Child advocate demands change after baby death

The Alberta legislature.

EDMONTON – Alberta’s child advocate is demanding changes in social services and health care following a newborn’s death in 2012.

Del Graff said in his report Monday that the two-week-old girl’s cause of death was undetermined. But her mother, whose six other children ended up in government care, had been abusing prescription drugs while pregnant.

He found that 11 doctors had prescribed the woman nearly 5,000 pills during her pregnancy — many were refills that didn’t require a doctor’s appointment and many came from the same pharmacy.

An investigation showed the woman’s primary doctor wasn’t aware of her pregnancy and an obstetrician initially didn’t know she was taking any drugs.

The obstetrician eventually checked a health database and, discovering the woman had been prescribed large amounts of medication, left a message for the other doctor, but received no response. The obstetrician also called a hospital social worker.

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Despite the information, mother and baby were released from hospital, 17 hours after the child was born, by a pediatrician who didn’t know of the mother’s drug abuse. The next day, a public health nurse visited the family’s home and, also unaware of the drug problem, found nothing wrong.

Graff said only later was a letter placed on the baby’s medical file flagging concerns about her mother’s drug use and parenting abilities, as well as the need for the baby to see a doctor within seven days.

The mother missed a public health appointment four days before she found her baby, sitting in a car seat at home, not breathing. At the time, social workers on the file were still completing a safety assessment.

An autopsy showed the baby had abnormal weight loss, an infection in her lungs and blood, and traces of anti-anxiety drugs in her system that experts believe came from her mother during pregnancy.

It found no clear cause of death. But the advocate’s report described how neonatal abstinence syndrome occurs in newborns exposed in utero to drugs, and how those babies must be closely monitored in hospital after birth.

The baby cannot be named under Alberta’s child protection laws. Graff referred to her by a pseudonym, Annie.

“Although it appears that the right supports for Annie’s family were largely in place at any particular time, there was no common thread linking them together,” wrote Graff.

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“The circumstances around Annie’s short life have illuminated several opportunities to strengthen aspects of the child intervention and health-care systems, so that Alberta’s children can be better protected and their families better supported.”

Graff made five recommendations, including a demand for better information sharing among agencies.

He said a review panel that studied the death of a young child in 2011 made a similar recommendation that called on Child Intervention Services and Alberta Health Services to work better together. “The Ministry of Human Services has indicated that this recommendation has been accepted and completed. However, this approach was not evident in Annie’s case.”

Graff said social workers need to be more proactive in planning before a child is born into a family already receiving intervention services, and he called for a multi-service response to deal with families of at-risk children.

He also said the College of Physicians and Surgeons of Alberta and the Alberta College of Pharmacists need to review if they are effectively flagging “multi-doctoring” to prevent fetal drug exposure.

Last summer, the colleges encouraged physicians to join with other doctors and pharmacists to develop monitoring plans for high-risk patients. Kelly Eby, a spokeswoman with the College of Physicians and Surgeons, said the province needs to give doctors more access to certain drugs listed in the database and more funding to analyze the data.

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The registrar for the Alberta College of Pharmacists, Greg Eberhart, said in a statement that his office will consult with the advocate’s office and look at “measures that can improve practices of all pharmacists.”

Kerry Towle, a critic with the Opposition Wildrose, said the case exposes gaps in the system. “In light of baby’s Annie’s tragic death, the Alberta government needs to step up their efforts to eliminate these gaps in the system and get vulnerable and innocent children the protection they deserve.”

The NDP’s Rachel Notley said reviews dating back to 2009 have found information sharing among agencies to be a problem.

“All we have seen from this government are piecemeal responses that are clearly not closing the gaps,” Notley said. “It is time for concrete action.”

A spokesman with Alberta Health said his office is reviewing the report and could make no other comment.

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