This document discusses a case involving the death of a 18-month old child, BDS, from methadone toxicity. There were multiple explanations for how the child ingested the methadone, including that it was accidentally or deliberately administered. The document then outlines actions taken in response, including increased home visits, training, and testing policies for parents in drug treatment programs. It also discusses the issue of children ingesting drugs more broadly, citing reports and cases of methadone and other drugs being found in children. The key themes are protecting children from accidental or deliberate drug exposure, and ensuring proper protocols and support are in place for parents in recovery.

1. Protecting Children
Martin Smith Recovery Lead
Master slide option 1
Date10/11/2015

2. Background BDS12
Mother was 33 and had been in treatment since 1998
6 separate episodes of treatment
Two children, one aged two and half and one who was
18months old
Her partner didn’t use drugs
Lived in ripley
Crossed border for prescribing

3. Incident
• On 12th March 2012 parents call 999 and ask for BDS
to be admitted to hospital as he’d ingested
methadone
• BD was pronounced dead. After autopsy cause of
death was given of methadone toxicity.

4. Multiple Explanations for the cause of death
• Methadone put in child’s cup and left on bedside table
for mother when she woke.
• Accidental administration (parent’s explanation)
• Methadone decanted into child beaker to sell and left
beside bedside.
• Accidental administration (Sub Mis evidence)
• Methadone routinely given to the child
• Deliberate administration (prosecution explanation)

5. What was happening?
• Methadone storage box had been given to SD prior
to birth of BDS along with information which she’d
signed to say she understood.
• Attended Appointments/Good engagement
• Methadone pick ups x 3 weekly
• Presented well
• Supportive Grandparent
• Testing

6. Baseline Audit
• 543 parents in treatment
• 476 On Methadone (88%)
• 67 On Buprenorphine (12%)
• 289 Of The Methadone Parents Were Taking Their
Meds Home
• Over All Population on Buprenorphine (187) 97
testing negative on a consistent basis

7. Action Plan
• Home Visits to ensure every parent had a storage box
• Training for all staff
• HV Training Neo Natal addiction
• Joint assessments (HV)
• System One
• Once per month joint team meeting dedicated to social
care issues (SW&HV)

8. Parenting Group
• Kickstart to manage group programme for parents. (
Crèche for children)
• Environment: Away from clinical services in a recovery
centre (Exposure to other activity)
• Prescribing for this group to occur in the recovery
centre,On-going Have we got the right facilities for
women and parents?

9. Prescribing
• Decisional check list for prescribers (Parents)
• Other options to be encouraged beyond just methadone
(safest form)
• New prescribing environment (exposure to people in
recovery)
• Prescribing changes to be communicated with all
agencies not just the GP.

10. Methadone Soothing
• During the course of the review it emerged that there
may have been a view among some drugusers that the
practice of giving drugs to babies to calm them down
was appropriate and possibly widespread. (A thematic
report of Ofsted’s evaluation of serious case reviews
from 1 April 2007 to 31 March 2011)
• Adfam Report 2014 Adfam Report 2015
• Disclosures and testing and hair strand testing showing it
is more common than we like to acknowledge

11. 2014
• SCR Oct 14Death of a 2-year-7-month-old boy Child
T by drowning. Mum fell into a drug-induced sleep
• for about two hours, after putting him in the bath. Test
results showed heroin, cocaine and cannabis,
• along with diazepam, temazepam, nitrazepam,
methadone, tramadol and the painkiller pregabalin.

12. 2014
• Blackpool toddler death: Sophie Jones ingested
methadone – BBC Nov 2014
• Mother charged after son's methadone poisoning
death (Birmingham) Sept 2014
• A WOMAN let a toddler drink enough methadone to
kill an adult – then tried to stop a 999 crew rushing
the unconscious child to hospital. Oct 2014

13. http://www.scotsman.com/news/health/big-rise-in-babies-
hooked-on-drugs-before-birth-1-
3939194?#axzz3qhrWDMah
Baby left home alone and syringe found in kids' clothes at
Derby house
Read more: http://www.derbytelegraph.co.uk/Baby-left-
home-drug-needle-kids-clothes/story-28116406-
detail/story.html#ixzz3qilsQ2AD
Suspended jail sentence for dad who failed to raise
alarm after his baby son drank heroin substitute

14. National SCR Messages
• SCR from 14 years ago :Poor information sharing.
The need for child protection training. More joined
up working.
• SCR in 2014: Poor information sharing. The need for
children protection training. More joined up working.

15. Recovery=Honesty&Courage
• Has a sector do we reflect this?
• Lets not shy away from difficult challenges?
• increase in DRDs 2013 and 2014 ONS
• Hep C testing and Treatment
• Older generation, end of life conditions
• Children and Methadone
• There are around 400 adult deaths involving
methadone per year.
• More deaths in Scotland due to Methadone than
heroin