Protecting ChildrenMartin Smith Recovery Lead

Master slide option 1

Date10/11/2015

Background BDS12Mother was 33 and had been in treatment since 19986 separate episodes of treatmentTwo children, one aged two and half and one who was 18months oldHer partner didn’t use drugsLived in ripleyCrossed border for prescribing

Incident• On 12th March 2012 parents call 999 and ask for BDS

to be admitted to hospital as he’d ingested methadone

• BD was pronounced dead. After autopsy cause of death was given of methadone toxicity.

Multiple Explanations for the cause of death

• Methadone put in child’s cup and left on bedside table for mother when she woke.

• Accidental administration (parent’s explanation)

• Methadone decanted into child beaker to sell and left beside bedside.

• Accidental administration (Sub Mis evidence)

• Methadone routinely given to the child• Deliberate administration (prosecution explanation)

What was happening?• Methadone storage box had been given to SD prior

to birth of BDS along with information which she’d signed to say she understood.

• Attended Appointments/Good engagement• Methadone pick ups x 3 weekly• Presented well• Supportive Grandparent• Testing

Baseline Audit• 543 parents in treatment • 476 On Methadone (88%)• 67 On Buprenorphine (12%)• 289 Of The Methadone Parents Were Taking Their

Meds Home

• Over All Population on Buprenorphine (187) 97 testing negative on a consistent basis

Action Plan• Home Visits to ensure every parent had a storage box• Training for all staff• HV Training Neo Natal addiction• Joint assessments (HV)• System One• Once per month joint team meeting dedicated to social

care issues (SW&HV)

Parenting Group• Kickstart to manage group programme for parents.

( Crèche for children)• Environment: Away from clinical services in a recovery

centre (Exposure to other activity)• Prescribing for this group to occur in the recovery

centre,On-going Have we got the right facilities for women and parents?

Prescribing• Decisional check list for prescribers (Parents)• Other options to be encouraged beyond just methadone

(safest form)• New prescribing environment (exposure to people in

recovery)• Prescribing changes to be communicated with all

agencies not just the GP.

Methadone Soothing• During the course of the review it emerged that there

may have been a view among some drugusers that the practice of giving drugs to babies to calm them down was appropriate and possibly widespread. (A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011)

• Adfam Report 2014 Adfam Report 2015• Disclosures and testing and hair strand testing showing it

is more common than we like to acknowledge

2014

• SCR Oct 14Death of a 2-year-7-month-old boy Child T by drowning. Mum fell into a drug-induced sleep

• for about two hours, after putting him in the bath. Test results showed heroin, cocaine and cannabis,

• along with diazepam, temazepam, nitrazepam, methadone, tramadol and the painkiller pregabalin.

2014• Blackpool toddler death: Sophie Jones ingested met

hadone – BBC Nov 2014

• Mother charged after son's methadone poisoning death (Birmingham) Sept 2014

• A WOMAN let a toddler drink enough methadone to kill an adult – then tried to stop a 999 crew rushing the unconscious child to hospital. Oct 2014

http://www.scotsman.com/news/health/big-rise-in-babies-hooked-on-drugs-before-birth-1-3939194?#axzz3qhrWDMah

Baby left home alone and syringe found in kids' clothes at Derby house

Read more: http://www.derbytelegraph.co.uk/Baby-left-home-drug-needle-kids-clothes/story-28116406-detail/story.html#ixzz3qilsQ2AD 

Suspended jail sentence for dad who failed to raise alarm after his baby son drank heroin substitute

National SCR Messages• SCR from 14 years ago :Poor information sharing.

The need for child protection training. More joined up working.

• SCR in 2014: Poor information sharing. The need for children protection training. More joined up working.

Recovery=Honesty&Courage• Has a sector do we reflect this?• Lets not shy away from difficult challenges?• increase in DRDs 2013 and 2014 ONS• Hep C testing and Treatment• Older generation, end of life conditions• Children and Methadone• There are around 400 adult deaths involving

methadone per year.• More deaths in Scotland due to Methadone than

heroin