Concerning J.A.D., n/k/a J.A.Z., Appellant. v. << (2023)

JUDGMENT AFFIRMED

¶ 1 J.A.Z. (mother) appeals the juvenile court's judgment adjudicating K.P.P. (the child) dependent or neglected. We affirm.

I. Background

¶ 2 This case began when the Denver Human Services Department received a report that the then-five-year-old child was wandering his neighborhood alone while mother slept. The Department opened an informal case and offered mother services, including a psychological evaluation, but she declined to take the evaluation or accept many of the other services offered.

¶ 3 The Department eventually filed a petition in dependency or neglect alleging that mother and the child had been diagnosed with type 1 diabetes, and mother's mental health was declining. The Department alleged that because of mother's mental health challenges she could not adequately manage the child's extensive medical needs, and he lacked adequate supervision. Mother denied the allegations and requested a trial.

¶ 4 The Department later filed an amended petition in which it alleged that medical professionals had strongly recommended the child receive long-acting insulin, but mother had refused to administer it, favoring instead the use of short-acting insulin to manage the child's diabetes. The Department also alleged that, when the caseworker arrived at a recent home visit, she discovered that mother had overslept the night before and failed to administer the child's nighttime insulin. The child had extremely high blood sugar and ketone levels (a concerning sign of metabolic abnormalities). The caseworker called the child's medical provider, who advised that mother should administer the recommended dose of insulin, but mother was only willing to administer a reduced dose. Mother declined the provider's request that she take the child to the hospital, but she was willing to take him to a camp staffed by diabetes-trained professionals.

¶ 5 After hearing the evidence presented at an adjudicatory bench trial, the juvenile court concluded that the child was dependent or neglected because mother had not provided proper parental care, she had subjected the child to medical neglect, and the child's environment was injurious to his welfare. Mother appeals.

II. Adjudication

¶ 6 Mother contends there was insufficient evidence to support the adjudication because she presented expert testimony that she provided adequate medical care, and the child's blood glucose data supported this testimony. Although the Department's expert opined that mother had subjected the child to medical neglect, mother contends the blood glucose data did not support that opinion. We disagree.

A. Standard of Review

¶ 7 Whether a child is dependent or neglected presents a mixed question of fact and law because it requires the application of evidentiary facts to statutory criteria. People in Interest of S.N. v. S.N., 2014 CO 64, ¶ 21. We review the juvenile court's factual findings for clear error, and we will not disturb them if they have record support. People in Interest of S.G.L., 214 P.3d 580, 583 (Colo. App. 2009). However, we review the court's legal conclusions de novo, and we may set aside a judgment based on errors of law or legal findings that do not conform to the statutory criteria. People in Interest of S.K., 2019 COA 36, ¶ 41; S.G.L., 214 P.3d at 583.

¶ 8 The credibility of witnesses and the sufficiency, probative effect, and weight of the evidence are within the juvenile court's purview. S.G.L., 214 P.3d at 583. When examining the sufficiency of the evidence, we review the record in the light most favorable to the prevailing party, and we draw every inference fairly deducible from the evidence in favor of the juvenile court's decision. Id.

B. Applicable law

¶ 9 The purpose of an adjudicatory trial is to determine whether the factual allegations in the dependency and neglect petition are supported by a preponderance of the evidence, and thus, whether the status of the child warrants intrusive protective or corrective intervention into the familial relationship. People in Interest of A.M., 786 P.2d 476, 479 (Colo. App. 1989). A child is dependent and neglected if, as pertinent here, (1) the child lacks proper parental care through the actions or omissions of the parent; (2) the child's environment is injurious to his or her welfare; or (3) a parent fails or refuses to provide the child with proper or necessary medical care or other care necessary for the child's health or well-being. § 19-3-102(1)(b)-(d), C.R.S. 2022.

¶ 10 An injurious environment exists when a child is in a situation that is likely harmful to the child. People in Interest of J.G., 2016 CO 39, ¶ 26. Proper parental care includes the minimum level of care required to prevent any serious threat to the child's health or welfare, including threats arising from failure to provide proper medical care. See § 19-3-102(1)(b),(d).

C. Analysis

¶ 11 Viewing the evidence in the light most favorable to the Department, we conclude that the evidence presented was sufficient to establish that mother did not provide proper medical care for the child, and thus, she also failed to provide proper parental care, creating an injurious environment in which the child was likely to suffer harm. More specifically, due to mother's mental health challenges, the medical care she provided did not meet the standard of care for children with type 1 diabetes or otherwise comport with the recommendations made by the child's providers, creating a risk the child would suffer a severe adverse outcome.

1. The Department's Case

¶ 12 The Department's pediatrician, who was qualified as an expert in pediatric abuse and neglect, reviewed the child's medical records and made a diagnosis of medical neglect. She defined medical neglect as care that poses a risk of severe harm to the child. Although she is not an endocrinologist, her opinions were based, in part, on records from the Barbara Davis Center, including those of a nurse practitioner who specializes in endocrinology and had treated the child. She also testified that, if not managed properly, diabetes can result in severe harm, including permanent disability or death. Therefore, failure to properly manage diabetes is consistent with neglect.

¶ 13 The Department's expert opined that mother had failed to properly manage the child's diabetes in two primary ways.

¶ 14 First, after the child was diagnosed, mother increasingly changed his insulin regimen without consulting his medical team and administered doses of short-acting insulin at inappropriate times. Changes in insulin dosing can cause a person to have low glucose or high glucose, both of which have serious health ramifications, including the possibility of disability or death. Giving insulin at the wrong time can also make blood glucose fluctuate out of control, which is dangerous.

¶ 15 Second, mother sought to avoid giving the child long-acting insulin at the doses recommended by the child's medical providers. According to the Department's expert, to avoid highs and lows, there are only two medically accepted protocols that meet the standard of care for type 1 diabetes: manually administering both short-acting and long-acting insulin by injection or administering short-acting insulin through a pump that provides a base rate of insulin and additional insulin as needed. If a family selects the manual method, as mother apparently did, young children typically start at four or five units of long-acting insulin a day. However, mother would only consent to give the child one unit of long-acting insulin a day, which was not adequate based on the child's age and size. A nurse practitioner who had treated the child, and who was qualified as an expert in pediatric nursing with an emphasis in pediatric endocrinology, opined that mother's refusal to follow medical recommendations regarding long-acting insulin put the child at risk.

2. Mother's Case

¶ 16 As mother points out, the child had not experienced any concrete adverse health outcomes at the time of trial, and mother's expert, who was qualified as an expert in pediatric care with an emphasis in child neglect, but who also was not a pediatric endocrinologist, testified that the child's blood glucose data demonstrated mother's care was “good to good enough overall.” Therefore, mother argues, the child was not harmed nor was there a legitimate risk of harm.

¶ 17 As stated above, the juvenile court determines the credibility of witnesses and the sufficiency, probative effect, and weight of the evidence. S.G.L., 214 P.3d at 583. The court did not credit the testimony of mother's expert, and this decision was well within its authority. Id.

¶ 18 Moreover, the record reveals there were several reasons for the court's decision. The court noted that, according to mother's expert, mother had trouble telling the truth and absorbing information conveyed by medical providers, which in and of itself created doubts about the medical care mother was capable of providing. Mother's expert also admitted that mother did not follow the medically accepted regimen for treating type 1 diabetes. We further note that, according to mother's attorney, mother and the child were sharing glucose monitors or using more than one glucometer to keep track of their blood sugar. Multiple experts testified that such practices raised valid concerns about the accuracy and probity of the blood glucose readings upon which mother's expert relied.

¶ 19 In addition, several pieces of evidence showed that mother's conduct increasingly posed severe risks to the child's health, legitimizing concerns that the level of risk was becoming untenable. Mother's expert testified that there were real concerns that the child's post-diagnosis “honeymoon” period — the period where a person does not require as much, or sometimes any, treatment — was coming to an end. The nurse practitioner testified that the child's A1C number (a number that reflects average blood glucose over three months) was trending upwards, indicating that he was generally not getting enough insulin. And all the medical experts testified that, on the day that the caseworker discovered mother had failed to administer overnight insulin, the child's ketones and glucose levels were concerning, and he was put in situation where he needed immediate treatment. The caseworker testified that, when she called the child's medical provider on that day, the provider advised her that the child was in imminent danger.

¶ 20 This evidence supports the juvenile court's conclusion that mother was not providing proper medical care and the child was in an injurious environment. Thus, we decline to disturb the juvenile court's adjudication of the child as dependent or neglected.

III. Disposition

¶ 21 We affirm the judgment.

Opinion by JUDGE SCHUTZ

Harris and Lipinsky, JJ., concur JUDGE HARRIS and JUDGE LIPINSKY concur.