Staff Nurse - when I phone you and say "I am the OT for your patient Mr X's son. I am not working with Mr X but I am aware that he is in your ward having surgery to remove a cancerous tumour. He is the main carer for his son who has a severe progressive neurological condition and he finds this very stressful. I am only dealing with the bathroom adaptation for the son, but I know that Mr X wil require a lot of help when he first comes home. He is likely to tell you he can manage, but the reality is he was struggling to manage before the surgery, let alone now. Please do not send him home without referring him to the hospital discharge team for community follow up as he will not cope," that is what I mean.
I do not mean send him home the same day I phoned you without referring him on, and without even notifying me. I was not pleased today to get a frantic phonecall from his daughter telling me he came home about an hour after I spoke to you, is in a lot of pain, and can't get out of his chair, let alone care for his son.