* CHRONOLOGY * * Second Trimester * * Mother attended her community drug and alcohol team (CDAT) were she was on a methadone programme. Referral was made by her key worker stated concerns that she may be pregnant and concealing it * * Pre - birth conference was held to establish the issues surrounding the mother, her pregnancy and her parenting skills. Mother did not attend. The pre – birth conference attended by the CDAT key worker, safeguarding midwife, health visitor, GP, social worker. The pre – birth conference took place as mum was concealing her pregnancy and that she was heavily * * DAY 1
Jack was born by caesarean section because they were concerns with the Zoe. Zoe was unwell – she had a heart valve problem. Jack was admitted to the intensive care unit, needing ventilation support for six hours
12pm
* Safeguarding midwife aware that Jack been born, states that all people who needed to be aware of baby being born are. Informed us that her current partner and father of baby are not allowed to visit. Security, front desk at the main entrance of unit and nurses made aware * Urine virology/toxicology sent * Morphine started as Jack was Ventilated due to the respiratory distress
15pm
* Out of hours social worker called inquiring about baby and mum
1630pm
* Maternity support worker visited unit, updated on baby’s condition. Mum had her surgery – she will go and update mum
1830pm
* Nurse looking after mum on ITU informed us on mum’s condition. Nurse informed us of name of mum’s current partner who is aware baby is born – nurse said he sounded concerned

DAY 2
15pm
* No signs of withdrawal

DAY 3
14pm
* Duty social worker given us the details of named social worker who is aware baby is born. Asked how long baby is expected to be an inpatient – informed likely 2 – 3 weeks possible longer however should be prepared for him to be discharge soon. Named social worker fax all current documentation relating to the care. Stated social services will apply for an inform care order
18pm
* Withdrawal score 3 -4 * Second toxicology sent

DAY 4
12pm
* Jack started on oral morphine as second toxicology came back positive * Withdrawal score 4 -5
14pm
* Advised that social worker and foster carer would visit baby * Baby social worker visited. Plan is to initiate care proceedings ASAP reasons; history of substance misuse, concealed pregnancy, poor engagement with treatment and services

DAY 8
18pm
* Mum visited for the first time, had a cuddle with Jack

DAY 10
19pm
* Mum visited twice during day, had a cuddle with jack for an hour
22pm
* Midwife rang saying mum on her way to visit, left the ward 10mins ago
2230pm
* Mum phoned saying unable to visit as she planned because she in too much pain

DAY 11
16pm
* Mum visited for 15mins, asked how baby doing, had a cuddle. Mum wasn’t very clean, smelt overwhelmingly of cigarettes. She said she got visitors coming but didn’t say who. Beware of who and who not allowed to visit

DAY 12
Discussed at weekly social meeting, it was discussed how Jack was doing and the parental involvement. Mum was not engaging with the nurses, she showing very little interested in getting involved in Jack’s care. Social worker to get in contact with the named social worker t discuss where they are in the process of taking over care, and weather they found suitable foster care
DAY 15 – 20
Jack was discharge into the care of social services. A suitable foster carer was found, they was interacting and engaging well with Jack and members of the team. Mum was only allowed to have supervised times visits. Jack remained on oral morphine.

In the essay, I am going to discuss and analyse the decisions taken and processes used in relation to an identified child where they were concerns that the child might be ‘in need’ or ‘at risk’. It will include a chronology and proposals to improve the ‘safeguarding’ within the clinical environment. Due to the word limitation, the discussion will focus on the safeguarding the premature baby rather than the other siblings. Relevant issues involved in this particular case domestic violence, and neonatal abstinence syndrome (NAS) will also be discussed.

Throughout the essay confidentiality and anonymity of all aspect of the care provided for the baby will maintained by disclosing the trust, staff and the patient and their family involved. “Nurses and midwives have a duty to protect confidential information. The person who is in the care of a nurse or midwife has a right to believe that information given to them in confidence is only used for the purposes for which it was given and will not be disclosed to others without permission” (NMC 2007) Confidentiality would be addressed in accordance with the Nursing and Midwifery council guidelines. Names of individuals, hospitals and local authorities involved have been changed.

In the United Kingdom, the overall health, safety and well-being of a child takes priority hence the provision of many programmes like the Every Child Matter: Change for Children and the Children’s Plan: Building Brighter Future. Every child matters is a Green Paper which was published by the government in 2003. It outlines the government’s approach to the well-being of children and young people from birth to the age of nineteen. The publication was alongside to the formal responses to the inquiry into the death of Victoria Climbie (Lord Lamming 2003) The Children’s Plan takes care of the collaborative partnerships among other local agencies and provides services and improvements for all children and young people (www.dcsf.gov.uk/everychildmatters). In local trust particularly in the neonatal unit, processes are undertaken to safeguard children under its care. These are governed by the Children’s Act 2004 as cited in Waterman et al (2004) to protect and safeguard all children in the United Kingdom. In the year 2009 they had been reported a total of 538,500 referrals of children identified as ‘at risk’ of maltreatment to social service departments (Thain 2009)
Zoe was a thirty four old who was unemployed lived in hostel accommodation. She was a known drug user who remained chaotic. She was regularly injecting drugs (heroin) into the groin, consuming excessive amounts of alcohol and she had history of criminal activity in the form of shop lifting. Her three older children were taken into care, Zoe was in unstable relationships. They were concerns relating to domestic violence in which the last incident occurred in July 2010, were the partner spent some time in jail. It was unclear of who the father was of her fourth baby. Zoe gave birth to Jack.
A referral was made to the relevant child protection authority from the community drug and alcohol team (CDAT), which Zoe was under because they were concerns that she was highly dependent on drugs while they was the possibility that she was pregnant however it appeared she was concealing the pregnancy. The child protection authority were informed of Zoe’s use of alcohol and drug use as well as Zoe being put onto the methadone programme which is designed to help her with her opioid dependence. Substance abusing woman are at high risk of experiencing multiple problems that may undermine their ability to care for their children. These included depression, increased exposure to parental and partner violence, sexual abuse, psychiatric disorder, violet behaviour and criminal behaviour (Schuler and Nair 2001) Any one or a combination of these factors can increase risk for poor parenting, placing the child at risk of poor development and behavioural and child neglect and/or abuse (Miller and Stermac 2000) It is noted that there is a considerable body of research showing that children who grew up in families where there is domestic violence and/or parental alcohol or drug misuse are at increased risk of significant harm (Kroll 2004) It is generally known that family environments are usually disrupted. It has been estimated that 30% of child abuse cases involved alcoholic parents and 60% of domestic violence cases have occurred when the perpetrator was under the influence of alcohol (Collins and Messerschmidit 1993 cited Dube et al 2001) Parental substance misuse can adversely affect attachment (Flores 2001) family dynamics, relationships and functioning (Cleaver et al 1999 cited Kroll 2004) and significantly increase the risk of violence.
The drug misuse was seemed to cause significant harm to the Zoe unborn infant. “Significant harm is defined as a situation where the child is likely to suffer a degree of physical harm such that it requires a compulsory intervention by child protection agencies” stated from London Child Protection Procedures (LCPP 2007). With the recognition of significant harm it was important to start to initiate the safeguarding referral process as early as possible. In the study done by Forrester (2000), it was found that substance misuse was an issue in 52% of cases and in their analysis of the care plans of 100 children Harwin et al (2003) found it a major factor in care proceedings for 40% of their sample of children subject to care orders.
From the referral being made it was decided that a Pre-birth conference and core assessment was needed. A pre – birth conference is considered an initial child protection conference concerning the unborn child, identifying major risks factors such as mental health illness, learning disabilities, substance misuse and domestic violence and is timed well before the due date of delivery to allow sufficient time for planning (London Safeguarding Children Board 2007) Pre – birth assessment and conference can be easily be subjected to scrutiny because of how comprehensive it is and how well it is designed to each and every single safeguarding case however the assessment is a huge component for the whole safeguarding process. With Zoe current situation as well as her pervious history it was essential to undertake a thorough initial assessment for her unborn baby under The Framework for the Assessment of Children in Need and their Families (Department of Health, 2000) The framework has three integral components; the child’s developmental needs, parenting capacity and family and environment factors. The assessment framework provides a detail tool for the assessment of children and their families. The framework is intended to be used by all practitioners to help and guide them when making decisions about a child and family however the framework is not intended to delay the provision of services if a child or family is recognised to be in need of any form of service provision during the assessment progress, they should be instigated immediately and should not wait until the assessment is complete (DH 1999) ) It was clear at this point that a thorough assessment needs to be undertaken to ensure that Jack would be safe from future maltreatment or neglect.
Street et al (2004) states that children of substance abusing parents are at greater risks of child abuse and neglect where’s Dube et al (2001) stressed that children raised in homes where parents are regularly taking drugs and alcohol are more likely to have problems with brain development and learning difficulties with emotional control, behaviour and social adjustment. Zoe’s social worker reported in the pre – conference that Zoe’s oldest son has serve learning difficulties as well as behavioural problems, finding it difficult to make attachments.
A pre – birth plan was devised following the pre - birth conference. The panel that sat on the child protection conference included Zoe’s drug and alcohol keyworker, social worker, safeguarding midwife, GP and police worker. The planned identify key elements in how to help Zoe and her unborn baby, which Zoe did not engage with, putting her unborn baby at risk.
Following a second meeting, the Child protection investigation case presented that it would be in the best interest of the unborn baby being removed from Zoe care at birth. McBride (2002) states parents who misuse substances may interact poorly with their children, inconsistent and/or emotionally unresponsive and may live a lifestyle of chaos and lack of routine. Zoe was not engaging with the supporting services, she was not attending conference meetings as well as the antenatal checks and classes. Her history in caring for her pervious children and remaining to be chaotic while pregnant was taking into consideration. All which was seemed will be a high risk of significant harm. Harm is defined as the impairment of the child’s health or development. The question of whether the harm is of sufficient degree to be considered ‘significant’ is measured by comparison with ‘that which could reasonably be expected of a similar child’ (Meadow et al 2007) Parents who misuse substances may interact poorly with their children, inconsistent and/or emotionally unresponsive and may live a lifestyle of chaos and lack of routine.
Taking all this into consideration, it was appropriate for every single practitioner at the pre-birth conference to raise their concerns regarding the parental capacity. The input of the social worker, substance misuse nurse, health visitor, safeguarding midwife, the police play an important role in identifying risks as well as needs. It also allows for good inter-professional relations and communications (Hughes, 2009) A well written pre – birth conference summary of assessment and plan, clearly stating the objectives and how they planned to meant disseminated to all relevant practitioners should ensure everyone to keep focus on their aims to keep the child safe and protect the best interest of the child (DH, 1995)
Zoe give birth to a baby boy named Jack. Jack was born prematurely at thirty two weeks, weighing 1.3kg. Jack was admitted to the neonatal unit because of prematurity, low birth weight and respiratory distress which was secondary to Jack being born prematurity and by caesarean section and the possibility of neonatal abstinence syndrome. He was initially treated for respiratory distress requiring ventilation. Hamden (2009) defined neonatal abstinence syndrome as a complex disorder composed of behavioural and psychological signs and symptoms relative to the causative agent. He divided it into two categories: parental or maternal use of substances which results in a withdrawal symptoms in the new-born and postnatal neonatal abstinence syndrome secondary to discontinuation of drugs for example morphine, fentanyl which are used in pain therapy. Jack’s case came under maternal substance misuse. On day four Jack was showing signs of withdrawal. His withdrawal score was three to four, a few typical signs which can persist for two – three weeks after birth and in the sub-acute stage for four – six months (Kouimtsidis and Baldacchiono 2003). Jack began to show signs of irritability, hypertonic, jitteriness, poor feeding and high pitched cry which all linked to signs of neonatal abstinence (Campbell 2003)
Street et al (2004) found that from the 68 participating woman, of the infants born to those woman 67 (99%) went onto display symptoms of signs of abstinence syndrome of which 5 (7%) had fits and 26 (38%) required treatment with morphine in which 20 (29%) of these for more than seven days. Two of the case infants were born with down syndrome (Street et al 2004) The risks of neonatal withdrawal is greatest with narcotic drugs, but has been reported in neonates following exposure to alcohol, cocaine, nicotine and amphetamines. In view of maternal history, consent was obtained to test jack’s urine sample for toxicology. Second urine toxicology was sent was sent on day three. Comprehensive screening of all new-born’s has been suggested but it not currently desirable, given concerns about cost and privacy. So infants are selectively screened for the presence of drug to confirm a diagnosis of NAS when the mother’s history of drug use is confirmed or suspected, to evaluate for the presence of additional drug exposures, or to evaluate unexplained symptoms suggestive of withdrawal. The presence of maternal drugs can be detected in neonatal urine, serum hair and meconium samples. Urine sampling is the most frequent performed study, although its sensitivity is limited (Greene, 2003)
Jack urine toxicology result tested positive to heroin and cocaine which explained Jack’s withdrawal from maternal drug abuse. Johnson et al (2003) stated that the severity and the onset of symptoms is usually dependant on what type of substances a mother takes during their pregnancy. The amount of alcohol and drugs Zoe took while pregnant cannot be identified. Jack was started on oral morphine sulphate; dose prescribed was in accordance with the medicine formulary. Jack’s withdrawal was closely observed and monitored using the withdrawal chart. He was weaned from the oral morphine appropriately. Problems of communication seem to haunt professional practice. Since the 1970’s virtually all reviews of fatal child abuse cases in the United Kingdom report that they was evidence of communication failure between professionals (Lord Lamming, 2003) Sinclair and Bullock (2002) prepared on behalf of the Department of Health a reanalysis of 40 randomly selected child abuse case reviews in the UK (now to be called ‘Serious Case’ Reviews instead of ‘Part 8’ Reviews). Among the communication problems they identified were inadequate sharing of knowledge because practitioners lacked an understanding about issues of confidentiality, consent and referral processes. An uncertain knowledge-based therefore impacted on inter-professional communication.
In line with unit policy unit policy, the neonatal nurse in charge on the day that Jack was born, made the neonatal unit’s child protection link nurse and the safeguarding midwife aware of Jack born, updated on the babies condition and progress as well enquire on how we can facilitate the safeguarding process following his birth. As the nurse in charge was communicating with the different people involved in the safeguarding process I started filling out the safeguarding children pro-forma and identified the key people involved in Zoe and Jack’s care with regards to safeguarding. The pro-forma is used trust wide to identify the vulnerability of Jack as a child. The form is attached to the medical notes. A social form was created to write any contact or interactions we had with Zoe, and other members of the multidisciplinary team involve in caring for Jack. Documentation of parental involvement was strongly emphasized because there is a possibility of neglectful behaviour on the most substance abusing parents as identified by Kroll (2004)
As Jack’s nurse, my role was to liase with the safeguarding midwife the hospital trust and the midwife caring for Zoe. This was to identify what were the potential risks factor’s involved in the care of Jack especially in relation to drug withdrawal. Communicating with the safeguarding midwife and the midwife in charge of Jack was extremely helpful in identifying potential risks involved and the available resources that can be utilized to best support Zoe.
During the discussion with the safeguarding midwife it was brought to the attention that Zoe has been a victim of domestic violence. Zoe was not communicating and engaging with the services so it was difficult to clarify certain things as well as discussing particular things. It was agreed at the pre – birth conference plan that because they was history of domestic violence and the uncertainty of who was Jack dad that no male visitors were allowed. It is difficult to determine the precise incidence of domestic violence because most cases were not reported. In the United Kingdom, they were an estimated 6.6 million reported cases of domestic violence in 1995 (Mirrless-Black 1999) In the United States, approximately 5.3 million cases of intimate partner violence occur every year among woman over 18 years of age. 324,000 of which were during pregnancy (Kramer 2007) Every woman of any socio-economic stats and educational background are vulnerable to abuse by their partners during pregnancy. Woman with unintended or mistimed pregnancy reported 2.5 times the abuse of intended pregnancies (Schoffner 2008) It was mentioned in the shift hand, informed the receptionist at the front desk and security over how Jack was not allowed no visitors. If they was no receptionist covering the front desk then it would be covered by a member of security
Even so social services were starting legal proceedings into taking over care of Jack they allowed Zoe to have supervised visits which was overseen by the nurses caring for jack. Zoe did not visit Jack until day eight of him being born, she did have a major heart operation following the caesarean which was taken into consideration. On her first visit to see Jack, Zoe was not interacting and engaging with me well. She just wanted to do her own thing, responding to my questions with just one word answers. I found it difficult to interact or build a relationship with Zoe. Zoe was treated like any mother who needed parenting support and not to focus on her drug/alcohol misuses. Good professional support during the post-partum period enables the mothers to adjust and cope with their new life that their infant will bring them and eventually make them good parents (Wiegers, 2006) Child abuse can take many forms which emphasises the need and necessitates accurate and timely communication between all members of the multi-professionaling services at all stages of work with children and families is needed.
Social services agencies both in the USA and the UK both prefer and are mandated to look to the extended family as a first part of call where children are taken out of the parental care (Kelly 1993 cited Barnard 2003) Grandparents and other relatives have long been stepping into breach were parents have difficulties in providing the full care of their children. The informal support offered by the extended family can be crucial in keeping families intact and in keeping children safe and well through hard times. In families were parents have drug problems however the evidence suggests that the hard times may last indefinitely (Kroll and Taylor 2002) with substantial numbers of relatives taking on the long term and often sole care of the children (Barnard 2003) From the information that social services had, they only had the name of Zoe sister as she was her next of kin. They only her name which meant that they were unable to trace. Zoe oldest son is currently in care however when he was first removed from Zoe’s care he was being looked after by an uncle. The oldest son soon developed learning and behavioural problems which the uncle found difficult to manage hence why he went back into the care of the local authorites.
The true extent of drug use in the United Kingdom population is difficult to determine. The recent inquiry by the Advisory Council on the misuse of drug estimates that there are between 25,000 and 350,000 children of problem drug users in the UK (inquiry by advisory council on the misuse of drugs, 2003) They state that reducing the harm to children from parental problem drug use should become a main objective of policy and practice. However drug use does not necessarily
Parenting can be difficult and demanding, and there is no signs, right way to bring up a child however in some instances children are not being cared for or brought up adequately (DH 1999). It is important to remember that we live in a multicultural society and difficulties can arise when considering the influence of culture on parenting skills and styles. The DH (1999) states that irrespective of culture, that children should have the opportunity to achieve their fully potential.
As nurses working in acute setting, everyone who comes into contact with children of families during their everyday work has a responsibility to protect and promote the wellbeing of children. If any practitioners has concerns about a child’s welfare, detailed advice is given about these concerns should be raised, with whom they should be discussed and further action that should be taken it necessary (DH 2003) This involves ensuring that we safeguard and ensure a child’s; physical , mental and emotional wellbeing, educational opportunities, living arrangements, accommodation, ability or care for themselves and cope with everyday life and sense of identifying including cultural and racial identify
Chudleigh (2005) recognises that safeguarding issues are complex to deal with. As nurses working in the neonatal intensive care setting we are often faced with this challenge. The unit advocates the philosophy of family centred care where all members of staff, medical and nursing staff always encourage parental involvement in the infant care giving and an open communication with parents. Griffin (2006) wrote the design of the neonatal intensive care unit – should not interfere with its implementation of family centred care approach to benefit not only the families and the patients but also the staff. As nurse’s we should know who is our link nurse, midwife and consultant within the trust. As part of mandatory training we should continue to have sessions on child protection so we are kept up to date on new cases, recent changes and publications/policies.
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