Case study: learning disability assessment for ‘Lizzy’

Client demographics: White British Female, mid-40’s

Housing status: Hostel accommodation with inconsistent use and periods of rough sleeping

Reason for referral: Query Learning Disability

January 2024


Lizzy (pseudonym) was referred to Pathways in October 2022 with a request for support with sustaining accommodation, and linking with mental and physical health services. Intensive Support Worker was assigned and began supporting Lizzy with managing accommodation, finances, and other life skills, as well as seeking put from social services.

Systems Navigator reviewed social services involvement and found:

  • In 2017 there was a capacity & best interests assessment in relation to something else, and she was found not to have capacity to safely assess those decisions.
  • In 2018 there was a Supported Self Assessment which states Lizzy has a mild learning disability and poor short-term memory. It states Lizzy needs ongoing prompting and support in every aspect.
  • Social Worker had been involved until 2021, recommending supported living, however this has not happened and Lizzy was ultimately closed due to non-engagement.
  • A safeguarding referral was reported in November 2022 due to self-neglect and requiring additional support. Unclear as to whether this was actioned

Intensive Support Worker actioned a Careline referral, and continued to advocate for Lizzy to receive a Social Work assessment. It took some time, but Social Services reported that there was no learning disability, no need for onward referrals and no action due to previous non-engagement. Intensive Support Worker continued to advocate, worked very intensively with Lizzy, and was able to convince Social Services to conduct a new assessment, however there continued to be a disparity between Social Services appraisal of needs, compared to that of the accommodation provider, and also the intensive Support Worker who reported:

“What I’ve seen is that Lizzy seems unable to fully engage with conversations, you will be speaking to her about something and she will respond about something completely different, and just doesn’t really seem to be taking anything in. She doesn’t refer to anything that’s not there or seem to be experiencing any psychosis / hallucinations or anything of that type which is why it seems potentially more cognitive.

One example of this is where she currently lives is only a 6 – 8 week stay hostel which has been told many, many times but when you speak to her about moving she basically says why would I be thinking about moving I’ve only been here about 6 weeks. I’ve had this same conversation with her about 4 or 5 times.

Also another worker who now works at Whitechapel used to work with Lizzy 2 -3 years ago, and she says she has definitely noticed a decline compared to 2 – 3 years ago, possibly suggesting some kind of brain injury since then.”

NeuroTriage input

After contributing to multiple discussions and informal advice in Pathways team meetings, NeuroTriage was asked to assess Lizzy for Learning Disability. The following is directly quoted from a letter to the Intensive Support Worker and Social Worker allocated following the Careline referral:

I appreciate your patience in waiting for me to be able to complete a brief neuropsychological screening assessment with Lizzy. As you know it has taken a long time due to non-attendance. It took seven attempts, and a number of additional efforts from the Intensive Support Worker checking to see if she was present at the hostel before me calling over. This is in large part due to Lizzy’s struggles coping with life, and understandably she was unable to prioritise a neuropsychological assessment. As you’ll recall, we met Lizzy together outside a café in town, and managed to confirm a few things remotely in the meantime, so this assessment was really just a brief screening to see if we could gain a better profile of her cognitive functioning. I am pleased to be able to say that when I met her, she had been up from bed for a little while, had had a coffee, and was in her best physical and emotional state, so the assessment can be considered an accurate picture of her current optimal cognitive functioning.

There has in the recent past been a query about Learning Disability, so I hope I can help here. I can confirm that Lizzy does have a Learning Disability. In order to have a Learning Disability, the following criteria must be met: IQ below 70, significant impairment in social or behavioural functioning, childhood onset. Lizzy meets all these criteria.

Lizzy was diagnosed with Learning Disability in childhood and went to a school for children with special educational needs. This school has since been closed due to widespread abuse of children, leading to convictions reported int eh media, which was taking place during the time Lizzy would have been attending.

With respect to IQ, my assessment shows her has having an IQ scaled score of 48; well below the boundary of 70 to meet Learning Disability criteria. This is consistent with Lizzy’s interaction style and presentation.

There are other patterns in Lizzy’s performance during assessment which are consistent with common profiles seen in people with a learning disability. Lizzy tended to persist with incorrect patterns of responses even if they were unsuccessful, she found it very hard to shift her approach, even with a little bit of guidance. She found it extremely hard to follow anything but the simplest of instructions, and performed significantly better when instructions were very straight forward. For example, she could repeat small threads of numbers back to me, but found it extremely hard to do a coding exercise where she had to match a symbol with a number.

I am in no doubt whatsoever that Lizzy DOES HAVE A LEARNING DISABILITY and any failure to acknowledge this is a failure in seeing Lizzy’s needs and associated vulnerabilities.

It is Lizzy’s vulnerabilities that led to the request for this assessment. The Intensive Support Worker previously sent examples of this such as:

  • Whilst in Lizzy’s room there was an extremely strong smell of urine, the smell was permutating out onto the landing also.  The smell was coming from Lizzy’s clothing and also from Lizzy & the bedding on the bed.  One of my colleagues informed me that Lizzy seems to be both wetting and soiling herself in her clothes and is not washing.  Other residents have apparently commented about Lizzy’s hygiene.
  • Last time we went to count her vouchers she had 7 vouchers, 5 for £100, one for £95 and one for £96 and was not able to count even the £100 vouchers. The time before this she left the counter at the post office £100 short and I had to bring this to her attention or I’m sure she would’ve left £100 short without realising. I also supported her at CEX to get a phone charger and she was unable to present the right money (the charger was £10.99 she gave I think £10.35) when the shop assistant tried to resolve this with her she just looked at him blankly as though she did not understand. I had to guide her to get a £1 coin which took quite a long time due to Lizzy’s confusion around this.
  • The last time I supported her (at the post office) the cashier originally gave her £100 less than she was due by accident, which Lizzy didn’t pick up on. I supported her to rectify this but there’s no way she would have realised this if she was on her own as it took time to register even after I’d pointed it out.

We can see from these three examples, and there are many others, that Lizzy’s ability to self-care are very low, and her financial capacity should be questioned.

I am extremely concerned about Lizzy’s vulnerability. We have a responsibility to ensure she has support in line with her complex needs. This includes the importance of ensuring she is accommodated and supported in an environment for people with the level of learning disability she has.

Lizzy’s IQ, memory and language all lie below the first percentile, placing her in at least the moderate learning disability range. Her attention and visuo-spatial skills are slightly higher, but still put her below the fifth percentile.

I would be happy to be involved in any MDT, care planning meeting, or review for Lizzy, and I hope this assessment is useful.

Outcome and reflections

Whilst there were many unsuccessful attempts to engage Lizzy, persistence proved to be worthwhile, as The Intensive Support Worker, Assigned Social Worker, and NeuroTriage continued to show commitment to this vulnerable person, and changed the way the systems around her viewed her needs.

It was agreed that Lizzy does have a learning disability, lacks capacity to manage finances and has significant support needs relating to mental health, physical health, and daily living skills. Prior to the assessment from NeuroTriage, Social Work Management had declined all three of these very important areas of need.

The advocacy and collaboration between the three key professionals have now ensured that Lizzy’s needs are acknowledged and an appropriate referral made to a new form of accommodation that has the potential to meet her needs. At the point of writing, Lizzy is awaiting assessment from the service. Should she be accepted, it is likely that she will then be closed to Pathways, but NeuroTriage will remain available to support the accommodation provider and have already had initial conversations offering:

  • Support with initial assessment of needs
  • Staff training
  • Ad hoc consultation if required