Patient story · Specialist neurorehabilitation

Hunger, empty hours and too much at once

How Oakleaf's clinical team used behavioural observations recorded in Melo to understand Dean's distress, and to inform his rehabilitation after a traumatic brain injury.

Specialist neurorehabilitationTraumatic brain injuryBehaviour that challenges
Read Dean's story
Organisation
The Oakleaf Group
Service
Specialist brain injury rehabilitation
Using Melo since
2025
Dean's stay
Six months

The challenge

Distress he couldn't put into words

Dean came to Oakleaf soon after a traumatic brain injury. His speech and mobility were limited, and he relied on staff for all of his personal care.

Assessment suggested he was in . He was disoriented, and often unsure where he was or where his bedroom was. Episodes of aggression were frequent, in what he said, towards objects and towards other people, and sedative medication was being offered when they happened.

To help Dean, the team first needed to understand when his distress happened, and why.

The solution

Three patterns in Dean's record

Staff recorded Dean's episodes in Melo from the day he arrived, mostly on the Overt Aggression Scale Modified for Neurorehabilitation (OAS-MNR).

Choose a pattern to follow it from the first record to the change in Dean's care.

AssessRecord at the point of care

New episode record

What was happening at the time?

HungryNo planned activitySeveral people talkingPersonal care

Added to the record

HungerEpisodes recorded from his first weeks, while he was still disoriented.

New episode record

What was happening at the time?

HungryNo planned activitySeveral people talkingPersonal care

Added to the record

Empty hoursRecording carried on as he joined more therapy sessions.

New episode record

What was happening at the time?

HungryNo planned activitySeveral people talkingPersonal care

Added to the record

Too much at onceWhen agitated, he gave staff clues about what helped.

FormulateSee the pattern

Through the day
Breakfast
Between meals, hungry
Lunch
Between meals, hungry
Evening meal
Aggression more likely

HungerAggression was more likely when he was hungry.

Through the day
Physiotherapy
Unstructured time
Occupational therapy
Unstructured time
Speech and language therapy
More aggressionMore hope and purpose

Empty hoursMore aggression in unstructured time. More hope and purpose in sessions.

Around him
Several people talking at once

Too much at onceToo many people talking at once left him overwhelmed.

InterveneAgree what to change

Behaviour support plan
StrategyOffer snacks between meals

Agreed by the team

HungerSnacks between meals, which reduced his agitation.

Behaviour support plan
StrategyFollow his structured activity timetable

Agreed by the team

Empty hoursA structured timetable of activities in his behaviour support plan.

Behaviour support plan
StrategyOne team member speaks to him, clearly, when he is distressed

Agreed by the team

Too much at onceOne team member spoke to him, clearly, whenever he became distressed.

Oakleaf's clinicians read the record and decided what to change. The pictures are simplified to show what they found. They aren't screens from Dean's record.

The team built these changes into Dean's behaviour support plan, within a wider rehabilitation programme. Psychology sessions helped him understand his injury and manage impulsivity, the psychiatrist moved him onto regular medication instead of sedation when episodes happened, and he worked with physiotherapy, occupational therapy and speech and language therapy.

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The impact

Dean saw the graph too

He was thrilled to see the graph showing he was mastering his temper, and delighted in the positive feedback he received.

Melo's Behaviour over time graph for Dean across 28 weeks. The combined behaviour score is highest in weeks 1 to 5, with peaks at weeks 2 and 4, then falls steeply by week 7. There is a smaller rise around week 10. From week 18 the score stays at zero through to week 28. A marker at week 4 reads: behaviour support plan and regular medication commenced.

Scroll sideways to see all 28 weeks.

The pink line combines how often aggression was recorded with how severe it was. The blue line shows how intrusive staff responses were, on average. Adapted from Melo's Behaviour over time view, with week numbers in place of dates. The plotted data is unchanged.

The team put the same picture at the centre of regular reviews with everyone involved in his care, and used it to make the case for extending his funding.

The outcome

Home, with support around him

Dean was discharged to his own home, with community support.

By then he was walking again, showering on his own and speaking more clearly to say what he wanted. His medication was being reduced, and no episodes of aggression had been recorded in his final two months.

Dean's progress came from the people who cared for him every day, his therapists, his psychologist and his psychiatrist. Melo gave them a shared record to work from, and a way to show others how far he had come.

About this evidence

What this story shows, and what it does not

  • One patient. This shows how one team used Melo. It may not reflect what happens for other patients or services.
  • Confidentiality. Dean is not his real name. Identifying details have been removed or changed to protect his confidentiality.
  • A full programme of care. Dean's progress came from rehabilitation, treatment and support, and from his recovery after brain injury.
  • How behaviour was recorded. Mostly with the OAS-MNR (Alderman, Knight and Morgan, 1997), a structured scale for aggression after brain injury.
  • Clinical judgement. Melo supports clinical teams. It does not diagnose, recommend treatment or make decisions.
How we handle data and clinical safety

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