When David retired from his job as a mechanic, he lived life to the full at his home in the South Hams in Devon.
He restored classic cars and travelled around Europe, he loved fishing and would go to the gym five times a week. He could even do a yoga headstand well into his seventies.
His daughter Jo, who is a retired nurse, admits it was a shock to notice he started to be forgetful when she would visit.
She recalls: “He wasn’t really looking after himself that well with things like eating and drinking, and we noticed changes in his memory. He would get confused about the time. For example, he would think it was six o’clock in the evening, when it was six o’clock in the morning. Neighbours would call us to say he was wandering around outside at funny times.
“We finally got an appointment at the memory clinic and the Psychiatrist diagnosed dementia there and then.”
Jo and father David
David continued to live at home with support from carers, but in November 2024, he was admitted to Derriford Hospital after collapsing on his way to the local shop. He had an infection and delirium which is a state of mental confusion that starts suddenly and is caused by a physical condition of some sort.
This is where he came under the care of Livewell Southwest’s ‘Transitions of Care’ Admiral Nurses.
Emma Hughes and Tracy Browne have been supporting the wards at Derriford Hospital since 2022.
Admiral Nurses Emma Hughes and Tracy Browne
People living with dementia can experience longer hospital stays, delays in leaving hospital, high risk of complications and a decline in their general wellbeing. The role of the Admiral Nurse is to support not only the care of patients, but also the carer, to improve the quality and experience of their eventual transition away from hospital.
There are an estimated 6,400 people living with dementia across Plymouth, the South Hams and West Devon. Emma and Tracy work with nearly 170 care homes across their patch, although home first is always the preferred option.
Emma remembers: “When I first met David, he was very poorly. People with dementia are particularly susceptible to delirium, which meant he was extremely confused, over and above what he would normally be.
“I always see the families and us are a team to get the best outcome for the person who has got dementia. There are a lot of very big decisions to make. In those circumstances, we have got the privilege of being able to be alongside families, really find out the in-depth history of how things were before they came to hospital and help families to make decisions in the person’s best interests.”
Emma and Tracy’s roles are funded by Livewell Southwest and Dementia UK to
- work with family carers on admission to hospital to do a person-centred needs assessment to inform discharge planning and appropriate placement matching
- work with ward staff to manage distressed behaviours and help prevent further deterioration and deconditioning
- promote the least restrictive discharge option, supporting a return to home wherever possible
- enable the acceptance of care home placements for people with dementia with the most complex needs by sharing information across care
- provide intensive post-discharge support in people’s own homes or care homes over a six-week period
- coordinate care across settings, guiding families through complex systems and processes and reducing distress
A study by Dementia UK shows the Admiral Nurses working at University Hospitals Plymouth are
- reducing the number of hospital readmissions
- ensuring more people are discharged from hospital within 48 hours of being referred to the Admiral Nurse
- increasing the number of people being discharged to their own home
- supporting more care homes to manage people with complex needs
Jo says Emma’s support in hospital was invaluable. “Emma just came like a vision in a way, just at the end of dad’s bed and introduced herself. I just thought ‘Oh hallelujah’, we’ve got somebody here to help us, to guide us, to support us and to be dad’s advocate in hospital, as well as us being his advocate. She was just an absolute godsend.”
83-year-old David now lives in a care home in Plymouth, which specialises in caring for people with dementia. This was chosen by David and his family after working with Emma.
Jo said: “We were struggling to do the right thing for dad because it is a role reversal. He was always our person to go to for advice and guidance, and then we were sort of having to step into that role. I cannot thank them enough for what they have done for us, and unfortunately, I suspect might do for us in the future.”
Admiral Nurses also offer continuous specialist support for people caring for loved ones with dementia.
Chrissie Milward works as an Admiral Nurse in around Tavistock in West Devon. The role is a collaboration between NHS Devon, Livewell Southwest and Dementia UK.
Admiral Nurse Chrissie Milward
She works alongside colleagues in the Tavistock Healthy Ageing Team which includes a Frailty Nurse, Long Term Conditions Matron, Health Care Assistant and Administrator.
Chrissie said: “My role is community-focussed. I support people with dementia, but primarily their carers and loved ones. Being a community Admiral Nurse, I attend Memory Café sessions and dementia awareness events – I even go to cattle markets to speak to farmers living in very rural areas, to let them know that support is there. I also share Dementia UK best practice with my wider Livewell colleagues supporting people with dementia and carers and care homes.
“There is no typical day being an Admiral Nurse in West Devon – it is such a varied role. The best part is being able to make a connection with people and being allowed into their lives, hopefully making a difference, at their most vulnerable or challenging times. I am so lucky to be able to be the nurse I have always wanted to be, as the role is truly person-centred and led by the person with dementia and carer/loved one.”
Rachel Johnstone, Regional Account Manager at Dementia UK said: “One in two of us will be affected by dementia in our lifetime – either by caring for someone with the condition, developing it ourselves, or both. It can be exhausting and overwhelming, not only for the person with dementia, but also for the people caring for them, and their wider family and friends.”
“Unpaid carers are the backbone of dementia care but they need specialist support so that they are not left to cope alone. Admiral Nurses are there when people need them most, providing health advice, offering compassionate emotional and psychological support, and helping families with the most complex needs plan for the future.”
