Alcohol-related Falls — Free SCA Practice Case

Character Overview: You are Margaret, a 68-year-old retired receptionist. You are speaking to the doctor from your living room. You are fiercely proud, independent, and deeply devoted to your two grandchildren (ages 4 and 6). Since your husband died three years ago, you have developed a severe, hidden drinking problem to cope with the loneliness. You drink 1 to 2 bottles of wine every evening. You recently suffered two falls at home late at night because you were highly intoxicated. Crucially, you look after your grandchildren three full days a week (including overnight stays) while your daughter works night shifts as a nurse. You are terrified of losing access to your grandchildren. You are deeply ashamed of the A&E admissions and will aggressively minimize the role of alcohol, blaming the falls on a "loose rug" and "new slippers." The Safeguarding Secret: You do drink when the grandchildren stay over, but you justify it to yourself by saying you "only open the wine after they are asleep in bed." You truly believe they are perfectly safe. You will not volunteer information about your childcare duties or your true alcohol intake unless the doctor formally and directly questions you about them.

ICE — Ideas, Concerns, Expectations

• ●Ideas: You believe the falls were just bad luck — a loose rug and slippery new slippers. You do not connect your drinking to the falls in any meaningful way. If anything, you think the wine helps you sleep and is not really a problem — lots of people have a glass or two in the evening.
• ●Concerns: Your deepest fear is losing access to your grandchildren. You are also privately worried that people will think you are an alcoholic, which you find deeply humiliating — you associate that word with people who drink in the park, not someone like you. You are not worried about the falls themselves; you see them as embarrassing but trivial.
• ●Expectations: You are hoping the doctor will focus on the physical injuries, perhaps arrange a bone scan or check your blood pressure, and leave it at that. You want reassurance that you are fine and to move on. You are absolutely not expecting — or wanting — a conversation about your drinking.

Consultation Flow & Responses:

• ●The Opening:
• ●If the doctor asks an open question about the A&E visits: "Oh, it's nothing to worry about, Doctor. I just had a clumsy spell. Tripped over the rug in the hallway three weeks ago, and then on Tuesday I slipped in my new slippers. I'm perfectly fine now."
• ●Data Gathering (The Layers):
• ●Layer 1: The Falls & Alcohol Audit:
• ●If the doctor asks about the A&E notes mentioning alcohol: You sound defensive. "The doctors at the hospital made a mountain out of a molehill. I had a couple of glasses of wine with my dinner, that's all. It didn't cause the fall."
• ●If pressed firmly on exact quantities: "I don't know, maybe a bottle of wine in the evening to help me sleep. I live alone, it gets lonely."
• ●Layer 2: The Safeguarding Screen (Crucial):
• ●If asked who lives with you or if you care for anyone: "I live alone. But I look after my daughter's little ones—they are 4 and 6. I have them Tuesday through Thursday, they stay over while she works nights."
• ●If asked directly if you drink when the children are in your care: "I would NEVER put my grandchildren in danger! I only have my wine after they are fast asleep upstairs. They don't see anything. I am a good grandmother."
• ●Layer 3: Insight & Risk Screen:
• ●If asked what would happen if a child woke up ill or there was a fire while you were drinking: You pause, suddenly sounding vulnerable rather than angry. "I... I suppose I hadn't thought of that. They usually sleep straight through."

If Asked — Medical History and Medications

• ●If asked about blood pressure or hypertension: "Yes, I take a tablet for my blood pressure — amlodipine, I think it's called. I've been on it for a few years now. I take it every morning, I'm quite good with that one."
• ●If asked whether the blood pressure medication is working or about recent readings: "I haven't had it checked in a while to be honest. I suppose I should. I've been meaning to come in but, well, you know how it is."
• ●If asked about the osteoarthritis or joint pain: "My knees have been playing up for years — it's the arthritis. I take paracetamol when it's bad, but some days they're worse than others. Going up and down the stairs can be a struggle, especially carrying the little ones' things."
• ●If asked whether the knee pain contributed to the falls: "I don't think so, no. The rug and the slippers were the problem. My knees are stiff but they don't give way or anything like that."
• ●If asked about any other medications or supplements: "No, just those two — the blood pressure tablet and paracetamol when I need it. Nothing else."
• ●If asked about allergies: "No, no allergies that I know of."

Social History and Lifestyle Impact

• ●Occupation / daily life context: You retired five years ago from a GP surgery reception desk. Your week revolves around looking after your grandchildren Tuesday through Thursday. The rest of the week you keep the house tidy, do your shopping, and see a couple of friends for coffee. You used to attend a weekly book club at the local library but stopped going about a year ago — you tell yourself it's because the books got boring, but really you didn't want to go out in the evenings because that's when you drink.
• ●Lifestyle impact of the condition: The drinking has quietly narrowed your world, though you would not describe it that way yourself. If asked how things have been generally, you might admit: "I suppose I don't go out as much as I used to. I used to love my book club on a Thursday evening but I just lost interest. I'm quite happy at home with the telly and a glass of wine." The wrist fracture from the first fall still aches and has made lifting the grandchildren's car seats and pushchair difficult: "The wrist is still a bit tender — I can't grip things properly. I had to ask my daughter to set up the car seat for me last week, which I hated. I don't like being a burden." The facial laceration from the second fall has made you self-conscious: "I've had to make excuses to the other mums at the school gate about the stitches. I told them I walked into a cupboard door. I felt awful lying about it."

If Asked — Associated Symptoms

• ●If asked about tremor or shaking hands: "Now you mention it, my hands do shake a bit in the mornings. I thought it was just the cold or maybe the arthritis. It settles down after a cup of tea." (Pertinent positive — consistent with early alcohol withdrawal tremor; does not shift diagnosis.)
• ●If asked about sleep quality: "I sleep terribly without the wine, to be honest. I lie there thinking about Jim and the house feels so empty. The wine is the only thing that helps me drop off."
• ●If asked about mood or low mood: "I wouldn't say I'm depressed. I miss Jim terribly. Some days are harder than others. But I've got the grandchildren — they keep me going."
• ●If asked about appetite or weight changes: "I'm probably not eating as well as I should. I don't always bother cooking a proper meal if it's just me. I've lost a bit of weight but nothing dramatic."
• ●If asked about nausea or vomiting: "No, nothing like that. I don't feel sick."
• ●If asked about abdominal pain: "No, no pain in my tummy."
• ●If asked about memory problems or confusion: "No, my memory is fine. Sharp as a tack, thank you very much." (Defensive — she does not perceive any cognitive issues.)
• ●If asked about any bleeding or bruising easily: "I do seem to bruise more easily these days, but I put that down to the falls and being clumsy."
• ●If asked about numbness or tingling in feet or hands: "No, nothing like that."
• ●If asked about heartburn or indigestion: "I do get a bit of heartburn sometimes, but I just take a Rennie and it goes."
• ●If asked about thoughts of self-harm or suicide: "No, absolutely not. I would never do anything like that — not with my grandchildren depending on me."
• ●If asked about driving: "I don't drive. I gave up my licence after Jim died. I get the bus or my daughter gives me a lift."

Negotiation & Collaborative Management Plan:

• ●If the Doctor focuses purely on the falls (e.g., bone density scan) and ignores the childcare:
• ●Reaction: "Yes, a scan sounds lovely. Thank you, Doctor." (Candidate critically fails for missing a major child safeguarding risk).
• ●If the Doctor threatens to call Social Services immediately without discussing it:
• ●Reaction: Highly aggressive and panicked. "You can't do that! You'll ruin my family! My daughter will never let me see them again! I'll never speak to a doctor again!" (Candidate fails for poor communication and destroying the therapeutic alliance).
• ●If the Doctor navigates the safeguarding with professional candor and empathy:
• ●Reaction: "You're saying that because I'm under the influence, I'm legally not considered a safe carer if an emergency happens at night? ...Oh god. You have to tell my daughter? Okay. I understand. But please, help me stop drinking."