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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 • • • • • • • • 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 • • • • • • • • 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?