Steve is a taxi driver and has been for 20 years. He is self-employed and works flexible hours around his physical functioning, only working when he feels able to. Working as a taxi driver is extremely important to Steve, he is well-liked by his regular clients, is known in his local community and has a vivacious and outgoing personality.

On first meeting Steve, he recounts stories from his work and famous people he has met over the years. He lives alone in a ground floor flat in a complex which has a large number of blocks of 2 storey flats, all rented from a housing management company.

Steve finds some daily activities challenging as he weighs 26 stones and this impacts on his exercise tolerance, standing tolerance and ability to undertake daily occupations in the bathroom.

A referral was received by the community occupational therapy department regarding bath transfers and Steve had been on a waiting list for an assessment. The occupational therapist established that Steve had received psychological intervention around his eating habits over a number of years which have not proved successful. The complications of being plus sized has impacted on Steve’s ability to exercise, mobilise and as a result his lifestyle and job role are sedentary in nature.

It was important to establish a swift rapport with Steve, as on assessment, his size, shape and weight would likely be impacting on his ability to undertake other occupations in the bathroom in addition to bathing.

Steve’s weight is carried around his torso, mostly to the anterior and lateral sides of his abdomen and upper thighs. It was noted during the initial assessment that Steve could not reach the pockets of his trousers, which based on the activity analysis indicated that he may have issues with attending to toilet hygiene needs. The occupational therapist discussed issues that other plus sized clients have encountered that they have worked with, and this allowed Steve to open up a little more about the difficulties he was having managing his bowel movements.

When a review of the bathroom environment was undertaken with the client, it was noted that there was a hose attached to the taps on the hand basin. Bath transfers were reviewed which deemed them unsafe and recommendations were discussed. The occupational therapist was able to demonstrate how risk can be reduced and dignity and independence promoted through occupational therapy intervention around the provision of a level access shower. This allowed a dialogue to open up about toileting and Steve felt comfortable at that point to reveal how much he had been struggling to cleanse after opening his bowels.

A more holistic assessment of transfers was undertaken, and Steve was able to complete these independently; however, when seated on the toilet, could not reach his intimate areas either via the front of the bowl (as when seated with his legs apart, there was no space between his legs), from the side (as he was unable to lean) or from the rear as his size prevented the reach required.

A dynamic performance analysis (DPA) of Steve’s current toileting routine was established. This framework analyses the performance of a person carrying out an occupation, task, or activity. The purpose of a DPA is to address difficulties in occupational performance by identifying what makes the task difficult and subsequently test solutions. Steve had been feeding a hose between his legs in an attempt to cleanse after bowel movements. He had found this distressing and had not revealed the difficulties he was having before the occupational therapy assessment.

A virtual assessment with a Closomat representative was booked and this established that a ‘Big John’ toilet seat was required and the Closomat toilet located 500mm from the wall to the centre of the seat would allow sufficient room for turning, transfers and the posture Steve adopted when seated. The Closomat was fitted alongside other environmental changes to the bathroom including a level access shower and a new, smaller wash hand basin to allow space for the Closomat to be located appropriately. The changes were funded via a Disabled Facilities Grant as Steve was eligible due to his modest income.

Following the provision of the Closomat with ‘Big John’ toilet seat, alongside changes to the bathroom environment, Steve was able to use the toilet in a more dignified way which had a positive impact on his overall well-being.

The DPA supports occupational performance and emphasises the importance of the interaction of person, environment, and occupation and is therefore highly individualistic and is a useful tool for guiding intervention.

Closomat’s solution: The Bariatric Palma Vita with Big John seat

The Bariatric Palma Vita is engineered for long-lasting durability. The stylish design has a more comfortable, contoured opening to the seat offering greater stability, comfort, safety and is purpose-designed to correctly position the user for an effective clean.

The standard Palma Vita can bear up to 190kg/30st: 25% more than the strengthened versions of alternative systems. The Bariatric Palma Vita featuring the Big John seat provides an increased safe working load of 362kg/57st.