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The first X-Concord Seminar was held at Drug Health Services at Royal Prince
Alfred Hospital (RPAH) on 22 February, and attended by over 60 people.
The topic was child protection: “The role of Community Services where parents
use substances, and the obligations of health professionals”.
Guest presenters were: Jeannie Minnis, Perinatal & Family Drug Health Clinical
Nurse Consultant with RPAH Drug Health Services; and Olwyn Neill, Manager
Consultancy Team, Clinical Issues Unit, NSW Community Services.
Do you know when you must make reports to Community Services and how to
make them?
Do you know what to do if a school principal or counselor requests that you
provide confidential patient information on grounds of child protection?
Do you know how many positive urine tests are sufficient grounds to prevent
restoration of a child to a substance dependent parent?
Do you know how long parents have to achieve abstinence in order to keep or
regain custody of their child?
Scroll down to find the answers......
Contents of this Seminar Summary:
Part 1: Jack and Jill – the clinicians’ perspective and what else Community
Services knew.
Part 2: Introduction to “Keep Them Safe”
Part 3: The CS Parental Drug Testing Policy - what clinicians should know.
Part 4: The real case of Lucy & Nobby
Part 5: A “hypothetical” case – Jetty. Imagine the following.....
Community Services (formerly DoCS) is the New South Wales Government agency
responsible for promoting the safety and wellbeing of children and young people. We
hope this summary may also be of interest to readers further afield.
As parental substance use is often grounds for notification of child protection authorities
and for removal of children, this is a critical issue for health professionals working in the
field of “alcohol and other drugs”. It is also an emotive and controversial issue. Referring
to a recent 70% increase in infant removals by Community Services (CS) in NSW,
Opposition spokeswoman, Pru Goward, commented: “…… the civil liberties issue is one
that cannot be ignored: are they simply creating another stolen generation?''
Part 1: Jack and Jill – the clinicians’ perspective and what else Community
Services knew.
The seminar started with a case study, presented first from the clinicians’ perspective by
Jeannie Minnis.
Jill was a 30 year old woman of an indigenous background, on methadone maintenance
treatment 60mg/day. Her two previous children had been “assumed into care” by DoCS
and were now in care of their father. There had been overdoses in both previous
pregnancies, and she had a custodial sentence years ago for drug related offenses.
This pregnancy was planned, and she was supported by her current partner, Jack. Jack
had served a long sentence for a violent crime committed in his youth, but considered that
long behind him; he stated he had come off MMT and claimed to be free of substance
use.
Jill was stable in MMT, at a specialist clinic, with no indications of problematic
substance use for more than 3 years. However, her first attendance at the antenatal clinic
was late, at 34 weeks, and included an interview with a social worker whom she and her
partner perceived to be judgmental. They refused to provide detailed information, felt
stigmatized and threatened by talk of CS involvement, and walked out. The social worker
made a report to the CS Helpline.
A “Section S248 Request” was received, meaning that the antenatal clinic was required to
report in detail to CS, and further a “BIRTH ALERT” was circulated to hospitals in the
area. This meant that CS would be notified by any facility where the baby might be born.
Jeannie Minnis summarized: On the negative side the mother-to-be had past
polysubstance use, poor antenatal care, few social supports, unwillingness to engage in
services and past removal of children, also much was unknown about her partner. On the
positive side the mother had 3 years stability on MMT with clear urine toxicology, stable
housing, she had made adequate preparations for the baby, and she was well nourished.
Jill’s son was born healthy at term. Jill started breastfeeding, and was seen as a “ model
mum” on the ward, although Jack was described by postnatal staff as “weird”. Two
workers from Community Services “assumed care” of the baby on day 2, who was taken
to the nursery. The parents were very distressed & the midwives were traumatized.
The baby went to a foster home at 2 weeks. At this time the father disclosed his own
history of abuse in institutional care. Like the midwives, nursery staff were traumatized.
Jill provided expressed breast milk for 6 weeks and had it delivered to the foster mother.
Over months to come, Jill made the long trip 3 times a week for a “chain of custody”
urine test, and for her one hour of access to her son, in an office. She was determined to
get her baby back and do whatever CS required. However, one day she informed her
doctor that they had given up.
Olwyn Neill was then able to give the CS perspective, which told a very different story.
CS has access to a much wider range of information than is available to clinicians, and in
this case there were criminal records, police reports, and reports from the community. In
contrast to Jack’s assertion that he was abstinent, there was evidence of recent criminal
activity and drug use; there were also reports of possible ongoing domestic violence, with
concerned calls from neighbours to police. Unlike Jill, Jack had attended for urine tests
on only two occasions since the baby was born.
This contrasting CS perspective was startling for the audience after the clinicians’ more
rosy account.
Olwyn Neill made an important point about CS reluctance necessarily to support supply
of expressed breast milk (EBM). If EBM supply is not absolutely regular, it is difficult
for foster parents who have to alternate it with formula milk, and may entail some risk if
there is methadone or benzodiazepine in the breast milk. Olwyn stressed that CS cannot
use as evidence urine toxicology which is less frequent than twice a week and which is
not strictly supervised, while Dr Andrew Byrne remarked that the perspective of
clinicians over extended periods should also be taken into account, even in the absence of
“chain of custody” urine testing.
Part 2: Introduction to “Keep Them Safe”
Olwyn Neill went on to explain changes to CS in response to the The Wood Enquiry
(2008) which found that many children who did not require statutory intervention of the
State were being reported to the Child Protection Helpline, overburdening available
resources.
The result is “Keep Them Safe” (KTS), a five-year action plan aimed at greater shared
responsibility for protecting children, greater focus on prevention and early intervention,
increased role of non-government organizations (NGOs) in service delivery, and
addressing the over-representation of Aboriginal children in the child protection system.
http://www.keepthemsafe.nsw.gov.au/
The Consultancy team within the Clinical Issues Unit, which Olwyn leads, was set up to
support frontline child protection work in assessing complex risk factors including mental
health and domestic violence. 55% of the 156 children whose deaths were reviewable in
2007 were connected with a prior report of domestic violence, with suspicion or evidence
of parental substance abuse in 55% of cases and parental mental health concerns in 24%.
•
The CS focus is on ‘serious and persistent’ use of alcohol, illicit drugs,
prescription medications and over the counter preparations. This may be either
“daily or near daily” (regular or dependent) use, or “binge pattern” (erratic, high
dose episodes), which often poses a greater risk of harm.
•
•
KTS increased the threshold for mandatory reporting from “risk of harm” to “risk
of significant harm” (ROSH): “…sufficiently serious to warrant a response by a
statutory authority irrespective of a family’s consent….. not minor or trivial and
may reasonably be expected to produce a substantial and demonstrably adverse
impact on the child or young person’s safety, welfare or well being…. can result
from a single act or omission or an accumulation of these…”
KTS also implemented changes to how child protection concerns are reported. In
short, any “mandatory reporter” (if you are reading this, probably THIS MEANS
YOU) should assess ROSH and, depending on their assessment, may make a
report to the CS Helpline, or a referral to Child Wellbeing Unit, or “continue to
engage and monitor”. They may choose to use the Mandatory Reporter Guide
(MRG), an online interactive Structured Decision Making tool, to assist in this
process.
http://sdm.community.nsw.gov.au/mrg/app/summary.page
•
•
•
When a report is made to the CS Helpline, the staff there make their own
assessment of the information provided using structured decision making tools. If
the report meets criteria for ROSH they forward the report to the relevant CS
office. If not, they may refer the case back to the Child Wellbeing Unit.
Child Wellbeing Units have been established in the four government agencies
responsible for 60% of all CS reports: Police, Health, Education and Training,
Human Services. Their job is to provide an alternative pathway for providing
support for families that do not meet the ROSH threshold and to drive better
coordination of agency service systems.
The new S16A provisions extend mandatory reporting obligation to NGOs and
NSW Government agencies (for example, schools) that are identified as
“prescribed bodies”, and they permit authorised staff in prescribed bodies to
exchange information. General Practitioners working in incorporated practices are
considered prescribed bodies under the new legislation and are therefore required
to share information, while sole practitioners are not.
Some clinicians in the audience were surprised to hear that they might be requested to
give confidential patient information to NGOs, for example, to a school principal or
counselor. Olwyn stated that one could refuse on certain grounds, but this may well be
followed by a subpoena, which would however come from CS, not from the school.
The intention of these changes is to reverse a trend that followed on the introduction of
mandatory reporting requirement, which had paradoxically resulted in a reluctance to
share information among agencies.
Part 3: The CS Parental Drug Testing Policy - what clinicians should know.
Richard Hallinan went on to sketch some basic principles which clinicians need to be
aware of. abstracted from the CS “Parental Drug Testing Policy”.
•
First, as mentioned above “serious and persistent drug use” is defined either as
drug dependency and/or heavy or binge patterns of use….. “the policy is not
intended to deal with parents whose drug use is at a low level and where there are
no concerns… that drug use is having an adverse effect on parenting capacity”.
•
A second principle is that repeated removal and restoration is harmful for children
of any age, particularly for babies and infants. Therefore a decision about whether
restoration is realistic should take no longer than six months for children under
two years of age, and no longer than twelve months for other children.
Restoration must be achieved within this time, or not at all.
•
Third, while “drug use itself does not automatically equate to risk of harm to a
child”, ..abstinence is generally an expected outcome for people with substance
dependence. Complete abstinence is not necessarily required for individuals who
meet the diagnostic criteria for substance abuse. Thus there are two scenarios with
different drug testing requirements:
Prior to removal of a child:…. “serious and persistent drug use supports
removal…. low or reduced drug use may support the child remaining at
home.” ie full abstinence is not required.
2. Prior to restoration and following restoration: “Abstinence is a
requirement ….. after the agreed period of stabilisation in treatment, a
positive test result at any time during the testing period means that, as a
general principle, restoration should no longer be considered as an option.
This principle is the core of the policy.” ie full abstinence is required.
1.
•
Where a parent fails to appear for a drug test, this is counted as a positive result
and a probable indication of serious and persistent drug use.
•
How long have parents got to achieve abstinence? “Where an individual enters
treatment they require a minimum of three months to stabilise on replacement
therapies and positive tests would generally be expected over this period. ….. In
line with this advice, Community Services would only seek results from tests
subsequent to the first three months in treatment.”
Part 4: The case of Lucy & Nobby
Jeannie Minnis then presented a second case. Lucy, a 25 yrs Aboriginal woman resided
in long-term public housing with Nobby, a 28 yr old non-Aboriginal, her partner of 4
years, and their children: a 3yo son and twins 12 months old. Family members sometimes
stayed with the family. Lucy was on methadone, and used cannabis $50/day; she had
been incarcerated in 2002 & 2008 for theft. Nobby had been a State Ward, and had
frequent custodial sentences for charges related to substance use. He was on
buprenorphine and had current heavy cannabis use.
It was an unplanned pregnancy, with first antenatal visit at 12 weeks and only 2 other
antenatal visits. Lucy was poorly nourished, with hyperemesis and poor dentition.
During pregnancy reports were made to CS owing to lack of antenatal care. Travel
assistance to antenatal clinic was offered and not utilized. They were assisted with an
application for larger home. Clinicians worked together with CS, with a Case Meeting &
Case Plan discussed. Drug Health Staff noted the children seemed well cared for – clean
diapers, food available, appropriate clothing. However there were concerns about missing
medical appointments to assess Jim’s squint and appointments for twins’ developmental
checks.
The children were removed when Lucy was 28 weeks pregnant as a result of a
presentation with a ‘non accidental injury’ to one of the twins, and a birth alert was
issued. The baby Mary was born at 38 weeks, after placental abruption during labour, 2.5
kg (5th percentile) HC 31cm (<1st percentile) and Apgar 7:9.
Mary was assumed into care on day 1. Lucy and Nobby were anticipating this. They
visited her in nursery until she was discharged to a foster home at 6 weeks of age. The
other 3 children are now in “out of home care” together and Mary is in another foster
home. Lucy and Nobby have not met the requirements for restoration of their children
This painful story required little discussion: while no-one could fault or challenge the
objective decision to remove the children, the resonance with previous generations of
Aboriginal “stolen children”, the painful realities of intergenerational disadvantage, and
in both Jack’s and Nobby’s cases of intergenerational removal into “out of home” care.
Jeannie pleaded for us to advocate for building the capacity of service providers to
engage vulnerable families, addressing the barriers preventing vulnerable families from
engaging with services, building stronger links between services and developing a
systematic outreach capacity to reach vulnerable families and lobbying for adequate
resourcing of Community Services to enable antenatal engagement for all families with
identified prenatal risk of significant harm. In relation to the last, Olwyn Neill’s Clinical
Issues Unit started with only 2 staff: there are now 6, serving the entire state of NSW.
Part 5: A “hypothetical” case - Jetty
A final brief “hypothetical” case study rounded out the evening. Imagine the following.....
You are a nurse at an opioid treatment clinic. Your patient Jetty is a 38yo woman on
MMT who has recently given birth to her third baby. Prior to pregnancy being
established she had been using amphetamines and heroin. Jetty’s 2 previous children had
been taken by DoCS a decade ago.
In the pregnancy there was early referral to Perinatal & Family Drug Health and to CS,
good compliance with antenatal care and no evidence of illicit drug use for >6 months.
However Jetty’s baby suffered a serious medical complication at birth and remains in
hospital 4 weeks later. Jetty is being dosed with methadone at the hospital as she is
staying in quarters there.
Today, Jetty appears at your clinic distressed saying her baby was assumed into care by
CS yesterday, citing a urine test taken some 3 weeks prior at your clinic, which was
positive for 6-monoacetyl morphine. She denies using heroin and says she was unaware
of the urine test result. Urine tests are not compulsory at your clinic. The urine tested
negative for quetiapine, a medication Jetty has been taking in high dose for some years
(as a “mood stabiliser”).
Later that same day, an officer from CS calls & asks for a copy of the urine test result to
be faxed, stating CS were notified about the urine test result by phone, but the officer
cannot say by whom. There is no record on Jetty’s medical file of this urine test being
reviewed by a doctor, discussed with the patient, or notified to CS. There is no ROSH
assessment on file.
Questions arising:
Q: Is a health care provider exempted from provisions of the Privacy Act if information
provided to CS is not covered by documented ROSH or a Section 248 request?
A: Olwyn Neill was able to assure us, the provider is exempt under new legislation.
Q: Should information about urine toxicology be provided to CS without formal review
of the results by a medical officer/ discussion by the team?
A: Professor Paul Haber stressed the pitfalls of interpretation of urine toxicology, and
argued that there should be greater expert medical input into this stage. Also the CS
website states “Where appropriate, a client should be informed that information about
them is being disclosed to another agency so long as this does not place the child or
young person at further risk. Keeping the client informed is part of best practice case
management and helps to maximise client engagement.” So ideally the mother should
have been advised of this urine test before it was communicated to CS.
Q: Should information about urine toxicology be provided to other health care providers,
who might then provide it to CS?
A: At least it seems prudent to consider this possibility before passing such information
on to 3rd parties.
Q: What is the correct response to the scenario above where no known person has
reported confidential patient information to CS?
A: All such communications ought to be documented formally. If this is omitted in error,
it is possible to document this retrospectively. One response from the audience was, the
problem of non-documentation notwithstanding, we should be encouraging, not
discouraging, inter-agency communication (Jennifer Holmes, MSIC). Another participant
was less complimentary about CS commitment to a broad view of circumstances when a
single urine test is considered grounds to prevent restoration of a child.
Closing words from Olwyn Neill: ‘--it takes a community to raise a child’. Substance use
can be the final outcome of societal and personal trauma. This trauma cannot be resolved
by dealing with substance use alone. The challenge is to address the well being of the
entire community whilst at the same time addressing the need of the individual who is
misusing a substance.
http://www.shoalcoast.org.au/publications/9-the-childrens-court-care-my-child-andme.html