Medical Neglect

1
Medical Neglect

• What does this case teach us?

2
Medical Neglect

• Encompasses a parent or guardians 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

3
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, didnt attend dietician
  appointments
• Well known to gastroenterology team (RCH), seen
  same specialist since diagnosis

4
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

5
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
  hadnt been since Term 3, 2014
• Brother, who has no medical problems wasnt
  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,
  Crohns or irritable bowel)
• Mother stated no education about condition
• Mother unable to recall hospital admissions for
  flare-ups in 2014 (September October)

6
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

7
Hospital Admission

• Taken to Resuscitation Bay from Outpatients.
• Febrile, tachycardia (?HR), ?BP, emaciated, pale,
  cap refill gt2sec (?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.

8
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
  mothers care

9
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
• Mothers 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
• Mothers apparent poor understanding of childs
  illness
• Poor school attendance/school not aware of
  medical condition
• Not seeking mental health care

10
Other Types of Neglect

• Physical\Environmental
• Nutritional poor growth, poor diet
• Emotional
• Maternal drug use
• Lack of school friends
• Educational
• Lack of school attendance

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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?

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Where to from here?