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Troubled teenager has not registered new baby

Case history

Sixteen-year-old Lisa had a baby four months ago. Lisa was in care as a child and is now living with a drug addict. She was a poor attender at the antenatal clinic and has missed several appointments at the surgery, including her postnatal.

You haven't seen her son yet because Lisa hasn't registered him with the practice (or with any other doctor). He hasn't had his eight-week check or any immunisations. Lisa does allow the health visitor to call, but has ignored her encouragement to attend surgery, register her baby and so on.

At the weekly team meeting the health visitor says she is concerned for the welfare of both Lisa and her baby.

Dr Deborah Hammond

'The cycle of poor parenting continues'

Obviously my first concern is the unregistered child, but Lisa is also young and vulnerable. Her partner clearly has needs, but may not be ready to address them. The cycle of poor parenting continues.

First I'd want more information from the health visitor. What is the nature and urgency of her concern: financial problems, lack of support from family and friends, depression or insecurity, drug taking, neglect, abuse? How is the baby relating to the mother, and how is he growing?

The health visitor knows the family best, so what does she want to do? Assuming there's no urgent concern, the health visitor could find out whether Lisa and her baby would come with her for an appointment.

Alternatively, she could ask to bring a doctor with her next time she visits. These options might be more acceptable than meeting some scary old doctor on her own. We could then do a six-week check, talk more about immunisations and see how Lisa is managing.

She might then co-operate a bit more, and we could look into her own needs, offer counselling or antidepressants if indicated, and encourage her to try local support groups for young parents. We should keep a close eye on both of them at the baby clinic, especially with regular weight checks for the baby.

If we can't address the problems ourselves, or if there are urgent or ongoing concerns, we would need to discuss with Lisa a referral to social services. We could explain gently that we think she needs some help with her son, and acknowledge that things are hard for her. Hopefully she'd consent, but if not we'd have to let Lisa know that we have to talk to social services anyway.

I would consider referring Lisa to the community paediatricians. Liaising regularly with the health visitor and social services would be important. And we would need to treat the whole affair as tactfully and supportively as possible in order to engage rather than alienate Lisa. This would be the best way of maximising the outcome all round.

Deborah Hammond is a salaried GP, working for City and Hackney PCT ­ she completed the VTS in 2003

Dr Claire Wilkie

'Babies and young mothers have died in less worrying situations'

This is an extremely worrying situation, and I'd be surprised if we hadn't discussed Lisa at previous team meetings. Clearly, although the baby is not registered we have a duty of care both to him and to Lisa. And a very young parent failing to engage with health and welfare agencies in these vital early months is a recognised risk factor for abuse, neglect and developmental delay.

So what are the health visitor's exact concerns? Does she think the baby is being physically harmed? Is he being fed appropriately and enough? Is the house clean or is the baby at risk of infection from his surroundings? Is he thriving?

Lisa too is very vulnerable because of her history of being in care, her age, and her partner's substance misuse. She may well have conceived at the age of 15.

There is, of course, a strong possibility that Lisa is also misusing drugs, which would put her at great risk of debility, infection and debt. She needs, but probably does not have access to, reliable contraception.

I need to offer Lisa a friendly invitation by letter and by phone to consult and register her baby. I would emphasise that the team is hoping to help and support her and monitor her son's progress. The health visitor will record her findings at every visit and will check with Sure Start locally to see what contact, if any, it has had with Lisa.

If Lisa doesn't respond within a week I wouldn't hesitate in referring the family for an early assessment by the child protection team. Babies and young mothers have died in less worrying situations.

Clare Wilkie obtained a degree in classics before taking up medicine ­ she finished the VTS in 1988 and practises in south London

Dr Peter Saul

'I'm under no illusions, things look bleak for Lisa'

There is a double dose of child protection issues here, but my first priority has to be the baby who is at serious risk. My concern is less that the baby hasn't registered or attended surgery, but whether this is a symptom of wider issues such as Lisa's competence and the possible effects on the baby of living with her drug addict partner. I take our health visitor's concern extremely seriously.

In the practice, the health visitor has the main responsibility for Lisa and her baby at present because my knowledge, as the GP, is only second-hand. I would advise her to make a formal referral identifying the baby as being 'at risk'.

It would be most appropriate to do this during the conversation with Lisa's social worker. But if we have difficulties getting hold of the social worker then we should inform the duty officer instead.

Although the baby is now four months old, we must take steps to address our concerns today.

We will have to make difficult decisions about Lisa. It's quite possible that her baby will need to be taken into care. If this happens she might disengage from support services altogether. The social services team will need think imaginatively to get Lisa into a suitable environment, where she can be given the support she needs to look after her baby. Her situation may be complicated further if she too has a drug problem.

The practice can offer Lisa and her baby a supportive and responsive approach. Perhaps we can help prioritise access to drug services and help plan support for their future. But I'm under no illusions ­ we can't perform miracles and things look bleak for Lisa.

Peter Saul has been a GP for 18 years and practises in Wrexham ­ he is a CPD tutor and a member of his local health board

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