I watched, admittedly with a wry smile, as the residential home manager and 3 other staff tested their athleticism against Thomas, the 9yr old sprightly little boy who was leading them a dance as he hurdled the 6ft perimeter fence. He was running like the wind whilst glancing and smirking back; he'd managed to break the office window we were meeting in sending shards of glass all over the place- thankfully no one was injured.
Once caught he gave up the fight pretty quickly and accepted his punishment though couldn't quite explain why he'd done it apart from boredom.
During my observation of the keystone cops show I noted Thomas had a defined limp. I asked if anyone knew why but as he'd only arrived a couple of hours earlier he'd not been fully checked in.
After a long and challenging couple of weeks tracking down records, negotiating information sharing, confidentiality and quoting the Children Act and 'in the best interests of the child' ad nauseum to numerous health colleagues in order to gain a comprehensive health history, it shocked me to the core when I sadly realised how we, as corporate parents; health, social care and education had failed this young boy. And how we, as public health nurses, had missed so many opportunities that could have shaped his little life so differently.
You see, his records revealed that at his birth check by the midwife he had 'clicky hips', she noted she was 'concerned' at mums 'apparent apathy', that 'she was from a known family' and that she was 'one to watch', however this was retained in the hospital records and was not highlighted on the handover notes to the health visitor on discharge. At his 8 week health visitor check at baby clinical the clicking persisted. The HV asked the Paediatrician on site to take a look; he referred him to the hospital. Thomas notes indicate that he failed to attend his hospital referral to an orthopaedic consultant on 3 occasions so he was discharged. There is no record of follow up by Paediatrican, GP or Health Visitor, though there were letters from the hospital on file sent to all.
By the age of 2 Thomas was in the care of the local authority, he had 4 placements across the country in 12 months to avoid traumatic family contact ; he was not walking at age 3yrs. Thomas was seen at age 3.6 and was recommended for surgery as he was now too old for the opportunity for treatment by splinting. Thomas was placed into a brace after surgery for up to 6 months. During this post op period he returned to live with his birth mum.
When he started nursery at age 4 there was no mention of a brace just 'walks with a slight limp' noted by his health visitor. There was no reference to his previous health history.
At age 5 Thomas was returned to the care of the local authority and, once again, placed well away from the family home. His HV records stated his foster carers said he was 'an unruly child with sudden outbursts in school' and 'temper tantrums during the night faking pain and being over-dramatic'. This placement broke down after only 6 months
In his 7th placement by the age of 7, Thomas was assessed by an educational psychologist, had a statutory health needs assessment by a paediatrician, was on a 'behaviour plan' at school and was found stealing paracetamol from his foster families grandma. No reference was made to his hip or limp. This placement broke down after 4 months- Thomas was placed in a residential home.
The looked after children's nurse who saw Thomas soon after he settled in, conducted an holistic health needs assessment using communication tools that helped Thomas describe his pain, 'peg-leg' and 'old mans back' ache which 'did his head in'. She facilitated a fast track referral and within a month Thomas had an extensive procedure with open reduction and soft tissue stabilisation of the joint, followed by a 6 month cast. He recovered well and the change in his 'mood, persona and behaviour' was noted as 'commendable'. So much so that Thomas was able to settle well into a new foster home and, according to his foster carers records became 'a lovely little boy enjoying football and cycling; making up for lost time'.
Sadly his foster mum became acutely ill and subsequently died. Thomas was placed in temporary foster care- many miles away- and had no access to his dying foster mum and family. The school and school nurse were concerned at Thomas 'sad demeanour, lack of concentration and appetite', they conducted a mental health screen which resulted in a referral to child and adolescent mental health services; there was a 5 month waiting list. In the interim the school nurse offered support but Thomas declined, she provided his foster carers and school with resources and information regarding bereavement, however, noted that his carers said 'they didn't do mental health and that he'd have to 'man up'; there was no indication that she shared these concerns with his social worker.
Excluded from school for 'repeated violent behaviour' and a further placement breakdown, Thomas arrived at the residential home that I met him in.
It took 16 weeks of building up a trusting relationship through dog walking, gardening and sharing mealtimes before Thomas would entertain any health professional for a reassessment. His looked after children's nurse, Catherine, eventually cajoled him into an appointment with an orthopaedic consultant. His investigations revealed a damaged head of femur and degenerative changes to his lower back.
Bribery and corruption ensued in the form of a remote controlled rise and fall bed, side ward, flat screen TV and play station before Thomas agreed to surgery for a hip replacement!
He's doing well in his new foster placement, swimming is his new favourite activity with competitions between him, foster dad and brother. His prognosis is for a full recovery though very likely to need a further hip replacement in later life.
Thomas is now 11, has just started high school and is hoping to be chosen for the school football team.
He has weekly physio and daily heat pads and analgesia that makes him sleepy for constant back pain. He walks with a defined limp and struggles with stairs and other aspects of mobility
Looked after children are some of the most vulnerable children in our society. Over 50% enter care with a health condition that requires a hospital referral. Over ....% go on to have children who are placed into the care of the local authority.
Public health nurses have the opportunity to prevent, detect, screen, identify, refer and, more importantly, advocate and act as champion for their health needs to be met.
High quality ante and post natal care from midwives, intense pregnancy and early parenting support to young and vulnerable parents from family nurse partnership and early help to families in need from health visitors and school nurses are critical to a cycle of change and improved health outcomes for looked after children and young people.
Sharon White is professional officer for the School and Public Health Nurses Association (SAPHNA)
