Deborah Waddell, Respiratory Specialist Nurse Asthma and Lung UK
An 8-year-old girl and her family were referred to me as part of an Asthma Friendly Schools Project. In addition to working with schools to achieve Asthma Friendly School Status, I would receive referrals to support individual children with troublesome asthma that was affecting their school attendance and education. I will call the child H for the purpose of the case study.
The Headteacher and Educational Welfare Officer were very concerned about H falling behind at school because of continuous absence. This was also affecting her ability to build friendships. I was asked to offer my support to H and her family, to liaise with her secondary care team, GP and School Nursing Service.
I first met H and her mum in school. Her attendance for the school year was only 5% and the days she was at school there was such anxiety about her asthma that she did not go out to play or join her friends at lunchtime. Instead, she sat outside the headteacher’s office with some books and her lunch.
H’s mum was worried and visibly distressed at the letters she had been receiving from the local authority about H’s absence; they felt threatening and accusatory. She did not know where to turn and said the fear of prosecution was adding to the family’s stress.
The impact of poor housing
A home visit revealed very poor housing that was both cold and damp. Standard advice to ventilate was given, but it was not appropriate to leave windows open all day due to security as well as the cold temperature. Green and black mould covered the bathroom walls and was visible in the kitchen and bedrooms. The walls in some places were soft and damp through. H’s mum was worried about cooking because there were cockroaches and beetles in the kitchen, which had dropped from the ceiling in the past onto the cooker. Notably, I was the first person to do a home visit and home environment had not featured in any conversation with a healthcare professional up to that point. H’s mum felt a degree of shame about the living conditions so would not have openly talked about it.
This visit helped me to fully appreciate the complex social factors that were contributing to H’s poorly controlled asthma and frequent asthma admissions. However, as a community asthma specialist nurse, I was able to liaise with secondary and primary care and school. We were able to work together to put on hold the plan for H to attend a special school and the school was able to put in place more learning resources for when she was unable to come into school.
I requested an urgent MDT social services referral as this child was at risk of ‘significant harm’. This was refused, however, as the case did not meet the ‘threshold’. An NHS MDT request resulted in referral to a tertiary, severe asthma service. Meanwhile I made a 2nd social services referral and raised further concerns about the quality of the private rented accommodation with the Local Authority (this involved me sitting in the Local Authority Offices until a social worker was able to meet me face to face). An urgent request for rehousing was subsequently made and, after a couple of months, the family was rehoused in a new-build house. Throughout this process, I reassured H’s parents that the referral was to help them get the support they needed as they were fearful of what this could mean.
I think everyone had expected the move to improve H’s health immediately. Unfortunately, her symptoms continued and her health in general was poor. Further tests and gathering of clinical, radiological and microbiological results confirmed a diagnosis of pulmonary aspergillosis. Fortunately, it was identified and treated in good time as a delay can result in severe, life threatening or even fatal complications. A treatment regime including antifungals was commenced and, over time, H’s health improved. Frequent MDTs and updates to the ‘Child in Need’ plan meant that H and her family received ongoing support. It was agreed as her health improved that a special school was not the correct route for H and, with extra support in school, she successfully moved from primary school to the faith-based secondary school of her choice, which was so important to her family.
12 year later H is now working in social care, having successfully completed a degree in social work.
This case study not only demonstrates the impact of poor housing on a child’s respiratory and general health but also the importance of integrated health and social care that focuses on the needs of the child and the family. It also demonstrates the value of effective communication between agencies.
I was privileged to be a community asthma specialist nurse within a service which encouraged proactive care and recognised the importance of advocacy for families who are disadvantaged and struggling with poverty and poor housing. Hopefully this is more common now than it was 12 years ago.
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