Forensic Paediatrics A Report by the Short Life Working Group

Report outlining findings and recommendations from expert group


Summary of Recommendations

The following recommendations were agreed by the Short Life Working Group as minimum requirements to deliver a safe, sustainable clinical service for the examination of children who have suffered physical abuse and neglect and sexual abuse. The recommendations for Child Sexual Abuse describe services for children who may present with historical sexual abuse or acute sexual assault. For this Report historical abuse is defined as any sexual abuse occurring more than 7 days previously. Acute sexual abuse is that which is committed within the previous 7 days. Acute sexual assault is that which has occurred in the previous 72 hours.

The NHSScotland Healthcare Quality Strategy launched in 2010, stated a whole systems approach, aligned to deliver three Quality Ambitions which provides the focus for everything NHSScotland does. These three Ambitions state that care encounters should be consistently person centred, clinically effective and safe for every person, every time. The six healthcare quality outcomes provide a more comprehensive description of the priority areas for improvement in support of the Quality Ambitions, and provide a context for discussions about actions. The six healthcare Quality outcomes are listed in Annex B. The following recommendations have been mapped to one or more of these quality outcomes.

These recommendations should significantly contribute to continuous quality improvement in clinical services for children who have been abused and will help NHSScotland and its partner agencies to consistently deliver care that is person-centred, clinically effective and safe, for every person, all the time.

PROVISION OF SERVICE FOR CSA IN CHILDREN

1. All Boards will provide access to a competently trained paediatrician who can carry out examinations with videocolopscopy for CSA examination together with a forensic physician within 4 hours of referral as clinically and forensically appropriate in cases of acute sexual assault in children and young people under 16 years old to comply with RCPCH standards of clinical care and gathering forensic samples. The maximum waiting time for an examination will be dependant on clinical presentation but should not exceed 12 hours. (Quality Outcomes 3,6)

2. All Boards should provide facilities to record high quality images using colposcopic equipment in all cases of CSA which should be similar in make and model across Regions. These images should be digitally recorded and may be sent for specialist opinions when required. A consent form for digital recordings should be nationally agreed and available. (Quality Outcome 3)

3. In Boards where general paediatricians who are competent and skilled carry out joint 2 doctor examinations, the provision of access to specialist paediatric forensic opinion will be developed across network areas (regions), to provide specialist medical opinion and a Stage 2 Medical Report. (Quality Outcome 5)

4. All Boards will ensure a national medical report template will be used by all paediatricians and forensic physicians conducting forensic examinations for CSA. (Quality Outcome 5)

5. All Boards will ensure standardised cleaning and decontamination policies for the child friendly examination suites which are adopted by all NHS and police premises with a protocol agreed by police, COPFS and NHS Boards. (Quality Outcome 3)

PROVISION OF SERVICES FOR PHYSICAL ABUSE AND NEGLECT IN CHILDREN

1. All Boards will provide access to a consultant paediatrician 24 hours a day to give advice about physical injuries and neglect in children. These consultants must have completed RCPCH level 3 Safeguarding Children and Young People. (Quality Outcomes 3,4,5)

2. All Boards should ensure robust processes are in place to deliver joint forensic 2 doctor examination in significant or complex physical abuse e.g. complex bruising, burns, non accidental head injury (NAHI), fractures, suffocation and poisoning. These examinations should be conducted by a consultant with special interest in child protection and another appropriately trained and experienced doctor (which could include a forensic physician) to corroborate findings and collate best evidence and advise on clinical management. (Quality Outcomes 3,4,6)

3. All Boards will provide access to a consultant with special interest in child protection for advice for all complex injuries e.g. burns, fractures, NAHI, suffocation, poisonings and complex patterns of bruising. These specialist paediatricians should have additional training and experience. (Quality Outcomes 3,4,5)

4. All Boards should demonstrate that out of hours paediatric services for children who have suffered physical abuse meet RCPCH and FFLM quality standards and provide safe forensic and clinical care to any child and young person who presents with acute physical abuse. Boards should consider establishing a regional out of hours service with access to paediatricians with special interest in child protection to provide advice and medical opinion in child protection. (Quality Outcomes 3,5)

5. All Boards should ensure that there are compliance procedures to ensure MCN standards for the investigation and management of common (forensic) presentations of child abuse, e.g. NAHI, bruising for children under 1 year, and child deaths are adhered to. (Quality Outcome 6)

WORKFORCE AND SUSTAINABILITY

1. Regional Planning Groups should demonstrate that there is access to specialist advice, support and medical examinations for CSA services for all DGH and specialist children's hospitals. (Quality Outcomes 5,6)

2. All Boards should identify at least one consultant paediatrician with special interest in child protection. In larger Boards there may be a requirement for more consultants to have post CCT training, to obtain safeguarding competencies (level 4 and 5). (Quality Outcomes 5,6)

3. There is an urgent need for the NHS in Scotland, in conjunction with NHS Education for Scotland (NES) and RCPCH, to ensure there are sufficient paediatric trainees in specialist CCH training programmes at ST 5 - 8, to replace present consultants in tertiary hospitals, who are “Specialist Paediatric Consultants in Child Protection”, fulfilling the role of “designated” doctors. (Quality Outcomes 3,5,6)

4. An option appraisal should be carried out at a national level by the Scottish Government to consider new models for workforce and skill mix to deliver high quality specialist forensic examination for children and young people who have suffered CSA. Further expansion of the Tayside pilot should be considered in order to encourage local paediatricians to develop interest and specialist training in forensic paediatrics. (Quality Outcomes 5,6)

TRAINING AND SKILLS FOR PAEDIATRICIANS

1. All MCN leads should carry out a training needs analysis to ensure that all consultants in acute general paediatrics who examine children with physical injuries are competent and skilled, in the diagnosis and management of child abuse. (Quality Outcomes 5,6)

2. All MCN leads should stipulate the training requirements for Consultants who perform CSA examinations in their region, based on the RCPCH competencies (training matrix). All MCN network leads should develop a system to ensure current paediatricians performing CSA examinations in their region have appropriate supervision over the MCN Region and advise local Board systems for clinical governance and appraisal about these requirements. All doctors carrying out CSA examinations should have updates on the clinical evaluation of sexual abuse in children, including the use of the colposcope, every 4 years. (Quality Outcomes 5,6)

3. All consultant paediatricians "with a Special Interest in Child Protection" should evidence the maintenance of skills and training in child protection including number of cases seen, peer review sessions attended (NAI and CSA) other courses and CPD undertaken. This information on numbers and quality may be collated locally or regionally to ensure standards for training are maintained over the MCN Region. This will be done by the MCN lead clinicians working across Scotland and will be in job description. (Quality Outcomes 5,6)

4. RCPCH and NES should work to create an accreditation scheme to ensure local, regional and national training courses in child protection for paediatricians and forensic physicians are delivering appropriate skills and knowledge of competency framework. (Quality Outcomes 5,6)

5. All job descriptions for new consultant posts for general paediatrics should stipulate as essential the minimum requirements for competency in examination of children suspected of having suffered child abuse. Additional specific competencies should be stipulated for any new specialist consultant post in Child Protection. (Quality Outcomes 4,5,6)

6. All job descriptions for consultant posts for general paediatricians which have acute on-call duties should detail explicitly the responsibilities for examination of children with physical and sexual abuse and participation in 2 doctor forensic examinations for sexual abuse. (Quality Outcomes 4,5,6)

7. Joint training programme for paediatricians and forensic physicians should take place annually, with input from COPFS and ACPOS to standardise the quality of forensic paediatric reports used for court purposes across Scotland. (Quality Outcomes 5,6)

8. MCN leads will promote the RCPCH recommendations regarding the number of peer review sessions required per year to maintain competence. (Quality Outcome 5)

TRAINING AND SKILLS FOR FORENSIC PHYSICIANS

1. All forensic physicians who perform paediatric forensic examinations should have undertaken a basic level of paediatric training accredited by FFLM or other recognised training bodies (e.g. NES, RCPCH). (Quality Outcomes 3,5,6)

2. All forensic physicians should comply with the basic requirements to maintain competencies and skills in CSA examinations. This should be agreed across Scotland. (Quality Outcome 3)

3. Forensic physicians should access appropriate courses to obtain and retain their skills in examination of children and young people. (Quality Outcome 3, 5)

4. FFLM will set out necessary requirements for revalidation, including evidence of CPD, peer review and qualifications plus minimum caseload. (Quality Outcome 5)

5. New forensic physicians should have job descriptions which indicate their requirement to achieve relevant post-graduate qualification (membership of the Faculty of Forensic and Legal Medicine (MFFLM) or Diploma in Forensic and Clinical Aspects of Sexual Assault (DFCASA)) in forensic paediatrics. (Quality Outcomes 3,5,6)

6. FFLM to offer more courses throughout the year, of an introductory and developmental nature (Quality Outcomes 3,5,6 )

GOVERNANCE, DATA COLLECTION AND ACTIVITY

1. Data sets for all specialist child protection cases in a region should be created across an MCN region, in order to capture standardised information on all paediatric forensic activity, and provide the basis for robust governance, accountability and audit arrangements. (Quality Outcomes 5,6)

2. All three MCNs should implement a quality assurance programme using the available tools from Healthcare Improvement Scotland (NHS HIS) and National Services Division (NHS NSD ).  (Quality Outcomes 5,6)

3. There should be a national strategic planning and review group which provide an overview of specialist paediatric forensic services across Scotland, and should include MCN leads and forensic physician representation. (Quality Outcomes 5,6)

4. The NHS in conjunction with the police boards/authorities should ensure that forensic paediatric services meet these standards, by providing a joint governance process. (Quality Outcomes 5,6)

5. The three regional MCNs for child protection should report to Regional Planning Groups and produce annual reports, which outline key performance indicators and outcome measures against which progress can be measured. (Quality Outcomes 5,6)

6. MCN's should support consultant paediatricians with special interest in child protection who may work across a Region to provide specialist services in child protection. They should meet regularly for peer review at Board or Regional level and national peer review. (Quality Outcomes 5,6)

Contact

Email: Fiona McKinlay

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