Dr Thashangan Murugathas (referrer) and

Dr Gunjan Singh (regular GP)

Crestwood Family Practice

Suite 3, 21–31 Lexington Drive

Bella Vista, NSW 2153

25.08.24

Re: David Best (DOB: 11.03.1968) Extended PTS plan review

Dear Dr Murugathas and Dr Singh,

Thank you for referring David Best under Wentworth Healthcare’s PTS program, for psychological support for low mood, anxiety and PTSD. I write to provide you with a review at the end of this plan.

David attended the first session of this plan on the 29th of March, 2024. He attended fortnightly appointments since that time, with his review being held on the 16th of August. (David had previous referrals to see me between January, 2021 and May, 2022). He would like to request a new referral.

Current presentation and update

At the time of his initial consultation under this plan, Dave reported a deterioration in mental health following multiple biopsychosocial stressors, including:

MVA in January, 2023 where he sustained a right grade 3 open trimalleolar ankle fracture, requiring multiple surgeries and plastics at John Hunter Hospital (from GP referral)

Setback in December 2023 when ankle developed an internal infection requiring IV antibiotics and prolonged courses of oral antibiotics throughout 2024

Recurring infection and increased pain every time antibiotics were stopped

Progressive post-traumatic arthritis to the ankle joint, culminating in suspected permanent disability

Chronic pain management

Anxiety concerning possible amputation of right leg

Significant deterioration in mobility

Social isolation

Loss of employment opportunities

Unsatisfactory resolution of work place injury/workers compensation claim, resulting in Dave having to pay his previous employer $42K

He received an eviction notice for not paying rent whilst in hospital

Financial insecurity

Breakdown in relationship with his two children, Chloe and Craig

Neglected care of his dog and property whilst in hospital

Right shoulder injury (work related) requiring surgery

Prolonged wait for referral to mental health services

Lost his campsite (place of refuge), as managers not wanting a ‘single male’ hanging around

Dental issues and difficulty eating

He arrived to the first session using a walking stick and evidently in pain when ambulating. His right foot angled out to the side and was grossly swollen. He described his mood as “very low” and expressed thoughts of wanting to give up. He stated “I have nothing worth living for; I feel useless; it’s just battle after battle; I have no support; people are running daggers into me; I’m half the person I was; my friends didn’t even visit me in hospital” He reported suicidal ideation, with thoughts to cut his throat. He stated “6 weeks ago, I had had enough; I was crying and had no more fight left in me.” David stated “I have had several "breakdowns", where these thoughts intensified, however his dog, Ghost is a protective factor and he stated "I couldn't do that to her." Dave expressed the feeling of being a victim in many situations, to the point where he felt cursed. He reported low self-worth and hopelessness about his recovery and of ever finding a meaningful purpose in his life with the added impairments stemming from the accident.

Whilst dealing with the aftermath of the MVA, Dave was also impacted by his previous employer and their wanting to close his compensation claim after two-years of legal challenges seeking compensation for a work place injury and the distress encountered. The end result of the case was that David was found guilty of lodging a false claim, which raised feelings of injustice. He had also been required to repay all legal costs, of $45K, with no employment to draw from. His lawyers wanted to continue to pursue the matter, however Dave did not have the funds, so settled out of court.

29.03.24 K10: 40/50 – very high level of psychological distress

Mental health history (brief summary)

David has a background history of adverse childhood events.

He was diagnosed with anxiety and depression in 2011.

Marriage break up 1996 and ongoing emotional difficulties with the mother of his children.

PTSD caused by CSA and witnessing/assisting multiple traumatic events during work with Fire Brigade and MVAs.

David’s previous referrals to me in the past three years were triggered by situational crises in background of psychosocial stressors. These included workplace injuries and his son’s sexual assault and subsequent suicide attempts. Since Dave’s referrals to see me, he has experienced a significant loss of things that give him meaning in his life. His past career has been in the service sector, with the fire brigade, where he felt a valuable part of the community. He has since worked in corrections, which gave him another way to serve the community and have a meaningful purpose. Unfortunately, following his MVA causing total permanent disability, Dave is having to completely reconsider his life and goals. This, combined with a decreasing social support network, has contributed to his deterioration in mental health.

Physical health

MVA in January, 2023 where he sustained a right grade 3 open trimalleolar ankle fracture, requiring multiple surgeries and plastics at John Hunter Hospital (from GP referral)

Setback in December 2023 when ankle developed an internal infection requiring IV antibiotics and prolonged courses of oral antibiotics throughout 2024

Recurring infection and increased pain every time antibiotics were stopped.

Progressive post-traumatic arthritis to the ankle joint, culminating in suspected permanent disability

Chronic pain management

Left shoulder injury, scheduled for surgery on 14th August, 2024 (work cover) was postponed due to NaCl shortage in NSW Health.

In September, 2020, Dave was diagnosed with diabetes, which he considered was brought on by stress.

High cholesterol Lipitor.

LFTs high

In February, 2020 Dave was diagnosed with cancer of the salivary glands and lymph on his right jaw surgical excision.

Supports

Dave lives alone with his dog in a rental property in Windsor. He has a property in Tenterfield, NSW and plans to move there in the near future.

He has been advised that he will be permanently disabled, and unable to return to work. He has come to the realisation that he will have to retire and is coming to terms with that.

He is on Centrelink benefits and is applying for the DSP.

Dave has also applied for NDIS funding to help with domestics, such as cleaning and gardening. He has seen Leanne McCauley at Uniting NDIS, however has been advised he is unlikely to get it.

Dave has two good friends locally and one friend in Tenterfield, Northern NSW.

He has two adult children: Craig resides in Norther NSW and Chloe, resides in Queensland. He is currently estranged from them.

Update

David felt a shift in mood following the first consultation. He reported “moments of feeling OK” and felt more optimistic about his future. He had started doing more to help himself and was picking up some hobbies. He commenced seeing an infection specialist in Bella Vista (Dr Chapman) and pain specialist in Sydney (Dr Jane Standard), which gave him confidence that a solution would be found for his ongoing difficulties with his right ankle. He also had a mate who was helping him.

Unfortunately, psychosocial stressors continued over the past six months. David was impacted by flooding in the Hawkesbury, and frustrated that his rental property had mould issues and damp, with no support from landlords. He also had the arrival of his first grandchild, which he was very excited about. He travelled north to spend time with the new family, however within a short space of time, Dave felt pushed out of the ‘inner circle’, triggering feelings of disappointment, ‘heart break’, and of being unwanted. This has continued to impact Dave emotionally over the last few months and he has responded by estranging himself from them so as not to be hurt again.

A range of psychotherapeutic tools have been utilised to explore Dave’s emotional triggers, responses, and underlying causes (adverse childhood and life events) and Dave is developing awareness and insight about these. The next stage of work is to use this insight to start to find new ways of thinking and responding to psychological stressors, but this will take time.

At the time of his review, Dave reported an improvement in his right ankle. The infection appeared to have settled and the antibiotics stopped. His mobility had also improved, however he was complaining of joint pain in elbows and knees and questioned if this was related to cessation of antibiotics. I recommended that he follow up with his GPs.

We discussed care needs for the immediate post-operative period. I suggested a referral to Pink Finss cancer charity for additional supports if required and contacted Kym to see if Dave meets their intake criteria. I will provide the outcome to Dave once I have spoken with Kym.

29.03.24 K10 score: 40/50

16.08.24 K10 score: 39/50

Formulation

56 year old unemployed man, living alone in rental property, with a history of CPTSD, presenting with anxiety and depression, in background of complex psychosocial stressors, including work-related trauma and adverse childhood events.

Impression

Trauma disorder

Low mood

Lack of meaningful purpose

Social isolation

Impact of MVA

Plan

Dave would like to continue sessions with me. I believe he has used up all the Wentworth Healthcare Extended care plans available to him. Should there be no other PTS plans available, the other option is for David to be referred to see me under a Mental Health Nurse Incentive Programme plan (MHNIP)

Continue 2 – 4 weekly sessions.

Monitor mood and mental health.

Therapeutic intervention as needed.

Yours sincerely,

Michelle Hookham