Cases/Learning Disability

Care Home Staff Reporting Rectal Bleeding in A Non-verbal Man with A Severe Learning Disability — Free SCA Practice Case

Care home staff reporting rectal bleeding in a non-verbal man with a severe learning disability

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Colin Hartley

Age

68 years

Consultation Type

Telephone

Age

Caller's Name

Graham Hartley (Colin's brother, next of kin, and Lasting Power of Attorney for health and finance)

Situation

Telephone Consultation. Graham has booked a call to discuss new health concerns about Colin, raised by the care home.

Reason for Encounter

"I'm calling about my brother Colin. The care home have noticed he's losing weight and there's been blood in his stools. I have power of attorney for his health, and I want to talk through what happens now."

Medical Records (patient)

●PMH: Hypertension. Benign prostatic hyperplasia. Severe learning disability — non-verbal. Autism spectrum condition. Lives in a care home under a Deprivation of Liberty Safeguards (DOLS) order. Lacks mental capacity. Brother (Graham Hartley) holds Lasting Power of Attorney (LPA) for health and welfare, and finance.
●Medications: Ramipril 2.5 mg OD, tamsulosin 400 micrograms OD.
●Allergies: NKDA.
●Recent notes (11 weeks ago): Reviewed after declining annual blood tests on four occasions and becoming distressed/aggressive during attempts. Appeared well but could not tolerate assessment. Blood tests withheld as no imminent risk and clinically stable; to reassess.

Patient Script

For the friend playing the patient role

Character Overview: You are Graham, Colin's brother, next of kin, and holder of Lasting Power of Attorney for his health and finances. You are calm, caring, and deeply protective of Colin. You know him extremely well. You are worried about the new symptoms but you are also very anxious about him being put through anything distressing or invasive — you cared for a close friend through bowel cancer treatment and found the surgery and chemotherapy traumatic to witness. You want to understand what is going on and to be fully involved in decisions.

Opening Sentence: "Thanks for calling, Doctor. It's about my brother Colin. The care home staff have noticed over the last few weeks that he's losing weight — his clothes are hanging off him — and in the last few days the carers have twice seen blood mixed in with his stools. He's had some pain on the left side of his tummy too. As you know, Colin can't speak and doesn't have capacity, and I've got power of attorney for his health."

History if Asked (Data Gathering Phase — gathered via the brother/carers)

●The symptoms: "Over the last two to three weeks he's lost weight — noticeably. In the last three days the carers have seen blood mixed in his stools twice. His stools are sometimes loose, sometimes normal. And he's been holding the left side of his tummy as if it's sore."
●Weight (only if asked): "The care home weighed him — he was 81 kilos three months ago and he's 72 now. That's a big drop."
●How Colin is: "He's not in obvious distress and seems more settled when he's left alone. A nurse tried to examine him but he wouldn't allow it and got upset."
●Family history (only if asked): "Our uncle died of bowel cancer, and an aunt had it too. That's partly why the care home nurse is worried."
●Observations: "The nurse got his blood pressure — 112 over 70 — and pulse 72, a couple of days ago."

ICE — Ideas, Concerns, Expectations

The caller does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Graham is unsure of the cause, but the care home nurse has raised bowel cancer, and the family history worries him. "I don't know what it is, but the nurse mentioned bowel cancer, and with our family history that frightens me."
●Concerns: His dominant concern is that Colin should not be put through anything distressing or invasive — he witnessed a friend's traumatic cancer treatment and cannot bear the thought of Colin going through surgery, chemotherapy, or frightening tests. "I couldn't stand to see Colin put through invasive tests or aggressive treatment that frightens and hurts him. That matters more to me than anything."
●Expectations: He wants to understand what is happening and to be fully involved in deciding what is done. "I want to know what's going on, and I want to be part of every decision — I know Colin best."

If Asked — Symptom and Baseline Detail

The caller answers these only when directly asked.

●If asked about duration and pace of weight loss: "About 9 kilos over three months — quite fast."
●If asked about nature of the bleeding: "Blood mixed in with the stool, seen twice by carers over three days."
●If asked about change in bowel habit: "Sometimes loose, sometimes normal — different from his usual."
●If asked about abdominal pain/mass: "He's been holding his left side. No one's felt a lump, but he won't let anyone examine him properly."
●If asked about anaemia symptoms (tiredness, breathlessness, pallor): "He has seemed more tired and less active lately."
●If asked about his baseline health and function: "Normally he's physically fit and mobile, pottering about the home happily."
●If asked about his ability to tolerate examination/tests: "He gets very distressed and can be aggressive when people try to examine him or take blood — that's why the recent blood tests didn't happen."
●If asked about smoking/alcohol: "He doesn't smoke or drink."

Responses to Management (The Negotiation Phase)

●If the Doctor recognises these are red-flag symptoms needing investigation: "So you do think it needs looking into? I worry that because of his disability people might just... not bother, or assume it's not worth it." (The tested point is taking the red-flag symptoms seriously and not letting the learning disability cause under-investigation — diagnostic overshadowing.)
●If the Doctor proposes a non-invasive first step (FIT test and stool sample): "Would the carers be able to collect that? That sounds like something he could manage without being upset." (The tested point is offering the least-invasive, reasonable-adjustment first step.)
●If the Doctor explains a best-interests process for further investigation: "So if it comes back worrying, who decides what happens? Can I refuse things on his behalf? And could they do a camera test — would they sedate him?" (The tested point is explaining capacity, best interests, the LPA's role, and how invasive investigations would be considered.)
●If the Doctor discusses the possibility of comfort-focused care: "If we decided the tests would do more harm than good for Colin, could we just keep him comfortable instead?"
●If the Doctor offers a home visit / reasonable adjustments: "Would someone be able to come to the home to see him where he's comfortable?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Diagnostic Overshadowing — The Core Risk

●Diagnostic overshadowing is the tendency to attribute new symptoms to a person's learning disability (or mental illness) and so under-investigate treatable or serious conditions.
●People with learning disabilities have worse health outcomes and earlier deaths, partly because of this. Red-flag symptoms must be taken as seriously as for anyone else — the disability is a reason for more support, not less investigation.

Red-Flag Bowel Symptoms and Colorectal Cancer

●Rectal bleeding, unexplained weight loss, change in bowel habit, and abdominal pain are red flags for colorectal cancer, especially with a family history. NICE NG12 guides urgent (2-week-wait) referral.
●FIT (faecal immunochemical test) is used to support referral decisions even when there is rectal bleeding — it detects degraded haemoglobin (from bleeding higher in the bowel), not fresh surface blood. A positive FIT (or ongoing high clinical suspicion) prompts urgent referral.
●Faecal calprotectin should not be used when cancer is suspected — it can be raised in both inflammation and cancer and may cause false reassurance or delay; it is for distinguishing IBD from functional disorders when cancer is not suspected.

The Mental Capacity Act 2005 and Best Interests

●Where an adult lacks capacity for a specific decision, decisions are made in their best interests, using the least restrictive option, involving those close to them and relevant professionals.
●A best-interests meeting (LPA, care staff, GP, learning disability liaison nurse, and relevant specialists) should be convened for significant or invasive investigations/treatment, weighing clinical necessity, benefit, safety, and least distress.

Lasting Power of Attorney and DOLS

●A health and welfare LPA allows the attorney (here, the brother) to make health and care decisions on the person's behalf when they lack capacity — within the scope of the LPA and the best-interests framework. Clarify the type and scope of any LPA.
●A Deprivation of Liberty Safeguards (DOLS) order authorises the care arrangements that deprive the person of liberty in their best interests; it does not, by itself, authorise medical treatment decisions.

Reasonable Adjustments

●Under equality and mental-capacity duties, make reasonable adjustments: home/care-home visits, familiar staff present, carers assisting with non-invasive sample collection (FIT/stool), longer/quieter appointments, learning disability liaison nurses, and desensitisation approaches.
●Invasive investigations (e.g. colonoscopy) may require sedation or general anaesthetic, considered only if necessary, safe, and in the person's best interests.

Balancing Investigation Against Distress

●The aim is a proportionate plan: neither under-investigating (overshadowing) nor forcing distressing procedures regardless of benefit. Where the team and LPA judge that invasive testing/treatment would cause more harm than benefit, a comfort-focused approach may be in the person's best interests — a decision made through the proper process, not by default.

Interim Care and Safety-Netting

●Provide symptom relief (e.g. analgesia) while the pathway is decided, ensure the care home has a clear escalation route, and (if referred) advise recontact if no hospital appointment within 2 weeks.

Common Candidate Mistakes in This Case

●Diagnostic overshadowing: attributing the symptoms to the disability and under-investigating red-flag bowel symptoms — the key failure.
●Misusing investigations: using faecal calprotectin in a suspected-cancer context, or dismissing FIT because there is visible blood.
●Getting the legal framework wrong: ignoring capacity/best interests, or treating the LPA's authority as either absolute or irrelevant.
●All-or-nothing on invasive testing: either forcing distressing procedures regardless of benefit, or ruling everything out because of the disability, rather than a proportionate best-interests process.
●Neglecting reasonable adjustments and the person: proposing an unworkable standard plan, or losing sight of Colin's comfort, dignity, and quality of life.

Free MRCGP SCA practice case for GP registrars covering Care Home Staff Reporting Rectal Bleeding in A Non-verbal Man with A Severe Learning Disability — Learning Disability. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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