Interim care order for newborn infant whose mother suffering from mental illness – 2022vol1#21

An interim care order was granted in respect of a newborn infant, where the mother was suffering from a severe mental illness and there was a significant fear of relapse.

The solicitor for the Child and Family Agency (CFA) said the infant had been born one week previously and was due to be discharged from the maternity hospital in question. He said the mother was present in court and was fully contesting the application. The solicitor said the father was not in a relationship with the mother currently and there was some uncertainty as to whether he was in fact the baby’s father. A paternity test was due to take place in those circumstances.

The solicitor said the mother had been known to the department since 2007 and that an older child was already the subject of a full care order. He said the primary concern in relation to the newborn was the mother’s history of mental health difficulties as well as substance misuse. He said she had had 28 admissions to mental health facilities in the past, so there was a “real and pressing concern” that she would not be able to meet the needs of her newborn infant upon discharge.

The mother’s barrister said that while the mother acknowledged her medical and psychiatric background, she was “adamant” she was receiving adequate treatment for it and was “wholly committed” to caring for her child. He said he did not intend on calling the mother to give evidence unless she was required to clarify anything.

Evidence of medical social worker  

The medical social worker gave evidence that she first met the mother a month before the infant’s birth, following a referral from a consultant psychiatrist working in the maternity hospital. She said the consultant had reported that the mother had a history of cocaine and cannabis addiction during her pregnancy, as well as a mental health diagnosis. She said she was aware the mother had been attending the ante-natal clinic, as well as the mental health service and that she was compliant with her medications when she met her. She said the mother’s attendance was “fairly okay,” but that she had missed some appointments.

In respect of the mother’s presentation, the witness said she did not present as under the influence of substances on their first meeting. She said the mother informed her that she was not using any illegal substances, but admitted that she had had “prior slips” during the early stages of her pregnancy.

CFA solicitor: “How many slips did she say she had?”

Witness: “She said there had been four prior slips in total.”

The witness said the mother had been admitted to hospital three times during the course of her pregnancy on health related matters, the last time as she had gone into labour.

The witness described speaking with the mother about her previous experience with her older son and her mental health diagnosis. She said the mother told her that she was feeling under pressure, but that “being a mum was what suited her best.” She said the mother told her that her baby and her son were her priority and that she was in a better place and was drug free. She offered to make a referral to the drugs liaison nurse attached to the hospital, but this was refused. She said the mother initially stated that she had the support of the baby’s father, but in subsequent conversations she said this was no longer the case.

The witness said a multi-disciplinary meeting took place in which the team discussed supports for the mother in the latter stages of her pregnancy, but the infant was then born the next day, almost one month early. She said when she met the mother post-delivery, “she looked very comfortable with the baby in her arms,” and referred to the child as “a perfect miracle.”

The mother was kept under review over the course of the next few days and it was documented in her chart that she was having some “ongoing paranoid thoughts” about the father wanting to take the child from her. It was noted that she needed “one-to-one care at all times” in order to support her with the newborn. She said it was also documented that the mother had declined to take her anti-psychotic medication over the weekend, and when asked about this, she said the medication was making her drowsy and she wanted to ensure she was able to fully care for the baby.

She said: “[The mother] does have a diagnosis of schizoaffective disorder and a history of non-compliance with her medications. On top of that, she admitted to using crack cocaine during her pregnancy, so I am worried that without the right supports she could relapse in her drug use.”

In cross-examination, it was put to the witness that the concerns raised related to matters of “some antiquity,” and that broadly speaking, the mother had been compliant with treatment for her illness over the years. It was further put to the witness that the mother had taken an active role in the infant’s care since birth. The witness agreed and said she had seen the mother with the child on several occasions and the child was clearly happy. She commented, “I can see the bond she has with the baby and the love which is there.”

Mother’s barrister: “Would you accept that [the mother] abandoned all substance abuse for the majority of her pregnancy?”

Witness: “I would from what she has reported to me, but she did say she had four to five slips during the pregnancy.”

Mother’s barrister: “But those slips were in the early part of her pregnancy, weren’t they?”

Witness: “Early to mid-pregnancy I suppose.”

Mother’s barrister: “And are you happy that the child hasn’t been affected by any drug use?”

Witness: “Yes. Tests were carried out and the verbal report from the lab is that the tests were negative for all substances, which is great. We are still waiting on the formal report but we don’t expect it to say any different.”

The mother’s barrister said his client was willing to undergo regular urine testing if necessary and also had the support of her wider family network in terms of caring for the baby.

Evidence of Consultant Psychiatrist

The expert described the mother’s condition as a “severe and enduring” mental illness. She said it involved hallucinations and delusions as well as mood issues such as depression and anxiety. It was a chronic illness which could be relapsing and cause readmitting, but with the right treatment a person could have good functioning overall. She said the most significant complicating factor for the mother’s condition was her substance misuse. The mother had used crack cocaine which was highly addictive and could exacerbate her mental illness. She said there was also a history of cannabis abuse, but noted that the mother had been abstinent in respect of both drugs in recent months and that in general, she was in “a good place, with stability overall during her pregnancy.”

The mother was presently prescribed two different types of anti-psychotic medications, one of which was administered by means of a monthly injection, and the other was taken orally. She said the mother was fully compliant with her injection treatment, but was not good with the other. The mother had told her that she had stopped taking this because of its sedative effect and that this was impacting her ability to care for the baby. The witness said it was important for the mother’s stability that she was compliant with both medications.

On her most recent review, the mother had been “calm and relaxed,” and denied any form of intrusive thoughts, but told the witness that she had been having some “active psychotic symptoms,” some days previously. She said the mother had attended a colleague in the hospital for review in relation to her symptoms, who noted that she had been suffering from auditory hallucinations and delusions.

In cross-examination, the witness said she was aware the mother had been under the care of a consultant psychiatrist in a clinic close to her home, that she had engaged well with the team there and they had a good relationship with her. She further agreed that the mother had insight into her previous substance misuse and the impact of this on her pregnancy and ability to care for her child.

When asked whether the medication with which the mother was not compliant could be substituted for a similar one without the same sedative side effect, the witness said there was a long-acting version of the medication, but it could not be taken with the injection treatment she was also receiving.

Mother’s barrister: “Is there not a hope that her stability can continue into the future?”

Witness: “Yes, I do hope so, but it’s very difficult to say. From what I saw yesterday she was very responsive to the infant’s needs, she was looking after her well, but this is just a snapshot really. It’s hard to say how she would be in the community without the assistance of the medical team in the hospital.”

The judge queried how quickly the situation might deteriorate if the mother stopped taking her medication entirely. The witness said: “Fairly quickly… If we look back on just the two days of not taking it, her symptoms were much more prominent, so it’s the consistency of taking it that is very important.”

Evidence of team leader

The team leader said she had only worked with the mother for the last three months, but was aware of her social work file and the details in relation to the care order previously made in respect of her older son. She said the concerns which led to that care order were similar to those being raised in respect of her newborn child.

She said considerable supports had been offered to the mother from 2007 onwards and the CFA did its best to try to ensure the older child remained in his mother’s care. She said the father of this child had passed away at the time of his birth, and the mother had been provided with a family support worker and also had the assistance of the father’s family, as well as her own mother. Despite this, engagement was sporadic, which was put down to her drug use and significant mental health concerns.

The witness said the department was alerted to the mother’s new pregnancy when she attended a clinic in late 2021 and the staff had concerns about her presentation. The mother appeared to be under the influence of drugs at the time. A further referral later came in from a consultant psychiatrist in the relevant maternity hospital and those concerns related to crack cocaine usage and issues with the mother’s medication regime.

When the department raised the issues with the mother, the witness said it was clear she was very concerned about her baby being taken away from her. The witness told the mother to accept all supports offered to her and a home visit was organised. On the day of the visit, the mother questioned the level of concern which “made me worry she had a lack of insight into her issues.” She said they spoke about the lack of family support in place and the fact that the mother was quite isolated. She said the mother told her that the child’s maternal grandmother was more than willing to assist with the baby’s care, but the witness was concerned that the grandmother had insufficient capacity and ability to look after the baby as she was elderly and was suffering from numerous medical difficulties.

On the day of the visit, the witness said she noticed a “white powdery substance” on the table in the kitchen and she asked what it was. The mother “wiped it away and said it was nothing.” The witness clarified that she had not tested the substance in question so she could not say what it was but she was “worried.” She noted that the mother had earlier told her that she had been taking cocaine to medicate herself for Attention Deficit Hyperactivity Disorder (ADHD), which was a diagnosis she did not have. However, on the date of the visit, the mother assured her that she had been drug-free for numerous weeks, and “seemed quite proud of this.”

The witness was asked what attempts had been made to seek alternative care options for the infant.

She said: “We always try to keep baby with mum and we have worked hard to locate someone in the family, but at this point there is no one available to us. The paternal grandmother has come forward but on the basis that a paternity test determines that the baby is their son’s.”

According to the community team, there were serious concerns as to how the mother might present post-natal when the baby was at home with her. She said the hospital was a structured environment and the mother had an abundance of support there, but in the community the fear was that the mother would not put her mental health first and could relapse.

The witness was aware the mother had linked in with an addiction service close to her home, which was a very positive step, but the most recent update from the service in question was that the mother had failed to engage after her first meeting with them.

The mother’s barrister put it to the witness that there had been a “material change” in the mother’s circumstances since 2007. He said that at the time her older son was taken into care, she had an “unmanaged” serious psychiatric illness, but the difference was that it was now under control. The witness accepted that “things were different then,” but reiterated her concerns around the lack of family support for the mother.

She said: “Back in 2007, [the mother] had the full support of her mum, but she doesn’t have that now. Her mum doesn’t have that ability or capacity to support the baby, so while her mental health was definitely worse at that time, she actually had more support around her then.”

Mother’s barrister: “Are there parenting support groups available to her [in her home county]?”

Witness: “Yes and these were offered to her, but due to non-engagement they were stopped. We can bring in all the supports available but she has to be willing to engage with them and commit to be the best that she can be.”

The judge queried what access would look like if the court granted the application. The witness said it was hoped that supervised access could take place in the mother’s home four to five times per week, as it was important to maintain the bond between the mother and baby. She said it was dependant on the mother and her level of mental health so constant reviews would be required. She said there was “always a hope for reunification” and the CFA would continuously monitor how best to support the mother.

Having heard the evidence, the judge said he had considered the possibility of a supervision order in the first instance, but that if there was any relapse, the evidence suggested the situation could deteriorate “very rapidly.” He said it was this which left the court “very concerned” about making a supervision order, in spite of the positive efforts being made by the mother to tackle her substance misuse. He said in those circumstances the interim care order was necessary and proportionate. He noted that there was an access plan identified which was “not set in stone” and would depend on what worked best for the mother. He made a direction that access take place and noted that it would be helpful if the paternity test was carried out prior to the next court date.