Station 22 · A carer calls about a man with a learning disability

Candidates: do not open until you have consulted.

Persona and manner

• Kelly Hughes, 29, Daniel's key worker for two years; fond of him, practical, under pressure; the manager has asked her to get the GP to “do something about his behaviour” and she half-suspects that is not the right question.
• You answer what you are asked; you volunteer the physical changes only if asked about them; relieved if the doctor takes it seriously as an illness.

Opening line (verbatim)

• “Hi, it's Kelly from Birch House about Daniel Reed. He's just not been himself for a couple of months — he's slow, he doesn't want to do anything, he's been refusing the bus and he's snappy with the other residents. The manager thinks it's behavioural and wants to know if there's anything you can give him.”

The story

• “It started maybe three months ago. He used to be up at seven with the radio on. Now we have to wake him and he'd stay in bed all day if we let him.”
• If asked about his body: weight on, trousers that do not do up; always cold; dry skin; thin hair; a croakier voice; constipated; slower walking.
• If asked about mood: he does not cry or say he is sad; he has stopped asking for his music; he still smiles at the dog.
• If asked about memory or confusion: no; he knows everyone and the day the bus comes; he just will not go.
• If asked about his hearing or his eyes: he had a hearing test two years ago; he had wax; no one has checked since.
• If asked about changes at the home: a new resident who shouts moved in four months ago; Daniel's favourite worker left; the day centre closed on Wednesdays.
• If asked whether Daniel can come to the phone: yes. If the doctor speaks to him simply: “I'm tired.” “Cold.” “Don't want the bus.” He can say yes and no and “bloods, no”.
• If asked what the home has done: a behaviour chart; a referral to the learning-disability team for challenging behaviour, still waiting.
• If asked about bloods: he hates them; last time it took two staff, numbing cream and a lot of music; he did it.
• His mother visits on Sundays and thinks he is getting old before his time.

Ideas, concerns and expectations

• Idea: The manager's: behaviour, needing a tablet. Yours: “I don't know, he seems ill to me.”
• Concern: That he will be labelled and medicated; that it is something you have missed; that the manager will not accept a medical answer.
• Expectation: To be told what to do, and for someone to see him properly.

Impact

• Daniel: has stopped the bus, the day centre and the music; sleeps; is cold; is constipated.
• The home: a new resident who shouts; a worker gone; staff stretched; the manager wants an answer.
• His mother: worried; Sundays are harder.

Red flags

• Present: Three months of slowing, weight gain, cold intolerance, dry skin, hair thinning, a hoarse voice, constipation and sleepiness in a man with Down syndrome: the pattern of hypothyroidism, with diagnostic overshadowing by a behaviour label; a referral for challenging behaviour already made.
• Absent: No confusion, no memory loss, no change in recognition or orientation; no self-harm; no new seizures; no chest pain or breathlessness; eating and drinking.

Hidden facts and their triggers

• The physical changes: weight, cold, skin, hair, voice, constipation, slowness — released only only if asked about his body rather than his behaviour
• That a resident who shouts moved in and his favourite worker left — released only if asked what has changed at the home
• The hearing test and the wax two years ago — released only if asked about hearing or eyes
• That he hates bloods but managed last time with cream, music and two staff — released only if bloods are raised
• That you think he seems ill, not naughty — released only if the doctor asks what you think is going on

Behaviour

• Minute 1: “The manager thinks it's behavioural.”
• Minute 4, if asked what you think: “I don't know, he seems ill to me.”
• Minute 6, if Daniel is brought to the phone: he says “Tired. Cold.”
• If the doctor asks about his body and not only his behaviour, says this is probably an illness, speaks to Daniel simply, arranges a face-to-face review with the adjustments (a longer appointment, you present, easy-read, cream and music for the bloods), explains what the tests are for, addresses the changes at the home too, and reviews with the result: relieved. “So it might be something we can treat? I'll tell the manager.”
• If the doctor offers a tablet for behaviour over the phone: “Right. OK.” Doubtful.
• If the doctor says it is probably the new resident and the staffing: “Maybe. But he's cold all the time.”
• If the doctor talks only to you and never asks for Daniel: do not offer him.

Examination findings, if the candidate states what they would examine and why

• None today: audio-only telephone consultation; Daniel can be brought to the phone and speaks in short sentences.
• If the candidate arranges the face-to-face review and states what they would examine and why, the findings are given for the plan: weight 86 kg (78 kg at the health check); pulse 54; blood pressure 128/80; dry skin; a hoarse voice; slow-relaxing reflexes; a small goitre; no focal signs; thyroid function pending.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Taking the manager's framing and never asking about Daniel's body, so that three months of weight gain, cold and slowing are never heard (statement D1)
• Arranging bloods and a review without the adjustments, so that the bloods never happen (statement C6)
• Never asking for Daniel himself, so that his own “Tired. Cold.” is never evidence (statement R3)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated: probably an illness, most likely an underactive thyroid, in a man labelled with a behaviour problem. The examiner is listening for: the face-to-face review this week with every adjustment named; the bloods and how Daniel will manage them; the hearing check; the referral reframed; what would need same-day help; the review with the results and the treatment if confirmed; who tells the manager and the mother; and Kelly's own words on what she will do and say when she puts the phone down.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Thyroid disease is common in people with Down syndrome at all ages, and hypothyroidism develops insidiously; the annual learning-disability health check includes thyroid function, and a change in energy, weight or behaviour prompts testing regardless of a recent normal result. NHS England — Annual health checks for people with a learning disability: the health check template and Down syndrome, 2023 guidance, checked 10 Oct 2026
2. Symptoms and signs of hypothyroidism include fatigue, weight gain, cold intolerance, dry skin, hair thinning, a hoarse voice, constipation, bradycardia, slow-relaxing reflexes and depression or slowed cognition; diagnosis is by thyroid-stimulating hormone and free thyroxine, and treatment is levothyroxine with the dose titrated to the TSH. NICE — NG145 Thyroid disease: assessment and management, section 1.2, investigating suspected thyroid dysfunction; section 1.5, managing primary hypothyroidism, 2019, last updated October 2023, checked 10 Oct 2026
3. Diagnostic overshadowing, in which symptoms of physical illness are attributed to a person's learning disability or to behaviour, is a recurring cause of avoidable harm and death in people with a learning disability; a change in behaviour is assessed as a possible symptom of illness, pain or sensory impairment before it is treated as behaviour. NHS England — LeDeR: learning from lives and deaths of people with a learning disability and autistic people, diagnostic overshadowing; recommendations, 2022 report, checked 10 Oct 2026
4. Before treating behaviour that challenges in a person with a learning disability, assess for physical health problems, pain, sensory impairment, mental health problems and changes in the person's environment or relationships; do not offer antipsychotic medication for behaviour unless psychological interventions have not worked and the risk is severe, and only with a review plan. NICE — NG11 Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges, section 1.4, assessment; section 1.8, medication, May 2015, checked 10 Oct 2026
5. People with Down syndrome have a high prevalence of hearing loss, including from ear wax, and of visual impairment; hearing and vision are checked at the annual health check and whenever behaviour or communication changes. NICE CKS — Learning disabilities, management: health checks; common health problems, current online version, checked 10 Oct 2026
6. Reasonable adjustments are a legal duty under the Equality Act 2010: longer appointments, a familiar supporter present, easy-read information, topical anaesthetic and distraction for blood tests, and use of the person's hospital passport; a person is presumed to have capacity, and support to decide is given before any best-interests decision is made. GOV.UK (Ministry of Justice) — Mental Capacity Act 2005: Code of Practice, chapters 2 and 3, the principles; helping people to make their own decisions, 2007, checked 10 Oct 2026
7. Depression and dementia in people with Down syndrome can present as withdrawal, slowing and loss of skills; dementia occurs at a younger age in Down syndrome and is assessed against a baseline of function, after physical causes including hypothyroidism, hearing loss and depression have been excluded. NICE — NG97 Dementia: assessment, management and support, section 1.2, diagnosis: people with a learning disability, June 2018, checked 10 Oct 2026
8. Overt hypothyroidism is a TSH above the reference range with a free thyroxine below it; a raised TSH with a normal free thyroxine is subclinical, and levothyroxine is considered when the TSH is 10 mU/L or more on two occasions, or as a six-month trial in a symptomatic adult under 65 with a TSH between 4 and 10. The starting dose under 65 without heart disease is 1.6 micrograms per kilogram daily, rounded to the nearest 25 micrograms; TSH is rechecked three-monthly until stable, then yearly. NICE CKS — Hypothyroidism, diagnosis: interpretation of thyroid function tests; management: starting levothyroxine and monitoring, current online version, checked 10 Oct 2026
9. Mental health problems are more common in people with a learning disability and present differently: depression may show as withdrawal, loss of skills, irritability, change in sleep or appetite, or slowing, rather than expressed sadness. NG54 says to assess with the person and with someone who knows them well, against the person's own baseline of function, using assessment tools adapted for learning disability, after physical illness, pain, sensory loss and recent life events have been considered; the annual health check includes a review of mental health. NICE — NG54 Mental health problems in people with learning disabilities: prevention, assessment and management, section 1.3, assessment of mental health problems; section 1.2, annual health check, September 2016, checked 10 Oct 2026
10. Capacity is decision-specific and time-specific. The two-stage test asks whether there is an impairment of, or disturbance in, the functioning of the mind or brain and, if so, whether the person cannot understand, retain, use or weigh the relevant information, or communicate the decision. A person is not treated as unable to decide unless all practicable steps to help have failed, and an unwise decision is not evidence of incapacity. Where capacity is lacking, the best-interests decision consults carers and family and takes the least restrictive option. GOV.UK (Ministry of Justice) — Mental Capacity Act 2005: Code of Practice, chapter 4, assessing capacity; chapter 5, best interests, 2007, checked 10 Oct 2026
11. Good medical practice (2024) requires doctors to treat patients fairly, to take account of the needs of disabled patients and to make reasonable adjustments to their practice so that disabled patients receive care that meets those needs; to take steps to meet patients' language and communication needs; and to give information in a way the patient can understand, checking that it has been understood. For a patient who speaks in short sentences and uses Makaton, this means speaking to him directly and using the adjustments recorded in his hospital passport. GMC — Good medical practice, domain 2, patients, partnership and communication: treating patients fairly; communicating with patients, 2024 edition, checked 10 Oct 2026
12. The Learning disability Topic Guide expects the GP to communicate directly with the person and adapt the consultation to their needs, to recognise diagnostic overshadowing when a change in behaviour is reported, to deliver and act on the annual health check and health action plan, to know the physical conditions that cluster with particular syndromes (thyroid disease, hearing and visual impairment and early-onset dementia in Down syndrome), to apply the Mental Capacity Act, and to work with family carers, paid carers and the community learning-disability team. RCGP — GP curriculum: Learning disability, Topic Guide: knowledge, skills and attitudes for the care of people with a learning disability, 2025 curriculum (Being a GP), checked 10 Oct 2026

Working references for this station

12 statements, 764 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-22