Child Protection Medical Assessments

The aim of this procedure is for all staff to understand the process required when a medical assessment within the area of safeguarding children is required.

Overview

Medical Assessment of child/young person for all suspected abuse

A Medical assessment should always be considered when there is an allegation, a suspicion or a disclosure of child abuse involving a suspicious injury, suspected sexual abuse or serious neglect.

A medical assessment involves a holistic approach to the child and considers the child’s wellbeing including an assessment of the child’s development and a broad understanding of their cognitive ability.

Types of Assessment

1. Urgent Assessment

Where the child appears in urgent need of medical attention e.g. suspected fracture, bleeding, loss of consciousness, severe burns, he/she should be taken to the nearest A&E department as for any other seriously ill or injured child. An urgent assessment is an assessment of child’s immediate health needs and not a Child Protection Medical Assessment’. In the event of there being any suspicion and or consideration of child abuse, the doctor should confer with their senior clinician and refer to Children’s Social Care (CSC). Doctors should inform and involve Paediatric Doctors as early as possible but should not wait for paediatric opinion before referring to CSC.

2. Child Protection Medical Assessment

Where NAI (non-accidental injury) is suspected by a health professional and a referral is made, a Strategy discussion must always take place with Police, CSC, and the referring Health professional. This may not result in a section 47 enquiry but supervision arrangements should be considered during this discussion. This discussion will also determine the need and timing of a child protection medical assessment if one is deemed necessary.

Response to requests for a medical assessment should be prompt, appropriate and proportionate to the child’s needs. However this should never result in a delay where there is a need to secure evidence particularly when police protection has been undertaken.

Requests for child protection medicals must only be made by the Social Worker or a member of the Police Vulnerability Unit to the local paediatric service In accordance with the Trust’s local protocol. Most examinations will be done in a paediatric out patients / day unit on a date and time mutually agreed by the examining doctor with the requestor of the assessment.

If a child protection medical assessment is required out of hours then the child will be admitted to the ward if clinically needed or a place of safety cannot be found.

During the strategy discussion all relevant information will be shared and a decision made re the most appropriate person to attend the hospital with the child

The child should not be brought to the Emergency Department for child protection assessments without the agreement of the Senior Paediatric Doctor, unless they are in need of urgent medical treatment.

The Paediatrician may arrange to examine the child him/herself, or arrange for the child to be seen by a member of the paediatric team in the hospital or community who is appropriately trained and experienced in undertaking such assessments. Priority should be given to the assessment to avoid any delay for the child and family and to obtain evidence in a timely fashion. The time of the assessment will be agreed by the Paediatrician and the Social Worker. If available, a copy of the Safer Referral should be given to the examining paediatrician at the time of the assessment.

Medical assessments cannot be arranged without a strategy discussion having taken place.

When planning the examination, the Social Worker, the Police Vulnerability Unit and relevant Paediatrician must consider whether it might be necessary to take photographic evidence for use in care or criminal proceedings.

3. Acute Child Sexual Abuse Medical Assessment

Where acute child sexual abuse is suspected, (acute meaning within the preceding seven days) the children will be seen at the Paediatric Forensic Network (PNF) at Newcastle Great North Children Hospital (GNCH).

The Social Worker or Police Vulnerability Unit will directly contact the Unit above and arrange for the child to be examined there. The child should not be taken to the Emergency Department or local paediatric ward. Refer to: Sexual Abuse / Violence Care Pathways in the Tees Procedures Guidance Section.

In cases of CSE consideration should be given to a referral to the PFN even if the child or young person states that sex was consensual. Where a child presents to a doctor with a genital injury / problem it may be appropriate for the child to be seen directly by the GNCH. This should be discussed with the local Consultant paediatrician on call and PFN doctor. Consideration should be given as to whether a Safer Referral is required at this time.

Where a child has presented to a doctor with genito urinary symptoms or concerning medical history but there is no disclosure or consideration of abuse and they would like a second opinion they should refer the child to the local paediatric consultant for same day assessment on Paediatric day unit.

4. Historic Child Sexual Abuse Medical Assessment

If the sexual abuse concern predates seven days then it would be defined as historic sexual abuse. Such cases of historic sexual abuse (more than 7 days) will be seen at James Cook University Hospital (JCUH) by a nominated paediatrician.

In such cases there should be a Safer Referral form submitted followed by a strategy meeting or discussion by CSC with the on call Paediatrician and Community Paediatricians at JCUH via their secretary which will determine the need, timing and place for the paediatric assessment

5. Neglect Medical Assessment (When subject to a Protection Plan)

Where a child becomes subject to a Child Protection Plan under the category of Neglect and there are outstanding unmet health needs identified, such as growth or developmental delay which cannot be addressed by universal services, for example GP, Health Visitor or School Nurse, a discussion will be held by the conference members at the Initial Child Protection Conference (ICPC) as to whether a neglect medical assessment is required.

Health Professionals attending the ICPC will provide advice and guidance based on their knowledge and consideration of the above mentioned issues. The rationale and outcome of this decision will be clearly documented in the ICPC minutes and recorded on the paediatric assessment referral form when this is sent to the paediatrician. Where it is agreed that a neglect medical assessment is required this should be an integral part of the Child Protection Plan.

In cases where it is unclear at the Initial Child Protection Conference whether there are outstanding health needs, an assessment will be undertaken by the Health Visitor or School Nurse and the outcome shared at the first Core Group meeting. Where there are identified health needs which cannot be addressed by universal services a referral for a neglect medical assessment will be made by the Social Worker.

Where an assessment is deemed necessary then either the Paediatrician currently providing care to the child or an allocated Paediatrician will undertake the Neglect medical. Each provider trust will have its own process in place for arranging this and auditing the process.

Parents / Carers will be informed at either the Initial Child Protection Conference or the first Core Group that the child is required to have a neglect medical assessment as part of the Protection Plan.

The child’s Social Worker, as the key worker, will complete a Paediatric Assessment Referral Form for children subject to a child protection plan for neglect, within 5 working days of the decision to refer to a paediatrician and send this to the associated hospital via an agreed secure process. Parental consent must be sought and recorded (see ‘Consent for Medical Assessments’).

Where an interpreter is requested by the Social Worker the hospital provider trust will arrange this at the time of arranging the child’s appointment. Family members or friends should not provide interpretation.

The hospital provider trust, on receiving the referral, will contact the Social Worker and offer an appointment for the child within 8 weeks or earlier if the child’s condition necessitates. The Child Protection Conference Administrator will securely forward the health professionals’ reports submitted to the ICPC to the relevant contact referral point.

The paediatrician who is to carry out the neglect medical assessment will obtain any records on the child, which are held by the hospital trust including any Emergency Department notes.

The hospital provider trust will send to the child’s parent/carer and the Social Worker the appointment date, time and venue for the neglect medical assessment plus the name and designation of the clinician the child is to see.

Wherever possible sibling groups will be seen at the same appointment but will undergo separate medicals.

The Social Worker, with the support of the health professionals involved in the Core Group will make every effort to support the child and family to attend the neglect medical assessment as part of the child Protection Plan.

The worker with the most appropriate information about the child and family, (this could be the Social Worker , Health Visitor, School Nurse , Family Support Worker) should accompany the child for the Paediatric appointment so that the examining Paediatrician has the relevant information in respect of the child. The paediatrician should document on the form the name and job title of the practitioner in attendance.

Following the paediatric assessment the Paediatrician will complete a report, using the appropriate pro forma, showing the outcome of the neglect medical assessment and the plan in relation to any findings. This will be sent to the Social Worker, GP and Health Visitor / School Nurse within 2 weeks of the assessment taking place. The report must be available for the Review Child Protection Conference (RCPC).

The Paediatrician will also send an appropriate report / letter to the parents / carers. If the Child is over the age of 12 years the Social Worker will be responsible for sharing the report with the child and capturing their views for feedback to the Core Group and RCPC. If this is not to be shared with the child the Social Worker will record the reasons why not.

The Paediatrician will, as necessary, refer the child for additional services and this will be facilitated in accordance with the hospital provider Trust’s policy. The Paediatrician will inform the Social Worker where a child is not bought for assessment and a further appointment will be offered.

Consent for Medical Assessments

Wherever possible the permission of a parent / carer with parental responsibility should be sought for children under 16 prior to any medical assessment and/or other medical treatment taking place, which may include photographic evidence.

The following may give consent to a paediatric assessment:

  • Any person with parental responsibility;
  • A child of sufficient age and understanding to make a fully informed decision can provide lawful consent to all or part of a medical assessment or emergency treatment; generally the Doctor will assess whether the child has sufficient understanding with advice from other professionals. A child who is of sufficient age and understanding may refuse some or all of the medical assessment though a court can potentially override refusal;
  • The Local Authority when the child is the subject of a Care Order, or an Interim Care Order. If appropriate, parents should also be informed.
  • The High Court when the child is a Ward of Court;
  • A Family Proceedings Court as part of a direction attached to an Emergency Protection Order, an Interim Care Order or a Child Assessment Order;
  • A young person aged 16 or 17 has an explicit right (Section 8 Family Reform Act 1969) to provide or deny consent to surgical, medical or dental treatment and unless grounds exist for doubting her/his mental capacity, no further consent is required.

When a child is looked after under Section 20 and a parent/carer with parental responsibility has given general consent authorising medical treatment for the child, a separate consent must be obtained for a child protection medical assessment, If consent is refused legal advice must be sought by the Provider Trust and CSC.

Where English is not the first language for either the parent or the child an interpreter will be required. It is the responsibility of the Provider Trust to provide an appropriate service. Under no circumstances should family or friends be used as interpreters.

Considerations Regarding Consent

Prior to seeking parent / carer consent for a Neglect medical assessment, professionals must consider whether the child is mature enough to give consent i.e. following Fraser Guidelines and whether the child wishes for parents/carers to be informed or not. If the child declines consent the implications of this will be explored by the Core Group and appropriate action taken where necessary.

Where a parent fails to present a child for a neglect medical assessment on two or more occasions and the Social Worker, supported by the health professionals within the Core Group, are unable to facilitate the child’s attendance; the Local Authority will consider what action to take to safeguard the child’s welfare. This may require the Local Authority to seek legal advice.

Supervision

Where abuse is suspected and the parent / carer are identified as possible perpetrators, arrangements need to be put in place for the contact between the parent/carer and child to be supervised. This will be arranged by Children’s Social Care and could be an approved family member or friend or an identified professional. If the child is to be admitted to the ward then these supervision arrangements need to be determined as part of the strategy discussion and clearly recorded on health records with this information available during transfer from the Emergency Department to the ward.

N.B. Guidance for Supervision of Parents/Carers of Children and Young People in Hospital

Hospital Transfer of a child

Where abuse is suspected and the child or young person needs to be transferred to another hospital, and the parent / carer is identified as a possible perpetrator, the same arrangements re supervision as discussed above will apply.

The Medical Assessment

The examining clinician should have information available from the child’s previous hospital attendances, wherever possible.

The examining clinician should obtain a thorough and comprehensive history including any explanations given by parents/carers for the injury and perform a complete clinical examination of the child/young person including an assessment of development and a broad understanding of the child’s cognitive ability.

Any visible marks or injuries should be charted on a body map and documented in detail in case notes.

A skeletal survey needs to be considered when a child presents with a physical injury and abuse is suspected. (Royal College of Radiologists, Royal College of Paediatrics and Child Health. Standards for radiological investigations of suspected non-accidental injury. 2008.) 

A repeat skeletal survey may be necessary where an abnormality has been identified or thought likely to be present, but the implications of repeated exposure to radiation need to be considered

All medical examinations should follow their own Trust Guidelines on Radiology in Child Abuse

Attention should be paid to differential diagnoses, including non-accidental injury and fabricated or induced illness.

Providing / Sharing the Medical Assessment Report

The examining Doctor(s) should provide a report to the Social Worker and where requested to the Police Vulnerability Unit within 72 hours of the examination as per national guidelines. The findings should be shared with parents/carers by the paediatrician at the time of assessment unless to do so would place the child at significant risk. The timing of any letters to parents should be determined in consultation with CSC and the Vulnerability Unit. Consideration must be given to the language used and its anticipated audience.

The report should follow Paediatric Medical Assessment report template and include:

  1. Date, time and place of examination;
  2. Those present;
  3. Who gave consent and how (child/parent, written/verbal);
  4. A verbatim record of the carer’s and child’s accounts of injuries and concerns, noting any discrepancies or changes of story;
  5. Listing of all marks/injuries indicating their site, size, shape and colour
  6. Documentary findings in both words and diagrams;
  7. Summary;
  8. Opinion;
  9. Follow up if indicated.

Flowcharts:

Managing Allegations of Sexual Abuse including Suspected Female Genital Mutilation (FGM)

Useful Guidance Pathway Tools, Contacts and Websites:

  1. Royal College of Radiologists, Royal College of Paediatrics and Child Health. Standards for radiological investigations of suspected non-accidental injury. 2008.
  2. Paediatric Assessment Referral Form for children subject to a child protection plan for neglect 
  3. Supervision of Parents/Carers of Children and Young People in Hospital
  4. Framework for information Collection and Assessment of a Child for whom there are concerns about Abuse
  5. Flow Chart for All Day Time Safeguarding Medical Assessment Requests