicated by other injuries sustained during his fall, including multiple fractures and soft tissue injuries. He was diagnosed with a prolonged disorder of consciousness (PDOC), and remained in intensive care for the first two months.
He was then transferred to an acute neurological ward where he continued to be non-verbal and rarely responsive to stimuli, requiring a high level of care. Emergence from PDOC took almost three months and, as he began improving, he was accepted onto and transferred to an NHS Rehabilitation Unit.
Given the severity of Ryan’s traumatic brain injury, prolonged disorder of consciousness, extended stay in intensive care and significant orthopaedic injuries, fatigue was an expected and prominent feature of his recovery.
Whilst on the rehabilitation unit, Ryan’s solicitor, who understood the benefits of early intervention, enquired about an Immediate Needs Assessment.
Our enquiry process includes a triaging clinician, who is able to explore individual nuances, ask the right questions at the right time, and anticipate the types of needs that may emerge as the client progresses through their recovery.
Through an exploratory conversation with the solicitor, the triaging clinician identified that the best case manager for Ryan was Gerald.
Gerald, an Occupational Therapist with an extensive background in neurological rehabilitation both within in-patient settings and in the home, had the specific experience Ryan needed.
Gerald understood that Ryan would face long-term cognitive, physical and functional challenges, and was keen to be involved in discussions with the hospital surrounding his rehabilitation pathway from an early stage. He knew that Ryan would likely need input from a variety of clinical areas, such as speech and language therapy, occupational therapy, neuropsychology and neuro-physiotherapy, and that he would also likely need an extensive care team in the short-term.
Gerald’s experience with multi-disciplinary teams within in-patient settings, plus his knowledge of home adaptations and care packages due to his previous work rehabilitating patients in the home, provided him with the foundation he needed to approach Ryan’s case holistically and with the long-term goal setting Ryan would need to support his progress.
Once Ryan was discharged from the acute neurological ward, he was accepted onto and transferred to an NHS Level 1 Rehabilitation Unit. Here, early provisions were established by the unit and, shortly after these commenced, Gerald was instructed to meet with Ryan and complete an Immediate Needs Assessment (INA).
This aimed to identify his immediate circumstances, needs and any barriers to rehabilitation.
Following the completion of the INA, and in line with the recommendations made, Gerald was instructed as Ryan’s case manager shortly before he was discharged home.
Ryan had spent a total of four months in the rehabilitation unit and, by discharge, had made improvements.
Ryan was able to complete a standing transfer with assistance of two and an appropriate aid. He had become involved in showering himself, but he did still require assistance from a carer to fully complete the task. He could also feed himself with adapted cutlery and participate in simple board games with family. The speech and language therapy provision that he had received on the unit enabled him to speak in simple sentences in order to hold a basic conversation. Ryan’s PEG feeding tube was removed before discharge as he was getting enough nutrition through a modified diet.
Gerald’s early instruction as Ryan’s case manager allowed him to be included in MDT review meetings and discharge planning, whilst also allowing him to monitor Ryan’s progress whilst on the rehabilitation unit.
Rehabilitation continued as Ryan made progress. Gerald continued to reassess goals, targets and services, altering plans as required.
After a further nine months of rehabilitation, Ryan’s mobility had improved significantly and he was able to walk short distances independently. He rarely required physical assistance with everyday functional tasks and had become increasingly confident within his home and local community.
Although his physical recovery continued to progress, Ryan continued to experience intermittent cognitive fatigue, particularly following periods of sustained concentration, complex tasks or busy environments. Fatigue management therefore remained an important component of his rehabilitation, with Ryan becoming increasingly able to recognise his own limits, pace activities appropriately and balance periods of activity with planned rest.
As Ryan’s rehabilitation goals evolved, Gerald began to focus on longer-term independence, community reintegration and meaningful occupation. Having developed a strong understanding of Ryan’s aspirations throughout his rehabilitation, he recognised his desire to return to productive activity and, ultimately, employment. Rehabilitation therefore shifted from restoring function towards maximising participation, independence and quality of life.
Two years after the incident, Ryan’s legal claim reached settlement. Although he continued to live with the long-term effects of a severe brain injury, including fluctuating cognitive fatigue, he had made significant progress across his physical, cognitive and emotional rehabilitation.
Gerald continued to work alongside Ryan to support his longer-term rehabilitation goals. As his confidence grew, they explored local hobby groups that reflected his interests and strengths. Improvements in Ryan’s communication, cognition and confidence, supported by speech and language therapy and neuropsychology, enabled him to participate more fully in these activities and rebuild his social identity.
Recognising that fatigue continued to affect Ryan’s endurance during longer community outings, Gerald revisited the recommendation for a powered wheelchair. This was obtained through private funding, enabling Ryan to independently access community activities, conserve energy and participate more fully in social and recreational opportunities that were meaningful to him.
Whilst Ryan’s friendship group naturally evolved over time, his lifelong friends remained a consistent source of encouragement throughout his recovery. Although he initially struggled to redefine his role within the group, he gradually regained confidence by sharing his practical knowledge and supporting friends with DIY projects in ways that reflected his current abilities. He remained affectionately known as ‘the practical one’, demonstrating how meaningful roles can be adapted following life-changing injury.
As Ryan’s confidence and independence increased, attention turned towards vocational rehabilitation. A Bush & Co Vocational Case Manager completed a comprehensive vocational assessment to identify realistic employment opportunities that reflected Ryan’s strengths whilst accounting for his ongoing cognitive and physical challenges. Fatigue management formed an important part of this planning, with recommendations including a gradual return to meaningful activity, flexible working hours, regular rest breaks and ongoing monitoring of cognitive endurance. Returning to construction was not considered appropriate due to the physical demands and safety-critical nature of the role, as well as the residual effects of his brain injury. Instead, vocational rehabilitation focused on identifying alternative employment that would allow Ryan to regain purpose, independence and long-term fulfilment.
Ryan and his family also continued to engage with their local Headway branch, where they had developed a valuable network of peer support. Through participation in community activities, vocational rehabilitation and ongoing case management, Ryan was able to rebuild a meaningful and rewarding life despite the lasting impact of his injuries.