Court Opinion

ID: 9392938
Source: CourtListenerOpinion
Date Created: 2023-05-08 18:12:52.296792+00
Date Added: 2024-06-11T17:18:49.980555
License: Public Domain

J-A04009-23

NON-PRECEDENTIAL DECISION - SEE SUPERIOR COURT I.O.P. 65.37

 IN THE INTEREST OF: N.D., A            :   IN THE SUPERIOR COURT OF
 MINOR                                  :        PENNSYLVANIA
                                        :
                                        :
 APPEAL OF: B.C.C.Y.S. AND GAL          :
                                        :
                                        :
                                        :
                                        :   No. 1201 MDA 2022

                Appeal from the Order Entered August 12, 2022
                 In the Court of Common Pleas of Berks County
               Juvenile Division at No: CP-06-DP-0000010-2022

BEFORE: STABILE, J., DUBOW, J., and McCAFFERY, J.

MEMORANDUM BY STABILE, J.:                            FILED: MAY 8, 2023

        Appellants, Berks County Children and Youth Services and Ashley E.

Esposito, Guardian Ad Litem (“GAL”) (collectively “BCCYS”), appeal from an

order denying Appellants’ petition to adjudicate N.D., a minor (“Child”),

dependent.    The court determined that BCCYS failed to provide clear and

convincing evidence that N.D. was without proper parental care or control

necessary for his physical, emotional or mental health and morals. We affirm.

        Child was born in December 2019. On December 26, 2021, Child was

hospitalized and required several emergency surgeries to remove 117

centimeters of necrotic bowels. He remained hospitalized throughout January

2022.

        On January 12, 2022, BCCYS filed a petition to adjudicate Child

dependent under 42 Pa.C.S.A. § 6302(1). On February 2, 2022, BCCYS filed

an amended petition making additional allegations of abuse under 23
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Pa.C.S.A. § 6303. In essence, BCCYS alleged that Child’s parents (“Parents”)

failed to provide consent for his immediate medical needs in a timely manner

following his hospitalization in late December 2021, as well as ongoing

concerns regarding Parents’ inability to appropriately parent him. Parents’

failure to provide timely consent, the petition alleged, necessitated removal of

117 centimeters of dead bowels from Child during subsequent surgeries.

BCCYS later filed amended petitions alleging a history of domestic violence

between Mother and Father. The docket also reflects that GAL participated in

the dependency proceedings.

      On January 20, 2022, BCCYS petitioned the court for emergency custody

of Child. On the same date, BCCYS received a report that Hershey Medical

Center obtained a 24-hour right to custody of Child. On January 21, 2022,

Child was removed from Parents’ custody pursuant to an Emergency Order.

Upon Child’s release from the hospital, he was placed in a licensed foster

home.

      The court held a series of evidentiary hearings between January 2022

and August 2022. On August 12, 2022, the court denied BCCYS’s petition to

declare Child dependent.    BCCYS timely appealed to this Court, and both

BCCYS and the court complied with Pa.R.A.P. 1925.

      Appellants raise a single issue in this appeal: “Did the trial court err in

failing to adjudicate Child dependent, as Child was without proper parental

care or control necessary for his physical, mental, or emotional health, or

morals, in accordance with 42 Pa.C.S.[A.] § 6302(1)?” Appellant’s Brief at 3.

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       The Juvenile Act defines “dependent child” in relevant part as a child

who:
       (1) Is without proper parental care or control, subsistence,
       education, as required by law, or other care or control necessary
       for his physical, mental, or emotional health, or morals. A
       determination that there is a lack of parental care or control may
       be based upon evidence of conduct by the parent .... that places
       the health, safety, or welfare of the child at risk...

42 Pa.C.S.A. § 6302(1). Child abuse is defined as intentionally, knowingly, or

recklessly causing “serious physical neglect of a child.”      23 Pa.C.S.A. §

6303(b.1)(7). Serious physical neglect of a child is defined as “any of the

following when committed by a perpetrator that endangers a child’s life or

health, threatens the child’s well-being, causes bodily injury or impairs a

child’s health, development or function: ... the failure to provide a child with

the adequate essentials of life, including ... medical care.” 23 Pa.C.S.A. §

6303(a).

       In order to adjudicate a child dependent, the court must determine that

this standard has been met by clear and convincing evidence. In re L.V., 127

A.3d 831, 835 (Pa. Super 2015). “Proper parental care” is that care which

addresses the particular needs of the child, and which, at a minimum, is likely

to prevent serious injury to the child.    In re A.S., 63 A.3d 345, 349 (Pa.

Super. 2013).      The “clear and convincing evidence” standard requires

“testimony that is so clear, direct, weighty and convincing as to enable the

trier of fact to come to a clear conviction, without hesitance, of the precise

facts at issue.” In re Novosielski, 992 A.2d 89, 107 (Pa. 2010). “Clear and

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convincing   evidence,”   however,   does   not   require   that   evidence   be

uncontradicted. Id. Further, “a trial court has the discretion to accept or

reject a witness’ testimony, including that of an expert, and is free to believe

all, part or none of the evidence presented.” In re Bosley, 26 A.3d 1104,

1111 (Pa. Super. 2011).

      An appellate court will accord great weight to the hearing judge’s

findings in a dependency case, because the hearing judge is in the best

position to observe and rule upon the credibility of witnesses. In re C.B., 264

A.3d 761, 778 n.31 (Pa. Super. 2021). Accordingly, an appellate court will

not overrule the findings of the trial court in a dependency case if they are

supported by competent evidence. Id.

      The evidence reflects that a series of disputes arose between medical

providers and Parents relating to Child’s medical treatment after Parents

brought Child to Penn State—St. Joseph’s Hospital on December 26, 2021.

The first dispute concerned Parents’ resistance to consenting to Child’s

transportation by helicopter to Penn State Milton S. Hershey Center. The court

summarized the evidence on this issue as follows:

      BCCYS alleged abuse for the alleged delay in transport from Penn
      State—St. Joseph’s to Penn State Milton S. Hershey Medical
      Center and for a delay to consent for treatment. The testimony
      on these issues was primarily from Dr. Sareen and Dr. Safford.

      The testimony by Dr. Sareen, one of the treating physicians of
      Penn State—St. Joseph’s Hospital, confirmed that he began
      working at 6:00 a.m. on December 26, 2021. He reported that
      within the first ten minutes or so of his shift that he would have
      gone to the Child’s bedside, examined him and determined that

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     there might have been something severe going on . . . in the
     Child’s abdomen. He immediately ordered a CAT scan of the
     abdomen and the Child was taken for the scan around 6:30 a.m.
     or 6:35 a.m. He was uncertain when the Child arrived at the
     hospital but suspected it was 5:30 a.m. The results of the CAT
     Scan came back around 7:00 a.m., and Dr. Sareen diagnosed the
     Child with intestinal angioedema, which is edema in the bowel wall
     indicating that the bowel is having backup blood flow to the
     intestine. This condition could lead to septic shock and death.
     There was no perfusion or diminished perfusion which suggested
     a possibility of needing surgery. Dr. Sareen immediately called a
     pediatric surgeon at Hershey Medical Center to consult regarding
     the Child. He relayed his findings to the parents and “He (Father)
     did not seem impressed at all as to what I was saying, ...” Dr.
     Sareen reported that he would be contacting the pediatric surgeon
     at Hershey Medical Center and the Child may need to go to that
     facility. He reported that Father had a significant number of
     questions as to why the Child could not stay at Penn State—St.
     Joseph’s. Dr. Sareen testified that after he spoke with Dr. Safford,
     a pediatric surgeon at Penn State—Hershey Medical Center,
     sometime between 7:07 a.m. and maybe 7:30 a.m., he informed
     the parents that they would be transporting the Child via
     helicopter to Hershey Medical Center, and that led to significant
     concerns and questioning by Father. Father said, “I thought you
     said that you were going to transport him by ambulance.” Father
     inquired if he could be allowed to fly with him (Child).

     On cross-examination, Dr Sareen confirmed that the Child arrived
     around 4:49 a.m. EST, some testing for COVID was done, along
     with other bloodwork, a CAT scan was done at 7:10 a.m., and
     another doctor was involved in Child’s care prior to him coming on
     duty at 6:00 a.m. Dr. Madtes probably evaluated the Child around
     5:15-5:30 a.m. and ordered the initial diagnostics. Initially, Dr.
     Sareen stated that they were going to transport the Child via
     ambulance and did not specify air ambulance. Initially, the
     transport form that parents were asked to sign and did sign at
     7:45 a.m. was checked for ALS Ambulance, not air ambulance.
     Then, the ALS Ambulance box was crossed out and a second box
     was checked for helicopter.        Dr. Sareen recalls having a
     conversation and clarifying the transportation issue with parents.
     Dr. Sareen admitted that he did not wait for the parents to have
     a full understanding of the transportation situation and did what
     he needed to do to provide appropriate transport. The helicopter
     received dispatch at 7:24 a.m. and was en route to Penn State—

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     St. Joseph’s at 7:44 a.m. Parents consented at 7:45 a.m. and the
     helicopter arrived at 8:05 a.m. Dr. Sareen was asked, “But in this
     case, based on the timeline that is involved, there was no delay
     in the Child getting on that helicopter and getting to Hershey
     caused by the parents disagreeing with you, was there?” Dr.
     Sareen responded, “I mean, if you’re saying that as far as the
     delay, I don’t know. I don’t think so. You know, I made a phone
     call, the helicopter deploys, the helicopter gets there, and the
     patient is transferred.”

     BCCYS also called Dr. Safford, the Chief of Pediatric Surgery at
     Penn State—Hershey Medical Children’s Hospital to testify at the
     March 18, 2022 hearing. He testified that he received a call from
     St. Joseph’s on December 26, 2021 regarding a child and he
     recommended that the patient be sent by helicopter to Penn
     State—Hershey Medical Children’s Hospital. He was told by the
     ER doctor (Dr. Sareen) that the Child was lethargic, not
     interacting, had poor colorization and significant abdominal
     distension. He reported that the Child arrived at his hospital
     within an hour or two of his conversation with the St. Joseph’s
     doctor. Upon his examination of the Child, he noted several
     findings including abdominal distension and got him immediately
     to the operating room for emergent exploration. The parents were
     not at the hospital when the Child was being prepared for surgery
     because they were still driving to Penn State Hershey Medical
     Center and the helicopter got there first. Dr. Safford reached out
     to the parents by phone with three successive calls, while the Child
     was being intubated at the number provided by the helicopter
     crew. He was unable to reach them. He did receive a call back
     within 10-15 minutes. He reviewed with Parents over the phone
     how sick the Child was and what possible procedures could be
     done for the Child depending on whether the bowel is dead or
     some of the bowel is dead. Father took the information in, stated
     he was on his way, verbally consented to the surgery and said
     they could talk after the surgery.

     Prior to conducting the initial surgery, Dr. Safford reported they
     did not have medical history upon receiving the child but noted
     that he was a preemie with necrotizing enterocolitis and had
     drains placed. He did report that he spoke with the parents later
     that night and discussed what he found, what he saw in the
     operating room and this is generally something that would not
     occur over a day. Parents discussed that they were seeing their
     pediatrician, spoke to the office within 12 hours of going to St.

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     Joseph’s and got more concerned when the Child seemed to get
     sicker.   The doctor testified that the condition the Child
     experienced would occur over an 18-36 hour window. It should
     be noted that Dr. Safford referenced distension would be present
     and he was told by the ER physician that there was distension. He
     reports that distension would be present in the first 6-12 hour
     window and it is seen throughout the 3 phases. However, it
     should also be noted that the original ER physician, Dr. Madtes,
     noted there was no distension on his examination and the Life Lion
     Crew noted in their physical findings assessment that the
     abdomen was non-distended.

     Dr. Safford also testified as to two additional abdominal surgeries
     that the Child had to undergo while in his care and the difficulties
     or “battle antagonistic relationship’’ he referenced with getting
     consents from the parents. He stated that at one point he tried
     to get Mother’s consent for surgery at bedside and she refused to
     consent without Father coming on the phone as well. Mother took
     a photo of the consent, sent it to Father, and Father requested
     that it be redone in better handwriting so they could read it. It
     took parents about forty-five minutes to consent to the surgery.
     Again, on cross-examination, Dr. Safford was questioned about
     whether there was any damage or harm to the Child as a result of
     the 30-to-45 minute delay and he stated, “There was no delay—
     there was no damage to the Child for that delay.” Parents did
     consent to all the suggested surgeries.

     Dr. Safford testified that he felt there was delay in getting Child
     to the hospital and they were making it harder to get the Child to
     the operating room. Specifically, he referenced the helicopter
     delay, but Dr. Sareen, who was present for the consent for the
     helicopter, stated he did not think there was a delay as he
     requested the helicopter prior to obtaining consent. In response
     to the question as to whether the parents should have brought
     him to the hospital on December 25, 2021 (Christmas Day), Dr.
     Safford’s response was “I would say 24th or 25th. My guess, just
     based on the history, really 24th based on his appearance.” On
     cross-examination, Dr. Safford looked at the Report titled General
     Medical Complaint PED by Dr. Kevin Madtes dated 12/26/21 at
     5:36 a.m. that referenced the Child as having a soft abdomen, not
     tender, nondistended with normal bowl sounds. Dr. Safford
     indicated that he was surprised by that assessment given what he
     saw and opined that this had to be done by “someone that does
     not take care of children and not a surgeon.”

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     Mother was called as a witness by BCCYS and her counsel during
     a hearing on July 8, 2022. Mother provided general medical
     background regarding the Child inclusive of his premature birth
     and several months of hospitalization following birth at Reading
     Hospital and CHOP, as well as general information regarding
     specialists he saw following his hospitalization after birth. She
     explained that “many of his visits were via Zoom due to COVID
     restrictions.” Mother went on to testify what gave rise to the
     parents’ concerns on December 25, 2021. She reported that the
     Child was fine and then suddenly, he was fussing more than usual,
     about twenty minutes. As a result, she and Father decided to call
     the Kimberton Clinic, Child’s pediatrician, and voice their
     concerns. In response to their call, Mother reported that if there
     were any more concerns to call them back. Later that night, the
     child threw up once and the parents did not want to wait to call
     the pediatrician and they called emergency. Mother stated that
     they checked his belly to see if he was sore or uncomfortable and
     he seemed fine. He did not seem lethargic but was not as cheerful
     as normal. Throughout the course of Mother’s testimony on this
     date, it was clear to this court that the period of December 25,
     2021 through the filing of the Dependency Petition, Mother was
     extremely concerned about the medical condition of her son, that
     his condition rapidly changed throughout the course of treatment,
     and that the circumstances took a major toll on this family.

     Father was called as a witness by BCCYS and his counsel during a
     hearing on July 8, 2022. He was asked about the events on
     December 25, 2021 that led to the Child being taken to the
     hospital. He reported that he and Mother decided to call the Clinic
     when the child was acting differently and they were uncertain as
     to what was wrong. He stated that the Child was crying and that
     was why they called the pediatrician. Child did not appear to be
     in pain. He spoke with the clinic and was told that based on what
     he described it did not seem like an emergency but if it progressed
     to call back. He stated that after the Child threw up once, they
     called 911. EMS responded in about thirty minutes. It was early
     in the morning on December 25, 2021 when the EMS arrived. Like
     Mother, it was clear throughout the course of Father’s testimony
     on this date, that throughout the period of December 25, 2021
     through the filing of the Dependency Petition, Father was
     extremely concerned about the medical condition of his son, that
     his condition rapidly changed throughout the course of treatment,

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      and that the circumstances, inclusive of his prior experiences with
      his son’s medical issues after birth, took a major toll on this family.

Trial Court Opinion, 9/29/22, at 5-11 (record citations omitted; minor

revisions for clarity). In addition, Dr. Safford testified that upon Child’s arrival

at Penn State—Hershey following helicopter transportation, “he was very toxic

appearing. He was not interacting . . . that is when a child is about to die . .

. This was by far one of the sickest children that I had seen that did not die.”

N.T., 3/18/22, at 67-68.

      Child underwent three surgeries over several days that resulted in loss

of 117 centimeters of necrotic bowel. The first operation was to remove the

dead bowel; the second was to sow the intestine back together; and the third

was to close the abdomen.         Id. at 79 (Safford).     This was “emergency

surgery.” Id. at 82. Father questioned why the second or third surgery was

necessary but ultimately consented to each procedure. Id.

      The court concluded:
      Despite Dr. Stafford’s testimony regarding what he perceived as
      a delay in the parents taking the Child to the hospital, it is clear
      from the testimony provided by Parents, which is deemed credible
      by this court, regarding the Child’s condition on December 25,
      2021 at their home, calling the pediatrician on Christmas because
      of their concerns, then contacting 911 when the Child threw up
      and they felt he progressed, and Dr. Madtes’ initial examination
      report and the Life Lion report previously referencing that the
      Child’s abdomen was not distended, there is not clear and
      convincing evidence that the parents in this matter caused any
      delay in getting the Child to the hospital on December 26, 2021
      to seek treatment. There was no clear and convincing evidence
      that Mother or Father acted in an intentional, knowing or reckless
      way to substantiate a finding of abuse pursuant to 23 Pa.C.S.A. §
      6303(b.1). As Dr. Stafford aptly stated during his testimony,
      minutes make a difference in a child’s care because, unlike in an
      adult, they look relatively well until they are ready to die. It is

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      clear from the testimony that even when the Child presented to
      the BPS via ambulance, the initial doctor, who must have formal
      medical training, failed to recognize that this Child was having a
      serious medical condition.

Trial Court Opinion, 9/29/22, at 11-12.

      BCCYS    alleges   that   the   evidence   compels   an   adjudication   of

dependency, and a finding of abuse, based on Parents’ delay in (1) taking

Child to the hospital, (2) consenting to transportation of Child by helicopter

from Penn State—St. Joseph Hospital to Penn State—Hershey Medical Center

and (3) consenting to surgery. We hold that the court’s findings are supported

by competent evidence.     With regard to the delays in taking Child to the

hospital and transporting Child by helicopter, the evidence credited by the

court demonstrated that Parents were genuinely concerned over Child’s

condition, as shown by their call to the pediatrician on Christmas Day and their

subsequent call to 911 when Child threw up. Equally as importantly, while it

was evident that Child was ailing, it was difficult for anyone but a pediatric

surgeon such as Dr. Safford to tell that Child was in immediate danger of

dying.   Even Dr. Madtes, the first physician who examined Child in Penn

State—St. Joseph’s emergency room on the morning of December 26, 2001,

did not recognize perhaps the most critical physical symptom, a distended

abdomen. Finally, while Parents initially resisted the transportation of Child

by helicopter to Penn State—Hershey Medical Center, they provided consent

before the helicopter arrived, so their initial refusal to consent did not delay

Child’s life-saving surgery at Penn State-Hershey.

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      BCCYS also sought an adjudication of dependency based on Parents’

insistence that Child be weaned from various controlled substances faster than

medical providers thought advisable. The court summarized the evidence as

follows:

      [BCCYS] offered Dr. Susannah Eckman, an expert in the field of
      palliative care for children, from Penn State Hershey Medical
      Center to testify as to the weaning off of morphine process for this
      Child and the difficulties she encountered while interacting with
      the parents. She explained that she was involved with this Child
      in order to assist in the weaning off process of morphine to allow
      the Child to transition to a step-down unit to from the intensive
      care unit. She reported as others that when she would interact
      with Mother alone, she would immediately call Father on the
      phone and he would do most of the talking. During the weaning
      process, Mother expressed a concern that the Child was always
      vomiting after a particular medication was administered. Dr.
      Eckman did not find that to be the case and felt like the parents
      were trying to get the Child off the medication quicker. She
      reported that due to pressure from the family, there was a rapid
      escalation of weaning off the infusions.

      Dr. Eckman stated that prior to the last day of the weaning
      process, she met with the parents and explained to them that the
      Child was showing some mild signs of withdrawal so they were not
      going to wean on that particular day and see if it could be changed
      the following day. The next day, the hospital attempted to
      administer that 8 a.m. dose and the parents refused. She thinks
      the dose was given an hour and half late due to the refusal. She
      went onto explain that a late or missed dose is a risk of performing
      withdrawal.

      On cross-examination, Dr. Eckman again reported that the
      parents withheld information. She acknowledged that she did
      review the inpatient consult report and as a result was aware that
      Father expressed challenges the family experienced when the
      Child had a five month natal intensive care unit stay due to his
      premature birth, that the Father thought the Child was in the
      hospital longer that was necessary due to a lack of planning for
      discharge, and that the Father was hoping to have a quick plan

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     for discharge from the hospital since the Child was now in
     recovery. She explained that the information that was withheld
     was about social history and that was odd. She reported that they
     continued to consult with the parents regarding the weaning
     process every day of the hospitalization until he was weaned off.

     Dr. Eckman went on to further explain the WAT scores for
     measuring withdrawal. She explained that they are determined
     by looking back over at least a four-hour period of time and look
     at sneezing, yawning, time to console the child, vomiting, diarrhea
     and temperature. The Child was weaned off the morphine on
     January 20, 2022 but only started the clonidine wean on January
     25, 2022. Clonidine was weaned after the last dose on January
     28, 2022. A January 19, 2022 note reported that parents brought
     up a concern about vomiting. Parents reported that they were
     concerned that Child’s WAT score was being affected due to his
     vomiting because of his feeding issues rather than an addiction to
     morphine or another drug. She agreed that it was fair to say that
     a parent may have a serious concern that their Child was addicted
     to a drug like morphine but it is extraordinarily common as a
     sequalae of critical illness. She also acknowledged Dr. Riley
     O’Neil’s report that parents had concerns about vomiting and their
     desire to have an aggressive wean schedule. She acknowledged
     that the team felt comfortable doing the aggressive wean to
     placate the parents’ desires and at the same time ensuring that
     the Child would be safe at all times during the wean. There was
     never a life-threatening issue or long-term damage as a result of
     the wean approach that was done at the hospital.                She
     acknowledged that this wean was not the preferred way to
     accomplish it but the Child was safely weaned. Dr. Eckman again
     reported that the last dose was refused/delayed but on cross-
     examination, Dr. Eckman confirmed that Father asked to speak to
     the team to make sure everyone was on the same page. She
     reported that Father was confused about the conversation the day
     prior and reported he was not comfortable with the nurse that
     spoke with him this morning. The team was consulted, and it was
     confirmed that the dose was needed and it was administered. She
     also confirmed that Father did not threaten to remove the Child
     against medical advice at any time that she was involved in this
     case. She reported that there were concerning statements
     suggesting that but it was not said.

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Trial Court Opinion, 9/29/22, at 13-15 (record citations omitted; minor

revisions for clarity).

      The court concluded that Parents exercised proper parental care with

regard to weaning:

      [T]he transcripts are replete with the parents asking questions
      and presenting their concerns to the medical staff. Parents were
      actively involved in their Child’s care and asked many questions
      of the staff. Parents wanted their Child weaned off the morphine
      and clonidine as quickly and safely as possible. As Father stated
      during his testimony, “if he needs something, it could be on
      another planet, he would get it.”

      Mother testified about her position regarding the weaning
      schedule for the Child at the July 8, 2022 hearing. She stated that
      the Child had required doses and optional doses. The Child
      received all the required doses. She reported she does not recall
      refusing six of the optional doses but may have refused one or
      two of the optional doses. She stated if the Child was feeling
      uncomfortable, she would want him to get what he needs. She
      reported that she and Father wanted the Child off the morphine
      as soon as possible because they wanted the Child home as soon
      as possible. She reported that they worked with the doctors to
      come up with a plan.

Trial Court Opinion, 9/29/22, at 15 (record citations omitted; minor

clarifications for style).

      Once again, the court’s factual findings are supported by evidence of

record. BCCYS argued below and in this Court that Parents were irrational

obstructionists who did not care about their child’s suffering and who were

bent upon interfering with trained medical professionals’ efforts to wean their

child from harmful drugs. The court, however, was in the best position to

observe and rule upon the credibility of witnesses, In re C.B., 264 A.3d at

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778 n.31, and it chose to believe that Parents were deeply concerned about

the Childs’ welfare and strove to work with hospital personnel to create the

best treatment plan. Since the record contains evidence that supports this

determination, we are not free to overrule it. Id.

      BCCYS makes an impassioned plea in its brief for this Court to override

the trial court’s refusal to make a declaration of dependency. Although BCCYS

emphatically states its view that Parents are unfit to care for Child, we cannot

disregard the fact that the trial court patiently sat through a series of hearings

and carefully reviewed the evidence in entering its decision against BCCYS.

For this reason, and for the others given above, we affirm the trial court’s

determination that BCCYS failed to present clear and convincing evidence in

support of its dependency petition.

      Order affirmed. Jurisdiction relinquished.

Judgment Entered.

Joseph D. Seletyn, Esq.
Prothonotary

Date: 5/8/2023

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