Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Headway Cornwall (H31)

Services for the Management of Traumatic Brain Injury in Cornwall



  The Evolution of the Cornwall Brain Injury Services

    Hosptial in-patient Services

    Community Services

    Headway Cornwall

    Cornwall Social Services

    Nursing Homes

  Health Authority Initiative

  Alternative Funding from:

    Research and Education

    Local Charities

    European Social Fund

  Provision from the RCH Trust

  Posts that have been lost due to lack of funds:

  Posts that have been disestablished:

  Facilities Closed:

  Loss of Community Rehabilitation Teams



  Appendix 1

  Appendix 2

  Appendix 3

  Appendix 4

  Appendix 5


  The present situation in Cornwall in 2001 is that the services for people who have suffered brain injury are patchy and inadequate, very much as they were in 1983. The purpose of this memorandum, produced by Headway Cornwall, is to show that there had been a much more comprehensive service, which developed and flourished until about 1997, which has now disintegrated and run down through lack of funding and direction. If the draft report commissioned by the Cornwall Health Authority and Social Services in 1997 were implemented now it could start the restoration of a credible service.


  Earlier demographic studies suggested that about 1,500 patients suffer TBI in Cornwall each year. The figures produced during the National Traumatic Brain Injury Survey v.i. showed there were 4,700 patients who went through one or other of the two A & E Departments in Cornwall between March 1993 and the end of November 1996. This represents about 1,700 new attendances annually. Of these, 50 had very severe injury, 45 had severe injury, and 110 moderate. The remaining 4,497 were mild (definitions at Appendix 1). Other studies show that 30 per cent of patients recorded as having mild or moderate TBI may have cognitive and executive problems severe enough to keep them off work for more than three months. Most patients with TBI are young, 1995 of the Cornish cohort were under 25. Two thirds were male.

  These figures substantiate the view that though there is a low incidence of new severe and very severe cases, they are mostly young, survive the initial danger period and then have a lifelong disability and handicap with a normal life expectancy. Therefore there is a growing prevalence of survivors with the long term effects of severe TBI. This has a major and growing impact on their families and the community services and is a perceived unmet need. There is also a much larger group with milder, but still significant injury, often left to find their own way, and many fail. This pattern is not likely to have changed recently and is another unmet need.


Hospital in-patient Services

  The development of the hospital brain injury services started in approximately 1983 when Marie Therese House (MTH), a Young Disabled Unit in Hayle was opened and the Cornwall Stroke and Rehabilitation Unit (CSRU) developed in Tehidy Hospital, Camborne. Both Units had a remit that included managing the effects of traumatic brain injury (TBI). Even in 1986, 20 patients with severe or very severe TBI were being admitted annually through the Intensive Treatment Unit (ITU) to the CSRU. The operational policy of the CSRU was maintained when it moved to the City Hospital in Truro and the links with the ITU at Treliske were strengthened.

  The cohesion of the Service was greatly enhanced by the appointment of a Liaison Nurse between 1992 and 1997. At that time the staffing on the CSRU included specialised Nursing and Medical staff, Specialist Social Worker, two Physiotherapists, two Occupational Therapists (OT), Speech and Language Therapist, Art Therapist, and regular visits by an Optometrist and Dietician. The Senior Clinical Neuro-psychologist worked from the same building and the assistant Clinical Psychologists worked between CSRU and MTH.

Community Services

  By 1987 the concept of Community Rehabilitation Teams (CRTs) had developed in Cornwall, and been published[3][4]. These teams integrated the work of Social Services and the Health Authority personnel and were coterminous with Social Service areas. They dealt with the consequences of TBI as well as disabling conditions such as Stroke, Multiple Sclerosis and Paraplegia, especially in the younger population.

  In 1992 there were two more OTs and four more part time Physiotherapists (PatH) based in the community and closely linked with both the CSRU, MTH and the CRTs. Throughout this time the CRT co-ordinated the work between Social Services and Health Authority. This work was also published[5].

Headway Cornwall

  Headway Cornwall was originally based at Tehidy Hospital. It has moved to St Austell in the grounds of a school. In April 2000 the unit was severely damaged by an arson attack and it has now opened at a Leisure Centre in Lostwithiel where at this stage of its development it is only able to offer a minimal, though important, social rehabilitation centre. It is open two days a week, but is difficult to get to for clients living in mid and West Cornwall.

Cornwall Social Services

  Social Services ran Kerensa, a Unit in St Austell, which provided vocational rehabilitation from an excellent workshop complex, and also respite and residential care as well as being a base for community support. This has now closed. Although small satellite centres have been opened they have little experience in dealing with TBI and no specialist staff.

Nurisng Homes

  There were, and still are, some Nursing Homes, notably the Cheshire Home in Marazion, Kenwyn in Truro and Fairholme in Camborne who take younger patients with TBI but this is not always appropriate as the Rehabilitation input is small and most residents old.


  The Cornwall and Isles of Scilly Health Authority employed Sheila Coia, to assess the situation and to make recommendations. She assessed the situation in 1997 and produced a practical draft report. She included a list of the facilities for TBI available then. (annex 2). The final version of the report has not been seen by Headway but the report was submitted to the Health Authority and Social Services. It has not been implemented.


Research and Education

  In 1992 Mark Sansom, an OT was appointed as Research Worker at MTH to study the long-term consequences of TBI. It was funded by the Nuffield Provincial Hospitals Trust. In 1994 he prepared a paper[6] describing an outcome study of patients with severe TBI and comparing them with an earlier cohort from the Armed Forces. He specifically looked at the stress on carers as well as on the patients. (Summary at annex 3).

  In 1994, a further grant was obtained through the European Social Fund (ESF) to develop the Horizon project in which educational resources for survivors of TBI were developed in Cornwall through the Open Learning Centres in conjunction with the rehabilitation services. Mark Sansom, again supported by Nuffield Provincial Hospital Trust looked at the effects of this initiative. He found that patients using the facilities offered through the Open Learning Centres did better than those who did not, and there was less stress perceived by their carers. [7](Summary at annex 4).

  Between 1992 and 1997 the Department of Health undertook the National Traumatic Brain Injury Survey (NTBIS). Twelve units in England and Wales were chosen out of over 80 applicants and were given extra funding in order to develop their service. The Cornwall Stroke and Rehabilitation Unit, in association with the Intensive Treatment Unit, were successful in this bid and, as a consequence, were able to appoint a Nurse co-ordinator, two assistant Clinical Psychologists and secretarial support for the principal Clinical Neuro-psychologist. These latter posts were at the Stroke and Rehabilitation Unit at the City Hospital. The nurse co-ordinator covered all the new admissions through West Cornwall Hospital and The Royal Cornwall Hospital Treliske, and Cornish patients who had been seen in Derriford Hospital, Plymouth, assessed them and ensured that they were managed appropriately. (Summary at annex 5).

Local Charities

  A local charitable trust funded the four part-time Physiotherapists in the community (PatH) for several years. This service was ultimately taken over and funded by the Health Authority.

  The Art Therapist post was funded for three years and a community OT were funded by the same charitable trust also for three years, but these four full time posts were not extended.

European Social Fund

  The European Social Fund had funded one Community OT through the Horizon project. For a time this post lapsed, but it now may be filled with money from the Guide Project, which succeeds the Horizon project. This will be one facility in the community available for people with TBI, though it is not now exclusively for the group but by anybody with a disability, and only a few people with TBI are now on the project.


  Pheonix ward (successor to the CSRU) together with the core of therapists were, and remain, the responsibility of the Royal Cornwall Hospital, now a Trust. Marie Therese House was run privately, but is now also part of the Royal Cornwall Hospital Trust. Marie Therese House continues to provide day care and assessment for patients in its area in the Southwest tip of Cornwall. They include some patients with TBI.

  Posts that have been lost due to lack of funds:

  Head Injury Liaison Nurse

  2 Assistant Clinical Psychologists

  1 Community Occupational Therapist

  Art Therapist

  Posts that have been disestablished:

  Specialised Social Worker (as part of the withdrawal of all Social Workers in the hospitals.)

  Posts difficult to fill: Clinical Neuro-psychologists

  Facilities Closed: Kerensa.

  Community Rehabilitation Teams survive in only two places; Kerrier in mid-Cornwall and Liskeard in the North.


  The consequences of TBI have never been given sufficient priority by Social Services, Health Authority or Trusts. All the service developments that took place were funded either by research grants, charitable donations or the European Social Fund. There is an urgent need to restore and develop the service. At the moment, although there is a committee that has been set up, no funds have been allocated or plans being made as far as Headway can find out.


  Re-examine the joint research sponsored by the Health Authority.

    —  Appoint a Head Injury Liaison Nurse.

    —  Restore the Clinical Neuropsychology Service, for mild as well as severe TBI.

    —  Develop the concept of Case Management, from acute care into the Community to provide an integrated service.

    —  Look at links with employment and developing the Guide project.

    —  Identify other activities for those who may be unemployable.

    —  Re-establish Community Rehabilitation Teams, or an equivalent integrating service.

  Examine the reports from Mark Sansom to identify unmet needs.

Annex 1


  Some of these definitions are derived from a report from the Working Party of the British Society of Rehabilitation Medicine (BSRM). This was first published in 1988 (McLellan 1988) and second edition in 1998. (McLellan 1998).

Traumatic brain injury (TBI)

  "Diffuse damage to the brain caused by trauma to the head including the effects of the immediate consequences of trauma such as lack of oxygen or low blood pressure. This definition includes collapse during anaesthesia or after cardiac arrest".

Diffuse acquired brain injury

  "Diffuse damage to the brain caused by a wide range of medical conditions including such as encephalitis, acute oxygen lack, subarachnoid haemorrhage and toxic encephalopathy.


  In earlier studies the definition of unconsciousness by Plum and Posner (1972) was "when communication returns to better than "yes" or "no" allowing for local impedimenta (eg tracheostomy, jaw injury)".

  More recently unconsciousness is defined as when "the level of consciousness scores 9 or less on the Glasgow Coma Score (GCS)". The GCS has become accepted as the standard measurement and is in use throughout the world.

Post-traumatic amnesia

  "The time between the injury and the restoration of continuous day to day memory is re-established". This is different from the first remembered event or "islands" and it implies the ability to acquire and retain new information. It is difficult to apply universally because some sequelae of head injury may mean that memory never returns to what it was before, but it would not be likely that post-traumatic amnesia (PTA) was an indefinite event.

Minor (Mild) brain injury

  "An injury causing unconsciousness of 15 minutes or less or post-traumatic amnesia for less than six hours and a GCS after original resuscitation of 13-15". This group is often neglected as though most get better, a significant percentage have problems after six months and help for this group to prevent unnecessary loss of work should be available.

Moderate brain injury

  "An injury causing unconsciousness for more than 15 minutes, (but less than six hours) and a GCS, after initial resuscitation, of 9-12". The older definition adds "or a post-traumatic amnesia of between 6 and 24 hours".

Severe brain injury

  "An injury causing unconsciousness for more than six hours, but less than two days and a GCS, after initial resuscitation of 3-8". The older definition includes "or a post-traumatic amnesia for more than 24 hours, but less than a week" (but see above for contemporary difficulties in definition).

Very severe brain injury

  "An injury causing unconsciousness of more than 48 hours or a post-traumatic amnesia of more than seven days."

Permanent (Persistent) vegetative state

  "A profound form of brain damage where the patient although having a sleep-awake pattern responds only in a reflex way and shows no evidence of meaningful response to the environment".

Annex 2

Extract from Provisional Report by Sheila Coia on the Joint Health and Social Services Strategy for People Suffering from Traumatic Brain Injury. 1997

  "A framework of services for the head injured already exists in Cornwall. Briefly, this comprises:

  GP surgeries; relatively few TBI sufferers present at their GP surgery in the first instance, and, for obvious reasons, these tend to be the minor cases. GPs will often advise attendance at A&E if they believe the patient would benefit from further assessment and investigations.

  Accident and Emergency Departments; these exist at Treliske, West Cornwall and Derriford Hospitals.

  Rehabilitation Units; the major centre is at City Hospital, Truro, which provides treatment on both an in-patient and day-care basis. The CSRU (Stroke and Rehabilitation Unit) has a total of 16 beds, of which an average of three are occupied by TBI patients. There is also a monthly head injury clinic for patients referred by their GP or for follow-up and monitoring of patients who have previously been under the care of the Consultant in Rehabilitation Medicine.

  In addition, Marie-Therese House provides in-patient and day care services at Hayle, as well as respite care. The Rowans, in Plymouth, provides services similar to those at Marie-Therese House. St Teresa's, the Leonard Cheshire Home at Long Rock, provides rehabilitation services although, at present, they have relatively few TBI cases; there are plans to develop these services. The Brain Injury Rehabilitation Trust (BIRT) are preparing to establish a specialist rehabilitation long stay unit in Devon. (now open)

  Voluntary sector; the only specialist voluntary sector provider for this group of patients is Headway Cornwall. The small centre, based in Lostwithiel, is open two day a week and provides recreational activities, some learning activities, social activity and day respite for carers. This is a much valued service which is limited by its location, and by funds, in what it can provide.

  Community services; community hospitals provide some rehabilitation services but there is a shortage of specialist physiotherapists. People suffering from TBI require the services of Neuro-physiotherapists, rather than (or as well as) the more readily available musculo-skeletal physiotherapists. Neuro-psychology services are provided by Cornwall Healthcare Trust; these services are at present significantly stretched.

  Nursing homes; a small number of patients are discharged into nursing homes from acute care at City Hospital. There is a widespread view that such placements are not always appropriate, given the relative youth of most TBI victims, and that were more short-term in-patient rehabilitation services available at community hospitals, this would benefit patients significantly.

  Social Services; Social Services provide personal and domestic care in the home, support for carers and some day care facilities. The contribution social workers are able to make increases as patients move from acute to community care and their aim will be to provide close supervision in community settings, focussing on enhancing the quality and productivity of life. Discharge planning into the community from City Hospital takes place with the resident social worker, an essential member of the rehabilitation team. It is important that this post continues to be funded. Social Services also provide some occupational therapy support to patients in the community."

Annex 4

Development and Evaluation of Educational Resources for Survivors of Head Injury

  Thirty three survivors of severe head injury, and 20 people with other acquired brain damage enrolled in a special programme of adult education designed to meet their individual learning needs. They were followed up 18 to 24 months later with postal questionnaires to measure functional, health and psycho-social status. Comparisons were made with a control group of 66 severely head injured people who did not enrol on the programme. Twenty one survivors of severe head injury and 15 people with acquired brain damage who had participated in the education programme returned questionnaires. 62 people in the control group returned questionnaires.

  At the time of starting educational programmes, three head injured survivors were employed, seven in training and education and 11 were unemployed or incapacitated. At follow-up, five people were employed, ten in training and education and six remained unemployed or incapacitated. The general health and psycho-social status of the participants had improved at follow-up. In comparison the control group had generally deteriorated in functional, psycho-social and general health status. When comparisons were made between unemployed or incapacitated participants in the educational programme and controls, statistically significant differences were reported. Participants (n=11) had significantly reduced pain, and improved mental health and general health status, and were more assertive than non-participants. Unemployed or incapacitated controls (n=23) had deteriorated in their general health and psycho-social status. There were no significant differences between participants and controls at the beginning of the study.

  Although the population for the study was limited in size, there is preliminary evidence that educational programmes for survivors of head injury improve "quality of life" in areas of general health and psycho-social status. The study also revealed that for survivors of severe head injury who do not return to their former employed status, "quality of life" continues to deteriorate for many years.

Annex 5

Cornwall Head Injury Research for the NTBIS

  Cornwall was one of 12 sites in England and Wales chosen to be part of the National Traumatic Brain Injury Survey. This was a study, sponsored and funded by the Department of Health, and managed by the school of Business Studies of the University of Warwick. Its first aim was to define centres, which could carry out specific tasks in the management and organisation of brain injury. There were two main tasks for the Cornwall sites.

  1.  To make an epidemiological study of all the patients who were admitted through Casualty Departments with a diagnosis of traumatic brain injury. Over 4,700 patients were seen and screened.

  2.  To evaluate the advantages of having a quick referral system between the Intensive Treatment Unit and the rehabilitation ward; attempting to by-pass wherever possible the need to go on to an intermediary ward after leaving the ITU service.

  The Departments directly involved with this service were the ITU as well as the Cornwall Stroke and Rehabilitation Unit. Liaison with Warwick University was primarily through John Stillwell and Carol Hawley.

  In order to facilitate the work five members of staff were recruited. The first was Mrs B Holmes who was in charge of the Neuropsychology Department and came on to the study part-time, and two trainee clinical psychologists under her supervision. The final member of staff recruited was Mrs L Berriman who was the Liaison Nurse linking with the A&E Departments. She was responsible for locating all the patients and recording them. Her work was written up and presented to the Department of Health.

  The Clinical Psychology Department additionally undertook a study in which patients who self-selected received further advice about the implications and the consequences of minor brain injury and who were reviewed to see whether their outcomes differed. This study data is available but has not been analysed.

3   Evans C D, 1987, Rehabilitation of head injury in a rural community. Clinical Rehabilitation 1 133-137. Back

4   Evans CD and Skidmore B, 1989, Rehabilitation in the Community (Chapter). Models of Brain Injury Rehabilitation (Wood & Eames eds). Chapman & Hall, London. Back

5   Evans C D, 1995, Developing Rehabilitation in the Community (Chapter), Traumatic Brain Injury Rehabilitation. Services, Treatments and Outcomes. (Chamberlain, Neumann and Tennant eds.) Chapman & Hall, London. Back

6   Sansom M and Williams M, 1994 The Cornwall Head Injury Research Project Nuffield Provincial Hospitals Trust, London. Back

7   Sansom M and Williams M, 1995, The Development and Evaluation of Educational Resources for Survivors of Head Injury. Nuffield Provincial Hospitals Trust, London. Back

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