Information

National Guidance for Child Protection in Scotland: Guidance for Health Professionals in Scotland

This guidance is intended to act as a practical reference point for all healthcare staff working within an adult and child service context.

It highlights the specific roles and responsibilities of specialist staff working in particular settings wherever children and young people will usually be seen.

It sets out the framework to aid practitioners in their role in dealing with child protection concerns.


Chapter 4 Medical Assessments in Child Abuse

This section:

  • Outlines which medical specialities examine children and young people.
  • Sets out the role of:
    • GP services
    • emergency and urgent care medical services
    • emergency medicine services.
  • Outlines when to request a medical assessment.
  • Describes the types of medical examination in child protection.

Some medical specialities will regularly see vulnerable children in their practice (child and adolescent psychiatry, paediatric specialties). Other medical specialities see adults where risk factors may exist which increase the potential risk to the wellbeing or actual harm to children and young people (e.g. mental health, addictions, or learning disability). Some services will see both children and adults; these include primary care and emergency medicine. In addition, Obstetrics will deal with pregnant women who may be vulnerable.

The medical, nursing and AHPs who work in these specialities will require to have high levels of competency and skill in managing vulnerable families and children, and should complete additional training to ensure they are able to recognise concerns to wellbeing, the signs and symptoms of child abuse and risk factors which make child abuse more likely.

All staff should know who to seek further advice and support from if they are concerned about a child's care and protection. Medical practitioners will have specific responsibilities regarding decision making, interpretation of injury and giving an opinion about the probability of abuse.

All doctors who provide care for children and young people must be aware of the signs and symptoms of abuse and neglect. They must also be aware of any other factors which increase the risk of abuse especially parental factors such as mental health problems, domestic abuse, drug and alcohol addiction, and learning disabilities.

Doctors must listen carefully to the history from the carer and the child or young person if it is appropriate and observe the child or young person to take into account the whole picture of the child or young person. If appropriate, the views of the child or young person themselves should be taken. They must seek an explanation for any presentation in an open and non-judgemental manner. The doctor must record all concerns as well as, exactly what is observed and heard from whom and when. Doctors must be direct, honest and empathetic with the parents but focus on the needs of the child or young person especially the care and protection of the child or young person. After examination, the doctor should explain any concerns about their observations and indicate their role in the protection of the child or young person to the parents, and seek senior opinion or follow local child protection health guidelines to access further advice.

Doctors must speak directly to social work services if they have a serious concern of abuse about any child or young person.

Specific advice is provided below regarding the role of GPs, Emergency Medicine Specialists and Paediatricians

Medical Staff

The General Medical Council (GMC) has issued new guidance to every doctor in the UK to help them protect children from abuse or neglect. Protecting children and young people: the responsibilities of all doctors underlines the duty on doctors to act if they are concerned that a child or young person is at risk. It provides detailed advice for doctors on information sharing, working in partnership with other agencies, consent for child protection examinations, acting as a witness in court, and where to turn for support. The guidance can be found on the GMC website www.gmc-uk.org/childprotection. The website also contains:

  • Short guides for GPs - highlighting the sections of the new guidance which are likely to be most useful for those working in primary care.
  • Short guides for doctors who treat adult patients - highlighting the sections in the guidance that are most likely to be relevant for doctors whose adult patients may pose a risk to children or young people.
  • Learning materials - including case studies and a flowchart to help doctors decide whether to share information about child protection concerns.

Doctors will often be asked to examine children or young people by parents or carers. If a child or young person has presented specifically because of concerns about their care or protection, the first examining doctor should follow the usual format for clinical assessment noting the following specific aspects:

  • The state of dress, cleanliness of child or young person including hair and skin.
  • The general demeanour and emotional state, and state of nutrition (including dentition), as well as other appropriate examination according to the symptoms.
  • Additional information, including a chronology of events in the child or young person's life should be sought from the Named Person for that child or young person.

Liaison with the local child protection adviser can be useful.

General Practitioners

GPs are an essential part of the health service as they provide universal contact for all children, young people and families. They are in a unique position to identify the child or young person with concerns based on both the child or young person's presentation and the GPs' wider holistic assessment of the family. There should be a system in place in each GP practice that facilitates the early effective sharing of information about vulnerable children, young people and families between GPs and other members of the primary care team.

GPs may identify children or young people where there may be concerns:

  • When receiving information or examining an adult with health problems including adults who are the carers of children or young people registered with another GP.
  • When a child or young person has general health problems.
  • When a child or young person has been brought by parents/carer following an allegation.
  • When a child or young person has been seen by another member of the primary care team (e.g. PHN-HV, family nurse).

GPs may identify children or young people where there are clear signs or indications of abuse or neglect and should follow local guidance for raising concerns about such children or young people with social work services. They may also see children or young people where the explanation for presenting concern may include abuse or neglect. In such cases they must also record concerns, share information with relevant professionals and consider raising concerns with social work. This is particularly important when considering neglect or emotional abuse where careful recording and discussion of concerns is important to avoid missing such presentations. NICE clinical guidelines 89, When to Suspect Child Maltreatment8 gives advice on identifying children and young people who may be being maltreated.

When GPs see adults who present potential risks to children or young people they must assess and consider the impact of this risk on the child or young person.

It is critical that the GP responds appropriately and follows local and national guidance. GPs have a duty to report concerns and share information about children or young people promptly and directly with other agencies. Further advice and guidance is provided in the RCGP Safeguarding Children Toolkit9 and the GMC guidance, 'Protecting Children and Young People - the Responsibilities of all Doctors10

Emergency and Urgent Care Medical Services

This includes Out of Hours GP Medical Services, NHS 24 and Scottish Ambulance Service. During office hours it is best practice for social work services to direct a request for health or medical assessment through the local NHS child protection services in the first instance. The urgency and type of health assessment can be discussed as part of the joint assessment with appropriate healthcare staff. It should therefore be rarely that a social worker contacts emergency medical services directly. If social work staff contact an emergency medical service/NHS 24 because of concerns regarding a child or young person's injuries or illness the first contact health professional should:

  • Establish whether social work have discussed the case with the local NHS child protection service and held a joint investigation.
  • Consult previous medical records (plus IT systems) to check any previous attendance.
  • Consider what clinical care is appropriate at the time of presentation.
  • Consider deferring the examination until the child protection doctor is available, as it may not be appropriate to examine the child.

It is critical that for all cases of child sexual abuse, where a specialist two doctor Joint Paediatric Examination must be conducted or for chronic neglect where a Comprehensive Medical Assessment can be planned at a later date when all relevant information has been collated, that the child protection service is involved as soon as possible.

Emergency Medicine Services

Children or young people with suspected abuse or neglect may be taken to the Emergency Department for the provision of immediate medical care or for an opinion about possible mechanisms of injury. Local procedures for raising child protection concerns should be followed as appropriate. Local systems should be in place if the child or young person or their parent/carer leave the Emergency Department prematurely or refuse treatment. The Named Person should be informed and child protection procedures for "immediate concerns" should be followed.

If, after examination, healthcare staff suspect that a child or young person attending the Emergency Department has experienced, or is at risk of abuse or neglect, Emergency Department staff should:

  • Provide any immediate medical care required.
  • Gather information from the child or young person's medical records and the local child protection register by contacting social work standby services.
  • Examine the child for evidence of injuries, remembering that these may be concealed under clothing.
  • Document carefully all clinical findings including skin condition, bruising, scars, weight and height.
  • Ensure that senior staff are involved in any decision-making process.
  • Follow local child protection procedures, including ensuring concerns are raised immediately with social work services.

Paediatric Assessments for Child Abuse and Neglect

If the first examining doctor suspects child abuse or neglect they should discuss this with their senior clinician and consult local child protection procedures. If it is deemed appropriate, their concerns should be shared immediately with social work before referral for paediatric assessment in order to initiate a child protection investigation. All details should be carefully recorded in the child or young person's medical record. If the doctor is not clear whether injuries or clinical features are suggestive of abuse, but considers abuse in his differential diagnosis, he may refer the child or young person for a general paediatric examination and opinion. It is important that an appropriate professional gives an opinion about the probability of abuse. In most cases this will be a consultant paediatrician. However, it is important to note there are a number of different types of paediatric examinations:

General Paediatric Assessment

This acute medical assessment is appropriate if there is a differential diagnosis which includes abuse (e.g. multiple bruising, seizures, failure to thrive, or fractures). This would only be appropriate if the child has no other concerning features in the history including social history. It is important that any paediatric examination provides the following:

  • Clinical care decisions for the child or young person.
  • Interpretation of evidence to support a diagnosis of abuse.
  • An opinion about the probability of abuse.
  • Identification of a child or young person's health needs and interventions.

Comprehensive Medical Assessment

This planned medical examination is done by a paediatrician usually as an outpatient. This specialist paediatric assessment would be indicated if there are concerns about neglect, or chronic abuse over a period of time. It is usually carried out as part of a social work investigation. It requires a number of additional tasks to be completed usually by the Lead Professional (e.g. collation of all previous medical records from PHN/HV, family nurse, school nurse, GP, hospital and Emergency Department records, community child health and child psychiatry records). A chronology would be expected prior to examination, and any social work reports should be made available. A full typewritten medical report and opinion will be given to social work and copies sent to the Reporter to the Children's Panel and GP. A proforma should be used to record all details (Appendix 4).

Specialist Child Protection Paediatric Assessment

This will usually be urgently requested after social work involvement (and after a joint investigation), if there are acute signs and symptoms suggestive of physical abuse. It is a single doctor examination and should be carried out by an experienced trained paediatrician, who has additional skills in child protection. There should be a proforma (see Appendix 4) for recording clinical assessment including history, examination (using body maps) and any investigations planned. It is imperative that clear and detailed notes are kept. Photographs will usually be taken, and a medical report completed with an opinion stated, for social work (and police) as part of the investigation. The child or young person may need admission to the paediatric ward for further tests (e.g. X-rays, blood investigations).

Joint Paediatric/Forensic Assessment

The need for a joint paediatric/forensic assessment is indicated if there are serious injuries or illness (e.g. complex fractures, head injuries, burns, or the result of preliminary assessment is inconclusive and a specialist's opinion is required to establish the diagnosis).

This two doctor examination is the most specialised type of examination and only undertaken after a joint discussion with social work, police and health. It is usually arranged during working hours with the appropriate skilled personnel and facilities available. This specialist examination provides a high standard of forensic evidence to sustain any criminal or care proceedings, provide treatment and ongoing care, and offers reassurance and advice to the child or young person and carer. It is always done for Child Sexual Abuse. It is usually carried out by a paediatrician and forensic physician, but can be carried out by paediatric and any other appropriately trained doctor.

There may be the need for appropriate specimens for trace evidence including semen, blood, fibres etc. The forensic physician takes responsibility for the gathering of any samples for forensic analysis while the paediatrician takes responsibility for arranging other investigations (e.g. X-rays, MRI, blood clotting tests).

The presence of two doctors in the joint paediatric forensic assessment is not only important for the corroboration of medical evidence in any subsequent criminal proceedings but is regarded as good practice. Following assessment the two doctors should confer immediately, and give an immediate statement to the police officers who may be in attendance.

Medical Report

If doctors are asked by social work or police for a report they should provide a typewritten report detailing the referral pathway to them, the time and place of examination, the names of those present, details of history and examination and specific details of any injuries or abnormalities. The report should summarise significant positive and negative findings as this will be considered evidence. Most doctors will be recording their involvement as witnesses "to fact". Some specialists such as consultant paediatricians will be expected to also give an opinion (as courts consider them "experts") based on their findings and will have to clearly state the probability of abuse.

It is imperative that all specialist paediatric medical examinations result in a clear report. This should also contain details of the doctor's role, experience and status. It should contain statements of fact (evidence found on history and examination), then an opinion about whether abuse may be possible or probable. It must be sufficiently detailed to meet the Reporter's requirement as well as the Procurator Fiscal, if necessary, in criminal cases. This is called a Stage 1 report.

A Stage 2 report may be completed after further investigations and results are available, and may have additional evidence from research to support the diagnosis of abuse. This is usually written by a specialist consultant in child protection.

Contact

Email: Fiona McKinlay

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