Theana Warden is a community matron with the West Suffolk NHS Foundation Trust.
A community matron is an experienced clinician, usually a nurse, who has done additional training. They are an integral part of the multidisciplinary team of health and care professionals who make sure people’s individual needs are met. The matron will liaise with colleagues across many services: community health, acute hospital, general practice and social services as well as voluntary and charitable organisations. The aim of the community matron is to support and enable frail people to retain their independence and remain at home safely if this is at all possible.
Taking a holistic and person-centred approach, they work with patients and their families to ensure the right care provided by the right people is in place to provide the best possible outcome. Referral to the community matron is usually via the patient’s GP, however referrals are also accepted from other health and social care professionals. West Suffolk NHS Foundation Trust has a community matron in each of the six integrated neighbourhood teams (INTs) – Bury Town, Bury Rural, Haverhill, Mildenhall and Brandon, Newmarket and Sudbury.
Here Theana shares the story of one patient – we shall call him G – and how he was cared for in the last weeks of his life through partnership working across organisations including Our Special Friends.
Theana became aware of G and his needs after his GP visited him to give him a flu vaccination, found him living in very difficult circumstances, and so referred him to social services. At the regular multidisciplinary team meeting at the GP surgery, Theana joined up with the social worker to see what could be done to help G and keep the rest of the team involved in his care informed.
Visiting him at home, Theana found G in a poor state physically, mentally and environmentally, with no immediate family and two cats for company. In pain and not really able to take care of himself, G also had problems with his lungs.
Working with the GP, Theana arranged for G to be admitted to the West Suffolk Hospital, with his agreement – while he was there, Our Special Friends cared for his cats. While he was an inpatient, diabetic specialist nurses reviewed his insulin treatment, and arranged for the community nursing team to help him manage that when he was discharged. Sadly, he was diagnosed with cancer while he was in the West Suffolk.
The INT co-ordinator, a colleague who liaises with all those involved in supporting a patient, contacted housing and social services colleagues, and with Theana, managed his housing situation so he could return home. To allow him to be discharged, social services arranged a care package, and once G got used to the idea, he enjoyed the company and the banter with the carers, and looked and felt much better.
With colleagues from the integrated neighbourhood team keeping Theana up to date with G’s health and wellbeing, she was able to devote more time to other patients and their needs. The final update she received was that G had decided he wanted to be back in hospital, and taken himself back to the WSH. The team set up community palliative care for him at home, but sadly, G died in hospital on the day he was due to be discharged.
Theana said, “I am proud to say everyone in every team involved in G’s care did it with the utmost kindness and it was lovely to see the relationships that developed for him. He looked much better on my last visit than my first, even though he was coming to the end of his life.
“I am so proud of the way integrated working delivered the best possible care for this patient: the community health team, housing, social services, GP and the voluntary sector through Our Special Friends. This is a patient and relationships that I developed with my colleagues that I will never forget. There is not a patient – or a day – that we do not learn from and that helps us to improve our service.”
Since G’s death, Our Special Friends has cared for the two cats that were his much-loved companions. Knowing they would be cared for must have been a great comfort to him.
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