DRUG AND ALCOHOL MISUSE IN PREGNANCY by gabyion

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									                   Southend, Essex & Thurrock Safeguarding Children




Drug and alcohol
    misuse in
       pregnancy

  Multi-agency guidelines for
     Southend, Essex and Thurrock




                                      January 2006
                                                    Drug and alcohol misuse in pregnancy




               This document has been produced in consultation
                         with the following agencies




Social Care


Health Trusts in Essex


North and South Essex Mental Partnership Trusts Substance Misuse Teams


Associate Specialist in Drug and Alcohol misuse for West Essex
                                                                                            Drug and alcohol misuse in pregnancy




Contents

Introduction ............................................................................................................................ 1

Aims of the Guidelines.............................................................................................................2

Role of the GP..........................................................................................................................2

Role of the Community Drug & Alcohol Team............................................................................4

Role of the Midwife..................................................................................................................6

Role of the Nominated Consultant Obstetrician........................................................................9

Neonatal Intensive or Special Baby Care Unit (NICU, SCBU).....................................................11

Role of the Health Visitor ....................................................................................................... 13

Role of Social Care................................................................................................................. 14

References ............................................................................................................................ 16

Appendices

1     Flowchart for antenatal care for substance misuse .......................................................... 17

2     Guidelines for Partnership Meetings & Proforma ............................................................. 18




                                                                                                                                Contents
                                                               Drug and alcohol misuse in pregnancy




Drug and Alcohol Misuse in Pregnancy
Introduction

Substance misuse has been defined by the World Health Organisation as:

           ‘A state, psychic and sometimes physical, resulting from the
          interaction between a living organism and a drug,
          characterised by behavioural and other responses that
          always include a compulsion to take a drug on a continuous
          basis in order to experience its psychic effects, and
          sometimes to avoid the discomfort of its absence. Tolerance
          may or may not be present.’

As part of a harm reduction philosophy, a multi-disciplinary working party developed these
guidelines, advocating shared antenatal and postnatal care for pregnant women who misuse
drugs and alcohol. The guidelines follow The Children Act 1989, which states that the interest
of the child is paramount.

It is hoped that in promoting a positive approach to women who substance misuse, pregnant
women will become more confident in reporting and reducing their drug and alcohol use.

The purpose of this guidance is to ensure that the best possible care is offered to women who
are substance misusers and their unborn babies. This will be achieved by working in
partnership with the parents-to-be and through multi-agency collaboration.

Women should be reassured that they will not be discriminated against as result of drug or
alcohol use and that the overall aim in each service is to provide non-judgemental care. This is
essential as the engagement of women is dependent on a feeling of confidence in the services.

The health worker should discuss the woman’s substance misuse throughout her pregnancy to
assist in the planning of appropriate care as this can have far reaching implications for her
future drug use and the well being of the baby. It is widely acknowledged that pregnancy can
be highly motivating for women in terms of exerting some control over drug/alcohol usage.




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                                                                   Drug and alcohol misuse in pregnancy




Aims of the Guidelines

            •   Identify risks of significant harm to the unborn child and ensure appropriate
                action.

            •   Ensure the substance abusing woman is offered appropriate antenatal care.

            •   Establish a comprehensive plan of care to meet the needs of the pregnant
                substance user and her child and identifies which professional undertakes the
                responsibility for convening and co-ordinating any meetings.

            •   Ensure that the client is involved in all aspects of her care planning throughout
                her pregnancy and postnatally.

            •   Encourage the female drug/alcohol user and, where appropriate, her partner, to
                seek help for their substance misuse.

            •   Provide information about HIV, Hepatitis B and C and risk reduction to pregnant
                substance users.

            •   Provide a flexible service according to client need with due respect to client
                individuality and culture.

            •   Establish effective communication between all professionals.

            •   Stabilise the client on a safe level of drugs or alcohol for the duration of the
                pregnancy.

1.    Role of the GP

      1.1       Contraception and safer sex are topics that should be discussed routinely with
                all substance misusers.

      1.2       Preconceptual care should be discussed routinely wherever possible.

      1.3       All women should be asked about drug and alcohol use as a routine part of
                antenatal care. The GP may be the first professional to suspect and confirm a
                substance misuser’s pregnancy. The GP’s first duty is to inform the client of the
                potential risks and the services that are available to assist her in substance




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      misuse reduction/stabilisation. The GP should undertake the following actions
      in consultation with the woman:

         •   arrange an urgent appointment with the Obstetrician who has
             responsibility for substance misuse and the Midwife;

         •   complete an Antenatal Booking form recording prescribed drugs,
             reported levels of other substances and alcohol being used;

         •   make a referral to the local Drug and Alcohol Service. If the woman
             refuses this service the Obstetrician and midwife must be informed;

         •   the GP should be aware of blood test results and any referral for further
             care that may be needed as a result of these tests.

1.4   If there are any concerns about the woman’s behaviour, mental health or social
      issues which will have an impact on the unborn baby a referral to Social Care
      must be made and the woman informed. Procedure in the Child Protection
      Policy must be followed.

1.5   The GP may be involved in substitute prescribing and should liaise with the
      Consultant in the local Drugs and Alcohol Team and inform the lead professional
      co-ordinating care.

1.6   If there are concerns that the unborn baby is or will be at significant risk of harm
      a Child Protection Conference may be convened to which the GP must submit a
      report and attend if possible.

1.7   A multi-disciplinary Partnership meeting should always be convened for any
      woman who is substance misusing to which the woman and her partner will be
      invited. The GP will be invited to participate in the meeting where a lead
      professional will be appointed. A care plan will be formulated and circulated to
      the woman and the professionals involved.

1.8   A further pre birth-planning meeting will take place as necessary to which the GP
      will be invited.

1.9   If the GP identifies any further concerns during the course of the pregnancy the
      co-ordinator of care must be informed as soon as possible.




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2.   Role of the Community Drug & Alcohol Team

     2.1   Professionals should make a referral to their local Substance Misuse Team
           indicating that the woman is pregnant. Pregnant drug/alcohol users are
           considered high priority and will be seen as soon as possible and always within
           5 working days. A woman can self refer by telephone or letter.

     2.2   The Drug and Alcohol receptionist/or duty worker will ask for brief information
           and arrange a triage assessment.

     2.3   A staff member from the local Substance Misuse Team will carry out a triage
           assessment.

     2.4   A full assessment summary will be made as soon as possible but with no more
           than two weeks wait. The assessment will include:

              • drug history, past and current

              • nature and frequency of any medication currently prescribed

              • GP/ pharmacy substitute prescribing

              • urine toxicology assessment

              • alcohol and tobacco consumption

              • psychiatric, psychological and social history

              • general health and medical history

              • treatment plan which identifies whether stabilising drug use in the
                  pregnancy or offering detox is appropriate before delivery

              • names and contact numbers of all agencies involved

              • any other concerns.

     2.5   Confidentiality will be dealt with in accordance with Trust and Essex County
           Council guidelines.




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                                                          Drug and alcohol misuse in pregnancy




2.6    Where a client first reveals her pregnancy to the Substance Misuse Team, a fast
       track system referral will be made to the Consultant Obstetrician. Confirmation
       of the pregnancy should be made by the GP and/or midwifery services.

2.7    The woman will be encouraged to access antenatal care as soon as possible (if
       she has not already booked) to establish the stage of her gestation as this will
       influence the drug/alcohol treatment plan. The worker will telephone maternity
       services and make direct contact.

2.8    The woman will be informed that the Substance Misuse Team can not take on
       the role of the obstetric/midwifery services, but will act in a liaison or advocacy
       capacity as required.

2.9    Substance Misuse practitioners are to contact and share relevant information
       with other professionals and the client/s informed that other professionals will
       be involved to ensure that maximum support can be offered and is in the best
       interests of both mother and unborn baby. These may include:

          •   Consultant Obstetrician

          •   Hospital and Community Midwives

          •   Health Visitor

          •   Social Worker

          •   General Practitioners

          •   Voluntary Organisations such as ADAS

          •   Probation, Housing and other agencies where appropriate

          •   Other professionals as appropriate.

       Contact should be made before 12th week of pregnancy if possible.

2.10   Various options are open to a pregnant woman who has drug or alcohol
       problems, depending on the stage of pregnancy, past obstetric history, the
       drugs or alcohol used, and level of care needed for the woman and the unborn
       baby. An individual care plan will be devised according to the woman’s and the




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                                                              Drug and alcohol misuse in pregnancy




            unborn child’s needs. The child may have a Child in Need Plan or a Child
            Protection Plan if a Child Protection Conference is convened and the unborn
            baby registered on the Child Protection Register. The Substance Misuse worker
            will provide the woman with information regarding the risks involved to her and
            her unborn baby as a result of her drug/alcohol use and the need to stabilise or
            reduce in a planned way.

     2.11   If any concerns arise about risks to the unborn baby consultation must take
            place with the Named Professional for Safeguarding Children (NEMHPT or SEPT)
            where consideration will be made about a referral to Social Care. Such
            consultation must be documented (in accordance with NEMHPT or SEPT policy
            with a copy placed in the service user’s clinical notes.

     2.12   It may be beneficial to both mother and unborn baby to prescribe, where
            appropriate, substitute medication as quickly as possible. Risk of sudden
            withdrawal either in pregnancy or during labour can be very significant, i.e.
            miscarriage, premature labour and foetal distress.

     2.13   The Substance Misuse worker will maintain regular contact with the client
            throughout pregnancy to include one to one contact and toxicology if needed
            and attend multi-agency or professional meetings as required. Part of the care
            plan will include regular drug and alcohol screening to monitor progress.

     2.14   Referral to residential drug/alcohol rehabilitation will be made through the local
            Substance Misuse Team as appropriate.

     2.15   The mother and baby’s well being will be everyone’s primary concern. The Drug
            and Alcohol worker has a duty to assist in involving the partner in the woman’s
            care. There will be regular communication with all professionals concerned with
            the woman’s care including pre-delivery discussion. Where there is conflict the
            interests of the unborn baby are paramount.

3.   Role of the Midwife

     3.1    If the GP is aware of substance misuse he or she should have indicated this on
            the Maternity Booking Form, which is sent to the Midwife. All women should be
            asked about their use of drugs and alcohol when they book care with the
            Midwifery services.




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3.2   All Midwifery Teams should have at least one named Midwife with specialist
      training in Substance Misuse in Pregnancy to help and support women and their
      colleagues. There should also be a Midwife who will provide specialist support
      in hospital based maternity services.

3.3   A booking should be completed and a consultant referral made by the 12th week
      of pregnancy if possible. If the woman declines care liaison must take place
      with the Drugs and Alcohol Service and the woman informed.

3.4   The woman will be offered Consultant care. The pattern of appointments for
      antenatal care and how this should be shared between professionals should be
      individually planned.

3.5   An urgent referral should be made to the Drugs and Alcohol Service for an initial
      assessment of drug use and the formulation of a plan of care.

3.6   A Partnership meeting will be held where a lead professional will identify risks,
      maternal support mechanisms and a care plan. (A proforma is attached at
      Appendix 3). The midwife will contribute to the care plan.

3.7   The Midwifery team will ensure that discussion around antenatal screening
      includes Hepatitis C, B and HIV. If a positive result ensues referral to Sexual
      Health will follow for treatment in consultation with the Consultant Obstetrician.

3.8   The woman will be encouraged to carry her Ante-natal notes with her at all times
      which will contain the history and up-to-date details of reported substance
      misuse, toxicology and serology reports and any treatment. A copy must be kept
      in the hospital record.

3.9   A ‘birth plan’ should be discussed with the woman. A copy of this should be
      included in all documentation and should include the full assessment summary
      completed at the Community Drug and Alcohol Team or if not available the
      following:

         •   drug history, past and current

         •   nature and frequency of any medication currently prescribed

         •   GP/ pharmacy substitute prescribing




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                                                         Drug and alcohol misuse in pregnancy




          •   urine toxicology assessment

          •   alcohol and tobacco consumption

          •   psychiatric, psychological and social history

          •   general health and medical history

          •   treatment plan which identifies whether stabilising drug use in the
              pregnancy or offering detox is appropriate before delivery

          •   names and contact numbers of all agencies involved

          •   any other concerns

       And in addition

       A birth plan with:

          •   management of the drug dependency

          •   pain relief during labour

          •   infant feeding

          •   parent craft classes

          •   management of known Hepatitis B/C or HIV infection

          •   the name of the Health Visitor and GP

3.10   The Midwife should arrange a visit to the:

          •   Special Care Baby Unit

          •   Labour Ward

Inform the Health Visitor so the Health Visitor can arrange an antenatal contact.

3.11   If any concerns arise about risks to the unborn baby consultation must take
       place with the Named Midwife for Child Protection where consideration will be
       made about a referral to Social Care. Child Protection Policy will be followed.




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                                                             Drug and alcohol misuse in pregnancy




            The woman must be informed of the referral. Concerns may include aspects of
            care or poor antenatal attendance. Local procedure must be followed for women
            who are in high-risk categories.

     3.12   After the birth of the baby care may continue from the midwife for twenty-eight
            days. A written handover will be made to the Health Visitor and GP.

4.   Role of the Nominated Consultant Obstetrician

     4.1    A named Consultant Obstetrician will be responsible for pregnant women with
            substance misuse.

     4.2    The nominated Consultant will participate in the assessment and the
            development of the care plan throughout the pregnancy.

     4.3    Best practice dictates the first assessment by the consultant should occur by
            twelve weeks of pregnancy or and then care based upon individual needs.

     4.4    The information needed by the Obstetric Team is as follows:

               •   drug history, past and current

               •   nature and frequency of any medication currently prescribed

               •   GP/ pharmacy substitute prescribing

               •   urine toxicology assessment

               •   alcohol and tobacco consumption

               •   psychiatric, psychological and social history

               •   general health and medical history

               •   treatment plan which identifies whether stabilising drug use in the
                   pregnancy or offering detox is appropriate before delivery

               •   names and contact numbers of all agencies involved

               •   any other concerns

            And in addition:




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      A birth plan with:

         •   management of the drug dependency

         •   pain relief during labour

         •   infant feeding

         •   parent craft classes

         •   management of known Hepatitis B/C or HIV infection

         •   the name of the Health Visitor and GP.

      This should be available from the Midwifery records.

4.5   All women will be screened for Hepatitis B, C and HIV.

4.6   A Partnership meeting with the woman will be called involving all professionals
      who are and will be involved with the woman. This meeting should include the
      Neonatologist, GP and HV. Members will:

         •   assess risk

         •   identify strengths and support within the family

         •   evaluate progress

         •   identify a care plan which should include the treatment plan

         •   pain relief during labour

         •   neonatal care

         •   discharge planning.

4.7   The obstetric team should:

         •   offer safer sex advice throughout pregnancy

         •   arrange anomaly scans at 20 weeks and 4-weekly scans to monitor
             growth as appropriate




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                                                               Drug and alcohol misuse in pregnancy




               •   obtain results of blood screening tests

               •   identify who will give contraceptive and pre-conception counselling after
                   delivery for future pregnancies

               •   ensure reviews are undertaken during pregnancy and communicated to
                   the midwife and Substance Misuse Team.

     4.8   In an emergency and where a woman is assessed as needing medication and
           unable to get a prescription it is the duty of the Obstetric Team to undertake this
           responsibility.

     4.9   Following birth the Obstetric Team should provide information to the Neonatal
           Unit if the baby is admitted detailing:

               •   what drugs and alcohol is used or was used by the client

               •   time and date of last use

               •   length of time of usage of substances by client

               •   urinalysis results

               •   substitute prescriptions being used where applicable

               •   name and contact number of Lead Professional.

5.   Neonatal Intensive or Special Baby Care Unit (NICU, SCBU)

     Antenatal Contacts with the Unit

     5.1   The Unit welcomes antenatal contact with women who have substance misuse
           problems as well as their partners as part of their birth plan.

     5.2   A visit to the Unit can be arranged by the Midwife with the senior nurse in charge
           of the Unit and will be recorded in the Unit Daily Diary.

     5.3   During the visit the senior nurse in charge will:

               •   show the client and her partner around the Unit




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          •   provide an opportunity, in private, to discuss what the parents can expect
              in terms of her infant’s likely physical condition and clinical care
              following birth

          •   explain that the infant’s nursing care will be co-ordinated by a named
              nurse, who will be introduced to the parents soon after the infant’s
              admission to the NICU. The named nurse will keep them updated on their
              baby’s progress and will liaise with the lead professional throughout the
              baby’s stay

          •   explain that during the infant’s stay, both parents will be supported and
              encouraged to care for their infant as much as possible. Practicalities
              such as “open visiting” and the use of the “rooming in” accommodation
              prior to discharge will be discussed. The alert folder on the Unit will be
              used for communication

          •   an explanation about the hospital policy on substance misuse on the
              hospital site will be given to the parents.

5.4 The medical and nursing staff will need information held by the Obstetric team
    when the baby is admitted, (see below). This will be kept in the alert folder with
    the baby on admission of the baby.

Admission to the Unit

5.5 At the time of the client’s admission to the Labour ward, midwifery staff should
    notify the Senior Nurse in charge on the NICU and alert the Medical Paediatric
    Team. The unit should obtain the following information from the Obstetric Team:

          •   what drugs and alcohol is used or was used by the client

          •   time and date of last use

          •   length of time of usage of substances by client

          •   urinalysis results

          •   substitute prescriptions being used where applicable

          •   name and contact number of Lead Professional.




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     5.6    The Paediatric Consultant or Registrar will undertake a formal medical
            assessment of the baby after birth. In most cases, admission to the NICU for
            observation will follow.

     5.7    Information about the birth and admission will be sent to the Paediatric Liaison
            Nurse within one working day who will inform the Named Nurse for Child
            Protection.

     Care Plan

     5.8    If the baby is not admitted to the Unit, the infant should remain in the postnatal
            maternity unit for a minimum of five days following delivery and be assessed in
            accordance with the Rivers Score Chart.

     5.9    Prior to discharging the baby appropriate feeding methods should be discussed,
            observations on parent and child interaction and any other care needs. The Lead
            Professional and Health Visitor should be notified.

     5.10   A Discharge planning meeting will be convened by the Lead Professional prior to
            the baby’s discharge.

6.   Role of the Health Visitor

     6.1    If a Health Visitor becomes aware that a woman is pregnant and substance
            misusing, support and advice should be offered. The mother should be
            informed of the steps that must be taken to ensure the safety and well being of
            herself and the unborn baby.

     6.2    The Health Visitor will contact the midwife to ensure that midwifery care is
            offered and that appropriate referrals take place to the Drugs and Alcohol Team.
            It will normally be the responsibility of the Midwife to proceed with the referral.

     6.3    Health Visitors will work in close liaison with the multi disciplinary team to
            identify those women who are pregnant and substance misusing to assist in the
            assessment of the client’s needs and plan care for the family. The School Nurse
            will be informed if there are school children in the family.




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     6.4    Health Visitors must establish systems for enabling effective communication
            with the multi disciplinary team; this involves regular contact and planning
            arrangements.

     6.5    The Named Nurse, Child Protection, must be informed of any woman who is
            substance misusing during pregnancy to support the Health Visitor in the
            management of care.

     6.6    The Health Visitor must be involved in the Partnership meetings with the woman.

     6.7    The Health Visitor will ensure that she liaises with the Midwife during the
            pregnancy and undertakes a contact with the woman to explain the Health
            Visiting service.

     6.8    The Health Visitor will be involved in the Discharge Planning Meeting before the
            baby is discharged from hospital.

     6.9    The Health Visitor will continue to support the woman and her baby following
            discharge from hospital.

7.   Role of Social Care

     7.1    Social Services provide advice, support and assistance to children and families
            in need. They also have a responsibility to investigate situations where there is
            a reason to believe that a child may have suffered, or be at risk of suffering
            significant harm.

     7.2    If an unborn baby or any other child in the family is believed to be at risk of
            significant harm a referral must be made to Social Care. Referrals will be made
            on the Inter-agency Referral Form from the relevant Social Care department.
            (Essex, Southend or Thurrock). Referrals will always be made with the
            knowledge and, where possible, the consent of the service user. Social
            Services, in consultation with other agencies, will determine the appropriate
            level of assessment indicated by the referral.

     7.3    The Drug and Alcohol Teams automatically inform Social Care whenever there is
            a risk of significant harm to a child including an unborn child. The referral to
            Social Care should be undertaken by the 12th week of pregnancy or as soon as




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         the Drug and Alcohol Team or other health professional becomes aware of the
         pregnancy.

7.4      A Partnership meeting will normally be called to assist in planning and support
         by the 20th week of pregnancy. A social worker should be invited to the
         partnership meeting. A care plan should be formulated with a copy for the
         woman and professionals involved.

7.5      Where it is believed that there is a risk of significant harm to the unborn baby a
         Child Protection Conference will be called and ideally a Child Protection Plan
         developed by the 24th week of pregnancy.

Members of the multi disciplinary team

      Paediatric liaison HV

      General Practitioner

      Midwifery Team

      Drug and Alcohol Team

      Consultant Obstetrician

      Health Visitor

      Neonatal Intensive Care Unit Lead

      Neonatologist

      Social Worker




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References

The Children Act 1989                                HMSO

The Children Act 2004                                HMSO

Child Protection 1997 Guidance for Senior Nurses,    DH
Health Visitors and Midwives and their Managers
Child Protection 1996 Medical Responsibilities       DH

Working Together to Safeguard Children 1999          DoH

Messages from Research 1995                          DoH

UKCC - A Midwife’s Rules and Code of Practice 1998   UKCC

National Service Framework 2004                      DH




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                                                                   Drug and alcohol misuse in pregnancy


                                                                                        Appendix 1

   Flowchart for antenatal care for substance misuse

                                GP sends Booking Form



                                      Team Midwife


                               Community Midwifery Manager

              Direct                                                       Social Services


                                                                      Children’s Assessment
                                                                        & Family Support
Local Substance        Alcohol & Drug
                                                                              Team
 Misuse Team           Advisory Service
                            (ADAS)

                                                                         Child               Child Care
                                                                      Protection           Plan & Family
                                     Antenatal Clinic              Conference Plan            Support
                                                                    for Mother and
                                                                         Baby
 Liaise with GP,
 Neonatal Team &
 Health Visitor
                                    Consultant Care 16/40                    Sexual Health Clinic
                                        Booking Scan                        for HIV & Hepatitis C
                                       Routine Bloods                       testing if appropriate
 Partnership Meeting

                                    20/40 detailed
                                    Structural Scan


  Care Plan with
  regular reviews                28/40 onwards. Growth
                                 scans every 2-3 weeks.


                       After delivery at Discharge Planning Meeting, GP,
                                             Health Visitor,
                             CDAT / ADAS worker and Social worker
                                         (as appropriate)




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                                                               Drug and alcohol misuse in pregnancy


                                                                                      Appendix 2

Guidelines for Partnership Meetings

Introduction

When there are concerns about a child a meeting may be called to assess the situation. A
Partnership meeting will involve the parents and can be used to assess the needs and identify
risks. The meeting should involve all relevant professionals.

Any professional can call the meeting and advice can be sought from the designated person in
their area of work. That person then becomes responsible for coordinating the meeting.

Professionals do not need to take along a report but should have all relevant records available.

Organising a Meeting

Make a decision on:      Date
                         Time
                         Venue
                         Professionals who can contribute to the discussion
                         Chairperson and Minute Taker
                         Invitation list
Follow Agenda Format

Record Outcomes

Circulate Action Plan and Minutes

If a parent has been unable to attend a professional must be nominated to discuss the
meeting, the minutes and outcomes with them.

Guidance and Agenda Format

1.   Record Attendees and apologies sent.

2.   Identify the purpose of the meeting.

3.   Identify concerns & risks to children and family members.

4.   Identify strengths in the family, this may include support mechanisms available to them
     and work already undertaken by family.




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5.   Draw up a care plan / action plan with specific, measurable, achievable, time related
     outcomes. It should be clear to professionals and the family what is expected of them by
     the end of the meeting.

6.   Set a date for the next meeting to review the Action Plan.

7.   Record where copies will be sent, date and sign.




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                                               Drug and alcohol misuse in pregnancy




                                                                     Appendix 2
Partnership Meeting

Family Name:                            Address:


Children’s Names:                       DOB:




Date:                                  Venue:


Present:




Apologies:                             (If Parents not present – state why)

Purpose of Meeting:




Concerns: (Bullet Points or numbers)




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                                                                Drug and alcohol misuse in pregnancy




Strengths:




Care Plan:

Action Required                                                   By Whom           By When




If Parents not present identify who will inform them

Date of Next Meeting:

Chair Person:

Signature:                                        Print Name:

Designation:




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