Download Medical Neglect

Medical Neglect
What does this case teach us?
Medical Neglect
• Encompasses a parent or guardian’s delay or
denial in seeking health care for a child
• Includes
• Failure to provide or allow needed care as
determined by appropriate health care professional
• Failure to seek timely and appropriate medical care
for a serious health condition any reasonable person
would have recognised as requiring treatment
• Can include not seeking preventative treatment also
e.g. preventative dental care and immunisations
Background
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11 year old boy
Diagnosed with Ulcerative Colitis 2yo
UC managed with medication
Unwell with recurrent flare-ups from 2-4yo, associated
with steroid weaning
Relatively well from 4-10yo (6 years). No flare-ups.
Normal colonoscopies.
Poor growth (height & weight) from age 2 years
Long standing poor diet – lots of fried foods, poor
nutritional value, didn’t attend dietician appointments
Well known to gastroenterology team (RCH), seen same
specialist since diagnosis
Background
• Overall outpatient appointment attendance was OK
• Missed 2 consecutive appointments btw March & August 2010
• Missed 3 consecutive appointments btw April 2011 & January
2012
• Missed 2 consecutive appointments btw May & October 2012
• Missed 2 consecutive appointments btw October 2012 & May
2013
• During most recent prolonged flare-up (started July
2014) mother cancelled 2 appointments – October
2014 and January 2015.
• Only attended GP for referrals
• History of anxiety especially around medical
procedures – therefore deferred iron infusion because
of anxiety associated with IV insertion
Background
• For the 6 months prior to admission recurrent UC flare-ups
requiring steroid treatment and hospital admissions in Sept &
Oct 2014
• Poor school attendance, at time of assessment hadn’t been
since Term 3, 2014
• Brother, who has no medical problems wasn’t attending either
• Lives at home with mother, younger brother and step-father
• Mother has history of anxiety and depression, chronic pain,
abusive partner, drug use, Child Protection involvement when
she was child
• Mother not able to identify his diagnosis (UC, Crohn’s or
irritable bowel)
• Mother stated no education about condition
• Mother unable to recall hospital admissions for flare-ups in
2014 (September & October)
Hospital Admission
• Admitted 16th February 2015 after outpatient attendance
• Last attended outpatients on 5th December 2014
• Cancelled Outpatient appointment on 30th January 2015
because sick, was advised still to come by treating doctor
• Unwell for the 3 weeks prior to admission – “flu”, “impetigo”,
“mouth ulcers”
• Mouth ulcers for 2 weeks and unable to eat over this time
• Unable to get out of bed for 2 weeks except to go to toilet
• Symptoms over the 3 weeks included diarrhoea, vomiting,
mouth ulcers, leg ulcers, weight loss
• Did not attend GP
• Applied cream to legs left over from brothers impetigo the
previous year
Hospital Admission
• Taken to Resuscitation Bay from Outpatients.
• Febrile, tachycardia (HR), BP, emaciated, pale, cap refill
>2sec (ed), leg ulcers.
• Admitted to ICU for 5 days – for stabilisation of fluid status &
electrolyte abnormalities
• Death possible as result of electrolyte abnormalities
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Potassium
Sodium
Anaemia
Calcium
Treated for flare of his UC – antibiotics, steroids, pantoprazole
Required blood transfusion x2
Fluid + Potassium replacement
NGT feeds started, initially nil orally.
Hospital Admission
• Vitamin blood tests – many deficiencies (Vit A, Vit D, Vit
C, Zinc)
• Vitamin supplements – Vit K, Vit A, Vit D, Thiamine, Folic
Acid, Zinc, Phosphate, Iron infusion
• Very low bone density
• Seen by inpatient psychiatric team
• VFPMS contacted by SW 10 days after admission
• Discharged home on NGT feeds plus normal diet, vitamin
supplements, steroids, immune modulating agents
• Child Protection involvement, discharged into mother’s
care
Case Specific Alerts
• Many of the below factors on their own may not raise
concern but when present together neglect needs to
be considered
• Not seeking appropriate medical care
• Mother’s history of drug use and mental health issues
• Missed outpatient appointments – especially increased
frequency
• Not following through with referrals eg to dietician
• Poor diet in child who had poor weight gain
• Chronic illness in child + anxiety to medical procedures
• Low soci0-economic background/financial hardship
• Mother’s apparent poor understanding of child’s illness
• Poor school attendance/school not aware of medical
condition
• Not seeking mental health care
Other Types of Neglect
• Physical\Environmental
• Nutritional – poor growth, poor diet
• Emotional
• Maternal drug use
• Lack of school friends
• Educational
• Lack of school attendance
Factors Limiting Recognition/Response
• Long standing relationship with patient & parent –
“adequate parenting”
• Not wanting to disrupt patient-doctor relationship, will
they stop coming all together
• Not always aware social situation eg financial stressors,
non school attendance
• Not wanting to seem to judge family
• Time poor – therefore focus on essential components of
appointment eg symptoms of UC/medications
• Lack of awareness of VFPMS role for inpatients?
WHERE TO FROM HERE?