Forensic Paediatrics A Report by the Short Life Working Group

Executive Summary

1. The delivery of high quality child protection services has been a key aim for the Scottish Government since the publication of 'It's everyone's job to make sure I'm alright'in 2002. The recent publication of National Guidance for Child Protection in Scotland continues to provide a national framework within which all agencies and practitioners at local level can agree processes for working together to safeguard and promote the welfare of children. 'Guidance for Health Professionals in Scotland' (2000)' Protecting Children: a shared responsibility' was produced to advise on the standardised pathways and templates for health examination of children with suspected or actual abuse and/or neglect. This guidance will be updated in 2012.

2. Since 2009 concerns have been expressed about the sustainability of forensic paediatric services for sexually abused children and in response a short life working group (SLWG) was established at the request of the then Head of Health and Social Care, Scottish Government, Dr Kevin Woods. Its remit was to examine the present service provision of medical examination to children who have been sexually abused across Scotland and identify means by which the availability and sustainability of these medical services could be improved. Although the SLWG was not specifically remitted to consider the examination of children who have been physically abused or neglected, it recognised that the same challenges face the provision of competently trained doctors for this group of children, for which the demand is far greater.

3. The prime importance of an interagency referral discussion (IRD) ALWAYS taking place in child protection referrals to police, social work or health professionals should be emphasised. The IRD allows decisions to be made primarily based on the needs and safety of the child and reduces the differences in expectation between police and health services on the timing of examination and collection of forensic evidence. It would also enable remote and rural areas to make decisions about the transfer of children to other centres where this is in the best interests of the child.

4. The medical assessment of sexually abused children is a low volume, highly specialised activity. The examination is usually carried out jointly by two doctors (a paediatrician and a forensic physician) with complementary skills. In the older age group (13-16 years old) an examination may be carried out by a doctor and a forensically trained nurse.  Both doctors require to have been trained appropriately, to have sufficient practical experience in the specialist area and maintain a prescribed level of competence.  Both must provide reports (whether joint or separate) and opinions which can later be used as oral and written evidence in court proceedings.  Most of these paediatricians have additional training and competencies in child protection and become paediatricians “with a Special Interest in Child Protection” will provide local services within district general hospital (DGH) settings, and will participate in on-call (out of hours) rotas in acute general paediatrics, or in specialist child protection rotas.  In addition there will be a few consultants with more specific specialist training and competencies who become “Specialist Paediatric Consultants in Child Protection”. These specialists will provide tertiary services, including leadership, specialist clinical care and expert forensic opinion in complex cases.  Any paediatrician who performs examination of children for child sexual abuse (CSA ) should carry out a number of examinations over a year to maintain their competencies and attend continuous professional development (CPD) in the field of child protection.

5. The provision of suitably trained doctors (both paediatrician and forensic physician) has been adversely affected over the last ten years. There have been a number of high profile inquiries with media coverage of significant child abuse cases and changes in the paediatric training numbers and requirements. This has resulted in fewer paediatricians specialising in Community Child Health (CCH), where most trainees learn specific examination skills and competencies in child protection. Attracting consultant paediatricians to this work has proven challenging for many health boards in Scotland.

6. Most of the CSA examinations required across Scotland can be arranged during office hours/early evening. There are enough trained paediatricians to provide daytime services without delay; this includes four Health Boards which send their cases to neighbouring Boards for examinations. Out of hours services are provided by rotas of general paediatric consultants, general paediatric consultants with a special interest and "specialist" consultants in child protection. All paediatricians who perform forensic examinations out of hours have the appropriate competencies and clinical skills and carry out joint examinations with a forensic physician. Those general paediatric consultants who are competent perform forensic examinations jointly with forensic physicians including recording findings by videocolposcopy. These recordings can be discussed the next working day with the local specialist paediatrician.

7. Medical examination for physical abuse and neglect is more commonly performed by paediatricians than examination for CSA. Every consultant paediatrician who sees children and young people should be competent in the diagnosis and management of physical abuse and neglect. Present national guidance states that for some of these children, with complex physical abuse or injuries which are not readily explained, there is the need for a specialist 2 doctor (joint) paediatric/forensic examination. These examinations may be required to establish the diagnosis, or to assess the need for further investigation or treatment. The presence of two doctors in the joint paediatric/forensic examination is important for the corroboration of medical evidence in any subsequent criminal proceeding and is also good medical practice. At present this 2 doctor examination is not routinely performed in a standardised way in all Board areas in Scotland.

8. Quality of clinical input by paediatricians is monitored by local clinical governance systems and GMC processes of appraisal and revalidation. The NHS Board Chief Executive and Medical Director are responsible for systems to monitor the performance of individual doctors, and these systems should identify training needs for paediatricians.

9. It is clear that there are enough consultant general paediatricians across the country that can provide examination and opinion in physical abuse and neglect 24 hours a day. These consultants should be equipped with a range of tools to help them provide this service better;

• Professional Standards  - protocols for assessment, recording of injuries, investigations, and management; e.g. provided by Royal College of Paediatrics and Child Health (RCPCH), West of Scotland managed clinical network (MCN)
• Support - from consultant paediatricians with a special interest in child protection on an on call rota for child protection; and
• Training - courses provided by local boards, Royal College of Paediatrics and Child Health (RCPCH), joint interagency courses, peer review.

10. Over the past 12 years, a range of local, regional and national Managed Clinical Networks have been established to support the delivery of healthcare services. A number of these networks support specialist children's services, which by their very nature, tend to face a number of key challenges including (but not exclusively):

• Workforce and service sustainability;
• Training and education;
• Variances in clinical practice across Scotland;
• The need for clinical audit to inform improvement;
• Transition;
• The need for holistic, inter-agency working (e.g. joint working between health, education, police and social care);
• the need to ensure equitable access to an equitable level of care;
• measuring service improvement outcomes

Scotland has three regional MCN's which deal with CSA. The West of Scotland network was set up in 2004 and is the most established. It encompasses all child protection matters. SEAT established a network in 2009 dealing exclusively with CSA. The North of Scotland network was established in December 2010. These three regional networks work closely together to standardise protocols for processing of referrals, standards of equipment, personnel, investigations and training, although the model of delivery may differ from region to region. To achieve consistency across Networks, standardised templates have been agreed, but are not yet fully implemented e.g.

• National Consent Form;
• Stage 1 Medical Report - completed by the paediatrician undertaking the direct examination of a child;
• Stage 2 Medical Report - required for court purposes and completed by the paediatrician who examined the child or by a specialist/expert commenting on the Stage 1 Report. This report contains an opinion and allows further analysis of findings, additional findings and supportive evidence from the literature when necessary.

11. New models for the provision of medical staff trained in forensic examination have been piloted in Tayside. The NHS has provided a new contract in agreement with local police authorities for forensic services i.e. health services to police custody cells, and examination of individuals in cases of sudden death, assault, sexual assault and road traffic accident (RTA). The service consists of a number of nurses and forensic physicians. Only forensic physicians (not nurses) participate in joint 2 doctor examinations in a standardised way with local paediatricians. Anecdotal evidence suggests this has improved the quality and consistency of examination and recording of physical evidence in child cases, and support to general paediatricians who take part in joint paediatric forensic examinations which encourages local paediatricians to participate in child protection. This model of provision of forensic paediatric services could be the benchmark for other Boards to follow.