Opinion
No. C6-01-938.
Filed April 30, 2002.
Appeal from the District Court, Hennepin County, File No. J70056965.
Leonardo Castro, Hennepin County Public Defender, Renée Bergeron, David Murrin, Assistant Public Defenders, (for appellant mother)
Amy J. Klobuchar, Hennepin County Attorney, Mary M. Lynch, Assistant County Attorney, (for respondent county)
Shirley A. Reider, (for guardian ad litem)
This opinion will be unpublished and may not be cited except as provided by Minn. Stat. § 480A.08, subd. 3 (2000).
UNPUBLISHED OPINION
Appellant challenges the termination of her parental rights, alleging the record does not show that (1) she is palpably unfit to be a parent; (2) termination is in the child's best interests; and (3) respondent provided reasonable efforts to reunite the family. Appellant also argues that respondent's failure to provide adequate efforts to reunite the family deprived her of due process of law, and that this court should grant equitable relief and remand for findings consistent with the record. We affirm.
FACTS
B.L., born June 26, 1992, is the child of appellant E.L. The child's father died in 2000. B.L. suffered a premature closure of his fontanel in infancy. As a result, he now scores between 60 to 65 on I.Q. tests, obsessive-compulsive disorder, developmental delays, attention deficit disorder, and speech problems. Since 1999, he has had seizures.
Appellant has normal intelligence, but has difficulty learning new information due to an impairment of her short-term memory. She suffers from depression and obsessive-compulsive disorder, which is expressed by hoarding and repetitive behavior.
In June 1998, B.L. was diagnosed with type-1 juvenile-onset diabetes after being treated at the Hennepin County Medical Center (HCMC). His condition requires constant monitoring and adjustments to his medication to keep his blood sugar levels within a normal range. He also requires multiple daily blood-sugar tests, insulin shots, a restricted diet, consistent meals on a regular schedule, and close monitoring of his food intake and insulin levels.
Because B.L.'s diabetes is difficult to control, his case was automatically referred to the Pediatric Diabetes Program at the University of Minnesota Hospital. B.L. was hospitalized because of problems with his diabetes and treated by Dr. Antoinette Moran, director of the program. Dr. Moran was assisted by her care team, which consisted of a nurse who provided diabetes education, a dietician who assessed the patient's nutritional needs, and a family therapist who helps patients and their families adjust to the role of diabetes in their lives. Dr. Moran testified that at that time, appellant, not unlike mothers in similar situations, was overwhelmed with the diagnosis. She was unable to give B.L. the necessary injections and there were many problems in the way she structured her day, such as irregular mealtimes and incomplete meals.
Appellant returned to the hospital a week later totally overwhelmed and told Dr. Moran that she was not sure she could manage her son's diabetes. Because appellant was not able to provide adequate nursing care and could not administer the necessary injections, B.L. was admitted to the hospital on July 2, 1998, and stayed until August 11, 1998, when he was placed in foster care. During the month of July, appellant was instructed by Dr. Moran's team on how to take care of B.L., including training on giving injections, dietary needs of diabetics, balancing B.L.'s diet, insulin, and activity. She was taught that B.L.'s most basic needs were eating at regular intervals and, if he was highly active, to eat more. Concurrently, Ann Tomnskemper, a public health nurse referred by HCMC, also provided home instruction to appellant on how to manage B.L.'s diabetes. During this hospitalization, behavioral specialist Dr. Laurel Wills, treated B.L.
On July 17, 1998, respondent Hennepin County filed a child in need of protective services (CHIPS) petition, alleging that appellant was not prepared to manage B.L.'s illness. After a hearing on July 31, 1998, temporary custody was transferred to the Hennepin County Department of Children and Family Services (DCFS) and B.L. was ordered into out-of-home placement. In a September 29, 1998 report, Dr. Moran noted that B.L. was doing "remarkably well" in foster care. His diabetes was under excellent control, he was no longer underweight, he was growing well, and his behavior and obsessions were being managed.
With DCFS assistance, appellant cared for B.L. during regular visitation. In August 1998, Dr. Moran referred appellant to a behavioral specialist to address issues that were interfering with B.L.'s care. Appellant's cognitive skills assessment revealed average intelligence with some short-term memory loss and difficulty with numbers. Dr. Moran and her team adjusted their education style accordingly.
On September 7, 1998, Dr. Moran and DCFS permitted appellant to take B.L. to the State Fair if another adult approved by DCFS accompanied her. Appellant arranged for her home health aide to accompany them, however, it was discovered that appellant and B.L. went alone. While there, appellant failed to feed B.L. dinner and his blood sugar dropped so low that he needed medical assistance and glucose injections. According to Dr. Moran, B.L. had abnormal blood-sugar levels the majority of the time he was in appellant's care through October 1998. At about this time, appellant changed physicians, transferring B.L.'s care to Kumud S. Sane, M.D., of Southdale Pediatrics.
At an October 1, 1998 hearing, appellant and DCFS agreed to allow the district court to adjudge B.L. in need of protection or services. On December 9, 1998, the district court ordered B.L. put in the custody of DCFS and in an out-of-home placement until appellant completed the requirements of her case plan. Tomnskemper visited with appellant and B.L. at least weekly. The case plan required that appellant: (1) undergo a program to educate her in homemaking skills; (2) participate and cooperate with the training provided by B.L.'s medical providers so that she could properly care for B.L.'s medical needs; (3) cooperate with the public health nurse and home health aide; (4) regularly visit B.L. and participate in training to provide for his special needs; and (5) participate in a full psychological evaluation and successfully participate in therapy with Dr. Wills.
At a February 26, 1999 hearing, the county attorney recommended that B.L. be returned to appellant's care, based on Dr. Sane and other medical professional's belief that appellant was able to render the proper care for B.L. The district court accordingly ordered B.L. returned to appellant's care.
At that time, DCFS increased the services provided to appellant, including more frequent visits by Tomnskemper, who reviewed signs and symptoms of low and high blood-sugar levels, observed appellant testing B.L.'s blood-sugar levels, giving insulin injections, monitoring food, and calculating carbohydrates to determine the amount of insulin to administer. Appellant and B.L. also received (1) parenting services biweekly from Kathryn Haskin, M.A., at the Reuben Lindh Family Services Center; (2) instruction from Dr. Wills in how to care for B.L.; (3) instruction from Dr. Sane and his staff, which included a nutritionist and a nurse; (4) care from an Association for Retarded Citizens (ARC) therapist; and (5) monitoring by the guardian ad litem. DCFS also provided housekeepers to assist appellant, but she did not get along with them, and that service was discontinued.
B.L. visited Dr. Sane at least bi-weekly during this time, and appellant spoke with Dr. Sane's nurse approximately twice per week.
During 1999, B.L. developed a seizure disorder that was, in Dr. Moran's opinion, triggered by the abnormal blood-sugar levels he suffered from, but was not a normal consequence of controlled diabetes. On April 22, 1999, B.L. was admitted to the HCMC emergency room with an abnormally high blood-sugar level, and on April 30, he was taken to his clinic because of blood-sugar problems. In July 1999, the district court ordered appellant to undergo a psychiatric evaluation. Dr. Michael Dieperink diagnosed her with obsessive-compulsive disorder. On August 11, B.L. was taken to HCMC emergency room by ambulance because of low blood sugar. In August or September 1999, appellant was told that Dr. Sane could no longer treat B.L. because of staffing shortages. Dr. Jennifer Kyllo saw B.L. on November 16, 1999. On November 18 and 20, B.L. received treatment at the HCMC emergency room because of abnormal blood-sugar levels and possible seizures.
On December 13, 1999, appellant's apartment failed an announced inspection by building management because of unsanitary conditions, and on December 20, 1999, a DCFS social worker visited the home and found it in an unsanitary condition. During December 1999, B.L. arrived at school at least five times with high blood-sugar levels, but appellant did not provide or seek outside medical attention for those abnormal levels.
On December 21, 1999, the district court ordered that legal custody of B.L. be turned over to the court. On January 3, 2000, the district court ordered B.L. placed with DCFS, and he was returned to his foster family. In February 2000, Dr. Moran began caring for B.L. again.
In April 2000, appellant resumed unsupervised visitation with B.L. and, in a co-parenting arrangement, B.L. lived with both appellant and his foster family. The foster care provider testified that appellant regularly failed to coordinate B.L.'s food intake.
On April 17, 2000, DCFS filed a petition to terminate appellant's parental rights to B.L. The petition alleged that (1) appellant refused to comply with parental duties, contravening Minn. Stat. § 260C.301, subd. 1b(2) (1998); (2) she was palpably unfit, contravening Minn. Stat. § 260C.301, subd. 1b(4) (1998); (3) reasonable efforts failed to correct the conditions that led to the out-of-home placement, contravening Minn. Stat. § 260C.301, subd. 1b(5) (1998); and (4) B.L. was neglected and in foster care, contravening Minn. Stat. § 260C.301, subd. 1b(8) (1998).
The matter was tried over a period beginning November 1, 2000, and ending January 19, 2001. Dr. Moran testified that B.L.'s medical condition is made more complicated by his obsessive-compulsive disorder, mental retardation, behavior problems, and seizure disorder. She also testified that he is a "brittle diabetic" whose condition is "very difficult to control," and who needs "really close supervision." She opined that B.L. needs a caretaker who can anticipate his dietary needs and make adjustments to prevent problems or can handle problems as they arise, and that due to appellant's short-term memory problem and organizational difficulties, she could not learn to manage B.L.'s diabetes. Dr. Moran also testified that B.L. did best when he had limited contact with appellant.
Dr. Elizabeth Giles, B.L.'s neurologist, began treating him in July 2000. She testified that B.L. needed a routine and consistent environment and a caregiver who knows his various treatments and conditions, participates in his behavioral management program to ensure that his diet is followed and medication regimented, and who takes initiative in his care. Dr. Giles testified that B.L. is at special risk for catastrophic consequences such as seizures, coma, brain damage, and death if his medical conditions are poorly managed. She opined that appellant's obsessive-compulsive disorder affected her ability to plan and perform sequencing. She observed that B.L. was in a better condition once his weekend visits with appellant were discontinued and visits were limited to a few hours once per week.
The district court ordered that appellant's parental rights be terminated on April 1, 2001, solely on the basis that she was palpably unfit as a parent. The district court also found that termination was in the child's best interest and that the county had made reasonable efforts to reunite the family.
The district court denied appellant's subsequent motion for a new trial or amended findings based on the sufficiency of the evidence. This appeal followed.
DECISION
When a district court's findings in a termination case are challenged, we are limited to determining whether those findings address the statutory criteria, are supported by substantial evidence, and if they are clearly erroneous. In re Welfare of M.D.O., 462 N.W.2d 370, 375 (Minn. 1990). Although some deference is given to the trial court's findings, we exercise great caution and "closely inquire into the sufficiency of the evidence to determine whether the evidence is clear and convincing." In re Welfare of A.H., 402 N.W.2d 598, 603 (Minn.App. 1987) (quotations omitted).
I.
"Parental rights are terminated only for grave and weighty reasons." M.D.O., 462 N.W.2d at 375. The court presumes that the natural parents are suitable to be entrusted with the care of their children and that it is in a child's best interest to be in the natural parent's care. In re Welfare of Clausen, 289 N.W.2d 153, 156 (Minn. 1980). We exercise great caution in termination proceedings, only finding termination proper when the evidence clearly mandates that result. In re Welfare of S.Z., 547 N.W.2d 886, 893 (Minn. 1996).
The party petitioning for termination must prove one or more of the statutory grounds for terminating parental rights by clear and convincing evidence. In re Welfare of J.S., 470 N.W.2d 697, 701 (Minn.App. 1991), review denied (Minn. July 24, 1991). While only one criterion must be proven to support termination, the "paramount consideration" in every termination case is the child's best interests. Minn. Stat. § 260C.301, subd. 7 (2000). In any termination proceeding, the district court is also required to make specific findings regarding the efforts made by the social services agency to rehabilitate the parent and reunite the family or that such reasonable efforts "are not required as provided under section 260.012." Minn. Stat. § 260C.301, subd. 8 (2000).
Palpably Unfit
The district court found that appellant was palpably unfit to parent and, accordingly, terminated her parental rights. Parental rights may be terminated when
a parent is palpably unfit to be a party to the parent and child relationship because of * * * specific conditions directly relating to the parent and child relationship * * * that renders the parent unable, for the reasonably forseeable future, to care appropriately for the ongoing physical, mental, or emotional needs of the child.
Minn. Stat. § 260C.301, subd. 1(b)(4) (2000). The burden of proving a parent "palpably unfit" is onerous. M.D.O., 462 N.W.2d at 376. The petitioning party must prove a consistent pattern of specific conduct or specific conditions that exist at the time of the hearing that will continue for a prolonged, indefinite period and that are permanently detrimental to the welfare of the child. Id. at 377.
The district court described in detail appellant's conditions and actions that constituted a failure to properly care for B.L. from 1998 through 2000. During that period, she received education on properly caring for B.L. from multiple sources. Despite these services, by 2000, she was still unable to properly care for him. Dr. Moran stated that it would not be safe to return B.L. to appellant's care, basing her opinion on a long history of treating B.L. and attempts by both herself and her staff to educate appellant on safely managing B.L.'s diabetes. She also reviewed the medical records of other treating physicians, and found that those records and the events of 2000 demonstrated that appellant was still unable to manage the diabetes. She testified that in June 2000, she reviewed with appellant B.L.'s care plan, and specifically discussed hypoglycemia and the need to carry food and anticipate unexpected events, but that one month later, appellant could not articulate that care plan. The district court noted that Dr. Moran's observation that appellant was unable to follow through with basic care of B.L.'s diabetes is corroborated by the foster mother's testimony that appellant has regularly failed since September 2000 to give B.L. his prescribed afternoon snack before returning him to the foster home. The district court also relied, in part, on Dr. Gilles's testimony that during a visit to assess appellant's understanding of B.L.'s neurological diagnoses and medications, appellant had essentially no understanding of these issues and was unable to tell her the name of B.L.'s anti-convulsant medication.
Best Interests
The best interests of the child is our "paramount consideration." Minn. Stat. § 260C.301, subd. 7. A child's best interests can preclude termination of parental rights despite one or more of the statutory prerequisites to terminating parental rights being met. In re Welfare of M.P., 542 N.W.2d 71, 74 (Minn.App. 1996). If the interests of the children conflict with the interests of the parents, then the children's interests are paramount. In re Welfare of R.T.B., 492 N.W.2d 1, 4 (Minn.App. 1992). In determining the best interests of the children three factors must be taken into consideration: "(1) the child's interest in preserving the parent-child relationship; (2) the parent's interest in preserving the parent-child relationship; and (3) any competing interest of the child." Id. In balancing the factors, the interests of the parents and the children are not necessarily equal. Id.
Here, the district court determined that appellant was unable, for the reasonably foreseeable future, to safely manage B.L.'s life-threatening medical conditions and provide the stable and consistent environment necessary for his needs. We are certain that appellant and her son share a strong bond. The district court noted:
It is with great sadness that I conclude the termination of [appellant's] parental rights of [B.L.] is necessary. I believe everyone involved in this case recognizes how much she loves her son. That love was evident throughout the trial.
But, as the district court also recognized, the evidence shows that B.L.'s condition is potentially life-threatening and that appellant is unable to properly care for him.
We recognize and have carefully considered Dr. Wills's and Dr. Gilles's testimony that it may not be in B.L.'s best interest to terminate appellant's parental rights because of the strong parent-child relationship and because that bond will be compromised with termination. But the district court found that B.L.'s interests in having a competent permanent caregiver who can safely manage his medical problems and provide him with a safe environment outweighed these concerns. After fully examining the record, we conclude that the district court's finding is not clearly erroneous and we ultimately agree with that assessment. The district court noted that the evidence showed that B.L. did not have an adverse reaction when contact with appellant was drastically reduced from long weekends to a few hours one day per week. In fact, his condition improved after the reduced visits commenced.
Reasonable Efforts
Every CHIPS intervention requires a case plan that reflects the reasonable efforts of the agency to facilitate reunification of the child with the family, and termination is appropriate when those reasonable efforts fail. In re Welfare of E.V., 634 N.W.2d 443, 446 (Minn.App. 2001). "The county's efforts must assist in alleviating the conditions that gave rise to the dependency adjudication." In re Welfare of H.K., 455 N.W.2d 529, 532 (Minn.App. 1990) (citation omitted), review denied (Minn. July 6, 1990). Reasonable efforts consist of services that "go beyond mere matters of form so as to include real, genuine assistance." Id. The services must be relevant to the safety and protection of the child, adequate to meet the needs of the family and the child, culturally appropriate, available and accessible, consistent and timely, and realistic under the circumstances. Minn. Stat. § 260.012(c) (2000).
Here, the district court found that DCFS made reasonable efforts to identify the issues affecting appellant's ability to manage B.L.'s medical conditions and provide for his special needs and to offer services to assist her. Dr. Moran, Dr. Sane, and their medical staffs provided B.L. with medical care to control his diabetes and other conditions arising out of his condition. When additional care was needed, B.L. was sent to Dr. Wills for behavior problems and Dr. Gillis for neurological problems. In August 1998, appellant underwent a psychological evaluation and, subsequently, medication for her mental disorders and difficulties. Dr. Moran's office changed their teaching style to reflect the results of the findings from the initial evaluation, including more frequent contact, presenting information in smaller bits, and frequent reviews. In January 1999, another psychological review was conducted that revealed normal intelligence and no cognitive defects that would prevent appellant from adequately learning to care for B.L. Professionals from the Reuben Lindh Family Partnership Program provided appellant with lessons in parenting skills, addressing special needs children, household management, and community support. A public health nurse and home health aide were provided to further educate and train appellant in managing B.L.'s condition and special problems, as well as in housekeeping. B.L. was also provided with therapeutic foster care, a personal care attendant, respite care, and case management by DCFS.
The district court specifically rejected the testimony of those witnesses who stated that DCFS did not make reasonable efforts to reunite the family because their beliefs were based on an incomplete knowledge of the situation. The district court also rejected testimony that appellant had not received appropriate psychiatric care. Appellant received an initial psychiatric evaluation in July 1999 and continued in the care of Dr. Dieperink until June 2000, when she lost her medical insurance. Appellant did not notify DCFS or the court that she was unable to continue her care for insurance reasons. Furthermore, the district court had no evidence that further psychiatric care would enable appellant to overcome her hoarding tendencies in the foreseeable future or that even if she could overcome her mental health issues that she would be able to manage B.L.'s condition.
Based on the foregoing evidence and analysis, and our review of the record, we conclude that the district court's factual findings were not clearly erroneous and supported its conclusion that appellant is palpably unfit, termination is in B.L.'s best interests, and the agency provided reasonable efforts to keep the family intact.
II.
Appellant contends that termination of her parental rights violated her right to due process because DCFS did not make reasonable efforts to reunite her with her child. The nature of due process is flexible and the amount of process due varies with the circumstances of the case. In re Matter of H.G.B., 306 N.W.2d 821, 825 (Minn. 1981). In termination of parental rights cases, the determination of what process is due involves a balancing of the interests involved in the specific situation at issue. Id. The focus of a termination proceeding is on the child's best interests, rather than those of the parent. In re Welfare of S.R.A., 527 N.W.2d 835, 839 (Minn.App. 1995), review denied (Minn. Mar. 29, 1995). Where there is a technical violation of a parent's due process right, there is no remedy if termination is in the child's best interests. Id.
Here, as stated above, the district court determined that termination was in B.L.'s best interests. DCFS provided appellant with the assistance required by statute. She had several chances over a two-year period to care for B.L., both on her own and in conjunction with a foster family. After that period, a petition for termination was filed and a trial was held at which appellant testified. We hold that under these circumstances, appellant's due process rights were not violated.
Appellant also requests that this court invoke its equitable powers to reverse the termination order in this case and remand to the district court for findings consistent with the best interests of B.L. Minnesota courts may invoke their inherent power to grant equitable relief "as the facts in each particular case and the ends of justice may require." E.V., 634 N.W.2d at 449 (citation omitted).
Here, the district court has already made a determination of B.L.'s best interests and the evidence supports that determination. We see no reason to use our equitable powers to reverse the district court. B.L. has defined and serious needs. DCFS was involved with the family for more than three years and many services were offered and utilized by appellant. Despite those services, appellant was still unable to properly care for B.L. In contrast, in E.V., this court reversed the termination finding because the parent's failure to utilize services provided, upon which termination was partially based, was not shown to be germane to the correction of the conditions that led to the out-of-home placement. Id. at 447.