Chris Deacon, a partner in the Aviation and International Injury department, chaired a panel discussion with leading clinicians on the issues arising in international injury and major trauma on 21 November 2023. We review the panel discussion here; the full video is available below.

Chris was joined by Dr Jan Gawronski, consultant and clinical lead in spinal cord injury rehabilitation at the London Spinal Cord Injury Centre, Dr Kudret Yelden, consultant in rehabilitation medicine at King’s College Hospital in London, and Dr Matthew Henley, consultant anaesthetist at the Royal National Orthopaedic Hospital and divisional clinical director for the surgery and cancer division.

The panel reflected on the many cases they have dealt with where there have been added challenges in accessing rehabilitation and with the repatriation and discharge process where the case has an international element. Opening the discussion, Chris noted that these complexities can arise for UK nationals who are critically injured overseas, but also for overseas visitors who are critically injured when visiting the UK.

The discussion focused on three key stages following international major trauma:

1. Immediate concerns with international patients following traumatic injury

This includes repatriation to the patient’s home country and the dilemma of whether a patient should remain overseas for a prolonged period to enjoy more advanced specialist rehabilitation input or be airlifted to their home country as soon as they are medically stable.

Dr Gawronski noted that patients injured in most European countries, Australia or New Zealand would be well advised to remain in hospital as long as possible to maximise their rehabilitation opportunities, because their problems are in some ways only starting when they return to the UK. Chris observed, however, that one of the driving forces behind the decision-making is usually funding, particularly where a travel insurer is involved in arranging and paying for the patient’s repatriation. The panel reflected on whether funding pressures can create the potential for poor decision-making that may not be in the patient’s best interests.

2. Admissions and rehabilitation following the acute phase of treatment

One of the biggest challenges identified in relation to rehabilitation following the acute phase of treatment was patient and family expectations around what the NHS knows about their situation before they arrive at a rehabilitation unit. It was noted that for a spinal cord injury rehabilitation admission, it is likely to be approximately 12 weeks from referral to admission. There is also a risk that a patient returning to the UK from overseas will not have been properly referred into the system and may go to the “back of the list”, further delaying their recovery.

Another issue the panel identified is infection control, which is particularly prevalent where a patient has been airlifted from overseas because of the various places they will travel through on the way. This will include the foreign hospital, the air ambulance, ground transportation and possibly even a stop-over at another medical facility on route. Dr Gawronski and Dr Henley both commented on how there is a good chance the patient will have picked up an infection along the way. NHS infection control may consider this risky and requires a side room or isolation, dramatically worsening the patient’s mental state and access to NHS rehabilitation services.

Dr Henley added that patients with high cervical cord injuries often experience airway problems, which, if untreated, may lead to problems with weaning, speech, eating and drinking. This compounds the delay in effective rehabilitation intervention, which can hinder the effectiveness of therapy in the longer-term.

Chris reflected on some of the challenges relating to funding, referring to the UK government’s guidance on charging for overseas patients, last published in September 2023 by the Department of Health & Social Care. He noted the additional complexities where a patient does not have capacity and the interplay with immigration issues for overseas visitors to the UK. Guidance from the UK government suggests that future immigration applications may be denied if a patient is subject to immigration control and does not pay for NHS treatment when a charge applies.

3. Looking ahead/discharge planning

Finally, the panel considered some of the issues around discharge planning and looking ahead to secure the best possible recovery for patients who sustain major trauma in an international context. The emphasis was on good communication with other stakeholders, including community teams, local authorities and even diplomatic channels.

Many of the rehabilitation case managers attending the webinar felt more could be done to involve their services in complex cases from an early stage. It was noted that funding can sometimes be a barrier to accessing the right support.

Themes arising from ISCoS (International Spinal Cord Society) conference in Edinburgh

In October 2023, Stewarts supported the ISCoS (International Spinal Cord Society) conference in Edinburgh. The panel discussion touched on some of the themes explored during the ISCoS conference. This included outcomes on recovery and integration across the first year of spinal cord injury where research by the Case Western Reserve University, Cleveland Ohio has found that insurance and access to legal advice can be a strong facilitator to a positive outcome.

The researchers identified a 2019 paper by Dr Andy Eynon and others (including Stewarts’ Kara Smith and Lucy Robinson) commenting on the effectiveness of introducing lawyers into the healthcare setting and rehabilitation multi-disciplinary team to facilitate successful rehabilitation and reintegration. The panel discussion touched on the extent to which lawyers and the litigation process may be able to help with navigating the challenges and complexities of international major trauma, particularly where there is a third-party liability claim, although that will not always be the case. Chris observed that through the free Legal Service that Stewarts provides to critically ill and seriously injured patients, the firm has supported many in navigating their legal and practical concerns through to a solution on a pro bono basis.

Reflecting on the issues explored by the panel, Dr Gawronski commented: “Individuals who sustain severe traumatic injuries overseas face multiple barriers and delays in accessing medical care and rehabilitation on returning to the UK. Better communication and coordination would achieve a better and more efficient outcome.”

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