Forensic Paediatrics A Report by the Short Life Working Group

Report outlining findings and recommendations from expert group


Chapter 1 Current Provision

1. Child abuse involves acts of commission or omission, which result in harm to the child. The type of abuse can be physical, emotional, sexual, or due to neglect. There are standard definitions produced by Scottish Government in the guidance 2010.

2. The pathway and management of physical and sexual abuse in children may be different depending on the initial agency involved and presentation of signs and symptoms. However, the interagency response and health involvement at the earliest stage should result in medical examination being carried out at an appropriate time, in an appropriate setting and by appropriately trained health professionals.

3. Responsibility for the provision of adequate clinical facilities for the forensic examination of children, and the provision of clinicians who are appropriately skilled and confident in carrying out medical examinations for all forms of child abuse, resides with health boards and police boards/authorities. Forensic physicians provide corroboration and forensic support in these examinations, and work closely with Police authorities in provision of health support to other forensic work. For sexual assault cases in older children (13-16) examination may be carried out in adult sexual assault centres, following discussion with paediatricians.

4. All child sexual abuse examinations (acute or historical) are undertaken as a two doctor joint exam (paediatrician and forensic physician) with videocolposcopy used to record the examination findings. The paediatrician may be a general or community paediatrician who has received additional training and skills in the use of videocolposcopy. To give an opinion in cases of sexual abuse, paediatricians must have received additional specialist training in the interpretation of the clinical signs, work within clinical networks for child protection and attend a regular Peer Review process with colleagues who perform similar examinations. Forensic physicians can be General Practitioners contracted by police to gather appropriate evidence or other medical professionals but must fulfil requirements as stipulated in the joint FFLM, RCP London document. The available number and training of these doctors varies considerably across Scotland as do the services provided and not all forensic physicians carry out examinations of children who have been sexually abused.

5. The service model which provides for children who require a forensic examination in cases of child sexual abuse varies across Scotland due to geographical and workforce demands. These challenges are not new - Mok and Bussitil carried out an audit of the medical services for CSA in Scotland in 2001/2 to establish how widely guidance was being followed by practitioners, NHS Trusts and health boards. They found a lack of standards across Scotland in the structure of local services, process of referral and documentation of injuries in children referred for investigation of child sexual abuse. Their report, 'Expertise in the medical examination of suspected child sexual abuse' made a number of recommendations for training and workforce development of both consultant paediatricians and forensic physicians.

Daytime Services

6. All Health boards provide daytime services for the examination of children who may have been sexually abused. This daytime service is provided Monday - Friday up to 5pm and in some areas until 8pm and on a Saturday and Sunday. This service can provide planned medical examinations for the vast majority of children with sexual abuse or who have made allegations of historical sexual abuse. In four Board areas (Dumfries and Galloway, Western Isles, Orkney and Shetland) arrangements for the transfer of children to neighbouring Boards for examination is made, as there are currently no trained paediatricians to carry out forensic examinations for CSA, and limited daytime availability of forensic physicians.

Out of Hours Services

7. It is much less common for a child to present with acute sexual assault and only in exceptional circumstances that an emergency out of hours forensic medical examination is required. The likelihood of gathering DNA evidence and of documenting ano-genital injuries declines steadily over time. The current recommendation is that evidence can be gathered up to 7 days post assault. RCPCH "Facing the Future: Standards for Paediatric Services" has stated that 'depending on the needs of the child or young person (clinical, forensic and safety) the child or young person must be assessed and an opinion provided usually within 12 hours of presentation when there are recent injuries. Specialist paediatric and forensic opinion should be available to all units within 4 hours of all acute sexual assaults.'

8. All Health Boards are currently able to provide a service for children with acute child sexual abuse. However, the service is vulnerable to the same workforce related challenges as other paediatric services, i.e. imminent retirals, locum positions to fill consultant gaps and no identified paediatrician currently in the training programmes training to become specialists in the area of child protection. In addition, keeping the competencies and skills for this work of those who have been trained is challenging because of the limited number of examinations carried out.

9. Cases of physical abuse and injuries will be seen in hospital by a variety of specialist paediatric services. More serious injuries may be managed in intensive care, orthopaedics, burns or neurosurgical units. The examination, investigation and recording of injuries may be inconsistent across these specialties although proformas should be available in all paediatric services to be used in child protection cases. In these complex cases a specialist 2 (joint) doctor paediatric forensic examination will be carried out to ensure specialist opinion and forensic evidence is collated in a standardised way. However this model is not practised in all Board areas.

10. Cases of child physical abuse including injuries will usually be seen in hospital settings by a variety of specialist teams e.g. general paediatric (acute on-call) team, trauma specialists, orthopaedics, burns, intensive care and neurosurgical teams. The examination, investigation and recording of forensic evidence can be inconsistent across these specialties in some areas of Scotland. In some areas, these complex injuries, will be examined by 2 doctors in a joint paediatric forensic examination to ensure a high standard of forensic evidence, provide specialist child protection advice, and medical care to the child.

Contact

Email: Fiona McKinlay

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