WHEN DOES OBESITY CONSTITUTE MEDICAL NEGLECT? Graham Vimpani, Senior Clinical Advisor, Child Protection and Wellbeing, NSW Kids + Families, North Sydney Jenny Marshall, Acting Director, Violence Prevention and Care, NSW Kids + Families, North Sydney Wendy Thompson, Manager, Northern Child Wellbeing Unit, Newcastle
OVERVIEW AA was 8 year old boy who died in hospital from complications of morbid obesity in 2010 Case reviewed by NSW Ombudsman 2011-2012 to identify and respond to systemic issues within and between agencies NSW Health review in February, 2012 Interagency review in Newcastle, 2012 Coroner s inquest and recommendations 2013-2015 Lessons for child protection services, hospital child protection teams and paediatric services more generally How could the Keep them Safe reforms improve the outcome? 2
CASE STUDY - 1 AA was a morbidly obese boy who initially presented aged 7y 10m (May 2008) with sleep apnoea managed in ICU (35Kg) Despite risks of adding to weight gain, parents demonstrated non-compliant and odd behaviour in hospital and subsequently Referred to ICU dietician (low priority -> JHCH dietician) and SW No other strategy identified to deal with signs of odd parental behaviour during the admission despite a past Hx of maternal drug abuse (including IV) being recorded in admission Hx
CASE STUDY - 2 Referred to child protection team meeting (poorly staffed annual RACP conference) and seen by paediatric SW afterwards who decided Helpline referral unwarranted unless non-compliance with dietetic intervention posed a threat to health. Unclear who had responsibility for monitoring implementation of recommendations relevant to Child Protection. Numerous episodes of non-attendance as OP with respiratory paediatricians, dietician, endocrine team. Parents heavy smokers and equipment contaminated. SW referral by nursing to follow up on need for Community Services report but this didn t occur (August 2008)
CASE STUDY - 3 Reviewed by respiratory team Nov 2008 and major concerns about continuing weight gain and non-compliance were documented but not labelled as medical neglect. Non follow-up of recommended ENT referral No dietician had made contact with AA since admission numerous failed appointments adequacy of protocol of sending letters asking parents to contact for appointment for families who are resistant to engage
CASE STUDY - 4 March 2009 CP review meeting referral to Helpline following day. No documentation in health record of information provided. Case referred to Charlestown Community Services Centre (medium risk) and after enquiries to school confirmed immobility, noisy breathing and poor attendance, case was closed because of competing priorities on 7 May 2009 7 May 2009 allegedly playing soccer for school attended dietician (1 st ), respiratory team, given diet. Failed to attend dietician follow-up.
CASE STUDY - 5 Readmitted June 2009?inter-current URTI, continuing noncompliance with diet and case conference held but attendance and outcomes not specifically documented although FU with dietetics, physio, respiratory, endocrine (still had not had Glucose Tolerance Test - diabetes) and ENT organised. Morbid obesity now regarded as being at medical emergency stage. No mention of contact with school or CS.
CASE STUDY - 6 Numerous failed appointments from the end of July 2009. After two visits in September 2009 to physio and dietician failed to attend respiratory clinic that month and was not seen by anyone of the treating team until September 2010. Risk Of Significant Harm report for non-attendance for OGTT made and concerns about medical neglect raised. No further report made when failed to attend again. Brought by parents to hospital in gross respiratory distress. Had a cardio-respiratory arrest outside the JHH Emergency Department in September 2010. Died 10 days later. 80Kg
CASE STUDY - 7 Mother s health Mother had extensive involvement with D&A services at Mater Hospital on methadone but known to be intermittently using IV speed - during the 2008-2010 period An admission to JHH (15 May June 29 2009) - (overlapped with AA s second admission) for endocarditis related to drug use none of which was known to paediatric staff. ROSH report made on 17 May 2009 by D&A. Escalating IV use noted throughout July-August 2009 and Jan-March 2010 including heroin leading to a second ROSH report on September 21 2009, which was closed unallocated because of competing priorities a week later.
CASE STUDY - 8 School AA s Public School reported chronically poor school attendance and behaviour that was inconsistent with that being reported by the parents (E.g. ability to play soccer). No documented contact with the school was made by paediatric staff. School said AA frequently fell asleep in class and was either sent home in care of parents or other children were asked to try to keep him awake in class
ISSUES FOR HEALTH STAFF Belief that parents were doing their best despite difficult circumstances and (in retrospect) unwarranted credulity in their story. Lack of understanding of parents perception of his weight (family belief that AA was same as other children in extended family who had been overweight but lost weight when teenagers) Non consideration of the family and social issues contributing to the parent s non-compliance. How might have these parents health problems be contributing to their non-compliance? Failure to name the parents non-compliant behaviour as medical neglect Failure to recognise mother s suspicious behaviour as a possible marker of drug misuse given documented Hx of drug use
ISSUES FOR HEALTH STAFF Absence of any contact with mother s treating D&A and ID team when enquiries would have been legitimate and now facilitated by Chapter 16A Lack of interagency contact (school/education, CS) to check out story being given by parents No identifiable case manager Non-recognition of what the child protection team could offer not invited to case conference prior to discharge on second admission
Case Study Child Protection Issues Risk of Harm issues identified: Medical neglect obesity, respiratory issues, sleep apnoea (limited compliance with treatment recommendations) Neglect poor nutrition, failure to see dietician Carer concern Drug use by mother and father; mental health issues for mother Educational neglect Habitual non-attendance
ISSUES FOR HEALTH STAFF No case conference with CS and school ever organised Under what circumstances does non-compliance with treatment in children with chronic and complex care needs become a child protection concern? Importance of consultation between treating clinical team and child protection team Improved documentation of child protection cases
INTERAGENCY REVIEW
Case Study - Communication Contact between agencies Health to CS - 7 (ROH and ROSH reports only) CS to Health 1 (follow up on ROSH report by Health) CS to School 2 (follow up on 2 ROSH reports by Health) School to CS Nil Health School Nil Some contact between some of the health services involved, but no contact between Drug and Alcohol / Hospital Services treating mother and Health Services involved with Child
What went well? - Health Reports made to Community Services Helpline Some case meetings held with some members of treating team
What went well? Community Services Significance of the need for the child to be presented for medical treatment in March 2009 report was understood by the Intake Caseworker who recommended CS monitoring of appointment attendance & compliance
What went well? Education School Learning Support team/student Welfare Team meeting regarding concerns about absenteeism in 2008; Parents advised of legislative requirements for school attendance and the consequences for continued non attendance in writing in October 2008; Referral to Home School Liaison Program by school in November 2008; Timely follow up (3 home visits) by Home School Liaison Officer (HSLO) following referral (during November/December 2008). Child continued to be identified with poor school attendance by HSLO in 2009/10.
Opportunities lost - Health Communication with other health services Communication with School Communication with Community Services Collaborative interagency practice Failure to engage fully with child protection team Knowledge and recognition of child protection concerns especially in relation to medical neglect Reporting of child protection concerns Active follow up of non-attendance
Opportunities lost Community Services Reports could have been the catalyst for: Detailed information gathering & understanding of AA s health condition & its potential fatal consequences Engagement with parents re their ability to understand & respond to AA s medical needs & treatment regime Formation of a partnership between CS & Health re risk management
Opportunities lost Education Early intervention when absences first became an issue; Early engagement of parents regarding medical needs of the child and how they could be accommodated by the school; Need for re-referral for HSLO intervention when file was closed at the end of 2008; Collaboration with other agencies and within the Department; Lack of understanding of how Departmental policies and guidelines applied in unique cases; and Lack of understanding of new reporting requirements under Keep Them Safe.
KEEP THEM SAFE - BENEFITS
Potential Benefits of Keep them Safe for similar cases (progressively rolled out from early 2009) Mandatory Reporter s Guide Child Wellbeing Units assist with advocacy at Helpline and CSCs; opportunity for appraisal of cumulative harm; information exchange Chapter 16a legislation Training of all staff child protection is everyone s business your job doesn t stop with a call to the Helpline Awareness of the 70%:30% phenomenon and its implications 24
CORONER S RECOMMENDATIONS
Coroner s recommendations Weight Management Unit Child Protection Unit staff to monitor reports to Helpline Child Protection Service to become a Unit 26
Broader Implications Child protection issues often arise in the management of children with chronic and complex health needs Eating disorders, diabetes, cystic fibrosis, cancer, school refusal due to chronic low-grade illness. Challenge for clinicians to address child obesity if parents are also obese. These groups of children are becoming more common in paediatric practice Lead clinicians not always aware of how to negotiate the statutory child protection system Important supportive role of hospital child protection teams and interagency case review meetings Management protocols helpful tool Good documentation essential SCAN protocol Child abuse Sexual assault clinical advice line (CASACAL)