Jersey Unreported Judgments

[2008]JRC026A

royal court

(Family Division)

20^th February 2008

Before     :

M. C. St. J. Birt, Esq., Deputy Bailiff (sitting as a single judge).

IN THE MATTER OF AN APPLICATION BY THE MINISTER FOR HEALTH AND SOCIAL SERVICES FOR AN EMERGENCY PROTECTION ORDER IN RESPECT OF B.

Advocate E. J. Hollywood for the Minister.

Advocate S. A. Pearmain as Guardian ad litem on B, in person.

The parents appeared in person.

judgment

the deputy bailiff:

1.        On 1st February I sat as a matter of urgency to hear an application by the Minister for Health and Social Services for an Emergency Protection Order under Article 37 of the Children (Jersey) Law 2002 ("the 2002 Law") in respect of B.  At the conclusion of the hearing I granted the order but said that I would give my reasons later.  I now do so.

2.        The written material before me at the hearing included reports from Ms Patricia Ruiz de Azua, a senior practitioner with the Children's Service and Dr Carolyn Coverley, a consultant in child and adolescent psychiatry with the Child and Adolescent Mental Health Service (CAMHS).  There were also written statements from DC Le Marquand of the States Police and Ms Linda Dodds, manager of the Child Protection Team of the Children's Service as well as other documentary material.

3.        At the hearing I heard oral evidence from Dr Coverley, Ms Ruiz de Azua and Ms Dodds.  They were cross examined by Advocate Pearmain and the mother.  The mother also gave oral evidence.  I would like to express my particular thanks to Advocate Pearmain who had been appointed Guardian Ad Litem.  She had in the very short time available met with B and had assimilated the facts of the case so as to subject the evidence of the witnesses called for the Minister to close scrutiny and testing.  

Factual background

4.        The background as it emerges from the reports and evidence presented to me is as follows.

5.        B was born on 15th April 1992 and is therefore now 15¾.  She lives with her parents and her brother C.  She first came to the attention of the social services agencies when she was referred to CAMHS by her general practitioner on 31st May 2007 because of concerns over her eating.  She was seen by Dr Coverley and Martina Conway, a member of the Eating Disorder Team. 

6.        Dr Coverley concluded that B suffered from Obsessive Compulsive Disorder (OCD) related to cleanliness.  This appeared to have developed following a placement at a veterinary surgery in February 2007.  She had since then developed an obsession about contamination by germs and dirt.  She was worried about any new items coming into the home and they all had to be washed or cleaned.  Her parents would frequently wash objects so that she could touch or use them.  She was particularly concerned about school and did not want any items from school coming into the house.  She tended to do all her homework at school so as to avoid contaminating her home with school books. 

7.        It was clear to CAMHS that B also had significant issues related to eating.  On examination she was below the 0.4th percentile for weight (i.e. only four children in a thousand of her age would be of her weight or less).  Dr Coverley did not believe that she met the criteria for anorexia nervosa in that she had no desire to be thinner; on the contrary Dr Coverley felt that the eating problem was associated with her OCD.  This appears to be consistent with the instructions given by B to Advocate Pearmain which are to the effect that she began to eat less because she did not wish to use the toilets at school for fear of contamination.

8.        CAMHS began a programme of work with B and her family to address these two issues.  However, according to Dr Coverley, B's level of cooperation fell away quite quickly so that she moved from some involvement in sessions to sitting for most of the session in silence.  On the last occasion that she came to the CAMHS premises at the beginning of September, she sat in silence throughout the session but stated, just before leaving, that CAMHS was trying to separate her from her mother and that she hated them.  On going down the stairs she started to scream in the corridor that she hated them and she wanted to kill herself.  Her parents had great difficulty in calming her and getting her home.

9.        Subsequently CAMHS endeavoured to engage with B in her home including offering a package of support with nursing staff attending on a daily basis.  On several occasions B tried to force her parents not to let CAMHS into the home.  Finally, in October, B's parents requested that CAMHS did not go to the home any further. They said that B had said that if CAMHS were not involved she would start to engage with the Education Department.  I should explain that she had not been to school since May 2007.  In the light of this expression of wishes, CAMHS arranged a meeting with Brenda Cochrane (senior educational welfare officer) but unfortunately, after one meeting at the Education Department, this has broken down and B has not done any school work at home or been to school since May 2007.

10.      According to Dr Coverley, during this period the CAMHS team developed a greater understanding of the family dynamics that she considers play an important part in B's difficulties.  The more significant aspects are as follows:-

(i)     B's mother has lost two close family members by suicide, including her father.  This was at a time when her father seemed to be content.  She is naturally very concerned about B's wellbeing.  It is the view of the professionals that whenever B makes threats to kill herself, often when she is angry or challenged, her mother immediately becomes very distressed and anxious and this leads her to comply with B's demands, whatever they may be.  Because of her experience that even when someone appears settled and content they can actually take their own life, she feels she can never be reassured that those close to her are safe.  She therefore feels a paramount responsibility to keep B safe whatever this takes even if to the detriment of B's other needs.  She does not feel that B is safe in other people's care, including professionals.

(ii)    B's mother had a very difficult relationship with her own mother and is keen that her relationship with her daughter is different.  Accordingly when B is angry or critical of her mother, the mother is desperate to restore their positive relationship.

(iii)   B is aware there have been difficulties within her parents' relationship and B does not want her parents to part.  From what her mother has said, she believes that one of the factors which enables a wife to separate from her husband is if she is in employment and has money.  Accordingly B has repeatedly stated that she does not wish her mother to work and sometimes holds on to her legs to prevent her from leaving.

(iv)   The mother has periods of low mood and threats of suicide.  Indeed on one occasion at the beginning of 2007 she went to the beach with the intention of killing herself.  When she went home she allowed her children to shut her in a locked cupboard as punishment. 

11.      At the beginning of November 2007 Dr Coverley wrote to the Children's Service (Ms Dodds) expressing concern about B's situation.  According to Ms Dodds, the family declined offers of assistance from the Children's Service.  Furthermore B was indicating that she would engage with the Education Department.  The Children's Service were concerned about her welfare but that concern was not sufficient to cause the Service to intervene against the family's wishes.  Accordingly they decided upon no further involvement at that stage.

12.      At a subsequent meeting in January the father reported that the situation within the home was deteriorating and that he was concerned about the wellbeing of his daughter and wife.  He said that B fluctuated between being withdrawn and miserable, aggressive and occasionally 'her old self'.  CAMHS said that it was imperative that there be a meeting with both the father and the mother but there was no response from the family to this suggestion.

13.      As no one had seen B for some time and there was concern about her welfare, it was decided to convene a multi-agency meeting including CAMHS, the Children's Service and the Education Department.  Dr Coverley wrote to the Children's Service on 18th January 2008 explaining the nature of her concerns and asking a representative from the Children's Service to attend the meeting.  Unfortunately, there was a mix-up over dates and no one from the Children's Service was at the meeting, which was held on 24th January.  However the father (but not the mother) did attend.  As a result of the information it received the group agreed to a further meeting on 30th January and that the Children's Service should visit B's home in the meantime. 

The events of 29th January

14.      The representative from the Children's Service nominated to go and see B in advance of the meeting was Ms Ruiz de Azua.  She had not previously had any involvement in the matter but read the papers before attending.  Accompanied by Brenda Cochrane, senior educational welfare office, she visited the family home on the morning of 29th January in order to see B.  The mother was out but the father was at home.  They asked to see B but this was unsuccessful.  The father explained that B would not see them, especially if her mother were not at home. 

15.      Ms Ruiz de Azua returned to the office to consult with Mrs Dobbs.  There was mounting concern.  No one had seen B for some two months and there were reports that her condition had worsened.  It was decided that Ms Ruiz de Azua should return to the home at a time when the mother was there so that she could see B.  Ms Ruiz de Azua returned at about 2 p.m. accompanied this time by DC Le Marquand, a member of the family protection team of the States Police, with whom the Children's Service is accustomed to work closely in such matters.  The parents were very welcoming and helpful.  After some conversation B was persuaded to come down to meet Ms Ruiz de Azua and DC Le Marquand.

16.      It is clear that they were both shocked by what they saw and heard.  They were informed that B spent almost all her time in her bedroom either lying in bed or standing at her window and watching the birds outside.  The parents explained that if B was removed from the house she would take her own life.  All the windows were locked due to the parents' concern that she might try to jump out of them pursuant to her suicide threats.  When she reluctantly came downstairs, she appeared very thin, withdrawn, and frail.  She appeared to have difficulty walking up the stairs.  It was explained that she feared the outside world because of the risk of contamination and would become extremely concerned if strangers entered the house.  She would then have to bath, have all her bed linen changed and would require her mother to vacuum in the area in which the visitor had stood.  B would refuse to enter that particular room until vigorous washing or cleaning had taken place.  The parents made it clear that whilst they had concerns about B, they believed that her treatment should not be intrusive but a gradual process.  They would not therefore agree to B leaving the house to be treated or assessed.

17.      Ms Ruiz de Azua returned to her office and reported what she had found to Ms Dodds.  She expressed concern about B's condition.  Ms Dodds decided to obtain the views of DC Le Marquand and spoke to her.  DC Le Marquand also expressed concern about how frail B was.  At this stage Ms Dodds decided to obtain advice from medical and psychiatric colleagues.  She spoke to Dr Coverley and to medical professionals at the hospital.  She then spoke to Acting Inspector Smith of the family protection team.  The information available to the various professionals was that B was expressing suicidal thoughts, she was physically extremely frail, she was spending her days lying in her bedroom or looking out of her bedroom window, she was not attending school and she was dependant entirely on her mother; yet the parents were refusing to agree to any treatment or assessment.  There was real concern about her safety and wellbeing.  It was agreed that the Children's Service should return once again to endeavour to persuade the parents to agree to B being transferred to hospital but if they would not, B would be taken into police protection pursuant to Article 41 of the 2002 Law.

18.      At about 5.30pm Ms Dodds, accompanied by Inspector Smith and DC Le Marquand went back to the family home.  They explained that they believed that B needed to be taken to hospital.  The parents vigorously opposed this proposal.  They did not want any action to be taken in relation to B until C had taken his A Levels as he might be disrupted by such steps so that his prospects of gaining sufficiently good A Levels to get into Cambridge would be adversely affected.  They just wanted to care for B on a daily basis and meet her basic needs until that point.  The mother said that B had been suicidal all day and attributed this to people coming to the house.  She explained that B's worries about contamination were such that she had been in the bath since Ms Ruiz de Azua and DC Le Marquand had left that afternoon and the mother had also had to vacuum the air.  Ms Dodds said that they spent about half an hour trying to persuade the parents to let B go voluntarily but eventually Inspector Smith insisted.  Ms Dodds said that she was taken aback when she first saw B as she came out of the bathroom because she was so frail.  When pressed as to why she had felt it appropriate to remove B over the objections of the family, Ms Dodds said that she did not feel that she could leave B overnight.  She had been told that B was suicidal.  She felt that if she had left B and B had committed suicide, she would have failed in her duty.  She added that the suicide tendency was not attributable simply to the events of that day.  When they arrived at hospital B said to Ms Dodds that she had not felt suicidal for the past few days until the people had come to the house that day.  When B arrived at hospital, she refused to go in the lift and her mother had to carry her 'piggy-back' up to Robin Ward.

19.      On medical examination it transpired that B was no thinner than when seen in June 2007; on the contrary she had put on three kilos.  However she remained in the lowest 0.4th percentile for her age.

20.      The postponed multi-disciplinary meeting was held the next day on 30th January.  The position was reviewed and I have seen the minutes of the meeting.  The outcome was that it was decided to apply for this emergency protection order.

The Law

21.      The relevant part of Article 37 of the 2002 Law provides as follows:-

"(1)     The Bailiff may, on the application of any person, make an emergency protection order with respect to a child if the Bailiff is satisfied that:-

(a) there is reasonable cause to believe that the child is likely to suffer significant harm if:-

(i) the child is not removed to accommodation provided by or on behalf of the Minister, or

(ii)the child does not remain in the place in which he or she is then being accommodated; or

(b)...................................."

This application is brought under Article 37(1)(a)(ii).

22.      I was referred to the case of X Council v B (Emergency Protection Orders) [2005] 1 FLR 341 which, at paragraph 57 of the judgment of Munby J, sets out the overriding principles which should be borne in mind when considering whether to grant an emergency protection order under the equivalent English legislation.  I have carefully considered the matters summarised there; in particular the fact that summarily removing a child from her parents is a draconian and extremely harsh measure requiring extraordinary compelling reasons.  Such an order should not be made unless I am satisfied that it is both necessary and proportionate and that no other less radical form of order will achieve the essential end of promoting B's welfare.

Submissions

23.      The Minister's case is that an order is required for the reasons summarised by Dr Coverley.  The agencies are faced with a 15 year old girl who suffers from OCD in relation to contamination.  As a result, she has not attended school since May 2007; she spends her days in her bedroom lying in bed or looking out of the windows; she does not even listen to the radio or watch television because of fear of radiation nor does she read books because of the fear of contamination; she does not eat properly and is seriously undernourished and underweight.  In short she has no social outlet, little intellectual challenge, no physical activity and no form of stimulation; she has become almost totally housebound and inactive.  She has regular thoughts of suicide.  Apart from the day of 29th January - which I accept was extremely stressful - the most recent occasion on which she had suicidal thoughts was a few days earlier.  The upstairs windows are locked so that B cannot throw herself out of them.

24.      The position is aggravated by the family dynamics.  The agencies accept unreservedly - as do I - that the parents love their daughter dearly and wish to do their best for her.  However, for the reasons mentioned earlier, the mother is incapable of setting any boundaries and invariably gives way to B's demands.  As a result, because B does not wish to engage with the agencies, the parents have until now refused to agree to any treatment or assessment.  Furthermore they are most concerned not to allow anything to distract C from his important A Levels.  In Ms Dodds' opinion they are thereby putting C's welfare ahead of that of B.

25.      Dr Coverley accepted that taking B into police protection had possibly increased the short term risks of self harm.  There was a risk of self harm even if she remained in Robin Ward.  However, the risk of self harm by returning B to her family after recent events was greater.  It was urgently required in B's interest that her underlying problems should be addressed.  This would be impossible if she remained in the family environment because there was no willingness to engage with any treatment.  What was required was that B should in the short term remain in Robin Ward where the agencies could work with her and where she could be weaned to some extent from her dependency on her mother.

26.      Advocate Pearmain, on the other hand, submitted that the circumstances did not justify the draconian step of an emergency protection order.  She outlined to me the result of her meeting with B on the day before the hearing.  B agreed that, following her placement at a veterinary surgery, she had developed an aversion to germs and dirt.  It was that aversion  (rather than any desire to be slim) which had led to her not eating much because she did not wish to risk using the toilets at school for fear of contamination.  Mrs Pearmain said that B was clearly an intelligent and articulate girl who knew her own mind.  B did not believe that an education was essential in her case as she hoped to live indefinitely with her mother and father.  She had not wished to have any treatment.  However, in view of the fact that she had been forcibly removed to Robin Ward she was now willing to co-operate if she could be treated at home.

27.      Mrs Pearmain submitted that the circumstances had not justified B being taken into police protection on 29th January.  The position was no worse that it had been for some time.  Far from assisting the position, the events of that day had now made it more difficult for co-operation to take place as the family felt let down by the various agencies.  There had never been any warning to them that, unless they co-operated, B might be moved compulsorily.  Be that as it may, they were now willing to co-operate with treatment and the family should be given an opportunity of working with the agencies at home rather than B being detained in Robin Ward.

28.      The parents supported Mrs Pearmain in her submissions.  The mother made it clear that they felt betrayed by the decision to remove B on 29th January.  She contended that B had been making slow but steady progress until that stage.  She had been eating more and her mood was better.  This progress had been put at risk by the decision to take her into police protection.  She said that the treatment which B and the parents wished to try was the Human Givens Treatment.  However, Dr Coverley said in evidence that this was not the 'miracle cure' which the family believed it to be.  It was not a mainstream form of treatment and could only form part of a package of treatment.  The parents submitted strongly that B should be returned to their care immediately. 

Conclusions

29.      I see some force in Mrs Pearmain's submission that it might have been more appropriate to give the family a little more time to come to terms with the need for B's problems to be addressed as a matter of urgency before a decision was taken to remove her from her home.  However I can also well understand the concern that was felt by the Children's Service, the police and CAMHS when they discovered the sort of life that B was leading, her thoughts of suicide and the refusal of the parents to countenance any treatment until C had taken his A Levels.

30.      Whether it was necessary to remove B to police protection on 29th January is not for me to decide.  The fact is that she was removed to Robin Ward and after 72 hours she will be able to return home unless I make the order requested.  As with all cases concerning children, I have to consider what is in B's best interests and I have to do so in the knowledge of the fact that she is now in Robin Ward.

31.      I am satisfied that, for the reasons given on behalf of the Minister and summarised above, B's safety requires me to grant this application.  I find that there is reasonable cause to believe that she is likely to suffer significant harm if she does not remain in Robin Ward. I accept Dr Coverley's opinion that the risk of self harm if B is allowed home after what has happened is greater than if she remains in Robin Ward.  Equally, I am satisfied that it is urgent that professionals begin treating B.  It is in my judgement extremely damaging to her welfare for B to be spending all her days as a 15 year old lying in her bedroom with no physical or mental stimulation whatsoever and obsessing about contamination, with her obsession being reinforced by her mother because of the mother's fears of the effect of any confrontation.  In view of B's and her parents' refusal to agree to treatment prior to her removal to Robin Ward, I do not think I can rely at this stage on assertions that the family is now willing for treatment to take place.

32.      As already mentioned, I accept entirely that B's parents love her and wish to do the best for her.  But I am also satisfied that their attitude, however well meaning, is reinforcing B's obsession and is therefore dangerous to her wellbeing.  If B is to live anything remotely resembling a normal life for a 15 year old, her obsession needs to be addressed.

33.      Article 37 (4) of the 2002 Law provides as follows:-

"Where the Bailiff makes an emergency protection order the Bailiff may give such directions, if any, as he considers appropriate, with respect to:-

(a) the contact which is, or is not, to be allowed between the child and any named person and may impose conditions on such contact; and

(b) the medical or psychiatric examination or other assessment of the child."

34.      The Minister has asked that, if I make the order, I should exercise the power under (a) above so as to limit the contact between B and her mother to such level as is deemed to be in B's best interests by medical and psychiatric staff and the Children's Service.  Dr Coverley explained that there was a need to separate B and her mother a little so as to enable progress to be made.  There was no intention of prohibiting contact, merely a wish to restrict it a little so that professionals had an opportunity of working with B in the absence of her mother.  I am satisfied for the reasons given by Dr Coverley that this is in B's interests and accordingly I make the order requested.  I also make an order for her to be medically and psychiatrically assessed.

35.      Article 40(1) of the 2002 Law provides that an emergency protection order shall have effect for such period not exceeding 28 days as may be specified in the order.  There is provision under Article 40(5) for application to be made at any stage to discharge an emergency protection order.  In the circumstances of this case I consider that 28 days is the appropriate period in order to give adequate time for the appropriate treatment to begin.

36.      I would end by repeating the thrust of some remarks which I made when announcing my decision.  I fully understand the family's strong feelings that B should not have been removed in the way she was on 29th January.  They feel let down by the agencies.  But I am in no doubt that the agencies have B's best interests at heart and are doing what they strongly believe to be necessary in her best interests.  Given that both the parents and the agencies wish to do the best thing for B, I urge them all to put recent events behind them and work together in trying to ensure that B can address her difficulties and begin to live the life of a normal teenager.  In particular I urge the parents to accept the help which they are being offered.

Authorities

Children (Jersey) Law 2002.

X Council v B (Emergency Protection Orders) [2005] 1 FLR 341.