Sentinel Event or business as usual? Removing children from parents with substance abuse problems

Dr Karen Fisher1, Dr  Sabrina Hasanouni

1Drug And Alcohol Service, NBMLHD, Kingswood , Australia


As part of quality assurance in the delivery of health care in Australian hospitals, a series of events are deemed “sentinel”, triggering an automatic review and systematic scrutiny of the factors leading to such an adverse outcome.  An infant discharged to the wrong family is a sentinel event .  In the NBMLHD the rates of the assumption into care of infants at birth is amongst the highest within  NSW. These are not however, reviewed and considered as “sentinel events”, despite being the most literal embodiment of a “wrong family”. This presentation will seek to interrogate the concept of the “right family” and will explore and discuss how applying the rigorous scrutiny seeing assumptions of infants as sentinel events, provides an invaluable framework to integrate the lessons learnt from the past.

Contemporary scholarship and assessment of outcomes for children whose familial existence is determined and organised by the State , suggests the issue is best considered a “wicked problem”, that is, one in which the very means of intervention will shift and change the definition of the problems its seeks to alleviate. This has been dramatically and painfully captured by testimonies for example, by the survivors of institutional abuse. If we are to change our practice to ensure we no longer cause lasting harms, the start must be in remaining vigilant to ensure certainty in the reasons, the evidence and the projected outcome for our intervention. Comparing and contrasting exemplar cases using the usual approach, with a framing based on the case as “sentinel”, this paper will argue for the urgent necessity we adopt the more comprehensive and considered lens.


Dr Fisher is Clinical Director of Drug and Alcohol Services, NBMLHD.  She is a committed clinical lecturer with Nepean Clinical School, Department of Psychological Medicine ,  University of Sydney, with research interests in stigma, public health, and Addiction Medicine.

Graduating in the UK Sabrina moved to Sydney in 2016 and worked as a registrar under the Nepean drug and Alcohol Service. She is now a core psychiatry trainee in Birmingham, UK with plans to undertake an academic clinical research fellowship in addiction psychiatry.

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