In re A.H.
| Decision Date | 19 June 2020 |
| Docket Number | No. 2093,2093 |
| Parties | IN RE: A.H. |
| Court | Court of Special Appeals of Maryland |
Circuit Court for Montgomery County
UNREPORTED
Nazarian, Arthur, Sharer, J., Frederick (Senior Judge, Specially Assigned), JJ.
Opinion by Arthur, J.
*This is an unreported opinion, and it may not be cited in any paper, brief, motion, or other document filed in this Court or any other Maryland Court as either precedent within the rule of stare decisis or as persuasive authority. Md. Rule 1-104.
This appeal concerns an infant child who has required frequent hospitalizations because of life-threatening episodes of breathing cessation. The Montgomery County Department of Health and Human Services received a report of suspected child abuse or neglect regarding the mother's conduct while she was attending to the child in the hospital. Based on that report, the Department petitioned for court intervention.
After a contested adjudicatory hearing, the Circuit Court for Montgomery County, sitting as juvenile court, found that the child had been neglected and that her parents were unable to give proper care and attention to the child and her needs. The court committed the child to the custody of the Department for placement in foster care. In addition, the court required that the parents' visits with the child be supervised by the Department.
The mother has appealed, contending that the court should have excluded certain evidence at the adjudicatory hearing, that the court made erroneous findings, and that the court made improper rulings regarding the ultimate disposition. For the reasons discussed in this opinion, the judgment will be affirmed.
A.H. was born in December 2018. She spent the first 10 months of her life in the care of her mother ("Mother") before she was removed from the home. At that time, Mother was 19 years old and resided with her parents while she was completing high school. A.H.'s father ("Father"), who was 17 years old at that time, lived in a separate residence and was not involved in caring for A.H.
When A.H. was six months old, she started to experience frequent episodes of apnea (temporary cessation of breathing) and perioral cyanosis (blue coloring around themouth). Mother observed that these episodes occurred about once per day, both while A.H. was asleep and while she was awake. Normally, Mother could resolve the episodes by blowing air onto A.H.'s face.
As reported by Mother, A.H. has a family history of apnea. A.H.'s father has had apnea since his early childhood. Mother's cousin requires frequent treatment for sleep apnea. Other members of Mother's family also have breathing issues. A year before A.H. was born, another child of Mother's died suddenly in her sleep, at the age of three months, from causes that could not be determined.
Mother sought treatment when she first observed A.H. experience an apneic episode in June 2019. A.H. was admitted for one week at Children's National Medical Center. At that time, A.H. tested positive for a respiratory infection.
While at home on July 16, 2019, A.H. experienced an episode that lasted for seven minutes. Her breathing stopped, her lips and face turned blue, and she did not respond to attempts to restore her breathing. Mother called for emergency medical assistance. A.H. was taken to Suburban Hospital and transferred to MedStar Georgetown University Hospital, where she underwent extensive testing over the next 13 days. A sleep study showed that she had severe obstructive sleep apnea. Overall, however, her physicians concluded that the etiology of her apnea was "[u]nclear."
After A.H. was admitted to MedStar Georgetown University Hospital, Mother received a home apnea monitor and instructions on how to use it. A few days later, a nurse observed that the apnea monitor in A.H.'s room had been turned off. The nurse noted that Mother said that she had turned the monitor off because it was not stayingcharged. Later that day, Mother received a replacement apnea monitor.
On one of the first days of A.H.'s stay, Mother made a police report claiming that an acquaintance had threatened to suffocate A.H. at the hospital. A few days later, the Montgomery County Department of Health and Human Services received a report alleging that Mother previously had subjected A.H. to unsafe treatment. While investigating that report, a case worker visited Mother and A.H. at the hospital. Mother told the case worker that she suspected that the allegations were retaliatory and malicious. After A.H. was discharged from the hospital, the case worker visited Mother's home and determined that Mother was providing appropriate care for A.H. The Department ultimately ruled out a finding of child neglect.
A.H. was discharged from MedStar Georgetown University Hospital on July 30, 2019. The doctors instructed Mother to continue using the home apnea monitor, to use a continuous positive airway pressure (CPAP) machine, to see A.H.'s primary care physician within two days, and to see a pulmonologist within one week.
While at home on August 17, 2019, A.H. experienced another episode in which she was unresponsive and had blue coloring around the mouth. The episode lasted for about five minutes, during which Mother attempted to revive her daughter. A.H. was transported to Shady Grove Hospital and then re-admitted to MedStar Georgetown University Hospital.
According to hospital records, Mother acknowledged that she had not taken A.H. to the follow-up appointment with a pulmonologist. Mother said that she missed the appointment because of her involvement in the child protective services investigation.Upon A.H.'s re-admission, a pulmonologist reviewed the data from the home apnea monitor, which showed "inconsistent use" of the monitor at home. When A.H. was discharged on August 22, 2019, Mother received instructions to continue using the home apnea monitor and the CPAP machine.1
While at home on September 15, 2019, A.H. stopped breathing and became unresponsive for a prolonged period of time. The maternal grandfather attempted to resuscitate A.H. while Mother called for emergency medical assistance. A.H. was transported to Shady Grove Hospital for apparent respiratory failure and was briefly intubated. Once stabilized, A.H. was admitted to MedStar Georgetown University Hospital for the third time.
During the next few weeks, health care providers observed two significant episodes of apnea, one of which occurred while A.H. was awake. Despite the comprehensive testing, A.H.'s physicians lacked findings that would explain the cause of A.H.'s life-threatening episodes. A.H.'s physicians considered performing a tracheostomy, a procedure that involves cutting an opening in a patient's neck and inserting a tube into the opening to allow air to flow into the lungs. After the surgery, A.H. would be connected to a ventilator, which would control her breathing.
While considering the treatment options, A.H.'s physicians consulted with a medical ethicist, Daniel Sulmasy, M.D., Ph.D. Dr. Sulmasy documented his discussions with the hospital staff in an entry titled "Consultation Notes." Noting that "the childnearly died at home while having been sent home with a monitor and failed to respond to [CPR]," Dr. Sulmasy recommended a tracheostomy instead of "continued monitoring."
A.H.'s physicians explained to Mother and her parents that A.H. would require a ventilator after the surgery and that she might require a transitional facility as well as in-home nursing. Mother gave her consent, and A.H. underwent a tracheostomy on October 4, 2019. Afterwards, Mother began receiving instructions on how to perform suctioning and other special care that A.H. would require after the tracheostomy.
The central focus of this case is Mother's conduct on the night of October 14, 2019, ten days after the tracheostomy. In a "Progress Note" regarding A.H.'s care during an overnight shift, Madeline Dwivedi, R.N., made a record of Mother's actions and statements while she was staying in A.H.'s hospital room.
At 7:51 p.m., Nurse Dwivedi recorded that she saw Mother "shove [the] patient aggressively down onto the bed from a sitting position to flat on her back." Nurse Dwivedi noted that A.H. was "crying and visibly upset," and that the "[v]entilator was alarming" at the time. Nurse Dwivedi wrote that, when she explained to Mother that her handling of the child was not appropriate, Mother said that A.H. "was 'tired' and 'needed to go to sleep.'"
At 8:25 p.m., Nurse Dwivedi wrote that she saw Mother "holding [the] patient down in the bed." Nurse Dwivedi wrote that A.H.'s "face [was] red" and that she was "screaming," but her "[c]ries were not audible because of [the] tracheostomy." Nurse Dwivedi noted that the ventilator alarm had been "disconnected, when previously, [the] alarm was connected and alarming" earlier in the evening. Nurse Dwivedi wrote that,when she "asked why [Mother] was holding [the] patient down in bed," Mother "shrugged [her] shoulders and stated again that [the] patient 'needed to go to bed and was tired.'" Nurse Dwivedi wrote that "Dr. Wright" then entered the room to ask why the child was crying, and Mother "stated, 'I don't know what she wants, she is crying there must be something wrong with her.'" [Sic.] Nurse Dwivedi wrote that Dr. Wright "explained to [the] patient's mother that her crying could be attributed to age appropriate behavior" and "suggested holding the patient and comforting her in an appropriate manner."
In the same entry, Nurse Dwivedi noted that she "found scissors in [the] patient[']s bed two separate times after witnessing [Mother] playing with scissors[.]" Nurse Dwivedi wrote that, after the first occurrence, she had "educated [Mother] about keeping sharp[ object]s out of the patient[']s bed for safety reasons." Nurse Dwivedi wrote that, after the second occurrence, "all sharp[ object]s [were] removed from [the] room."
Nurse Dwivedi also noted...
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