‘Graham Greene said “There is always one moment in childhood when the door opens and lets the future in.” We are responsible for opening that door,’ Joy Barlow told the Adfam/DDN Everybody’s business safeguarding conference, sharing her vision that we should refocus on the rights of the child.
The event brought together professionals with an interest in this sensitive issue and did not shy away from the challenging questions. Why were we missing signs that children were at risk? Were we aware that methadone soothing took place? How could we work more effectively with fewer resources? Why were we scared of even talking about this issue?
‘This is one of the most difficult and fraught areas of practice,’ said Barlow, who was formerly head of STRADA (Scottish Training on Drugs and Alcohol). ‘We need to incorporate respectful uncertainty,’ she said, quoting Dr Marion Brandon’s research from serious case reviews. ‘We need to demonstrate empathy and acceptance, but balance it with a healthy dose of scepticism… if the truth is not always presented to us, we have to ask why.’
Tackling safeguarding needed a fundamental shift in thinking, according to many of the day’s speakers and workshop contributors. Nic Adamson, CRI director, said drug and alcohol workers ‘often used to see it as their job to rock up and defend the client.’ But this area required a different way of working: ‘We need to learn to challenge clients’ behaviour – really challenge it,’ she said.
‘It’s a Pandora’s Box – there’s a fear in what we do,’ said one delegate, and this theme kept resurfacing, in relation to safeguarding, methadone, and the delicate issue of challenging clients and asking them difficult questions.
‘There are around 400 adult deaths involving methadone a year. Say this in the wrong room and you can be intellectually decapitated,’ said Martin Smith of Derbyshire Safeguarding Team, who brought the risks to children into sharp focus.
‘Hair testing has shown that methadone soothing is more common than we like to acknowledge,’ he said. Examples from his caseload included a child death which the mother had said was accidental, but tests had shown the child had been routinely given methadone: ‘A methadone storage box had been in place, she attended appointments, her engagement was good, there was a supportive grandmother – she gave the picture that all was OK.’ In another case, ‘a woman let a toddler ingest enough methadone to kill an adult’.
‘We lack honesty and courage as a sector – let’s not shy away from difficult challenges,’ he said. ‘It’s really hard to hear the bar is so low in certain areas… we’ve all got work to do.’
Austerity is ‘the spoiler’ that leads to ‘the deadening hand of conflicting priorities’, Pete Burkinshaw PHE
Rachael Evans, policy and research officer at Adfam, brought evidence from case reviews that the charity had examined to produce the new report, Medications in drug treatment: tackling the risks to children – one year on. The main findings confirmed that there was insufficient appreciation of the dangers of OST by parents and professionals, and critical issues around safe storage. Practitioners were struggling to accept the idea of intentional administration of OST and felt that having these conversations might risk disengagement.
‘We’re so busy we forget to ask the right questions,’ commented Sue Smith, CRI’s national safeguarding lead. ‘But we need to challenge… it’s our role.’
‘I was bemused and shocked that my staff used to struggle around asking about safeguarding,’ said Birmingham commissioning manager, Max Vaughan. But, he added, ‘the combination of policing and being supportive can be really difficult.’ It was about confidence, suggested one delegate, adding ‘It shocks me that other agencies say “how do we ask those questions?” You just do. You have to.’
So apart from asking the right questions – about drug and alcohol use, drug storage, and making sure that risks to children were minimised – what were the key areas for improvement? Better engagement between all of the professional partners involved with the family came high on the list.
In Birmingham, the safeguarding structure involved team leaders, who had been fully trained in safeguarding , providing real-time updates to social workers, explained Micky Browne, CRI’s safeguarding lead. The Multi-Agency Safeguarding Hub (MASH) not only improved collaborative practice, but it also reduced inappropriate referrals, he said. ‘The better agencies work together, the more efficiency will develop in the long term.’
‘This is one of the most difficult and fraught areas of practice.’ Joy Barlow (below left), pictured with (clockwise) Sue Smith, Max Vaughan, Martin Smith, Carole Sharma and Judith Yates.
DS Steve Rudd, of Birmingham police, added: ‘When we sit round the Mash table now, we look a what’s happening – do police actually need to run off and lock mum and dad up? In multi-agency working we all come from a different angle. We’ve developed an understanding of where we’re all coming from and issues are very quickly resolved.’
Exchanging data that was easy to comprehend was key to creating multi-agency risk assessments, said Sue Smith. Joy Barlow believed that we needed to overturn our culture of ‘educating in silos’, bringing drug and alcohol content to social work courses. ‘You’ve got to get people together in terms of learning and development,’ she said.
The Federation of Drug and Alcohol Professionals (FDAP) were working with Adfam to develop standards and identify competencies that people working with families should all have, said FDAP’s chief executive, Carole Sharma, who added: ‘This sector has been guilty of generating mystique around ourselves. We need to undo this.’
Dr Judith Yates was hopeful that Adfam’s new report would provide focus and remind commissioners of their power to make a difference.
‘I remember the Hidden Harm report landing on my desk and it’s stayed with me,’ she said. ‘Four years ago health visitors hadn’t had training on alcohol. I hope Adfam’s report will encourage people, including pharmacists, to talk to each other.’
Inevitably the question of diminishing resources came up throughout the day, and PHE’s Pete Burkinshaw described austerity as ‘the spoiler’ that led to ‘the deadening hand of conflicting priorities’. But Martin Smith urged delegates to remember that ‘profit should never come before the needs of children’.
‘We’ve got to have courage and honesty – and we’ve got to find evidence to back up what we’re trying to change,’ he said.
Among the challenging questions fired at the panel during the final session was the issue of whether children should be trained and supported to administer naloxone to their parent in the event of an overdose. Should they be given that responsibility?
While Dr Judith Yates was among campaigners who had welcomed the recent extension of naloxone prescribing, she was worried about ‘children having to parent their parent’: ‘It depends on the age of the child,’ she said. ‘There’s something not right about a six-year-old being entrusted to save a life.’
Martin Smith said the level of responsibility was too high, while Max Vaughan agreed ‘it doesn’t feel safe or right’. Sue Smith said that it shouldn’t be entrusted to a child ‘at this stage’. But several delegates threw back a challenge of double standards, referring to the ‘stigma of this client group’.
‘Many children are left to manage chaotic drug use who haven’t had proper support,’ said one. ‘Children, whether we like it or not, are managing their parents’ drug use. We’re guilty of double standards.’
At the beginning of the day, Joy Barlow had said: ‘I’m elated at what we’ve achieved and also severely disappointed at what we’ve achieved’ in this area of practice. Adfam’s chief executive, Vivienne Evans, finished on an optimistic note by saying that workers in this field had passion and commitment, which was ‘harder than rocket science’.
‘This is hugely complex and difficult work,’ she said. ‘We need to have that optimism that we can give children the best start.’
‘I was spotted, supported and encouraged,’ Ian Day.
In an emotional speech to the main conference, Ian Day looked back to 12 years ago when he was ‘deeply entrenched in addiction’. When his partner became pregnant he made a decision to be ‘a great dad’ – but nine months later he was in prison. ‘We slipped through the social services net,’ he said. ‘They had to be the enemy. But we were difficult people to work with.’
With his daughter taken into care he had spells of homelessness before being introduced to treatment service by an old friend, who was in treatment now herself and ‘looked good’. This is where ‘interventions came into play… it was a small window of opportunity to help a person. I was spotted, supported and encouraged’.
Six months out of treatment, he approached social services to try to win custody of his daughter who had been taken into foster care. He was ‘not, on paper, the person you’d give custody of a child to’ – ‘at that time the reaction was “you’re male”, I had nowhere to live and I hadn’t seen my five-year-old for three years. So I had to prove I could be that person.’
Securing a flat took two years, during which time he was tested continually by the agencies involved.
‘I had to see my daughter in a room with a person taking notes – I was very nervous,’ he said. ‘I got enrolled on courses and at the time it felt very demeaning – they asked very obvious questions. It was very frustrating, but looking back it was the right thing because of my previous history.’
With ‘all of the agencies speaking to each other throughout’ he had his day in court and won custody. Now settled with his daughter and current partner of six years, he says he is grateful for the ‘safe environment’ created by agencies working in partnership, which led him to an outcome he never dreamed possible.
A grim picture
Adfam’s new report shows children are still dying after ingesting medications used to treat drug addiction. Its author Rachael Evans, Adfam’s policy and research officer, shares findings
Adfam has particularly focused on safeguarding over the past couple of years. Publishing our new report Medications in drug treatment: tackling the risks to children – one year on, our research revealed that far more children than previously thought are dying and being hospitalised after ingesting medications prescribed to treat their parents’ drug addiction.
‘Specialist workers and midwives help a service maintain a whole-family focus.’ Rachael Evans, Adfam
In the ten years to 2013, at least 110 children and teenagers aged 18 and under in the UK died from the toxic effects of OST medications. In the same time, at least 328 children in England were hospitalised and diagnosed with methadone poisoning. Of the 73 deaths in England and Wales, only seven resulted in serious case reviews (SCRs).
Since Adfam first reported on this tragic phenomenon in 2014, these cases have continued to happen, with at least three new SCRs in the last year. While many children will have consumed the medications accidentally, some were given them by their parents in a misguided attempt to help soothe or send them to sleep. The statistics also show the majority of fatal poisonings involve older, rather than younger children – but little is known about how or why these incidents occur.
OST is proven to reduce dependence on street heroin, and by doing so it saves lives, improves health and wellbeing and cuts crime. The rightful place of these medications in addiction treatment is not at issue, but it’s imperative that the risks they pose to children are better addressed and future incidents prevented.
Our report makes a number of recommendations to help do this, starting with the need for all incidents involving a child’s ingestion of these medications to be fully investigated and recorded – and analysed centrally by government, with the learning shared with local services. The wide range of professionals who come into contact with parents and carers prescribed OST medications must all be trained about their potential harm to children, and services must work together and share information more effectively to minimise risk. Parents must also be educated about the potentially fatal risk posed by OST medications, and given a secure box to store them.
Vivienne Evans, Adfam’s chief executive, said: ‘The lessons from previous tragic cases have not been heeded, and a year after we called attention to the issue, children are still dying. The vast majority of parents prescribed these medications will use them safely and appropriately – but the number of children now identified as having been harmed lends the issue even greater urgency. Systemic and cultural failure means services are still not working closely enough to safeguard vulnerable children.’
Our research, along with the training we have delivered to local authorities, has identified some areas of good practice. One drug treatment service has appointed two specialist family workers to work with pregnant service users and families. Specialist workers and midwives can help a service maintain a whole-family focus, and this model was praised by SCR panels.
Another promising model is the development of inter-agency joint protocols between drug services and health visiting teams, so that information is shared and joint home visits can be conducted. More information and examples of good practice can be found throughout the report.
By the end of 2015, Adfam will have trained 19 local councils to reduce the risks to children posed by these medications, and we hope to continue this crucial work in 2016.