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Adoption Fostering and Termination of Pregnancy

Adoption Fostering and Termination of Pregnancy. Durham and Tees Valley GP Training Programme Half day release Paul McGowan GP trainer Alma Medical Centre Stockton Updated 2017 Dr DG Anderson GP Trainer. Wed 15 Nov. 2017 Session plan.

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Adoption Fostering and Termination of Pregnancy

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  1. Adoption Fostering and Termination of Pregnancy Durham and Tees Valley GP Training Programme Half day release Paul McGowan GP trainer Alma Medical Centre Stockton Updated 2017 Dr DG Anderson GP Trainer

  2. Wed 15 Nov. 2017Session plan • 14.00 – 14.45 Introduction and Quiz Adoption and fostering • 14.45 – 15.15 Small group work - The role of the GP • 15.15 - 15.30 Coffee • 15.30 – 15.45 Termination of pregnancy • 15.45 – 16.20 Small group work and case discussion • 16.20 – 16.30 Quiz answers feedback and close

  3. Definitions • Adoption is a legal process whereby children are cared for by adoptive parents who take on full legal and parental responsibility • Fostering is shared caring between foster parents the birth parents and the agency or authority responsible for the child’s welfare. Foster parents do not have parental rights or responsibility. The birth parents are usually encouraged to visit and the aim is for fostering to be a temporary process

  4. The Law • European Convention on the Adoption of Children 1967 • Adoption Act 1976 • Children Act 1989 • The Hague Convention on Intercountry Adoption 1993 • Family Law Act 1996 • Protection of Children Act 1999 • Adoption (Intercountry Aspects) Act 1999 • Children (Leaving Care) Act 2000 • Care Standards Act 2000 • Adoption and Children Act 2002 • Health and Social Care Bill (Community Health and Standards) Act 2003 • Children Act 2004 • Children and Adoption Act 2006 • Safeguarding Vulnerable Groups Act 2006 • Children and Young Persons Act 2008

  5. The Children and Families Act This act received royal assent on the 13 March 2014. The Act has 10 Parts, 7 Schedules and 140 sections. The commencement dates on those provisions relating to looked after children and adoption, including statutory instruments, DFE statutory and non statutory guidance are available in this

  6. Children in public care • 70,440 children were in the care of English local authorities on 31st March 2016 (Source British Association of Adoption and Fostering ) • 51,850 (74%) of the above figure were cared for in foster placements Gender • 56% boys and 44% girls Age • 5% under 1 year • 13% 1 -4 years • 20% 5 -9 years • 62% 10 years and over • Number of children looked after because of abuse or neglect in England was 42,710 - 60% of the total number in care (Children in Care in england: Statisitcs 2014)

  7. Children in public careEthnicity • 75% white • 9% mixed racial background • 4% Asian or Asian British • 7% Black or Black British • 3% other ethnic groups • 1% other (refused or information not yet available) • 4,210 (6%) unaccompanied asylum seeking children were looked after on 31st March 2016 • Unaccompanied asylum seeking children are predominantly male, 93% in 2016 (up from 88% in 2012), and 75% are aged 16 years or over.

  8. Legal status 0f looked after children at 31 March 2016 • 65% (45,440) of children looked after were looked after under a care order, • Voluntary agreements under Section 20 of the Children Act 1989, 27% • Placement orders 8% of children

  9. Placement of children in care • 75% living with foster carers • 9% secure units, children's homes or hostels • 5% placed with their parents • 5% placed for adoption • 3% another placement in the community • 3% residential schools or other residential settings

  10. Adopted children The numbers of looked after children who were adopted in 2016 decreased for the first time in recent years, Adoptions from Care • 4,690 children were adopted from care during the year ending 31st March 2016, compared to 5,360 in 2015 Gender • 53% males and 47% females Age • The average age at adoption was 3 years 5 months • 4% under 1 year old • 72% between 1 and 4 years old • 21% between 5 and 9 years old • 2% between 10 and 15 years old • <1% over 16 Ethnicity White – 83% Mixed - 11% Others – 6%

  11. Adopters and waiting times • 92% couples • 8% single adopters • 4% same sex couples (either in a civil partnership or not) Figures for year ending 31st March 2012 Updated figures are expected in December 2013 Waiting time The average duration between entry into care and being adopted in 201 was 2 years 3 months, the time between entry into care and the decision the child should be placed for adoption, in 2012 to was months in 2016. To keep siblings together there is often a longer wait for adoption As the age of a child increases the chance of adoption flls Birth parents often challenge adoptions leading to long legal delays

  12. Why the need for Local Authority care?

  13. Why the need for Local Authority care? Families unable to cope or care for their children for a number of reasons. Poor physical or mental health or have to be hospitalised Drug and alcohol abuse Neglect Abuse All the above typically cause a lack of stability and loving secure attachments essential for normal child development

  14. Daniel Pelka Khyra Ishaq and Baby P Daniel Pelka • Imprisoned in a box-room and died from a head injury in Coventry in March 2012. His mother, Magdelena Luczak, 27, and her partner, Mariusz Krezolek, 33, were convicted of murder after a catalogue of neglect and abuse including starvation. He was seen to scavenge for food at school. Khyra Ishaq • Died in May 2008 and was known to social services She was a seven years old girl who was mistreated and starved to death by her mother and her partner at a house in Handsworth, Birmingham. A lack of senior managers in child protection and a high sickness rate among social workers were major problems. Baby Peter • Died at the hands of his mother Tracey Connelly, boyfriend Stephen Barker and his brother Jason Owen on August 3, 2007 in Haringey, North London aged 17 months after sustaining more than 50 injuries, despite having been seen by child support professionals 60 times. He was seen by his GP shortly before his death

  15. GMC proceedings against Baby P’s GP • BMJ (19 July 2010) • Baby P’s GP is suspended for 12 months • The GP who failed to take urgent action to protect the toddler Peter Connolly has been suspended from practising for 12 months but was allowed to stay on the medical register. • GMC chair Judith Worthington said that Dr Ikwueke's actions were not 'fundamentally incompatible' with remaining on the register but stated that he failed to recognise that the interests of the child were paramount “You did not make the care of your patient your first concern. You did not prioritise the welfare of the child.”

  16. Media coverage of GMC proceedings • GP guilty of Baby P blunders suspended for 12 months over 'serious breach' of duty • The doctor who failed to spot the horrific abuse suffered by Baby P before his death has been suspended from practising for 12 months today. • Dr Jerome Ikwueke, 63, was found guilty of misconduct after a series of blunders during seven consultations at his surgery in north London, between May 2006 and July 2007. • He failed to 'fully and properly' examine 17-month-old Peter Connelly on July 26, 2007, just eight days before the toddler's death, the General Medical Council heard.

  17. Case Reviews 2015 37 Serious case reviews published Aug 2015 August 2015 – Stockton-on-Tees – Child H • Serious harm caused to a 12-year-old, identified in July 2013 when serious concerns were raised over poor home environment and Child H’s presentation, including impaired vision. Child H was taken into the care of the local authority and mother and mother’s partner were charged and sentenced to 30-months imprisonment for child cruelty. • Background: Child H was diagnosed with Juvenile Idiopathic Arthritis (JIA) when 5-years-old. JIA can lead to eye problems, which, if not detected and treated early, can cause permanent visual damage, including blindness. Child H was found to have early indicators of uveitis at an ophthalmology appointment in 2011; Child H did not attend any further ophthalmology appointments until July 2013. Children’s social care received three referrals between 2011 and 2013 and concerns had been raised regarding Child H’s presentation, hygiene and attendance at school and medical appointments. • Key issues: the system for screening children with complex eye problems is not designed around the needs of the child: the appointment system implied Child H was making informed choices about not attending, rather than parents’ non-attendance being seen as an indicator of neglect. • Learning: children with medical needs necessitating a range of specialists, require a lead professional to maintain coordination of services, in particular, the role of the school nurse should be developed to engage with children and parents and to assist schools in understanding the impact of specific conditions. • Recommendations: makes various recommendations and includes a multi-agency action plan. • Keywords: child neglect, children with a chronic illness, start-again syndrome

  18. Foster Children – a vulnerable groupNCFA ‘Foster Care in Crisis’ quoted in CoSLA ‘Foster Care’ p 21 A UK survey of foster children found that they were • • 10 times more likely to be excluded from school • • 12 times more likely to leave school with no qualifications • • 4 times more likely to be unemployed between 16 and 24 • • 60 times more likely to be homeless • • 50 times more likely to be sent to prison • • 88 times more likely to be drug abusers • • 4 times more likely to suffer from mental health problems.

  19. The Martin Narey report • Former chief executive of Barnardo’s and former head of the Prison Service • Published July 2011 • Very Critical of the bureaucratic delays in the adoption process result in too few UK adoptions • Strong assertion that adoption produces the best outcome for children and that the earlier done the better • Well meaning but misguided policies re ethnic matching leading to black and Asian children waiting twice to three times longer to be adopted that white children

  20. Chid abuse and care system then prison

  21. Care Leavers A Social Services Inspectorate report in 1997 ‘When Leaving Home is also Leaving Care’ quoted the following UK statistics • • More than 75% of care leavers have no academic qualification of any kind • • More than 50% of young people leaving care after 16 are unemployed • • 17% of young women leaving care are pregnant or already mothers • • 23% of adult prisoners and 38% of young prisoners have been in care • • 30% of young single homeless people have been in care.

  22. The Adoption ProcessCan take >12 months • Initial contact made with telephone discussion • Information pack sent out • Information meeting • Expression of interest form completed • Initial counselling visit • Application form completed • Checks and reference process starts • Assessment and preparation groups • Social worker allocated to complete prospective Adopter’s report which can run to 140 pages. This will include an exhaustive heath and safety check of the home as well as the couple’s relationship history (including sexual) and references from previous partners The religious beliefs and childhood backgrounds of the couple are also extensively recorded • Assessment plan agreed • Prospective Adopter’s report completed • Adoption panel • Recommendation and decision. • Once approved as suitable to adopt process of identifying a match commences

  23. The Fostering Process • Initial contact made with telephone discussion This can be with the local authority social service dept or a voluntary agency – e.g. British Association of Adoption and Fostering (BAAF) or Barnardo • Information meeting • Application completed • Attend preparation and training groups (the whole family needs to be involved) • Checks and reference process starts – including medical and CRB • Assessment by allocated social worker • Social work dept. submit a report to the Local Authority Fostering Panel • Recommendation and decision. • Foster parents receive an allowance to cover the cost of caring for the child but there is also a remuneration element The current minimum rate varies from £116 per week (babies) to £175 (16-17 year old) Allowance higher in South East and London. There also tax relief benefits and the work qualifies for National Insurance credits for the state pension.

  24. Who can adopt? • Agencies do not automatically exclude anyone from consideration on the grounds of upper age, marital status, gender, sexual orientation, disability or employment status. • By law there is a minimum age of 21, and certain offences exclude people from adopting. • Potential adopters' ability to meet the child’s needs throughout childhood and beyond is considered • Agencies seek prospective adopters who can engage in the assessment and preparation process openly and honestly.

  25. Private fostering • Private fostering is defined in the Children Act 1989 as a child under the age of 16 (or under 18 if disabled) being placed for 28 days or more in the care of someone who is not the child's guardian, or close relative, by private arrangement between parent and carer. • 1,500 children were known to be living under private fostering arrangements at 31st March 2013 • Potentially as many as 10,000 children may be living in this type of placement. If unknown to local social services these children and young people are not monitored potentially leading to undetected abuse • Legal obligation on carers in a private foster arrangement to notify the local authority • Victoria Climbie killed in 2000 aged 8 by her great aunt Marie-Thérèse Kouao and her boyfriend Carl Manning following months of torture Her parents were living in the Ivory Coast She was subject to a private fostering arrangement

  26. Small group work 1 • The role of the GP Discuss two case scenarios 1. A childless couple in their forties consult and ask your advice if you think that they will be considered fit to adopt They have been married for 5 years and have not been able to have birth children. Both are overweight She is white British, aged 46 and has type 2 diabetes as well as hypertension . He is 47 of South Asian background and is a smoker What advice would you give? 2 Tracey is brought to see you by her social worker She is 15 and has been in the care system for 2 years after her mother, an IV drug abuser, could not cope. Her father is in prison. Tracey is not attending school and has just run away from her most recent foster home. The social worker is at a loss to know what to do as Tracy will not engage. She thinks she has an older boyfriend . How do you deal with the situation? What are the priorities?

  27. Medical and social issues in adoption and fostering • Applicants for adoption or fostering must be fit enough to meet a child’s needs until that child reaches young adulthood • It is unlikely that an adoption agency or a local authority would place a child for adoption in a household where they would be exposed to smoke • Adoption agencies will consider applicants’ ethnic and social background in relation to the child’s background, and as close as match as possible will be sought • Medical reports will be sought from GPs for persons seeking to adopt or foster children • Local authorities will request that children in care will have regular medical checks to ensure normal development • If a health professional is aware of a private fostering arrangement there is a duty to inform the local authority • BREAK FOR COFFEE

  28. Termination of pregnancyThe Birth of Venus Botticelli c 1486

  29. Induced abortion / termination of pregnancy • Historical context • First recorded evidence of induced abortion is from the Egyptian Ebers Papyrus in 1550 BC. A Chinese record documents the number of royal concubines who had abortions in China between 515 and 500 BC Methods were mostly non-surgical e.g. physical activities like strenuous labour, the use of irritant leaves, fasting, bloodletting and pouring hot water onto the abdomen. • Aristotle 384-322 BC • In Aristotle's view abortion, if performed early was not the killing of something human. He would permit abortion if the birth rate was too high, but only at a certain stage as he considered the embryo to gain a human soul at 40 days if male and 90 days if female; before that it had vegetable and animal souls.

  30. Soranus and Hippocrates • Soranus a 2nd century Greek physician. Recommended abortion in cases involving health complications as well as emotional immaturity, and provided detailed suggestions in his work Gynecology. Diuretics enemas fasting and bloodletting were prescribed as safe abortion methods, although Soranus advised against the use of sharp instruments to induce miscarriage, due to the risk of organ perforation. He also advised women wishing to abort their pregnancies to engage in energetic walking, carrying heavy objects, riding animals, and jumping so that the woman's heels were to touch her buttocks with each jump • Hippocratic Oath (original translated into English) Historically taken by physicians and other healthcare professionals swearing to practice medicine ethically. Written by Hippocrates (460-380BC) father of western medicine, or by one of his students. “I swear by Apollo the healer…… I will not give a lethal drug to anyone if I am asked , nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.”

  31. The law and Termination of Pregnancy • TOP is legal in Great Britain under the Abortion Act 1967 Five categories A The continuation of the pregnancy would involve risk to the life of the pregnant woman B Termination is necessary to prevent grave permanent injury to the physical or mental health of the woman C The continuance of the pregnancy would involve a greater risk to the physical or mental health of the woman than if the pregnancy were terminated D The continuance of the pregnancy would involve a greater risk to the physical or mental health of any existing children of the woman than if the pregnancy were terminated E There is a substantial risk of physical or mental abnormalities leading to serious handicap Upper limit 24 weeks for C and D No upper limit for A and B or E Requires the signatures of two doctors Examples of the form Certificate A will be passed around 98% of all terminations in 2010 carried out under C

  32. Age-standardised abortion rate per 1,000 women aged 15-44

  33. Abortion Statistics, England and Wales: 2014www.dh.gov.uk/Publicationsandstatistics • The total number of abortions was 184,571. This was 0.4% less than in 2013 (185,311) and 0.6% less than in 2004 (185,713). • The age-standardised abortion rate was 15.9 per 1,000 resident women aged 15-44. This is 0.2% lower than in 2013 and 6.4% lower than in 2004 (17.1); the lowest rate for 16 years. • Abortion rate highest at 28 per 1,000 for women aged 22, • Under-16 abortion rate 2.5 per 1,000 women and the under-18 rate was 11.1 both lower than in 2013 • 98% of abortions were funded by the NHS. Over half (62%) took place in the independent sector under NHS contract • 92% of abortions carried out under 13 weeks gestation. 77% under 10 weeks • Medical abortions accounted for 48% of the total. • 3,099 abortions (2%) were carried out under ground E (risk that the child would be born handicapped) • 5521 abortions were carried out on non residents (lowest total since 1969) • 37% of women having abortions had one or more previous abortions..

  34. Abortion rate per 1,000 population by single year of age, England and Wales, 2004, 2013 and 2014

  35. The role of the GP • Firstly know the law and understand your ethical obligations • Counselling Empathy understanding and be non directional Confirm pregnancy if necessary and establish gestation Explore all options Discuss partner and family views Discuss coping post-TOP especially if in stable relationship/married and have existing children Explore previous mental health problems Discuss the procedure and possible complications including infection/PID small failure rate (necessitating surgical procedure) bleeding and psychological STI screening at time of procedure (chlamydia incidence around10%) Anti-D for rhesus negative women post procedure Discuss the referral process and safety netting – check up to date contact details and best way to contact the woman Follow up as appropriate and offer a follow up appointment.

  36. TOP methods • Complication rate lower the earlier the procedure is carried out – risk of major complications at 15 weeks is double that at 8 weeks • Medical termination is now the preferred procedure and avoids a GA • Medical TOP may be more effective <9 weeks and >12 weeks but can be carried out at any gestation Surgical TOP most effect 9-12 weeks • Surgical TOP may be required for a failed medical procedure Medical TOP – first trimester Mifepristone orally then admit 36-48 hours later for a prostaglandin pessary. 80% will pass POC within 4 hours. Women will bleed for up to 10 days. Follow up 2 weeks to confirm complete abortion. VE/USS if any doubt re retained products Less than 5% of women should need a uterine evacuation

  37. TOP methods • Medical termination – second trimester Mifepristone orally then admit 36-48 hours later for a prostaglandin pessary then fast until abortion occurs Further pessaries inserted at six hourly intervals (up to 24 hours) Most women abort in < 24 hours (average 8 hours) Need for analgesia and emotional support Approximately 6% will require a uterine evacuation • Surgical termination Usually under GA Prostaglandin pessary 4 hours before procedure to soften cervix and minimise trauma from the dilatation especially if primigravida or gestation >10 weeks Cervical os dilated and rigid or flexible suction curette introduced

  38. Teenage pregnancy • The under 18 conception rate for 2011 is the lowest since 1969 at 30.9 conception per thousand women aged 15–17. • A comparison of rates across regions in England shows that the North East had the highest under 18 conception rate in 2011, with 38.4 per thousand women aged 15–17. The South East had the lowest rate for women aged under 18 • It is possible to compare birth rates across Europe. The United Kingdom has one of the highest number of births per 1,000 women aged 15-17 in the European Union. For 2011 births, only Romania, Bulgaria, Slovakia, Hungary and Malta had higher birth rates for women aged 15-17 than the United Kingdom.

  39. TOP in girls under 16 years GMC guidelines Girls <16 years may be able to reach an informed decision depending on their capacity to comprehend everything involved in the procedure. However, in those cases where a competent underage girl refuses termination, it may be possible for a parent or guardian to authorise termination if it is the girl's best interests In Scotland, parental consent cannot be given if a competent girl has refused termination. In girls <16 years deemed unable to reach an informed decision, a parent or guardian may give consent to or refuse termination. However, a court may overrule if it is believed not to be in child's best interests to consent to or refuse treatment.

  40. Growing up in Britain today • Britain’s children are unhappiest in the Western world according to a 2009 UNICEF study of 21 industrialised countries. The report, which is the first of its kind by the international children’s organisation, was designed to show how countries compare internationally. • Britain’s children drink the most, smoke more and have more sex than their peers, they rate their health as the poorest, dislike school more and are among the least satisfied with life. • Relative poverty, a lack of time spent eating meals with their parents and mistrust of classmates mean that Britain languishes at the bottom of the wellbeing league table.

  41. Small group work 2 • Discuss the following scenarios in small groups 1 Mrs Y attends your afternoon surgery in a distraught state. She wants to be referred urgently for a TOP She is in a long term stable marriage and has three boys. She has just has a 20 week scan and was told it was another boy. She feels she will not be able to cope as she desperately wanted a girl She has a history of severe depression and overdoses What do you do? 2 Lisa attends with her boyfriend She is 18 and has learning difficulties but has just starting a college catering course. She has not been using contraception and stated that her boyfriend’s condom “split” She is now 11 weeks pregnant. Her boyfriend who is 32 is adamant that he wants the baby but she is not sure What are your options?

  42. Quiz answers • Number of children in care – 70,440 • Commonest age group -10 and over • The percentage of children in care in England due to neglect or abuse - is 60% • Children in care most often placed with foster carers • Children in care are up to 50 times more likely to experience homelessness drug abuse or a prison experience • At least 50% leave the care system at 16 unemployed and without academic qualification • Weekly foster care allowance is on average £450 per child but varies with the age of the child. • It is unlikely adoption would be allowed if smokers in the household • The Act which set the upper limit of Gestation for abortion - The Human Fertilisation and Embryology Act 1990 • In the Abortion Act categories A B and E have no upper time limit • The act that made Abortion legal and regulates abortion in the UK. - The Abortion Act 1967 • Percentage of termination in the UK after 13 weeks = 8% • The commonest age to have a TOP in Britain is 22 • The UK country in which abortion is illegal excepting ‘only save the life of the mother, or if continuing the pregnancy would result in the pregnant woman becoming a physical or mental wreck’ – Northern Ireland

  43. The Kids – Lou Reed They're taking her children away Because they said she was not a good mother They're taking her children away Because she was making it with sisters and brothers And everyone else, all of the others Like cheap officers who would stand there and flirt in front of me They're taking her children away Because they said she was not a good mother They're taking her children away Because of the things that they heard she had done The black Air Force sergeant was not the first one And all of the drugs she took, every one, every one And I am the Water Boy, the real game's not over here But my heart is overflowin' anyway I'm just a tired man, no words to say But since she lost her daughter It's her eyes that fill with water And I am much happier this way

  44. They're taking her children away Because they said she was not a good mother They're taking her children away Because number one was the girl friend from Paris The things that they did - ah - they didn't have to ask us And then the Welshman from India, who came here to stay They're taking her children away Because they said she was not a good mother They're taking her children away Because of the things she did in the streets In the alleys and bars, no she couldn't be beat That miserable rotten slut couldn't turn anyone away I am the Water Boy, the real game's not over here But my heart is overflowin' anyway I'm just a tired man, no words to say But since she lost her daughter It's her eyes that fill with water And I am much happier this way

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