In the Interest of T.R.C. v. the State of Texas
CourtTexas Court of Appeals, 9th District (Beaumont)
Date FiledJuly 6, 2026
Docket09-26-00019-CV
StatusPublished
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Full Opinion
In The
Court of Appeals
Ninth District of Texas at Beaumont
________________
NO. 09-26-00019-CV
________________
IN THE INTEREST OF T.R.C.
________________________________________________________________________
On Appeal from the County Court at Law No. 3
Montgomery County, Texas
Trial Cause No. 14-10-11718
________________________________________________________________________
OPINION
Mother appeals the trial court’s order terminating her parental rights to her
minor child, T.R.C. (“Tim”).1 Termination of parental rights should be reserved for
“extreme cases[.]” See In the Int. of H.S., No. 24-0307, 2026 Tex. App. LEXIS 533,
at *2 (June 5, 2026). “[A] parental-termination order must always be a last resort
and never a first impulse.” Id. We echo what was said by now Chief Justice
Blacklock in In the Int. of A.M.:
1
To preserve the parties’ privacy, we use pseudonyms to refer to the child,
Mother, foster parents, and family members. See Tex. Fam. Code Ann. § 109.002(d);
Tex. R. App. P. 9.8(b)(2).
1
Most of the [appeals] this Court receives in parental-termination cases
involve parents whose severe abuse or abandonment of their children,
debilitating drug addiction, or violent and criminal behavior provide the
clear and convincing evidence required for imposition of the draconian
remedy of termination. This case is more difficult than most. It raises
close questions of evidentiary sufficiency.
630 S.W.3d 25, 26 (Tex. 2019) (Blacklock, J.; concurring in the denial of the petition
for review). We conclude the evidence is legally insufficient to support the trial
court’s finding that the Department of Family and Protective Services (“the
Department”) made reasonable efforts to return Tim to Mother before trial and that
despite such efforts a continuing danger remains in the home that prevents Tim’s
return to Mother. See Tex. Fam. Code Ann. § 161.001(f)(1). We, therefore, reverse
the trial court’s order terminating Mother’s parental rights as to Tim, and render
judgment that Mother’s rights are not terminated. We also conclude the trial court
abused its discretion in ordering that the Department is Tim’s permanent managing
conservator, because the trial court did not make the finding required by section
153.002(c)(1). See id. § 153.002(c)(1). Therefore, we reverse the trial court’s order
appointing the Department as Tim’s permanent managing conservator.
The Scope of Our Review vs. The Parameters of Our Opinion
Although our legal sufficiency review requires us to conduct a thorough
review of the entire record, our rules of procedure require us to “hand down a written
opinion that is as brief as practicable but that addresses every issue raised and
necessary to final disposition of the appeal.” Tex. R. App. P. 47.1 (emphasis added).
2
The distinction between what is reviewed and what is included in the opinion is
particularly important in an appeal from a parental-termination order. “Appellate
opinions in these important cases should distinguish between facts that support
termination and facts that do not, rather than reciting every piece of evidence relied
upon by the government.” In the Int. of A.M., 630 S.W.3d at 27 (Blacklock, J.,
concurring in the denial of the petition for review). We will attempt to heed Justice
Massengale’s wise “caution against the dangers of kitchen-sink approaches to
opinion writing, particularly in the area of parental-termination appeals.” In the Int.
of A.K.T., No. 01-18-00647-CV, 2018 Tex. App. LEXIS 10018, at *47 (Tex. App.—
Houston [1st Dist.] Dec. 6, 2018, pet. denied) (mem. op.) (Massengale, J.,
concurring); see also In the Int. of K.N., No. 24-0881, 2026 Tex. App. LEXIS 535,
at *30 n.3 (June 5, 2026) (declining to recount evidence that “is not the basis of our
judgment[,]” noting, “A kitchen-sink approach risks misleading lower courts as to
what evidence matters.”).
We will not, therefore, rehearse all the evidence the Department offered at
trial and now argues on appeal as support for the trial court’s statutory-predicate and
best-interest findings. As explained below, we do not reach those issues; instead, we
decide this case by answering a separate question—whether the evidence is legally
sufficient to establish, clearly and convincingly, that despite reasonable efforts by
the Department to return Tim to Mother, a continuing danger remains in the home
3
that prevents his return. See Tex. Fam. Code Ann. § 161.001(f)(1). When deciding
what evidence to include in our opinion, we have attempted to focus on the evidence
that answers that question. Nevertheless, voluminous records were introduced at
trial, and in order to comply with Rule 47.1, we must include sufficient details from
those records to explain our disposition of this appeal. See Tex. R. App. P. 47.1
Factual Background
When Tim was 17 months old, he was diagnosed with Type 1 diabetes, a
serious condition which requires careful monitoring of Tim’s blood-sugar level. Too
low a level can be immediately life-threatening; too high a level risks diabetic
ketoacidosis which can potentially cause coma.
Tim has a brother, “Chris,” who is one year younger than Tim. Mother has
another son, “Trevor” who is several years older than Tim and Chris, and who was
an adult at the time of trial. In 2016, when Tim was four and Chris was almost three,
their parents divorced. The Final Decree of Divorce, signed in early 2017, appointed
Mother as Tim’s and Chris’s sole managing conservator. Father, who was appointed
possessory conservator, was to have periods of visitation, but these would be
supervised by Tim’s grandmother or someone else approved by Mother, because the
court found credible evidence Father engaged in a pattern of abuse and neglect
directed at Mother and the children. Before any such visitation would be allowed,
however, Father—and anyone else who would be supervising Tim during Father’s
4
periods of possession—would have to complete diabetes education training. No such
requirement was placed on Mother who was granted the exclusive right to consent
to the boys’ medical, dental, surgical, psychiatric and psychological treatment. 2
In September 2018, when Tim was six and Chris was five, Father died in a
motorcycle accident. Years later, when the Department filed this action to terminate
Mother’s parental rights in 2024, Tim and Chris were referred to Elizabeth Salmeron,
Ph.D., for comprehensive psychological evaluations. The Department’s caseworker,
Casandra Duran, informed Dr. Salmeron that Tim and Chris had been placed in
separate homes, and that “the brothers do not have healthy boundaries . . . they fight
often.” Dr. Salmeron did not testify, but her reports which were admitted into
evidence indicate that both boys were dealing with multiple issues, including “grief
and loss[.]” Tim expressed to Dr. Salmeron that he wished Father had “[n]ot
crash[ed] on that day” and that his “dad could come back and the dogs and we all be
together again as a family and the whole world not do bad things.”
Based on information obtained from Tim’s paternal uncle, with whom Tim
had been temporarily placed, Dr. Salmeron’s report indicates that Tim exhibited “the
following problematic behaviors to a moderate to clinically significant degree:” feels
sad; feels down on himself; worries a lot; fidgets or unable to sit still; distracts easily;
2
Father maintained the right to consent to non-invasive medical and dental
treatment for the boys during Father’s periods of possession, and surgical treatment
in the event of emergency.
5
has trouble concentrating; acts as if he were driven by a motor; fights with other
children; does not listen to rules; does not understand other people’s feelings; teases
others; refuses to share; takes things that do not belong to him; wants things right
away; seems “hyperactive;” temper tantrums; and avoids talking about his feelings.
Although Tim’s paternal uncle also reported that Tim “seems fearful of things that
are reminders of the situation with his mom[,]” when Dr. Salmeron asked Tim the
“one thing [he] want[ed] most in life[,]” Tim responded, “To be back with my mom.”
Tim also told Dr. Salmeron, “I want to see my mom more often[,]” and when asked
what he wished Mother would do differently, he replied, “I think she’s perfect.” As
for what made Tim sad, he said, “My brother not being with my mom and me not
being with my mom.”
Although Tim was, at the time of his evaluation in January 2025, “currently
functioning within the below average range in cognitive ability[,]” Dr. Salmeron’s
report indicates his prognosis was “Fair[,]” and she recommended a “Specialized”
level of care. Her report states:
[Tim] has the necessary cognitive resources to build a productive
problem-solving foundation; results suggest [Tim] has the potential to
exercise positive stress tolerance and control choices. [Tim]
comprehends the importance of cooperation; [Tim] is a good-natured
child who benefits from validation, structure and routine. Uncle says
[Tim] “is doing okay.” However, assessment information suggests
Tim’s internal interpretation of his surroundings is influenced by stress;
the impact of early significant loss and trauma also shapes how Tim is
learning to “cope” with life. [Tim] has trouble imagining productive
outcomes to events; test data show gaps in age level problem solving
6
skills sets. [Tim’s] private thoughts are marked by stress and tension,
taking energy that could otherwise be channeled to build a stable coping
structure. Given his age, [Tim] likely uses indirect ways of “signaling”
needs for support, such as with anxiety-driven behaviors (“aggressive
and dominates brother”; “argues with teacher”); the impact of early
trauma may interrupt the healing process and leave [Tim] prone to
inconsistent response to intervention over time. Test data suggest
potential to internalize instead of express feelings; therefore, [Tim] is
prone to denial, repression, minimization and avoidance over
responsible assertiveness. The effects of uneven processing can
exacerbate social problems as [Tim] may have trouble understanding
and remembering what is expected of him in an organized fashion.
Therefore, helping [Tim] develop productive communication and
coping skills using trust-based discipline practices will be an important
part of his treatment plan.
We provide more details about the treatment plan recommended by Dr.
Salmeron in our analysis below. But first, we believe it is necessary to include a
description of events referenced in the medical records introduced during the trial,
because the Department relies on those events in arguing that a continuing danger
remains in the home because Mother is unable to manage Tim’s diabetes, unable to
manage Tim’s behavior, and unfit to care for both Tim and Chris.
Three exhibits containing over 12,700 pages of medical records pertaining to
Tim were introduced during the trial, but only a handful of those records were ever
discussed. The Department separately introduced six exhibits containing 33 pages
excerpted out of the 12,700 pages and used those six exhibits to question Mother
about the number of times she removed Tim from a hospital against medical advice.
Only one other witness mentioned the medical records, citing them, globally, as the
7
basis for her concerns about Mother’s having removed Tim from hospitals against
medical advice. Other witnesses expressed similar concerns without mentioning the
records as the source of their knowledge, but none of the witnesses claimed to have
any medical expertise other than a paramedic. The paramedic, readily conceding that
lab values, metabolic status and treatment were “beyond [his] level of ability to
testify[,]” provided limited testimony about diabetes in general and said that it was
necessary for Tim to be transported to a hospital due to elevated blood-sugar on
October 26, 2024. He never referred to, nor explained, any of the medical records.
No doctor or nurse testified, either at trial or by way of deposition. In short,
nobody provided any medical testimony explaining anything contained in the 12,700
pages of medical records introduced into evidence in the trial court and eventually
forwarded to us as part of the appellate record. With that disclaimer, we provide the
following information from the records, focusing mainly on the events described
therein, touching on the medical information only as necessary to provide context
for those events, and hopefully avoiding speculation on medical issues in the absence
of medical testimony to explain the records.3
3
On appeal, the Department lists seven times Mother removed Tim against
medical advice, and our review provides excerpts of the records regarding each,
along with excerpts of other medical records containing relevant information.
8
December 5, 2018
When Tim was 6 years old, Mother called 911 and an ambulance transported
Tim to the emergency department at Texas Children’s Hospital (“TCH”) The
Woodlands due to “decreased PO intake [and] varying blood sugars (high and low)”
one day after Tim had undergone tonsillectomy and adenoidectomy surgery.
According to the records, Mother was “being demanding” and “interfering with
patient care” while at TCH The Woodlands. “Per mother, she left AMA [against
medical advice] because it took doctor so long to treat patient and were waiting on
more blood work[.]” A social worker got involved and called Child Protective
Services (“CPS”) because the medical staff was unsure whether Mother would take
the child elsewhere for treatment. “Per mother, they left and went straight to
Memorial Hermann ER. She is aware that CPS was called.” Memorial Hermann later
reported to TCH West Tower (located in the Houston Medical Center) that Mother
did, in fact, take Tim to Memorial Hermann, where blood work was done, Tim
received fluids, and Memorial Hermann discharged him home. According to the
records, Mother continued monitoring Tim’s blood sugar levels at home, and later
that same day she called the endocrinology clinic which recommended that she take
him to the emergency center, at which time she took him to TCH West Tower. The
records reveal that while at TCH West Tower, Mother was “upset and yelling at
healthcare staff at 0210 because PCA did not respond appropriately when she called.
9
Morning BG elevated at 292. Mother again upset and yelling this morning at 0800
because she reports that staff is not checking Tim’s BG levels often enough and is
concerned that he is ketotic.”
June 23, 2019
When Tim was 7 years old, Mother took Tim to the Kingwood Medical Center
Emergency Department and reported that Tim had “passed a large ‘bright red blood
clot’ during a BM today.” According to the records, Mother explained that Tim had
been treated at TCH for abdominal pain, fever and gastrointestinal bleeding but was
discharged two days prior with instructions to go to the emergency room if
symptoms returned. 4 After waiting in the Kingwood emergency department for
almost an hour, Mother left against medical advice. The records indicate the reason
for leaving was: “Wait too long, Refused transfer, wants to drive pt to TCH. wait too
long for transfer with EMS.” The records also indicate, “Doctor aware that mother
does not want to wait for transfer to Texas Children’s Hospital downtown and would
rather leave AMA at this time… Per doctor’s order at this time she would like for
primary nurse to put in a CPS case/phone call.” The records indicate that thirty-four
4
The records from TCH confirm Tim had, in fact, been seen at TCH The
Woodlands on June 20, 2019, for fever and bloody diarrhea and that Tim was
discharged home on June 21, 2019, despite Mother’s statement that “she does not
feel comfortable taking child home with continued diarrhea, fever, and elevated
blood sugars.”
10
minutes later, Mother and Tim arrived at TCH The Woodlands’ emergency
department where Tim was treated and later discharged.
June 8, 2020
When Tim was 8 years old, someone identified as “step dad” dropped Tim off
at TCH The Woodlands’s emergency department because Tim “was more tired than
normal.” According to the records, “BS on arrival was 533, with Ketones 7.2.” Tim
was diagnosed with diabetic ketoacidosis (DKA) and was admitted to the pediatric
intensive care unit. Mother called and told the social worker that the night before,
she took Tim to Taco Bell, watched him administer an insulin bolus, and then
dropped him off at his paternal grandparents’ house so that Mother and her “entire
family” could pack their things and move to another apartment since their current
one had repeatedly been broken into. According to the records, “Mother stated she
‘hasn’t been able to stop crying’ since she found out patient was admitted[]” but she
would not be able to come to the hospital until the next morning, stating that her ID
was expired and that of her “husband” had been given to the police during their
investigation of the break-in, and had not been returned. The records further indicate,
[Social Worker] was involved due to initiate discharge planning along
with CDE and clinical nutritionist as recommended. Mom was not at
bedside to initiate discharge planning and education. Mom had reported
to night shift that she would be here 06/09/2020 between 0600-0800 to
bring home supplies. After numerous unsuccessful attempts to reach
mom, [Social Worker] called for a wellness check. When PD arrived at
house, mom stated she was sending a gentleman over to pick up the
patient. PD initiated a CPS case at this time. The gentleman arrived with
11
no ID and was not allowed to pick up patient. As caregiver needed to
be at bedside to receive discharge instruction, education and
reinforcement regarding Type 1 DM management. Both mother and
CPS arrived shortly after. Mother was visibly upset and frustrated. At
this time, we tried consoling mother and letting her know that there still
needs to be education to be provided and that with the sensitivity
regarding the CPS case, [Tim] was not medically cleared for discharge.
Mother continued to be uncooperative and at this time left against
medical advice. CPS and [Social Worker] continues to be involved and
will be following.
….
CPS recommended not to release patient to mother initially, then agreed
to let them go AMA[.]
July 9, 2021
When Tim was 9 years old, Mother took Tim to the emergency center at TCH
West Tower and stated that they had been “around town most of the day, and when
they checked [Tim’s] glucose this evening for dinner it was 551.” She expressed
concerns that Tim’s “Omnipod was malfunctioning” so she gave him an injection
and some water, but he couldn’t drink much due to nausea and when she checked
again it was “still elevated in the 400s,” so she gave him another injection. The
records indicate that Tim’s nausea had “resolved” and his labs were “reassuring” as
he did not meet the criteria for DKA, but “aggressive subcutaneous management”
was recommended. The records indicate,
After discussion with endocrine, recommendations made to mother
including POC glucose, correction factor dosing, monitoring for
additional 2 hrs. Mother became upset, threatened staff, stated that “we
did not know about diabetes”, and that she needed to leave now. Mother
12
had already fed patient Whataburger, gave 2.5 units insulin. We
attempted to help to facilitate more rapid additional treatment,
reiterated recommendations, however mother refused additional
interventions. [Patient] had already pulled out his IV. Mother refused
to sign AMA paperwork however this remains AMA. Endocrine on call
notified.
….
Mother at nurses (sic) station and raised voice at nurses, EC MD
brought to nurse’s station for update. Mother continued to escalate as
she was escorted to room by two EC MD’s. Security called to bedside.
After discussion with endocrine and EC medical staff, mother refused
to stay for 2 hour observation per endocrine recommendations and
mother reports patient removed the IV himself. Mother refused to sign
AMA paperwork and left EC with security due to behavior. [Social
Worker] notified.
June 15, 2023
When Tim was 11 years old, Tim was transported by ambulance at the
emergency center at TCH West Tower, arriving around 8:00 p.m. According to the
records, Tim had threatened to harm his brother, and Mother was “concerned for
suicidal ideation.” “No acute medical issues [were] identified.” Mental health
services evaluated Tim, and inpatient psychiatric placement was recommended.
Around 10:00 p.m., Tim was examined by Mary Hofstetter, MD, and was medically
cleared. According to the nurse’s notes, around 11:00 p.m., Tim “escalat[ed] after
sitter change… [Tim] called the sitter a ‘pedophille’ (sic) because sitter said she
would need to accompany him to the bathroom for his safety. [Tim] was in the
sitter’s face saying he had corona virus; sitter continued to ask [Tim] to sit back.
13
[Tim] said he would hit her as well.” Around that time, Mother “returned to bedside
after getting coffee[,]” and a different sitter was assigned. By 3:08 p.m. the next day,
Tim was still “[p]ending inpatient psychiatric placement[.] Medically cleared[,]” but
one facility had “deferred admission” and another was listed only as a “potential”
placement and was “still determining if able to perform insulin[.]” Around 6:00 p.m.,
twenty-two hours after admission, and with no placement confirmed, Mother
“verbalized desire to leave with the patient.” Ashley Czaplicki, DO, was notified,
and her 6:23 p.m. entry states:
Called to bedside by nurse. Mother expressed frustration that placement
is taking too long and she wishes to leave the hospital. She is frustrated
with pt staying in same room for so long and is worried about insulin
regimen. I explained that we are following endocrinology
recommendations closely. Explained that placement is more difficult
given underlying type I diabetes. Mother states that she does not want
to wait any longer and would like to take him home. I explained that
MHS and our team recommend inpatient treatment and are concerned
that he could harm himself/others, disability, have worsening of his
condition, and death. Mother expressed understanding and states that
“has done this multiple times before. I don’t care if you call CPS. I’ve
had CPS visit 10 times before.” Mother expressed understanding that
she was leaving against medical advice. Advised return to ER for any
worsening of condition such as increased aggression, voicing thoughts
of harming self/others, fever, high blood glucose, or unable to eat/drink.
Explained that she can return to ER at any time. Mother expressed
understanding and agreement.
July 8, 2024
This Court takes judicial notice that on July 8, 2024, Hurricane Beryl struck
Montgomery County. Although it is unclear how Mother, Tim and Chris were
14
affected, medical records from November 2024 indicate, “Mother stated she filed
for FEMA money from Hurricane Beryl in July 2024 and they have been staying at
an extended stay hotel.”
July 25, 2024
Tim woke up vomiting, and his blood glucose was 266, so Mother “called
EMS for concerns for borderline DKA[,]” and Tim was transported to TCH The
Woodlands. Tim, who was 12 years old at the time, was admitted to the PICU, and
was seen by Bonnie McCann-Crosby, MD, for a Diabetes Consult on June 26, 2024.
Her narrative states,
[Tim] reports that he has been feeling bad for the past few days but he
didn’t want to tell his mom because he doesn’t like going to the
doctor… He is on Omnipod 5 insulin pump and the pump expired
yesterday. He reports that he has been missing doses and sneaking food.
He does not enter carb amounts in his pump. Mom feels that the
Omnipod has not been working as well as his previous Tandem pump.
She reports that the pump does not always connect with his Dexcom
properly and he is often kicked out of auto mode and either in manual
mode or limited mode. He is rotating his pump only on his arms. Doses
immediately before eating if he pre-boluses. Reports that blood
glucoses in general are in the 200s.
….
Impression:
Established DKA (DKA Resolved w/o ketones)
[Tim] is a 12 y.o. [] male with type 1 diabetes, with poor glycemic
control. He presented in critical condition with a clinical picture
consistent of moderate diabetic ketoacidosis… and moderate
dehydration.
15
….
Diabetes ketoacidosis is a hyperglycemic crises (sic) consistent with
lack of insulin. It can result in several complications, including:
hyperosmolality, dehydration, hypokalemia, hypophosphatemia,
hypoglycemia, VTE, cerebral edema, coma and death. His presentation
is suspected to be related to inadequate supervision, missed doses.
Management recommendation is outlined below.
We have discussed with the family that [Tim] was in serious condition,
and diabetes acidosis carries significant risk of electrolyte
abnormalities, cerebral edema and death. Ongoing parental supervision
is critical to achieving good glycemic control in children and
adolescents and preventing life-threatening complications of diabetes.
Underlying cause for admission related to diabetes is thought to be due
to missed insulin doses/inadequate supervision. Areas identified for
improvement includes: supervising all doses, taking insulin for all carb
meals and snacks, site rotation.
[Tim] and his family will receive assessment by our multidisciplinary
diabetes team during the admission to identify barriers of diabetes care,
and ensure safe discharge and home care.
….
Will switch to Lyumjev insulin upon discharge.
Family does not want to continue OP5 upon discharge. They are to
follow-up with primary endo about switching back to Tandem pump.
….
Before being discharged by the hospital, Tim was also seen by Staci Grant,
PsyD, for a Psychology Diagnostic Interview on June 26, 2024. Her narrative states,
Mother provided information surrounding recent admission. [Tim] was
reportedly admitted yesterday afternoon after he woke up and reported
feeling weak. Mother called EMS for higher level of care and, due to
16
high blood glucose levels, he was taken to TCH ER. Mother reported
that she believes this instance of DKA was due to possible “pod
malfunction,” as she and [Tim] have had difficulty managing his
glucometer and pump for the past few months. She noted that she
believes he is experiencing diabetes burnout, given he has been more
“forgetful” and “lazy,” and has been sneaking food at nighttime while
playing video games. She shared that he was initially diagnosed at 17
months of age and has been admitted for DKA approximately 2 to 3
times. She recognizes that he appears more distressed currently and
feels as if he needs to “push through.” As provider spoke with mother,
[Tim] briefly mentioned he is “not burned out” and “does not want to
do therapy.” Feels “interrogated” in meeting with several providers
Previous Evaluation/Intervention:
According to [Tim’s] caregiver, he has previously participated in
evaluation and/or intervention including family therapy, individual
therapy, and trauma services. Per mother, [Tim] has received multiple
services throughout his lifetime and had difficulty recalling dates and
names of providers. She noted that he was recently in foster care in
2022 and, as a result of physical abuse, he received trauma-informed
care. Additionally, he participated in occupational therapy in 2023. Per
mother’s report, she does not believe he has had a good experience with
individual therapy, as he continually states that he “does not want to
talk” and “feels forced” to participate. He has not received services to
address diabetes management and care; however, mother believes a
mentor and/or support groups would be more helpful. No official
diagnoses
Despite being evaluated on multiple occasions in the past, he has not
received any official diagnoses and has been told to address prior
trauma.
….
Current Diagnosis: F43.20 Adjustment Disorder, Unspecified
F90.2 Attention Deficit Hyperactivity Disorder, Combined (By history)
17
Recommendations/Plan:
1. Psychology follow-up is warranted and suggested at this time;
however, patient refused. Mother was informed about possible reasons
to request additional Psychology services should [Tim] be open to
support in the near future. She is welcome to ask their provider or call
Psychology directly… should they like another appointment.
2. Briefly discussed relationship between health and mood, highlighting
impact of trauma and stressors on ability to participate effectively in
management of health.
3. Encouraged mother to increase supervision of diabetes care daily and
to schedule times for [Tim] to participate in gaming following
participation in glucose checks and insulin administration.
Referred to Psychiatry? no
September 8, 2024
Tim woke up with a blood glucose level over 500. Tim was transported by
EMS to the emergency department at TCH The Woodlands where Tim informed the
staff that when he woke up, he found that his omnipod had expired. According to the
records, Tim was examined by Nancy Shan, MD, who reported Tim was “not in
DKA.” Nevertheless, Tim was admitted to the hospital with a nurse’s admission note
that indicates, “Patient received from EC with diagnosis of DKA.” He was
“accompanied by older brother [Trevor], [who] claims he is 20 yo and another
sibling, 10 yo. [Trevor] claims he is the guardian, and signed consent and other
documents at EC for admission[.]” The nurse’s notes indicate,
Received an outside call…claims to be mother of patient. Told her Im
(sic) am not able to give information since I have not met her and she
does not have the code. She wanted to speak to the doctor ASAP
18
because she said did not give consent for her son to be admitted. She
said her son is not in diabetes ketoacidosis, and that she can manage
this at home. Claims that the patient’s pump just malfunctioned last
night. Mother said that she wants her son discharged[.]
Dr. Shan’s narrative indicates,
[M]other not at bedside, older brother signed consent in ED to admit
Patient. MD spoke to mother over phone with bedside RN present.
Mother angry and belligerent on phone, stating that she did not want
her child to be admitted as he is not in DKA and she can take care of
his diabetes at home. Agreed with mother that yes, patient is not in
DKA however his glucose and ketones were very elevated, and he
required IVF and frequent insulin injections to prevent him from
progressing into DKA. Updated mother that patient’s labs are
improving but he has not yet met Endocrine criteria for discharge. Any
premature leaving the hospital would be against medical advice.
Mother stated that “Woodlands is stupid, they don’t know what they
are doing, they are harming my child” and that she will sue the hospital.
She also stated that if patient is not discharged home with older brother
and she came to the hospital, it will be a “big deal”. Security aware of
mother’s statements[.]
The hospital’s Discharge Summary states,
Mother arrived to bedside and refused to let RN given insulin for dinner
carb coverage. [Social Worker] was notified and arrived outside patient
room. As charge RN and MD were going to bedside, received
notification from bedside RN that mother had removed patient’s PIV
herself and left the hospital with him. MD had spoken to mother earlier
on the phone and told mother that leaving the hospital before meeting
Endocrine criteria for discharge would be against medical advise (sic).
Patient arrived to hospital without insulin pump in place, and uncertain
if/when new pump will be placed. He was not covered for his dinner
carbs and he is in danger of worsening ketosis and hyperglycemia.
Mother left with patient against medical advice. MD recommends CPS
being called and patient brought back to ED for continued medical
management. [Social Worker] aware.
19
October 9, 2024
Tim was transported by EMS to TCH The Woodlands for a “Behavioral
Problem[.]” According to the emergency department’s records,
Patient reports he gets angry sometimes. Reports he got mad at his
brother today and “said some things he didn’t mean”, and got into a
fight. Patient admits that he takes care of his diabetes, and monitors his
blood sugar with the help of his mother. Mom reports family recently
homeless, after moving out of a “questionable” hotel. Mom reports she
was recently awarded her financial benefits from death of family
member. Today family was at a motorcycle shop looking at dirt bikes,
and having a mechanic look at younger siblings dirt bike for repair.
Mom reports patient got upset, and started a fight with brother. In the
midst of fighting patient was heard saying “I want to kill everyone, and
then kill myself”. Patient has history of anger, and aggression. Mom
reports she believes he would do it, do (sic) to his past history. Mom
reports patient has had outside counseling, and psychiatry, however,
due to their current financial situation, he has not been going. Patient
unwilling to go into detail about what happened today, or how he feels,
but denies current SI/HI, auditory or visual hallucinations. In no acute
distress.
Tim was admitted to the hospital and on October 10, 2024, a Diabetes Consult
was conducted by Dr. McCann-Crosby, whose narrative indicates,
He was noted to have hyperglycemia with ketosis in the EC.
He is on an Omnipod pump but does not have a Dexcom currently and
has been in manual mode. Per mom he has not been checking his blood
sugars. He manages a lot of his diabetes on his own but does get some
help from his mother.
Mom reports that they are currently homeless. They were living in an
extended stay, however mom was concerned about sex trafficking
around the extended stay so they left and have been living in their car.
Mom reports that she has 2 pit bulls and it has been difficult for her to
find a place to rent that will accept the pit bulls… When asked about
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the insulin storage, mom reports that it has not been kept consistently
in a refrigerator recently…Yesterday [Tim] became upset and
threatened to kill mom and his brother and then kill himself. Mom
called EMS and they brought him to TCH The Woodlands.
Mom was very upset this morning because she was initially told by the
front desk on the 5th floor that they didn’t have record of [Tim] in the
system. She reports that [Tim] has been listed under different names
during several previous hospitalizations at TCH and she has had
difficulty being able to see him during his admissions because “they
can’t find him in the system”. She does not want to be admitted to TCH
Woodlands in the future because of these concerns. Mom mentioned
multiple times that she wants to take [Tim] and leave AMA. She reports
that if CPS is called again she will not answer her phone if they call her.
….
His presentation is to (sic) suspected to be related to missed insulin
doses/inadequate supervision, likely bad insulin due to lack of
refrigeration [].
We have discussed with the family that Tim was in serious condition,
and ketosis could result in acidosis/DKA and significant risk of
electrolyte abnormalities, cerebral edema, and death. Ongoing parental
supervision is critical to achieving good glycemic control in children
and adolescents and preventing life-threatening complications of
diabetes.
Of note, the family is currently homeless and patient is not in school
currently. [Social Worker] has met with the family and a new CPS case
has been opened today. It is recommended that he be admitted to
inpatient psych.
He is medically cleared from an endocrine standpoint.
Erlene Norris, LMSW, conducted a Social Work Psychological Assessment,
which indicates,
Per mother, she brought pt after he became agitated and got into a
physical fight with his younger brother. According to mother, pt
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became really upset and threatened to Kill himself and his mother and
brother.
Pt was previously diagnosed with ODD, ADHD and adjustment
disorder. Per mother pt is not receiving treatment or taking any
medication. Mother revealed the family is going through a crisis and
are currently homeless.
Mother also disclosed they have not been able to go to their endocrine
appointments due to their crisis. Sw asked mother to tell her more about
her crisis. Mother explained they were leaving (sic) at an apartment and
had to leave that apartment and they left the medicines and everything
behind. Mother disclosed they have been staying at ‘sketchy” hotels.
….
[Social Worker] discussed with mother next steps including
recommendation for inpatient treatment. Mother reporting she was in
agreement as long as she could be at bedside. Mother identified
Kingwood Pines as facility of choice.
Four hours later, when an ambulance arrived to transport Tim to Kingwood
Pines, Mother refused to sign the authorization. The nurse’s notes indicate Mother
“[s]tated she will not allow for patient to be transferred to any hospital associated
with TCH. Mother voiced frustration with our hospital contacting C