Refugees reunited

CASE NOTES

Practitioner: Rita Mooney, social worker.
Field: Children and families.
Location: Kensington & Chelsea, London.
Client:  Baby Frank – an abandoned child.
Case History: Early in 2002 an African woman
brought a baby boy into a police station saying that she wasn’t the
mother. She said a friend of a friend, whom she had never met
before, asked for help in taking the baby to the local Red Cross.
Enroute, the woman went to the toilet at a cafe and when she got
back the other woman had disappeared, leaving the baby. Police
realised that the baby was very ill and took him to the hospital.
The woman stuck to her story – so there was no idea where the baby
had come from, how he got into the country or where his family was.
Medical staff believed the boy – now temporarily named Frank – was
about six months old. He had biliary atresia – a rare liver
condition which affects only about 50 babies a year in England and
Wales. If an operation called kasai-poroenterostomy fails, a
transplant will be required.
Dilemma: Should a seriously ill baby abandoned by
his family be re-united with them?
Risk factor: With Frank in such poor health,
attempts to re-unite him with his family seeking asylum in Denmark
could be hazardous. Outcome: Although still
awaiting a transplant Frank is steadily improving and back with his
family.

Should a seriously ill baby in need of a liver transplant be
re-united with the family that abandoned him? This was the central
dilemma that faced social worker, Rita Mooney, after being called
to a hospital to help plan the care of baby “Frank”.

“We allocated foster carers who began visiting Frank in hospital.
When he was a little bit better he went home with them,” says
Mooney.
“In the meantime, the Red Cross contacted us and said that Frank’s
parents and three other children were staying at a Red Cross
refugee camp in Denmark and were claiming asylum. Apparently they
had tried to enter the UK – and had stayed for a short period in
Manchester – but had visas for Denmark, and so under the Dublin
Convention that’s where they had to go.”

Originally from Rwanda, they were fleeing violence because the
father, a preacher, was accused of preaching anti-government
propaganda. It later transpired that they left Frank with a friend
in Uganda, as they realised he was very ill and feared that a
journey to the unknown would be too dangerous.

Mooney went to the camp in Denmark – with help of an interpreter –
to assess the family’s suitability for the child to return to them.
“DNA tests proved they were parents. But they didn’t realise just
how sick Frank was and the treatment he needed. Indeed, he kept
contracting infections which meant he couldn’t go on the transplant
list,” she says.

Mooney believed the family’s story and thought they should have
Frank back. But not everyone agreed. “It was a very difficult case
– the medical staff disagreed completely with the child being
returned to the family,” says Mooney. “Their diagnosis was the baby
would have a life expectancy of up to two years without a
transplant. But even though there was no guarantee that he would
reach the top of the transplant list, they felt that his chances of
survival would be better if he remained in England.”

However, Mooney believed that if Frank was to die, “surely it was
better to be with his own family.” She made contact with a hospital
in Copenhagen that would take over the care of Frank should he be
moved to Denmark. “They could provide the transplant but were not
as specialised as the London hospital, and had never operated on a
child so young. And that also added to the case against moving
Frank.”

However, following a visit to the hospital, Mooney thought it was
“fantastic”. She says: “As well as great facilities, patients were
very well looked after.”

Communication posed a major difficulty, not least with the family
not speaking English or Danish. Danish staff, according to Mooney,
were shocked at the UK system being reliant on court cases, care
orders and having all parties in agreement. She says: “I had to
pester people all the time to put things in writing. But they’d
say: ‘But we’ve told you’.”

At this time the parents threw another potential hurdle in the way
– they had another baby. It was argued that this made sending Frank
back to his family more problematic, as they would have all of his
health needs to attend while having a new baby to care for.

Meanwhile the case was being heard in the High Court in London.
“The judge took a great deal of time to deliberate about the case.
I think he had personal experience of a member of his family having
a transplant. But in the end the judge agreed that Frank should be
returned to the family,” says Mooney.

The foster carers, who had become seriously attached to Frank, were
having problems about the thought of letting him go. “I could
really empathise with them – they had really nursed him through the
worse,” says Mooney. Following the court decision, Mooney, the
foster carers, a fostering support worker, and a nurse accompanied
baby Frank on the short flight to Copenhagen.

“I don’t think the family really understood just how poorly he was,
despite what we told them… And it wasn’t until they saw him did
it hit them: not least the amount of medication he had to
take.”

It had taken 14 months to locate Frank’s parents and finally return
him to them. The family were granted leave to remain in Denmark and
have now moved into a house. They receive excellent benefits and
support – although this is dependent upon the children and parents
learning Danish.

Frank, who will be three in July, still awaits his transplant but
has been responding well to treatment. “The hospital out there has
a different approach towards the urgency of a transplant. But he’s
doing very well and the whole family is now settled,” says
Mooney.

Arguments for risk 

• Rather than making assumptions about an uncaring family
  abandoning a sick child, Mooney’s first instinct was to see if it
  was possible to keep the family together. Information about the
  difficult circumstances faced by the family in fleeing Rwanda
  proved that her non-judgemental approach was correct. 
• There was professional confidence, despite the misgivings of
  medical staff, that support in Denmark would be available. “Social
  services assured us that support would be in place. For example, a
  Rwandan woman had been employed to help out with the family three
  times a week, and there was regular monitoring from the health
  visitor,” says Mooney.
• The children’s guardian agreed to keep the family together if
  possible.
• Mooney had carried out an assessment on the family’s
  capabilities and worked closely with Danish health and social
  services and had built up good relationships. 

Arguments against risk

• Whatever the circumstances facing the family in fleeing Rwanda,
  if they were looking for a safer and more secure life then why
  should the baby not be part of that? How can you trust the caring
  nature of parents who are willing to abandon their baby in Uganda
  and for it to turn up in England without their knowledge or
  support? It is a case of neglect.
• The baby was admitted to a specialist hospital where its
  medical staff strongly disagreed that the baby should be moved out
  of the country. They felt his best chance for survival was to
  remain in the UK until a transplant could take place. 
• Given the family’s initial circumstances – housed in a refugee
  camp, for example – any action to move the baby would have been
  worrying. But with leave to remain granted and a house  provided,
  these social concerns have reduced. However, we then discover that
  a new baby is born. This means the parents now have five children
  to care for, one of whom is a newborn baby and one who needs a
  liver transplant.

Independent Comment
This case scenario poses a number of thought-provoking
ethical, legal, health and care issues, writes Panos
Vostanis.

Without underestimating the importance of two specific factors – 
the best place for baby Frank’s liver transplant to take place, and
the restrictions posed by the parents’ refugee status – my first
question was: “What is the evidence that these parents wish and can
adequately care for this baby, taking into consideration their life
circumstances, but without making allowances to compromise the
baby’s care and upbringing?”

Every other component of the care plan that is drawn up should
ultimately be guided by this core judgement. If this proves
hierarchically correct, one would be confident that, no matter how
difficult, other solutions would be found. If this is a wrong
decision, no matter what the legal and medical priorities, the
child’s basic needs will not have been met. 

Although this sounds a very difficult and complex case, it may well
be that the actual assessment of parenting attitudes and capacity,
might be surprisingly straightforward, provided that one could see
through the other complicating issues. 

It is not the social worker’s responsibility to prove or
demonstrate the competence of those parenting attitude and capacity
factors, but rather to act as an objective catalyst in enabling a
balanced judgement with the baby’s needs primarily at heart.

Panos Vostanis is consultant child and adolescent
psychiatrist with the Leicestershire Partnership Trust’s young
people’s team, and professor of child psychiatry at the University
of Leicester