This month’s case has a fascinating set of facts. One can see how a situation like this could occur where parents refuse to communicate with each other, and it is easy to imagine how it could have resulted in tragedy for the pediatric patient.

Facts of the Case

Ms D was a licensed registered nurse working for a hospital system which operated some inpatient facilities as well as some clinics in 2 cities in Texas. As part of her job, Ms D was assigned to work with Dr K, a pediatric neurologist. One of the patients they cared for was a middle-school aged child who suffered from seizures. The child’s parents were divorced and shared custody, and the father was the one who brought the child in for appointments.

On May 4, 2016, after business hours, Ms D answered a phone call from the mother of the child. During the call, the mother told Ms D that both she and the child’s father, acting independently, had been seeking treatment from 2 different neurologists. The father had been taking the child to Dr K, but the mother was taking the child to a different neurologist in another city. The mother reported that Medicaid would not cover the child’s appointments with both neurologists, and that there was an apparent issue with the child’s medication. Both neurologists had prescribed different antiseizure medications for the child.

After getting off the phone with the child’s mother, Ms D was extremely concerned. From what the mother had said, it seemed as though the child was receiving different medication depending on which parent had custody at the time. She called the father and left a message but was unable to speak with him.

The next morning Ms D informed Dr K about the situation. The physician told her that it would be necessary to determine which neurologist would remain the child’s treating doctor. Ms D contacted the other neurologist who had no idea that Dr K was also treating the child or that other medication had been prescribed. The other neurologist told Ms D that he would inform the child’s mother that he would no longer treat the child while the child was being seen by Dr K.

Ms D then called the school nurse at the child’s middle school due to her concerns that the child was not getting the prescribed medication. Ms D advised the school nurse that the mother had called and said she was giving one medication and the other parent was giving another medication. The school nurse reported that there had been some increased behavioral issues, which were unusual for the child, and the child had been to an ‘in-patient psych center’ due to these issues. The school nurse told Ms D that she would be on the lookout for worsened behavior or increased seizure activity.

After talking to the school nurse, Ms D contacted her supervising charge nurse and advised her of the circumstances disclosed by the mother, and Ms D’s concerns about the child’s medications. The supervisor replied, “if you feel that there is a danger you need to make a report.”

The next day Ms D contacted the state’s child protective services (CPS) agency and made a report of suspected abuse or neglect of a child. Ms D reported possible harm in regard to seizure medication not being properly dispensed by divorced parents, and the fact that the parents had arranged for the child to be treated by 2 different neurologists and each had prescribed different medication. Ms D relayed to CPS that the mother was not giving the medication that the father’s neurologist had prescribed, and vice versa.