A mother and her two young children present to surgery for a review of one child's eczema. The mother tells you how bad the eczema has been and that her daughter's skin is often red and inflamed, and constantly itchy. However, you notice the mother has not taken the child to three dermatology appointments at the hospital and has had no prescriptions for her daughter's eczema from your surgery for the past six months, despite these medications being on a repeat prescription. On further questioning, the mother denies receiving any hospital appointments and states that she has a surplus of creams at home so did not need more. None of the children has attended for childhood immunisations. Their mother says she had forgotten about these.
A GP's response
Dr Tillmann Jacobi is a GP in York
There are several concerns - a dysfunction or potential lack of care regarding a chronic skin condition of one young child, forgotten immunisations for two children and potential inconsistency about the surplus of cream.
The mother's reaction to your questions and information can give important indicators regarding her awareness and her own concerns.
If she appears dismissive, defensive or apathetic, you will be worried about possible neglect and need to be able to tell her this unambiguously, and explain it is your professional duty to act on this.
The GMC expects you to protect and promote the health of patients and the public and, particularly, the safety or welfare of a child.
Are there any possible concerns raised by midwives, health visitors or others, who were involved with the children or the family?
Consider possible background risk factors, such as parental physical or mental health problems, or a parental history of abuse or neglect, drug abuse, poverty, isolation or domestic abuse. Be aware of religious or cultural beliefs, which may interfere with usual medical practice such as immunisations.
The mother may not have intentionally caused this situation, so it may feel difficult challenging her, without appearing judgmental or blaming. If you suspect dishonesty towards you, the situation would be more serious. Aim to communicate well, keep the parent(s) involved and point out the advantages of working in partnership.
Owing to the potential red flags, seek early advice from colleagues, such as a designated lead clinician, to help identify possible risks and discuss what to do next. Maintain clear, accurate, timely records of your concerns, communications, clinical findings, decisions and actions. A discussion with the hospital could be useful, if there is a system in place to flag up repeated non-attendance.
A medico-legal opinion
Dr Zaid Al-Najjar is a medico-legal adviser at the Medical Protection Society
Although the child has not been to the hospital appointments, the mother has clearly presented because she is concerned.
You should try to explore the mother's understanding of the disease, what is needed in terms of treatment, and whether further support is needed in obtaining prescriptions from the surgery or taking the child to hospital.
You should also explore why she has missed the dermatology appointments and not brought her children in for their immunisations. It may be that the invitations have gone to the wrong address.
The GMC advises that you should look out for signs that a family may need extra support. You should provide such support if that is part of your role, or refer the family to other services so they can obtain help.1
Children are in need if they are unlikely to achieve or maintain, or have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision of services by a local authority.1
If the mother is unwilling to engage in improving and maintaining her children's health, consider discussing matters with the child safeguarding team. Initially this should be on an anonymous basis, or you should obtain the mother's consent to disclose details, unless seeking consent would put the children at risk of significant harm.
A patient's opinion
Danny Daniels is an expert patient
The simple answer is, the doctor should pursue the welfare of these children. The difficult aspects are, the route to resolving the problems and whether anything will make a difference.
The doctor will need to undertake initial investigative work, followed by a measured approach.
Check that appointment letters were sent and acquire hard evidence that this was the case. Investigate the repeat prescriptions, to identify whether they were acquired regularly up until six months before your review. Try to estimate what would be reasonable usage of the creams. Offer the immunisations again.
It is not clear whether the mother has a partner. Has she experienced some trauma or difficulty in the past few months, which has affected her?
When the investigations are complete, the results should be documented and a meeting with the GP partners set up to discuss the case.
Following this, a meeting should be arranged with the mother and her partner, or if there is no partner, with a trusted relative or friend.
It may be in the doctor's interests to have a colleague with them as witness. As the children are young, a health visitor would be ideal.
The doctor must be clear and honest and outline the concerns. A non-judgmental approach is important.
The GMC provides information about doctors' role in protecting children and young people.2
You need to confront the mother with the evidence that you have obtained, but caution is required. It is to be hoped that in such a meeting, you may be able to unearth why the mother is behaving this way. However, the health and wellbeing of the children are of paramount importance. If you cannot resolve the situation, you will have a professional duty to refer your concerns to an appropriate agency.
1. Children Act 1989. Section 17 (10). www.legislation.gov.uk/
2. GMC. Protecting children and young people: the responsibilities of all doctors. Short guide for GPs, 2012. www.gmc-uk.org/ guidance/ethical_guidance/13257.asp