Speech-Language Pathology and Audiology Case Studies
Healthcare5 Case StudiesUpdated Sep 2026
Speech-language pathology and audiology work sits where communication, hearing, and feeding safety meet everyday decisions about referral, scheduling, and family communication. The five cases below are built around fictional services, yet the pressures will be familiar to anyone who has chased a missing report. Each case asks you to weigh patient needs, the clinical evidence available at the time, how the team communicates, and which local protocols apply. Read them as working records rather than model answers. The aim is to justify choices clearly, because in practice the reasoning is what other people inherit.
Case Study 1
Escalating a child's changing symptoms across a fragmented referral
Brightwater Family Health, a community service with three outpatient clinics and a shared referral desk for children and adults.
The situation
Tomas, a speech-language pathologist at Brightwater, had followed a seven-year-old boy named Ezra for four months. Initially his concerns were about unclear speech and limited sentence length. Over the following weeks, his parents reported more coughing during meals, a voice that sounded tired by the afternoon, and two episodes of unexplained tiredness at school. Tomas recorded each change in the shared notes and flagged a possible hearing component. The audiology appointment had been booked for the next available slot, which was eleven weeks away. The family's general practitioner had seen Ezra once, noted the speech concerns, and closed the referral to the regional speech service pending review.
The challenge
The difficulty lay in separating a genuine change in pattern from normal variation across the four months. Tomas had no authority to re-open the medical referral, and the regional protocol required a documented clinical reason before a case could be moved out of the standard queue. The team had to decide whether to request an earlier audiology slot, ask for a medical review, or hold the scheduled review and keep monitoring. Each route carried a different delay, and the notes did not yet show which concern was most urgent.
Analysis
Teams grounded in Speech-Language Pathology and Audiology usually begin by separating what the child reports from what the team has seen directly. The need here was a cluster rather than a single symptom: speech intelligibility, fatigue, and coughing at meals, appearing in sequence. Much of the evidence was observational and came from parents and school staff, so its weight depended on how consistently it was recorded. Tomas had dated each entry, which showed the coughing clustering around particular meals. A pattern like this does not confirm a diagnosis, but it does justify a closer look at investigations already available.
Coordination failed at the point where no one owned the decision to escalate. The general practitioner had closed the referral on the basis of the speech concern alone, and the regional service had no way to see the later notes. Local protocols allowed any treating clinician to request an urgent medical review when a new feeding or airway concern appeared, but they assumed the concern would be stated plainly. Tomas's notes described change without naming a risk, which made it easy for a reviewer to read them as routine. The protocol was sound; the handoff of the reasoning was not.
- Observe and record Dated notes capture change against the child's own baseline.
- Weigh the evidence Decide whether the pattern is new, persistent, or within expected variation.
- Escalate with reason Name the specific concern and the person expected to act on it.
- Review and hand over Confirm an owner and review the plan on a fixed date.
Actions taken
- Tomas wrote a structured summary that stated the specific risk, listed the dated observations, and asked the medical reviewer a direct question about whether an urgent review was warranted.
- The team agreed that the speech-language pathologist would hold the case lead until the audiology slot was confirmed, with a named person to receive any new concern in the interim.
- Tomas requested an earlier audiology slot on the basis of the documented pattern, and the booking coordinator recorded the request reason so that the cancellation list could be checked weekly.
- The family was told plainly what the team was watching for, which signs meant they should call the service the same day, and how the next review would be arranged.
Results
The medical review was brought forward by several weeks, and the reviewer's note cited the coughing and fatigue history. The audiology slot came through in the fourth week after the request and showed a hearing difference in one ear that the earlier screen had missed. The notes now carry a single named lead and a dated escalation log. Ezra's mother, Dana, said she knew whom to call when coughing returned at a second meal, and she called the same day. The outcome is still open. The team has added a stated-risk line to its escalation template.
Questions for discussion
- What specific information would have made the escalation request stronger on the first day it was drafted?
- How should a team decide between an earlier audiology slot and an urgent medical review when both are available but neither is clearly sufficient?
- Which parts of the local protocol assumed that a treating clinician would already know the risk, and how would you revise them?
Case Study 2
A mealtime precaution lost at ward transfer
Harrowgate Regional Hospital, a 412-bed acute hospital with an inpatient rehabilitation unit and a general medical ward.
The situation
Gerald, in his late sixties, was transferred from the rehabilitation unit to a general medical ward on a Friday afternoon. Three days earlier, Ruth, a speech-language pathologist, had completed a bedside assessment and recorded a mealtime safety recommendation. The recommendation asked for supervision at every meal and a note at the front of the chart. Ruth wrote it in the rehabilitation notes and mentioned it verbally to the outgoing nurse. The transfer summary generated by the electronic system listed diagnoses, medications, and mobility status, but it had no field for therapy recommendations, so the item was not carried across. The receiving ward worked from the summary, and the supervision requirement was not visible at the first meal.
The challenge
The question for the team was how a safety-relevant recommendation could be lost between two well-run services. Ruth had acted correctly by documenting and speaking to the nurse, and the ward had followed its usual summary process. The gap sat in the handover design, where therapy recommendations had no required field and no check at receipt. The team had to decide what to fix immediately for Gerald, and what to change for every future transfer without adding so much documentation that staff would skip it.
Analysis
The patient need in this case was continuity of a precaution that had been set for a reason. Clinical evidence in the notes was specific: the recommendation rested on observed mealtime behavior and on the speech-language pathologist's judgment of swallowing safety. Evidence that specific is only useful if it reaches the person making decisions at the moment they make them. Here the first meal on the new ward was the moment of risk, and the information that would have shaped staff attention sat in a rehabilitation chart nobody on the receiving ward was reading. A recommendation is only as strong as its route to the bedside.
Coordination broke down at the seam between two teams that each followed their own process correctly. Local protocol required the outgoing team to send a transfer summary and required the receiving team to reconcile medication lists on admission, but neither protocol named therapy recommendations as a category that must cross the boundary. Safeguards existed in principle: verbal handover to the nurse, a documented note, and the professional duty of the speech-language pathologist to escalate unresolved risk. None of these was a reliable check on its own. Verbal messages depend on memory, notes depend on being opened, and escalation depends on someone recognizing that a recommendation is still live.
Actions taken
- Add therapy recommendations as a required field in the transfer summary, with a visible flag that stays active until the receiving clinician acknowledges it.
- Require a read-back at the bedside for any active mealtime precaution, recorded by the receiving nurse within the first shift after transfer.
- Ruth and the ward manager added open therapy recommendations to the daily safety huddle, so they are named aloud each morning until closed.
- Track the measure monthly: the share of transfers where a therapy recommendation was carried into the receiving summary, with a target set by the quality committee.
Results
The required field went live in the second month, and the quality committee reviewed a sample of transfers at the end of the quarter. Of 212 transfers sampled, 189 carried every active therapy recommendation into the receiving summary. The other 23 were traced mostly to night transfers, where the summary was completed from an earlier draft. Gerald's supervision requirement was in place from his next meal on the ward once the gap was found, and no further safety event followed during his stay.
Questions for discussion
- Where in your own service would a recommendation with safety implications be most likely to drop out of a transfer, and why?
- Which of the proposed improvements would you measure first, and what would count as a result that justifies keeping it?
- How could a required field be designed so that it adds clarity without encouraging staff to tick boxes without reading?
Case Study 3
One audiology booth and a list of 1,340 referrals
Lantern Valley Community Clinic, a county outpatient service with a speech-language team, an audiology suite, and school outreach.
The situation
The waiting list for combined speech and hearing assessments at Lantern Valley had grown to 1,340 referrals. The audiology suite had one diagnostic booth in use five days a week, and two of the four speech-language pathologists were covering a school outreach contract that had been added in the spring. Demand was not evenly spread. Referrals for young children were marked urgent more often, while adults with gradual hearing change were the largest group by volume. Waiting times for adults had reached nearly seven months, and a number of school-age children were being seen only after the start of term had passed.
The challenge
The options were not all clinically equivalent. The clinic could move urgent work to the front of the queue and accept longer waits for routine adult assessments. It could extend the booth schedule into the evening, which would require staff overtime and a different risk profile for lone working. It could also group some school-age screening into shorter pre-assessment sessions, which would release clinician time but might reduce the depth of the first contact. The team had to protect the children's timelines without making adults' waits unsafe, and to record the criteria used.
Analysis
Patient need is the starting point for allocation, but it is rarely a single number. In this clinic, the urgency of a child's referral reflected developmental concern, while an adult's waiting time mattered for safety in ordinary daily life, such as managing conversation at work or hearing alarms at home. Clinical evidence in the referral letters was uneven. Some had audiology results from elsewhere, others had only a parent's description. Triage that relied on the letter alone would systematically favor the better-documented referrals. A short structured triage call, with a fixed set of questions, gave the team comparable evidence across the list.
Coordination here depended on the clinic's local allocation protocol, which set priorities by clinical need first and by date of referral second. The protocol required any change to the queue order to be recorded with a reason, and reviewed by the clinical lead every two weeks. Under that rule, the school outreach contract could not be used to justify moving adult cases without documented need. The two speech-language pathologists on outreach and the audiologist in the suite met weekly, but the meeting had no shared view of the queue. Reconciling the three views of the same list was the first step, before any option could be judged fairly.
Actions taken
- Adopt a single structured triage call for all new referrals, with the same five questions for children and adults, and file the answers in the shared queue record.
- Ring-fence one assessment slot each day for children flagged urgent, and have the clinical lead review those bookings at the weekly queue meeting.
- Trial the evening booth sessions for four weeks only, with lone working rules agreed in advance and overtime capped at a fixed number of hours.
- Publish the queue position for each referral and the reason for any change, so the waiting list can be checked by the families and referrers it affects.
Results
The triage call was in place by the fourth week, and referrals entered the queue in a consistent order for the first time. Urgent child referrals were assessed inside the clinic's target window in most cases during the following quarter. The evening sessions ran for four weeks and added 36 assessments, but the team chose not to extend them. The adult waiting time remains near five months, and the clinical lead now reports it at every queue meeting as an open risk. Shorter screening sessions were not adopted, because the first-contact depth was judged too low for school-age cases.
Questions for discussion
- Which criteria would you publish for queue order, and who should be able to challenge a placement?
- When is an evening or extended session a reasonable use of overtime, and what safeguards must it meet before it starts?
- How would you show a funder or commissioner that a long adult waiting list is a risk, not simply a backlog?
Case Study 4
Inconsistent discharge outcomes across six outpatient sites
Juniper Row Therapy Services, a six-site outpatient network providing speech-language and audiology care to adults and school-age children.
The situation
The network's quality committee reviewed a dashboard of anonymized indicators covering the previous two quarters across six sites. Outcome measures recorded at discharge showed a wide spread. Three sites reported most clients meeting their agreed communication goals, while two others reported noticeably fewer. The committee asked the clinical lead, Priya, to find out whether the difference reflected case mix, staffing, or recording practice. Priya began with the anonymized records of 1,860 episodes of care. She noticed that goal wording varied, that some sites recorded discharge scores at a different point, and that re-referrals were not consistently coded.
The challenge
The difficulty was that every plausible explanation pointed to a different fix. If case mix explained the spread, the answer was a risk adjustment and an honest conversation with commissioners. If staffing explained it, the fix was rota design. If recording practice explained it, the network needed agreed definitions before it could say anything about quality at all. The team had 90 days to produce a recommendation, and it could not change the core measure mid-period without breaking the trend line.
Analysis
Outcome data are only evidence of quality when the people behind them are described consistently. Here the patient needs varied widely: some adults were returning to work calls, others were learning to communicate after a change in hearing, and many school-age children had language goals that changed mid-episode. Goal wording that was broad at one site and narrow at another meant that a met goal in one place did not mean the same thing in another. The indicator spread was therefore partly a measure of how goals were written. The committee should read the clinical evidence as a set of records, not as a ranking of clinicians.
Protocol is where the network's own rules matter most. The service's outcome protocol asked each clinician to record a discharge score against goals agreed at the start of care, within the final session. In practice, two sites completed the score at the last visit, and two others completed it at the first visit after discharge, when the client had already left the active caseload. Clinicians were not careless; the protocol did not say which event defined discharge. Coordination between sites was limited to a quarterly call, so differences in practice were visible only in the summary numbers, where they looked like differences in outcome.
- 1Define dischargeAgree one definition of discharge and the point of scoring.
- 2Standardize goal wordingShared template with measurable condition, context, and review date.
- 3Align recording practiceScore in the final session and code every re-referral.
- 4Audit and report monthlySample goals at each site, reporting risk-adjusted figures beside raw ones.
- 5Review after two quartersCommittee decides whether to keep, change, or retire each step.
Actions taken
- Agree a single written definition of discharge and the point at which the outcome score is recorded, and circulate it to all six sites before the next quarter begins.
- Rewrite goal wording using a shared template with a measurable condition, a context, and a review date, and audit a sample of goals at each site each month.
- Adjust the recording rota so that discharge scores are completed in the final session, and add a coded field for re-referrals that cannot be left blank.
- Run the revised process as a monitored cycle for two quarters, with risk-adjusted indicators reported to the committee alongside the raw figures at each meeting.
Results
The definition and template were circulated before the next quarter began, and the first monthly audit found that goal wording met the template in most sampled goals at the two sites that had differed most. Recording in the final session rose across all six sites, and the gap between the highest and lowest discharge indicators narrowed over the monitoring period. Part of the remaining spread is case mix, which the committee has agreed to adjust for before drawing conclusions. Priya noted that two sites still leave the re-referral field incomplete, so that item stays on the monthly agenda.
Questions for discussion
- Which indicator would you adjust for case mix first, and what data would you need to do it credibly?
- How should a service share sensitive outcome comparisons between sites without creating blame or gaming?
- What would convince you that a change in recorded outcomes reflects practice rather than the new definition?
Case Study 5
A teenager's request for privacy during a school plan
Calder Street Communication Centre, a community service providing audiology and speech-language care to adults and adolescents.
The situation
Mireille, sixteen, had been seen at the Calder Street Communication Centre for an audiology and speech-language review after a gradual drop in hearing in one ear and changes in her speech in group settings. Her father, Anton, attended every appointment and asked to receive copies of all reports. In the eighth session, Mireille asked Tomas, the speech-language pathologist, not to share a specific concern about how she was coping at school with her father, and to keep it out of the written summary. Tomas explained that the summary would go to the school's learning support team under an agreed plan, and that the father held parental responsibility. Mireille became distressed and stopped attending for two weeks.
The challenge
The team had to balance a young person's right to be heard against a parent's legal standing, a school plan that depended on the summary, and a clinical need to know whether the concern affected safety at school. Tomas had a duty to be honest about what could be shared and with whom. He also had to decide whether the concern met the threshold for a safeguarding discussion, and how to word the summary so that the young person's voice stayed in it without hiding what the school needed.
Analysis
The evidence here was mostly observational and spoken in the room, which made it hard to hold as a record. Mireille's need was to be heard in her own communication, and to receive support that fitted her hearing and her social situation. Her report of coping difficulties was relevant to the school plan, yet it came from a single session and had not been tested against other sources. Good practice is to record what the young person said, how she said it, and what the clinician did with it. The notes should show that Mireille's view was weighed, not that it was simply recorded as an objection.
The applicable protocols were the consent and information-sharing policy, the school plan agreement, and the safeguarding procedure. Under the consent policy, a young person's views should be sought and recorded, and confidentiality kept unless serious harm or a legal duty required disclosure. The father's access to records depended on his status and on what the service had agreed with Mireille at intake, which had not been written down. Coordination was thin: the school learning support team had not been told that a summary might be partial, and Mireille had not been invited to the team meeting. Escalation to the clinical lead and the designated safeguarding lead was right, because no single clinician could settle the decision.
- In the eighth sessionRequest to withhold a concern made in the room.
- Same daySummary drafted, noting a concern without detail.
- Within two daysSafeguarding and clinical leads review the concern and record reasoning.
- Two weeks laterMireille returns and the scope of sharing is agreed in writing.
- Following reviewJoint meeting checks whether the agreed plan is working.
Actions taken
- Tomas met Mireille alone for part of the next session, explained what would be shared and why, and asked her to choose wording for the concern that she could accept.
- The clinical lead and safeguarding lead reviewed the concern against local procedure, and recorded the reasoning for why it did not meet the threshold for referral.
- The summary was rewritten to state that the young person had raised a concern she preferred not to detail, and that a follow-up review would take place with her present.
- Anton, her father, was offered a joint meeting focused on his daughter's communication goals, with the scope of shared information agreed in writing before the meeting began.
Results
Mireille returned after two weeks and agreed to a shorter plan with two goals she chose herself. The school learning support team received a summary that set out functional needs and noted, without detail, that a concern had been raised, and they arranged a check-in that Mireille attended. Anton accepted the written scope of sharing after one difficult conversation, and he continued to attend the joint sessions. The team added a line to its intake template recording what each young person has asked to keep private, and when that request will be reviewed. The follow-up is still pending.
Questions for discussion
- At what point in the session should a young person's request for privacy be explored, and who should be present?
- How would you explain the limits of confidentiality to a parent without undermining the young person's trust?
- What should be recorded when a clinician decides not to act on a request, and who should review that decision?
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