Information

Supporting children and young people who may have experienced child sexual abuse - clinical pathway: consultation analysis

An analysis of the responses to the consultation on the draft Clinical Pathway for healthcare professionals working to support children and young people who may have experienced child sexual abuse.


Section 4: Medical Examination

Do you agree with the medical examination section of the pathway?
Yes 30 52.63%
No 11 19.30%
Not Answered 16 28.07%
Comments
ID. Consultation comment Clinical pathways subgroup response
641V-S The delivery of planned medical examinations (>7 days since reported event) form the bulk of assessments in pre-pubertal children. These can be undertaken inlocal facilities close to the child's home by appropriately trained paediatricians and forensic medical examiners
Acute medical assessment (<7days since reported event) are fewer in number and more commonly affect older CYP, most typically over the age of 12 years. Forseveral years we have had a well functioning system for these individuals to travel to GGC facilities in Archway or the Children's Hospital. This provides theappropriate balance of clinical expertise and access to services in line with other highly specialist services for CYP that are centrally delivered. Young childrenoccasionally have acute anogenital injuries that require surgical intervention and treatment at the Royal Hospital for Children.
Paediatriciansexaminining children following acute sexual assualt require to assess a number of children to maintain competence in the field and to be able todeliver medical opinion in court. This expertise necessarily can only be provided by a small number of individuals with sufficient expertise. It is not possible to
deliver this level of expertise when larger numbers of individuals require to maintain competence e.g. where a service is provided from a number of DGHs ratherthan 1 regional location.
These are important points more appropriate for Boards and the Regional Planning Groups when planning services and the associated staffing and training needs.
641N-H It is essential that mental and emotional support are adequately built in to this section of the pathway and that steps are taken to ensure that all individuals fully understand the process. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
6418-U This section does not define a comprehensive medical assessment or indicate in what circumstances this may required or undertaken instead of a forensic medical assessment. This section should also include if/when a comprehensive medical should take place for non-acute cases, particularly since many
disclosures of sexual abuse are of an historical nature.
The comment has been noted and the pathway has been revised to include information on comprehensive medical examination.
641K-E Children and young people who reside in the Perth & Kinross area are expected to travel to Dundee for any forensic medical procedure even where deemed non-acute. The pathway states that “Service locations for the medical examination should be flexible” however the experiences of the consultation group were that children are all expected to travel to Dundee. It could be argued that in Perth we have a suitable medical facility at PRI and that this could be used flexibly and the appropriate medical staff could travel to that location. This has been an area of tension at times where it would be in a child’s best interests to be seen at a more familiar environment within easy commuting distance for them. The medical is a time of considerable anxiety for the victim and their family and a more localised environment would assist in removing some of this anxiety. The medical examination information also states that the clinicians should have “relevant experience for children and young people with complex conditions or additional needs” Our consultation group enquired how much access the clinicians have to for example to interpreters and specially trained staff where communication is an additional need for that child or young person. Although this requirement will be in the minority of situations consideration needs to be explicit. These points are more appropriate for NHS Tayside when planning services and the associated staffing and training needs.
6412-N Please could you clarify what you mean by medical examination under forensic standards? Most dental practitioners do not have the paediatric/ forensic dentistry
skills to take part in medical examination. If a dental assessment is deemed necessary as part of this, then this will be done by specialist colleagues. Dentists will be involved in this process mostly at the 'Management of Healthcare Needs' stage. Clinicians should be kept fully appraised of the patient's status and
background, so that this can be used to tailor their dental care package.
Advice received from the Children and Young People Expert Group and the Steering Group for the revised National Child Protection Guidance is that education, guidance and support on child protection is available from employers (or voluntary organisations/charities in the case of volunteers). The advice is that it is not necessary and may be unhelpful to duplicate material already available in this area.
6414-Q Agree broadly but have the following comments: P6.1 Page 18 “written consent from an individual with parental rights”. This does not reflect the fact that children and young people can give their own consent; (Age of Capacity (Scotland) Act plus recent case law) or may live with adults who do not have parental responsibilities. It is not appropriate to ask a parent who is an alleged perpetrator for consent or not to a medical examination of their children. Noted.
The approach to consent in the pathway has been expanded and clarified.
64SM-J Regarding timing of medical examinations in historic cases; paragraph 2, section 6 medical examinations is in direct contradiction to paragraph 3b1 of the same section. The first says the examination must be done within 2 weeks, the second that timing must be done in the best interest of the child. Timing of the medical examination for historic abuse needs to be appropriate for the child, the two week standard in the HIS standards seems to be arbitrary and may result in a tick box culture of undertaking examinations when the child is not ready. Why is this time period chosen? I agree there needs to be a responsive service which does not have long waiting times but interest of child paramount. In section 6.1 #10. Consider giving a brief written summary of findings and outcome as well as a clear list of contacts for follow up at the end of the examination”. Does this mean to police and social work or to young person/family? This is not clear The Pathway is intended to support implementation of the HIS standards by Boards (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards). The two-week indicator was arrived at by clinical consensus. In rare cases where this is not clinically appropriate we anticipate that clinicians will act in the best interests of the child.
64SR-Q The timing of the examination in section 6.1 - there is no reference to the agreed HIS Standards QIs for acute and non-acute examinations - just the following: Timing of the JPFE should be agreed as part of IRD process and would not usually place between 20:00 and 08:00 unless there are medical needs of the child which require immediate attention. For specific guidance on timings of examinations, please refer to the FFLM Guidance for the examination of children and the RCPCH “Purple book” (physical signs of child sexual abuse) (the website address is provided in the resources). Section 6.1 There should be reference to the updated version of the MCN Guidance on Consent The Pathway is intended to support implementation of the HIS standards by Boards (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards). The two-week indicator was arrived at by clinical consensus. In rare cases where this is not clinically appropriate we anticipate that clinicians will act in the best interests of the child.
The approach to consent in the pathway has been expanded and clarified.
64SE-A Police Scotland recognise during any disclosure of sexual abuse the medical examination to address the health and wellbeing of a child or young person is paramount and secondary to this is collation of forensic evidence. From a policing perspective, at this early stage it is important to establish if there are serious concerns in relation to the child or young person being examined or indeed any other children or young person who at that point may still be at risk from an abuser. Noted.
64SY-X Section 6, paragraph 2- timing of medical examinations in historic cases is in direct contradiction to paragraph 3b1 of the same section. The first says theexamination must be done within 2 weeks, the second that timing must be in the best interest of the child.
Timing of the medical examination for historic abuse needs to be appropriate for the child, the two week standard in the HIS standards seems to be arbitrary andmay result in a tick box culture of undertaking examinations when the child is not ready. Why is this time period chosen? There needs to be a responsive service
which does not have long waiting times but the interests of the child is paramount.
Section 6.1 #10. Consider giving a brief written summary of findings and outcome as well as a clear list of contacts for follow up at the end of the examination.
Does this mean to police and social work or to young person/family? This is not clear
The Pathway is intended to support implementation of the HIS standards by Boards (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards). The two-week indicator was arrived at by clinical consensus. In rare cases where this is not clinically appropriate we anticipate that clinicians will act in the best interests of the child.
64SN-K Agree with well-being of the child being primary concern but forensic examination for evidence collection is something we need to continually challenge. Submissions have continually been made to Scottish Government to abolish corroboration in Scots law, a unique feature which requires two different and independent sources of evidence before conviction can occur. This is likely reflected in the tables indicating the rate of incidence vs rate of conviction/criminal proceedings. The process of examination itself can never be trauma negative. Noted.
63SB-7 To some extent. Whilst this section comprehensively details the medical examination process, it does so in an entirely procedural manner, which fails to reflect the child-centred intentions expressed elsewhere in the document. Despite the opening paragraph of this section reflecting the primary purpose of the medical examination as identifying needs and planning to address the child’s needs in a holistic manner, the stated secondary purpose of collecting forensic evidence for formal police and court proceedings appears to be the main focus. Clearer reflection of the Barnahus principles and approach could redress this imbalance. Noted. The Pathway is ‘Barnahus ready’ in that it will facilitate the introduction of a Barnahus model in the Scottish legal and child protection context.
64SZ-Y We agree with much of the content with the following comments: Page 18. Re medical examinations the paper states: “In cases of non-acute sexual abuse that is outside the forensic capture window, a medical examination will still be required for the child. How quickly a non-acute case needs to be seen may vary according to clinical need. It is envisaged that such cases would be seen for paediatric assessment within two weeks of a decision being made that such an assessment is required.” The language here is a concern re the choice and control of the patient (the use of will rather than may). It assumes we are talking about a much younger child, and again links to the earlier point about the differences in children and adolescents who can make some decisions about their own healthcare needs and wishes. Trauma informed practice emphasises safety, trust, collaboration, choice and empowerment. If a 15 year old discloses to her GP that she was coerced into sex by her previous boyfriend this guidance reads like a medical examination will be required of her and she will have no choice. This is not what would happen in practice so we consider this needs some qualification in the main text. In this scenario the young woman does not need to engage with the Police if she chooses not to. Support & advocacy should be offered, as it would be for adults, to enable her to make an informed choice, but she and the pathway should be clear that this is her choice. Page 21, paragraph 9. The pathway states: “Follow up for other needs, for example referral to Children’s Reporter or other agencies, should be arranged and documented.” No mention is made of who these might be. Rape Crisis services across Scotland support young people aged 13+ with support and advocacy navigating the justice system, enabling them to make informed choices and supporting them and their families through what can be traumatic and confusing. Clinicians need clear information about 1) the need for support & advocacy and 2) where to access this locally. As the Right to Recovery Research highlights, in many areas these services do not exist, especially for children of primary school age and below, and their families. This gap needs to be addressed if we are to mitigate the impact of trauma in the longer term. The Pathway has been updated to note that not all cases of non-recent sexual abuse require an examination. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced Child sexual abuse and non-abusing parent/carer(s).
64ST-S Need to add somewhere in this section that the medical examination is optional (the young person has a right to refuse a medical examination) - the thought of a medical examination can put many young people off from disclosing sexual abuse or sexual assault. If report of sexual abuse is historic then a medical examination might not be required. Noted.
The Pathway is clear that a young person with capacity should give or not give consent as they choose.
64SU-T The use of abortifacients to abuse children by killing them in the womb is what is preventing me from supporting what in effect is actually the best most competent part of this proposition. Noted.
64SD-9 [Our organisation] notes and supports the statement around the primary purpose of medical examination and the secondary criminal justice considerations. Noted.
64SP-N Paragraph 6 refers to the management of taking forensic evidence. It would be helpful to have more detail to explain the phrase “carefully managed”, including reference to any existing protocols, guidelines, or similar measures and resources. We would suggest that the model of Joint Investigative Interviews should be applied to this pathway. This is an established and understood process, allowing for collaborative working and a tailored approach for each child or young person affected. There is published guidance on the Joint Investigative Interviewing of Child Witnesses in Scotland issued in December 2011. The Pathway now uses the language of the draft revised National Child Protection Guidance in discussing JII and IRDs.
64S7-V There should be more included on how to embed trauma informed practice into the medical examination There is now more information in the Pathway on trauma-informed practice.
64S4-S It references comprehensive medicals, but doesn't go into detail about where one type of medical may be used over another, especially in non-acute cases. Very rare that forensic medicals within the window present to services. Realistic Medicine is not mention, especially in relation to the person-centeredness. There is now more discussion about the different types of medical examination and when they are appropriate.
Do you have any further comments or suggested amendments to the medical examination section of the pathway document?
ID. Consultation comment Clinical pathways subgroup response
64HN-8 At present in my area there are no female FMEs and unless some are trained urgently I cannot see this situation improving. It has been difficult to attract female doctors into this area and this may require some thought about the roles of FME and how it can be combined with other interests Availability of female examiners is out with the scope of this pathway.
The Workforce and Training Subgroup of the Taskforce is leading work to support the increase in the number of female examiners.
64HD-X unable to access the 'purple book (physical signs of child sexual abuse) - so unable to comment Noted.
64S1-P

[Our organisation] supports the statement at the start of the section on medical examinations which outlines that the primary purpose of the medical examination is to address the health and wellbeing needs of the child and the secondary purpose being the gathering of forensic evidence. However, [our organisation] notes that while the document makes this assertion, the medical examination section of the pathway is focused on procedures around the gathering of evidence. While [our organisation] recognises the importance of this, to ensure this section reflects the primary statement, there is a need for a reframing towards a more child-centered approach. This could be achieved by dividing the medical examination into two sections:

  • The first on addressing the health and wellbeing of the child
  • The second on the collection of forensic evidence.

An expanded section on the health and wellbeing needs should address the wider needs of a child and young person, including potential referrals to appropriate support. This should also highlight the importance of medical examiners and other staff having positive and supportive attitudes to children and young people, including those with learning disabilities. Where possible this should be supported by training on unconscious bias and learning disability awareness training. Within the primary purpose, it may also be helpful to outline who can be present to support a child or young person during a joint pediatric examination and in what circumstances this may not be appropriate. Overall, by separating the two sections the pathway document can allow for equal weight to be given to both the primary and secondary purpose of this process and more detailed considerations within the two sections. In addition to this, [our organisation] would welcome further expansion on point 6.2 (p.18) regarding written consent from an individual with parental rights. In [our] earlier response to the Scottish Government, [we] expressed concern about consent being given for under 16-year-olds by parents or guardians. [we] said that this statement required further attention as there may be instances in which:

  • “A parent or guardian may be abusing
  • A parent or guardian is protecting an individual, with a relationship to the family, who is abusing
  • A parent or guardian is protecting a trusted caregiver
  • A parent or guardian does not believe the child or young person.” [we] went on to state that in such circumstances in which there are concerns about parents or guardians acting to conceal abuse, further legal processes should apply.

Within this process the following UNCRC articles should be considered:

  • the views of the child or young person should be heard and taken into account (UNCRC, Article 12,1989)
  • Children and young people should have access to high quality health services (UNCRC, Article 24,1989) and
  • Children and young people are protected from sexual exploitation (UNCRC, Article 33, 1989).

In understanding these rights, [our organisation] welcomes clear guidance being given within the pathway about appropriate measures when a professional suspects concealment. Further discussion with police, Health Scotland and third sector children’s organisations will be required to develop these steps

The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
641Z-W Timescales should be more explicit and examination should take place as soon as possible with support in place The Pathway is intended to support implementation of the HIS standards by Boards (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards). The indicators in the standards were arrived at by clinical consensus. In rare cases where these are not clinically appropriate we anticipate that clinicians will act in the best interests of the child.
641U-R Is there evidence available about precisely how quickly forensic evidence is lost after an acute sexual assault? This would help inform timings of examinations including the need for weekend services or out of hours services The HIS standards take account of this and the timescales for forensic examinations allow for capture of any relevant forensic evidence (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards).
641T-Q Importantly, the pathway document discusses that written consent must be obtained from an individual with parental rights and responsibilities if cannot be obtained from the child themselves. I feel that further guidance should be written on this regarding when a parent is the alleged assailant and where legally alternative consent can be obtained. This concern is now covered in the Pathway.
6418-U There are too many hyperlinks to other procedures and documents, in this section in particular, but also throughout the document. If another policy/document is of importance to the pathway, more explicit information and/or relevance to this pathway should be explained, supplemented by a hyperlink to the full document.
There is also no reference to Section 4 in Section 6. For this pathway to be truly trauma-informed, this should be more explicit. Sections 4.3 and 4.4 arestatements regarding Trauma-informed practice and ACEs, but do not appear to be directly incorporated into the pathway, for example how and where medicals take place.
If the document is to reflect the principles of the Barnahus model, this needs to be covered more comprehensively. Whilst we appreciate that there is ongoingwork/developments re the model, the basic principles could still be reflected in the pathway.
Point no. 9 on page 21 refers to the follow up support following a medical, however this needs to be more robust/comprehensive. It should make therole/responsibilities of medical staff more explicit, especially if mental health/emotional needs are identified. Again the principles of the Barnahus model would
offer some insight into how children and young people should be supported following medicals etc. The pathway should of course primarily focus on the process and immediate safety of children and young people, but to be truly trauma-informed, it should also consider how they could be supported in their recovery following abuse.
References in the Pathway have now been rationalised.
The Pathway now has more information and context on trauma informed care and adverse childhood experiences.
The Pathway is ‘Barnahus ready’ in that it will facilitate the introduction of a Barnahus model in the Scottish legal and child protection context.
The Pathway now includes an Annex with roles and responsibilities.
6412-N As above, more clarification needs to be given particularly to dentists about the term ‘medical examination’. Advice received from the Children and Young People Expert Group and the Steering Group for the revised National Child Protection Guidance is that education, guidance and support on child protection is available from employers (or voluntary organisations/charities in the case of volunteers). The advice is that it is not necessary and may be unhelpful to duplicate material already available in this area.
6414-Q Page 20 regarding the provision of report in 4 weeks. Reports on medicals will in many cases be required much more quickly in order to protect children, e.g. to apply for a Child Protection Order and this needs to be included. The comment has been noted and the Pathway has been revised to address this point.
6413-P There needs to be further consideration given to issues of consent, especially for disabled children and young people including those who may have a learningdisability, autism, capacity issues and/or communication needs. More on the vulnerability of disabled children and young people to all forms of abuse is now included. There is more on taking consent for examinations/information sharing etc. in the Pathway with hyperlinks to more detailed guidance if required.
64SM-J In section 6.1 3 iii – it is mentioned that the likelihood of obtaining positive forensic results decrease exponentially with time. It would be helpful if we had some actual Scottish figures regarding how often there is a positive result and the actual rate of positive results correlated with time the sample was taken after the assault. I am not aware how often a positive result is obtained and could not inform families accurately if they ask. Regarding acute abuse in Medical Section 6 “Examination should occur as soon as possible to obtain forensic evidence. Guidelines indicate that likelihood of obtaining positive forensics decreases exponentially with time. This is also true for documentation of injuries as the genital area heals extremely quickly”. It would be useful to have clearer information about research about how quickly forensic evidence such as semen and DNA disappears and how quickly genital injuries disappear in order to plan medical timing and service provision of paediatric examination services out of hours including weekends. Agree that medicals out of hours outside 8-8 may not be in the best interest of the young person. The HIS standards take account of this concern and the timescales for forensic examinations allow for capture of any relevant forensic evidence (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards).
64SV-U [Our organisation] would like to highlight that children and young people with disabilities may not have the linguistic ability to communicate that they have been abused, what kind of abuse they have experienced or name their abuser, plus professionals may not be aware of resources to assist communication. If a child and young person does not have access to someone who is familiar with their unique adapted communication styles at time of disclosure then effectively this may stop/ prevent the child / young person having their voice heard – which is conflicting with UNCRC, article 12 and The Children (Scotland) Act 1995 Noted. These circumstances are not unique to CSA and apply to other forms of abuse. Relevant services have an obligation to facilitate communication with service users as best they can.
64SE-A The medical examination section appears accurate and exemplifies best practice, however it does not reflect current practice and the varying standards that are being adhered to across the country. A reoccurring issue identified is that of children or young people being transported long distances to a specific medical establishment for the purpose of a Joint Paediatric Examination (JPFE), when there are obvious establishments nearer. Identifiably, issues and conflicts arise around where a JPFE will takes place impacted by availability of Paediatricians and Forensic Medical Examiners. It would be worthy of considering the option of appropriate medical staff travelling to the nearest and most suitable medical establishment to the child to reduce additional stress and anxiety placed on the child or young person due to unnecessary time or travel delays. Consent appears not to be consistent across the country with there being challenges relating to Paediatrician's refusing to examine children when a parent who is the suspect refuses to give consent for a medical examination of a child. Issues have also been identified relating to Paediatrician's refusing to conduct medical examinations even when a warrant has been granted by the court for the examination as it is deemed there is no parental consent. Some of these issues are out with the remit of the Pathway. However, the Pathway is intended to promote consistency of provision across Scotland and to support Boards to deliver services as locally as possible.
64SW-V Consideration could be given to including some guidance regarding support for the child/young person within the medical. At times young people attend for medical and are not allowed to have social work staff (or other support) with them during the medical even when they are requesting it. Having a trusted person with them can help to make the experience less traumatic for a young person however whether this is permitted is not consistent and does not appear to be related to medical need. The Pathway now states that the examination is carried out in child-friendly surroundings, with the right support for their age, stage and understanding.
64SB-7 A medical examination is likely to be an intrusive and frightening experience for any child, and particularly so for those who have experienced sexual abuse. This section could be significantly improved by acknowledging this, and integrating examples of the ways in which a trauma-informed approach to practice can be embedded. For example, setting out whose role it is to explain, in developmentally appropriate language, the process to the child; ensure the child has the opportunity to look at the room in which the examination will happen; talk the child through the process whilst it is going on; comfort the child; ask their permission; and support the parent or carer. This includes meeting the needs of the child and their family after the examination, in terms of any ongoing dialogue. Other specific amendments to this section include: • 6.1.2 – Complexities involving arrangements for written consent from an individual with parental rights should be made explicit. Such as, what arrangements are in place if the individual with such rights is potentially responsible for the abuse. Additionally, what arrangements are in place in the example of a child who is looked after away from home, whose parent cannot be contacted within the required timescales. • 6.1.3.b – Reference to neglect and emotional abuse is confusing in this heading. Additionally, rather than referrals being ‘assessed according to clinical need and requirements of the child protection process’, they should be assessed according to the child’s needs and best interests. The Pathway now states that the examination is carried out in child-friendly surroundings, with the right support for their age, stage and understanding.
Consent for examination is addressed in the Pathway with hyperlinks to more detailed guidance if required.
64SJ-F Suggestion to change of lay out / flow of 6. Medical Examination as follows Paragraph 3 starting “the Joint Paediatric Forensic examination ..” should become paragraph 2 i.e. after the first/ top paragraph Sentences at the beginning of paragraph 2: “It can be very hard for children and young people to reveal abuse. Often they fear there may be consequences. Some delay telling someone about abuse for a long time, while others never tell anyone, even if they want to.” Fits in better under 5.1 Disclosure by a child / young person: suggest it is placed prior to the sentence ending (NSPCC). The rest of Paragraph 2 starting “In cases of non-acute sexual abuse that is outside the forensic capture window, …… such an assessment is required”, should become final/ paragraph 3 in this section. The section on disclosure has now been revised.
46SF-B Paediatricians are given the responsibility of health assessment, in a medical / clinical sense forensic reports provide facts which is applicable and required however if holistic assessment is optimum for future care, GIRFEC assessment tools should be used and any further follow up by school nursing staff discussed. The section on GIRFEC in the Pathway has now been expanded.
64SA-6 I feel this should be reinforced to all services that this is part of the pathway as this was not something that is known in my area Noted.
64SH-D We welcome the clarification in the pathway document that the primary purpose of a medical examination is to address the health and wellbeing of the child or young person in a holistic manner. With this in mind, it is particularly important for this document to recognise the potential for medical examination to contribute to the trauma experienced by the child or young person, and the importance of taking all possible steps to avoid this. The issue of consent should be expanded within this section, to ensure that children’s rights are fully considered in each situation. If consent is not being sought from a child (for example, where parental consent is sought) or there is use of anaesthetic, then this should be made clear to the child while supporting them through the process – both before and after the examination. Discussion of the interplay between consent from children/young people and parental consent would also be useful in this document. It should be highlighted that a child can withdraw their consent for the examination at any time, and this should be explored with a child/young person prior to undertaking any examination, as well as discussions with children/young people about what to expect. Areas for expansion should include how examiners check in with young people and obtain consent throughout the process. It should be explicitly stated that if consent is withdrawn during the examination it must be stopped immediately. The document should support medical practitioners to recognise the interplay between the child having power within this situation and their power having been removed in a sexual abuse situation, in an effort to avoid further traumatisation The discussion of consent and capacity in the Pathway has been revised and emphasises these points.
64ST-S Again this presumes that all these cases go to medical examination - not all sexual abuse cases go to medical examination and this should be noted within the document The pathway has been revised to provide clarity.
64SD-9 In comparison to the Adult pathway, there is little detail on evidence based management of pregnancy and sexual health needs Noted. However, the Pathway has a hyperlink to the MCN Standards of Service Provision and Quality Indicators for the Paediatric Medical Component of Child Protection Services in Scotland.
64SP-N We would suggest that this section would benefit from a discussion of capacity, and how to assess the ability of a child or young person to consent to, or refuse, medical examination. Further detail on obtaining the views and wishes of a child or young person may also be helpful. In addition, we would suggest that there should be greater clarity in the role of parents in situations where the child or young person is capable of consenting to treatment, including situations where they may not want parental involvement. In a situation where the child or young person has capacity, parental consent is not a relevant factor. Section 2(4) of the Age of Criminal Responsibility (Scotland) Act 1991 expressly provides that a child under the age of 16 has the legal capacity to consent to medical procedures and treatments where they are capable of understanding the nature and possible consequences of such procedure or treatment. This is applicable in the context of the pathway, and should be reflected in the pathway document. Children and young people should be fully supported to understand and make decisions on these issues, and this is likely to be an area to be included in training and guidance for those who work with children and are involved in obtaining their consent or support in relation to such procedures. The discussion of consent and capacity in the Pathway has been revised and emphasises these points.
64SQ-P The separation of the primary and secondary purposes of the medical examination was helpful in maintaining an important focus on the needs of the child or young person Noted.
65SQ-P 6.1.8: This section could be strengthened to emphasise the responsibility of health professionals such as GPs, community paediatricians, mental health staff and the child’s health visitor/school nurse in ensuring that identified health needs, including emotional wellbeing needs, are being met. Noted.
64SQ-P 6.1.10/11: These paragraphs should be strengthened to include the responsibility of health professionals and their ongoing contribution to joint working for example providing written reports and participating in decisions affecting the child at child protection case conference etc The revised Pathway now includes a section on the roles and responsibilities of the professionals involved.
64S1-P [Our organisation] welcomes this clinical pathway and asks that going forward there is a more active inclusion of children and young people with learning disabilities within this. For this to be addressed, [our organisation] asks that rates of sexual abuse and rape experienced by children and young people with learning disabilities are included within the context section. [Our organisation] stresses that this should be framed in terms of rights and potential risks and not presented as ‘children and young people with learning disabilities are intrinsically vulnerable’. To support this [our organisation] welcomes a reframing of the pathways aims with a focus and weight being given to the rights, wishes, capabilities, and needs of the child or young person. Attention should also be given to guarantee that the pathway is age appropriate for each individual and that clearer definitions of trauma-informed practice are available More on the vulnerability of disabled children and young people to all forms of abuse is now included. There is more on taking consent for examinations/information sharing etc in the Pathway with hyperlinks to more detailed guidance if required.
The Adults with Incapacity Act and the Adult Support and Protection Act are now included within the pathway for consideration when appropriate. The limits to confidentiality when the person or others are considered to be at risk of ongoing harm are now included.
The Pathway makes provision for young people aged 16 and 17 with additional vulnerabilities to be included within its remit including the use of child protection procedures if appropriate. It also provides guidance on the appropriate approach to young people aged 16 and 17 where the provisions of the Adult Support and Protection (Scotland) Act 2007 may be appropriate. The Pathway advises practitioners that for particularly vulnerable young people aged 16 and 17 (and potentially up to 25 years if care experienced), that although the young person is on the adult pathway, the requirements of public bodies related to corporate parenting and/or Getting It Right For Every Child (GIRFEC) must be considered.
64S1-P To reinforce the inclusion of children and young people with learning disabilities within this pathway, it is critical that the document highlights the barriers experienced by this particular group. To support this the pathway should provide resources to facilitate the disclosure process as well as resources to help professionals identify potential child sexual exploitation. This should be supported with accessible information for children and young people with learning disabilities on what happens to them following a disclosure and advocacy provision as part of the ongoing work around the incorporation of the UNCRC. Finally, [our organisation] supports the child-centred and holistic approach outlined by the document. However, [our organisation] believes the section on medical examinations needs further development to ensure practice matches policy intention. More on the vulnerability of disabled children and young people to all forms of abuse is now included. There is more on taking consent for examinations/information sharing etc in the Pathway with hyperlinks to more detailed guidance if required.
The Adults with Incapacity Act and the Adult Support and Protection Act are now included within the pathway for consideration when appropriate. The limits to confidentiality when the person or others are considered to be at risk of ongoing harm are now included.
The Pathway makes provision for young people aged 16 and 17 with additional vulnerabilities to be included within its remit including the use of child protection procedures if appropriate. It also provides guidance on the appropriate approach to young people aged 16 and 17 where the provisions of the Adult Support and Protection (Scotland) Act 2007 may be appropriate. The Pathway advises practitioners that for particularly vulnerable young people aged 16 and 17 (and potentially up to 25 years if care experienced), that although the young person is on the adult pathway, the requirements of public bodies related to corporate parenting and/or Getting It Right For Every Child (GIRFEC) must be considered.
64S1-P [Our organisation] believes that by addressing the recommendations, we can ensure an equitable experience of service provision for children and young people with learning disabilities, to the rest of the population. Centrally, this work will help to ensure children and young people with learning disabilities are treated in a way that best preserves their dignity and allows for recovery from assault. Noted.
65SK-G Pg 18 'How quickly a non-acute case needs to be seen may vary according to clinical need--this doesn't read well from a person centred/trauma informed perspective. The pathway is varying between clinical need and health and wellbeing needs... needs consistency throughout. P 18- sentence regarding 2 doctors present is 'good medical practice'--again, not trauma informed.. what about it language that is supporting the young person The pathway has been revised to be consistent and promote child centred, trauma informed care.
64S6-U Early information sharing. Other agency inputs. Is there a need to put the child through examination, trauma informed. Consistent approach to medicals. 4 local authorities, one of the key things to iron out is timescales. Appreciation forensic windows, evidence for police if required timeously using the Standards for adults. Balanced with it remaining victim centred. Some areas where paediatricians are not involved. Forensic window needs to be considered. IRD should have health, social and police involvement. Reflect the current practice – issues around volumes etc. Lanarkshire does NAI Glasgow paediatrician will come in or neuro surgeon, which helps. Paediatrician won’t it’s a health representatives. Benefit having paediatrician at the time and everyone is there. Updates from social work is different from paediatrician. In Ayrshire, health protection advisors – rota system. Always health, social work and police. Same in Inverness. Early IRD stage that all the information is there at the time. First action is contact with paediatrician for medical need. CPAs and rota system available all the time. Reviewing joint protocol IRD Tayside child protection nurses are always at those, not always paediatricians – no issues up here. Dumfries – multi agency. Health social work and police works well for IRD. Paediatrician comes in to inform discussions. Medical examinations are the problem, age of the child The Pathway is aligned with current National Child Protection Guidance and aims to promote consistency with the flexibility to take account of local multi-agency IRD procedures. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.
It will fit in to a wider child protection context described by the revised National Child Protection Guidance for Scotland, which is currently out for public consultation.
64S7-V 6.1 Considerations for the Medical Examination and Follow up Should be something included that recognises the age and stage of the child being examined and adapting communication style to engage the child/young person and engage them in a way that helps them to feels safe. Something about how the physical examination can be re-triggering and having an agreed way for the child/young person to alert the examiner if they become overwhelmed and need a break or to stop. Something about how to include the child/young persons current ways of coping to help them before, during and after the examination. To support putting trauma informed principles in practice, would advise practitioners to walk through your service in the shoes of the child/young person, from first contact to last contact. Consider the communications you receive, the buildings you visit, the people you meet and interactions you have, the physical spaces you encounter and the policies you are affected by. Then thinking about how to implement trauma informed practice of safety, choice, collaboration, trust and empowerment. Would again advise looking at the Forensic Medical Examination Guidance and the Joint Investigative Interview training These considerations are part of the training of doctors and nurses undertaking examinations and therefore out with the scope of the Pathway.
64S4-S Trauma-informed practices and ACEs are referenced but this is not explicit in the medical section, and is not cross-referenced throughout the document. The Pathway now contains more information and context on trauma informed care and adverse childhood experiences.
64S4-S Education are not referenced in relation to the IRD. This is an omission given the new relationships, sexual health and parenting work is pertinent to this, as it may be through this that a young person may disclose or partially disclose. For wellbeing, all children will benefit. The comment has been noted and the Pathway now contains reference to education attending IRDs when appropriate.
64MX-Q Support, trauma informed and care afterwards. Please to see about the examination, wishes of the child should be taken into account and consent can be withdrawn at any time. Parent or carer with parental consent and agree to child participating in examination. See more around that it pretty much says that a parent can consent, the 2nd part take child’s view and children are competent to consent from 8 years old. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64MX-Q Young people haven’t been given a proper choice – that is my biggest concern they are coheres into examination by well-meaning clinicians, police and parents – not trauma informed and can be damaging to the young person children who are 13, 14, and 15. Should be led by the child always – stop at any point if they become uncomfortable. Laid out in pathway – might not be as clear as it could be. Children if young, can often make their own decision The Pathway now contains more information and context on trauma informed care and adverse childhood experiences.
The discussion of consent and capacity in the Pathway has been revised and emphasises these points.
64MX-Q How would consent work if parents are suspects – parents would not be there. Phone consent is possible. Usually go for joint consent. Part of the concern we have is standardising, different places doing different examinations, wide geographical area – experience is not always the same. We should be giving same standard of examination. 22 paediatricians doing this work in west of Scotland, do we know if these staff are competence? Standardise the examination. Set up services in different areas – 3 centres doing everything for all age groups. Body of trained staff, hub of expertise – putting little bits of money into different areas does not work. Look at ways to transport these people timeously to Aberdeen or Edinburgh from Shetland for example. Roles and responsibilities (notes in pathway) – police and social work, joint forensic examinations. Not practice we don’t currently have – no necessarily something we would comply with. The discussion of consent and capacity in the Pathway has been revised with hyperlinks to further guidance if required.
The Pathway aims to promote consistency with the flexibility to take account of local multi-agency IRD procedures. The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.
64MX-Q Acute – support and help is there as quick as possible. Forensic evidence. Equality issues, lack of translators, end up getting delays sometimes quite for some time. Nurses at Archway and translators and other people. Appropriate adults – disabilities. Other pathways fits in social, vulnerability – then there is constraints on resources, capacity and availability. Avoidable delays, interpreter that is an avoidable delay. Should not be delayed. These issues are for local services to consider within the parameters of the Pathway.
64MM-C While the pathway makes reference to forensic medicals, there are no comments made to how children and young people should be supported to attend. This is more of an issue in the evenings, Public Holidays and at the weekends particularly when medicals do not take place in D&G, with limited transport options - would health or police be able to assist with transporting? Best practice for children would be to have key people there to support them if and when possible and it would be beneficial if this was emphasised in the pathway. 6.1.2 - Written consent from a parent; clarity needs to be provided when the abuse has been perpretrated by a person who holds parental rights - can the child themselves give consent without parental consent? The discussion of consent and capacity in the Pathway has been revised with hyperlinks to further guidance if required.
These issues of support for Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
are for local services to consider within the parameters of the Pathway.
65M5-M Section 5 - Clinical Pathway Processes High level summary diagram The high-level summary of the pathway as currently drafted appears to represent parallel journeys through health processes and criminal justice/ child protection processes, which are almost entirely distinct. A trauma informed, child centred response to a child/ young person following abuse depends on close, collaborative working by the various services around the child and family at every stage and the pathway must endeavour to illustrate this. The health and social care needs of children and safe carers post abuse, for example, are often inextricably linked. Assessing a child’s emotional recovery needs depends on in-depth assessment and understanding of a child’s family context and wider social circumstances, and cannot progress without close collaboration with other agencies, most notably social work, where involved. Elsewhere in the pathway, evidence gathered directly from a child or young person during the Joint Investigative Interview process, may provide crucial information to inform emotional wellbeing assessment. The pathway should illustrate how this kind of collaborative working will enhance the health response to the child and family, minimising the risk of repeat trauma, for example by different assessment processes necessitating a child telling their story repeatedly. NSPCC is acutely aware that this kind of collaborative working is well underway in some areas in Scotland, and also that achieving it in practice depends on working out processes at a local level. However, the high-level pathway must illustrate the what of what needs to happen, in order to provide guidance for those working out the ‘how’ at local level. The Pathway now describes in broad terms what ongoing support to aid recovery should be available and emphasise the integrated response required for Children and Young People who have experienced child sexual abuse and non - abusing parent/carer(s).
65M5-M 5.1 Disclosure by a child / young person. The pathway has elsewhere importantly established that remarkably few children themselves report abuse, whilst it is happening, or ever. Initial concerns about child sexual abuse are much more likely to be raised or reported by others. The pathway should clearly reflect this (for example, this section/ box could be duel titled ‘Disclosure/ Concerns Raised about Abuse’). The pathway should underline the vital importance of the professional/ practitioner response to a child’s disclosure, in a meaningful way. The reaction of adults to disclosure is a critical first stage of a child’s journey to recovery and can have significant impact, either positive or negative. Unsupportive responses by caregivers or professionals to a disclosure of CSA may exacerbate victims and survivors’ feelings of guilt and shame, and may deter them from seeking support in the future. Supportive responses to disclosure, and supportive relationships, have been found to be significant factors in promoting recovery . It would be extremely helpful if the pathway contained basic information/ guidance for practitioners about what a child centred response to a direct disclosure of abuse by a child/ young person looks like. For example, Let Children Know You’re Listening (NSPCC, 2019) is a short animation providing simple, core messages on the most helpful ways for adults to respond to a child where they disclose/ try to disclose and would be a useful link. https://learning.nspcc.org.uk/research-resources/2019/let-children-know-you-re-listening/ Summary information on the nature of children and young people’s disclosures would also be very useful to help practitioners understand more ‘indirect’ ways children and young people may commonly try to communicate their experiences (ref). Section 5.1 briefly acknowledges the potential impact of disclosure on the child and the need to offer appropriate support as required. We would strongly support this section being strengthened, in line with previous comments, to include non-abusing carer support The Pathway now emphasises the need for the professional to respond to disclosures sensitively in a child-centred manner.
65M5-M Information about IRD contained in the Pathway must dovetail with a) Police Scotland Standard Procedure Protocol and b) National Guidance Child Protection. This section should be produced in close collaboration with Police Scotland and the SG team who are currently reviewing the National Guidance. This is not to suggest that the care pathway should contain a level of detail appropriate to other services, but rather that it is couched in similar language and reflects the same stages, in order to be recognisable and credible. The last paragraph detailing the responsibility of the paediatrician involved in the IRD could be fleshed out considerably to describe the nature of inter-agency collaboration at this stage. For example, social work and police colleagues may know the child and family far better than the paediatrician, and will be able to provide valuable insight to their early emotional care needs, at medical stage and beyond. The Pathway has been updated to reflect the language of the draft revised National Child Protection Guidance, in discussing IRDs.
The Pathway is to be considered an interim pathway and will be subject to review to take account of any changes to relevant guidance or legislation.
65M5-M The Joint Investigative interview is carried out in order to facilitate the child’s full disclosure. This has traditionally been understood as serving the evidential needs of the justice system. However, it is imperative that the JII and the child’s disclosure should be widely accepted and understood as a critical stage in a child’s journey to recovery. Enabling/ facilitating a child’s direct disclosure of abuse is central to their therapeutic recovery, as expressed in the principles of a Barnahus approach (REF). It would be extremely helpful if the care pathway helped articulate and promote this understanding about JII, in conjunction with police and social work colleagues. Additional information has been added on the role of JII within the child and young person journey of disclosure.
65M5-M The high-level summary pathway appears to suggest that all children who experience sexual abuse will be involved in interagency child protection procedures and that during this process, ‘multi-service and/ or multi-agency support is put in place’ (pg. 13, draft pathway document). This is not true in all cases. The Right to Recover research identified 2 distinct groups of children: those who are assessed as at risk of on-going harm and in need of protection, and those who are assessed to be at no on-going risk of harm. According to health practitioners, those children most likely to be assessed as not at on-going risk of harm are children who have experienced rape/ sexual assault by a ‘stranger’ or someone outside their ‘circle’, and those children whose families are judged to be coping. It may be that in some cases the emotional support needs of these children and families are considered and planned for at the stage in the process (multi-agency case conference) where they are assessed as not needing CP procedures. However, there is absolutely no guarantee that this is the case and our understanding is that no one profession/ practitioner is responsible for ensuring that these children’s and family’s needs for information, support and potentially therapeutic intervention are assessed and met. The document could be helpfully adapted to outline the pathway for both groups of children and young people; those in need of protection and those assessed to be of no further risk, and identifying the health needs of both. It is critical that this is done in conjunction with the National Guidance Child Protection. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
65M5-M [Our organisation] strongly welcomes the statement on the primary purpose of the medical examination, as being to address the health and wellbeing of the child in a holistic manner, including considering the immediate and long term emotional wellbeing needs of the child and arranging on-going care. However, the pathway does not provide guidance on the steps that need to be taken for this to be realised for children and families, nor whose role it will be to assess the emotional needs of the child and non-abusing carer. We note that the pathway details the responsibilities of the paediatrician and forensic medical examiner in the JPFE, but contains no guidance at all on the issue of emotional health assessment. This must be urgently amended. A key recommendation of the Right to Recover research is that medical assessment should include emotional wellbeing as a core component and that some kind of standardised emotional wellbeing assessment should be carried out with all children experiencing abuse, at an appropriate stage. It may be helpful to consider models which already exist; for example, the mental/ emotional wellbeing assessment which forms part of the holistic health and social care response to all children accessing the Lighthouse service in London may be helpful. Paragraph 2 of section 6 makes it clear that the pathway is for all children who have experienced sexual abuse, including non-acute abuse outside the forensic capture window. In doing so the pathway recognises, in line with the United Nations Convention on the Rights of the Child and with the HIS standards, the right of all children to a health response and support to recover. We are concerned, however, that this fundamental principle is not at all clearly articulated throughout the pathway. For example, the high-level summary diagram appears to contain no information about the ‘health response’ to children who do not undergo a joint paediatric/ forensic medical examination. Or is it the case that a joint paediatric/ forensic medical examination is indicated for all children who experience abuse, in acute and non-acute cases? This needs urgently clarified in the summary diagram and in the document. The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
65M5-M

Medical examination is a critical stage in the child’s journey after abuse, and can be very daunting. The pathway must underline the imperative of information and emotional support for children and families at this stage, in order that they fully understand what is happening. We are concerned that the issue of consent for medical examination is dealt with in a perfunctory manner in the draft document. Whilst links are provided to GMC guidance on consent, we consider it important for the pathway document to articulate the importance of a ‘trauma focussed’ approach to the issue of informed consent. Giving information about procedures, listening to and discussing concerns and ensuring the child/ family have choice and feel in control of what is happening, are all critical to obtaining informed consent. We are aware that there are good examples of child/ family friendly information about what happens at medical examination and of therapeutic play approaches being used to help children and young people relax prior to medical examination. The pathway should include examples and links to/ resources on best practise. Section 6 point 9 - Follow up of other needs, for example referral to the children’s reporter or other agencies, should be arranged and documented. [Our organisation] is extremely concerned that this vital stage in the care pathway is dealt with in one, perfunctory sentence. We consider it imperative that this section is fleshed out substantially, in the text and in the summary diagram, if the 2017 HIS standards are to be made real for children and young people. At the very least, the pathway must provide guidance on following up a child’s needs for on-going, longer term therapeutic recovery and the role of health in ensuring this happens. Critical information to support referral includes:

  • provision of therapeutic recovery services for children and families at a local level, including 3rd sector and ‘holistic’ provision.
  • information about the referral processes (often complex) and responsibilities
  • access to supportive interventions for non-abusing carers and family members as an intervention for the child’s recovery The pathway should also consider who else needs access to this information, for example G.Ps, Education etc, in order to refer children and/ or carers to services, in cases of historic abuse, or support them to access supportive services.
The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s)
There is now more information and context on trauma informed care and adverse childhood experiences.
Guidance on obtaining consent for an examination under various circumstances is included in the Pathway with references for further information if required by health staff.
64MY-R Remove the word ‘within’ which is in the final sentence of part 6 on page 20. Noted.
64MW-P In the section on the timing of medical examinations reference should be made to the timing of acute forensic assessment outlined in Sexual offences: Pre Pubertal and Post pubertal Complainants3” To enable a similarly high quality service across Scotland the CP committee would suggest that reference is made to the quality standards expected of each service as laid out in the Service specification for the clinical evaluation of children and young people who may have been sexually abused (p8)5. Although a number of these standards are addressed in the pathway there are some issues that are not identified, including an appropriate chaperone for the examination and the maintenance of competencies for clinicians. Point 8 on the follow up of health needs makes no mention of mental health so the committee would recommend the addition of ‘a risk assessment follow up for suicide, self■harm, child sexual exploitation or domestic violence’ as stated in Service specification for the clinical evaluation of children and young people who may have been sexually abuse. Referral to the Children’s Reporter, as mentioned in point 9, tends not to be carried out by the paediatrician – child protection medical information is used and added to other information and presented to the reporter by social care. The Pathway is intended to support consistent adherence to the NHS Healthcare Improvement Scotland Standards (Healthcare and forensic medical services for people who have experienced rape or sexual assault standards) which allow reporting and performance management using an agreed dataset.
A chaperone must be offered for all intimate examination according to GMC guidance.
The Pathway describes in broad terms what ongoing support to aid recovery should be available to Children and Young People who have experienced child sexual abuse and non-abusing parent/carer(s).
64MV-N More clarity is needed around consent issues for children and young people. The final paragraph of page 18 states “Written consent from an individual with parental rights (if child under 16) or child themselves must be obtained for the examination.” It is not clear from this when consent would be required from the child, and when it would be required from the individual with parental rights. It is also not made clear what would happen if a parent does not consent to an examination but a child does, or when a parent or carer consents but a child does not Guidance on obtaining consent for an examination under various circumstances is included in the Pathway with references for further information if required by health staff.

Contact

Email: CMOtaskforce.secretariat@gov.scot

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