Diabetic Syrian refugee, 11, dies in her parents' arms during sea crossing from Egypt to Italy after traffickers destroy her insulin

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Jordan Phelps
6 years ago
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1 Judith Oliver Senior lecturer in social work Clare MacArthur Lecturer practitioner in diabetes

2 Diabetic Syrian refugee, 11, dies in her parents' arms during sea crossing from Egypt to Italy after traffickers destroy her insulin Raghad Hasoun, from Aleppo in Syria, died on the fifth day at sea during journey from Egypt to Italy Traffickers allegedly threw life-saving insulin into the sea as they boarded Parents say they begged for mercy before the drugs were destroyed The 11-year-old died in the arms of her mother and father From the Daily Mail, July 2015

3 Diabetes Could be an undiagnosed medical issue for many: around 590,000 people in the UK have diabetes but have not been diagnosed Currently around 6.2% of people in the UK have diagnosed diabetes (confirmed statistics from 2014) Read more at Living in poverty doubles or triples the likelihood of type 2 diabetes and increases complications Poverty is bleak and cuts off your long-term brain It s best not to hope Quoted in Pearson, T (2015) Editorial. AADE in Practice; 8

4 Diabetes Individuals with type 1 diabetes & combined risk factors such as: mental health issues, low socio-economic status and high family conflict are particularly at risk of ketoacidosis (DKA), for example Wagner DV et al., (2015) Treating the most vulnerable and costly in diabetes. Curr Diab Rep; 15: 32

5 Workshop 2 case studies Harry and Raghad Four groups around 6 people in each please 5-10 minutes to discuss Then we will feedback & discuss further Summary

6 Harry Harry is a 48 year old individual who is alcohol dependent. He is homeless and living rough although he does sometimes access the local hostel for both food and the occasional bed for the night. He is said to be harmless by the staff who try to support him as best they can. He was seen recently in A&E complaining of painful feet which, on examination, were found to be in very poor condition with several small infected ulcers. He disclosed to staff that he has type 2 diabetes, controlled, according to Harry, by diet. This was diagnosed 18 months ago following an unrelated visit to A&E. He has failed to keep any follow up appointments although he remains registered with a local GP. He is admitted to the medical ward where it is felt that he would be better managed by twice-daily gliclazide tablets. It is also noted that his vision is poor. He is discharged back to his GP with appointments for foot clinic and eye clinic, and a month s supply of gliclazide along with some antibiotics. He fails to keep any of the appointments.

7 Harry No consistent care for eyes, feet, risk of effect of alcohol, diet? Not attending appts? no fixed abode, poor eyesight, no watch, no calendar, motivation Basic needs; alcohol, food, somewhere to sleep I feel ok today; short term thinking Money for the bus? Vs alcohol etc Aware of appt? Gliclazide high risk of hypos alcohol, not eating, is this safe? Alcoholism; can this be addressed if he wishes? Housing needs basic needs first food? Direct GP/PN care specific for needs of local homeless people His right not to be interested! Engagement with services important Social services

8 Harry At risk of further foot ulcers issues around appointments/access/ mental capacity issues: does he understand risks? Appts can be a barrier watch/calendar/involve friend?? Underlying causes; refer to housing advice/cab/ Shelter and similar charities Day centre? Meals etc priority Social care is a priority but what about safety aspect? Is gliclazide appropriate? Is he actually type 2?

9 Harry Social needs; housing, food, money, rather than just health Few choices: granary bread may not be available, be realistic about treatment Very high risk of amputation Health visitor for homeless? Other agencies, networking, signposting to services Medication vs food issues Appropriate treatments how to decide/plan Charities; mobile phone? Keeping in contact; reminders of appointments etc Informal networks friend being involved?

10 Raghad Raghad is 11 years old and she has had type 1 diabetes for three years, treated with twice-daily mixed insulin. You expect to refer her to secondary care children s diabetes services after seeing her today. She has an older brother and is accompanied by her parents and brother; she is the only member of the family with diabetes. Her parents speak some English but her older brother is the family interpreter. She lives in a home for asylum-seekers and had a traumatic journey to the UK.

11 Raghad Language, confidentiality; issue of brother being the interpreter Accommodation Storage and supply of insulin; do they have enough? Difference in health beliefs, cultural difference, experience and understanding of health care systems Appointments: access & understanding; seems fragile, letter in English: DNA, not from ignorance or low socioeconomic group just not understanding Stress, strange, possibly unfriendly country

12 Raghad Communication; what does she understand? Is her brother appropriate in terms of confidentiality, and understanding, as an interpreter? Continuity of care, secure environment for her long term Storage and supplies of insulin Why secondary care? GP surgery set up for asylum seekers Emotional stress Also blood glucose monitoring

13 Raghad Language, confidentiality, (sibling translator), language line, interpreter, Displacement, cold!, emotional issues, culture shock Supplies, equipment, knowledge, Stress affecting glucose control; many stresses Multi-occupation housing Dietary differences, different foods Finances, access to appointments does whole family need to come to appt Fear of engaging with services/people in power Registered with a GP? Schooling and education Discussion with children s diabetes nurse Multidisciplinary: social work, refugee liaison

14 Asylum seeker/ Refugee Multimorbidity Mental illness Personal trauma Disability Family issues Homeless What makes people potentially vulnerable? Age Literacy education Prison Language Traveller Cultural difference Poverty Learning disability

15 Drug & alcohol misuse Cultural attitudes to health Family conflict At risk of pregnancy Diabetes - specific vulnerability Chaotic environment Family cohesiveness & conflict Coping with technology Health literacy Teenager/ young adult

16 Some (reasonably) well-proven solutions: Intensive support Care coordination For example social support, psychology, school, family systems approaches Working with local groups such as community/religious Clinical needs: exceed usual care eg flexible care provision, phone call support, telemedicine Education (especially structured group education with peers)

Dorset Homeless Health Needs Audit Results 2017

Dorset Homeless Health Needs Audit Results 2017 These are some of the faces of homelessness Homelessness and Health The homeless population s life expectancy is half that of the general population, equating