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GPs' views - Would you expose depressed patient's neglect of her child?

Three GPs discuss a tricky problem

Case history

You have often felt your patient Susan has had a raw deal in life. Her 12-year-old daughter Joanne is severely physically and intellectually disabled, cannot speak, is prone to fits and is becoming increasingly violent. Susan cares for her at home and gets only three hours' respite a month when social services take Joanne out. Susan's husband left when the extent of Joanne's disability became clear.

She receives statutory benefits for Joanne's care and is on sickness certification for depressive illness. Recently she has been encouraged by a solicitor to sue the health authority, the obstetricians and paediatricians. Then over a few days you see Susan working ­ on a fruit stall, waitressing in a café and cleaning in a kebab shop late at night. You wonder who is looking after Joanne and are concerned Susan risks, at the very least, a charge of benefit fraud.

Dr Jane Bowskill

'Possible benefit fraud is hardly a medical issue'

There are a lot of issues here, and I think the priorities are to treat Susan's understandable depression, and to try to get some more help with looking after Joanne. Three hours help a week is appalling, considering the child's disabilities.

I would not regard the possible benefit fraud as a medical issue. Benefits in the UK are far from generous, and many people end up scarcely able to exist on benefits, but are worse off if they take low-paid employment since benefits such as housing, free school meals and so on disappear with employment. The black economy may be the only option.

When Susan is next seen, either for certification or for a further prescription, it could help to generally inquire how things are at home, how she is managing, and if there is anything more I could do to help. Options include a letter to social services and a telephone call to Joanne's social worker ­ if Susan agrees ­ and also the possibility of getting some help from Joanne's father via the Child Support Agency. Assuming Susan is well-known to the practice, these avenues may already be exhausted; there may be some help available from the voluntary sector. If she is taking antidepressants, these may need reviewing or the dose changing.

Susan may confide in me about her work and Joanne's care arrangements as long as she is certain of confidentiality and knows my role is not to be judgmental.

If she mentions the possibility of suing for compensation I would be inclined to advise her against it; after such a long time, proving the case might be difficult and it would certainly be very stressful.

Dr Seda Boghossian-Tighe

'A successful claim would help fund Joanne's care'

This is a complicated and sensitive case. First, I would contact Susan by documented telephone call to arrange a consultation ­ preferably a home visit. I would tell her it is about certain issues relating to her and Joanne that need discussion and clarification.

My position as their family GP bears certain responsibilities regarding Joanne's welfare. I would tell Susan I saw her working late at night on more than one occasion and ask her whether Joanne was on her own at those times. During my home consultation, I would assess the home environment, the facilities available for both, especially for Joanne's mobility and domestic care. I would try to find out whether Joanne's father is around and helping with Joanne or contributing financially towards Joanne's care.

I would also raise the issue of her taking legal action against health professionals. I would try to find out whether Susan stands to receive lump-sum compensation or expenses for lifetime care for Joanne. If she won the case this would obviously solve her financial worries and she could devote time to care for Joanne or pay for carers to look after her part of the time.

I would inquire about her income and the benefits she receives or is entitled to: child benefit, disability allowance, family and child tax credit, reduced payment of community charges, statutory benefit for Joanne's care and her income for long-term sickness via certification.

Finally, I would like to find out the extent of social services and charitable organisations involvement, or whether a care package has been agreed.

After collating my information, and having heard details from Susan, I would quote the Children Act (1989), which states that the child's best interest must be the paramount concern. I would emphasise to Susan that Joanne's welfare and her potential physical and mental state could be compromised if she is not supervising her, especially late at night. I would try to provide her with my professional support.

Dr Aran Gillespie

'I couldn't pussy-foot around the child protection issue'

Susan is going to have to come in for a sicknote at some stage and action will be forced upon me. I could attempt to contact her now, but I'm usually busy enough with the patients sitting in front of me without tracking them down. As I work in a group practice I would need to tell the others about what I had seen so that they too could deal with any potential meeting with her (they probably wouldn't thank me though).

When I next see her my options will be to be nice, or legal. I could smile nicely, keep quiet, and sign another sicknote. But I would be effectively lying, and helping her perpetuate benefit fraud. I don't need to be a lawyer to suspect that is illegal and might interfere with my career progression should I get caught. If I were to be legal I would decline to sign a further sicknote, stating that I have seen her working in three jobs.

I would ask who was looking after Joanne while she was at work. I don't think I could pussy-foot around the child protection issue. The child's safety is paramount, and should Susan be crazy enough to put her child at risk, I would have to report it. Unfortunately, taking the honest option will probably destroy our doctor-patient relationship. But should I back down from the confrontation, our relationship would be changed in a different way: she would be in a position of power, and I would be reduced to doing anything she asks.

She may need the money she can net from combining her jobs and benefit payments, but the system says it's wrong. She is attempting to seek recompense for her disadvantages by suing everybody. She can hardly seek legal redress while expecting me to participate in benefit fraud. I will have to do what's legal.

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