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Child Protection Medical Assessments: Luton and South Central Bedfordshire Protocol

SCOPE OF THIS CHAPTER

The areas covered by this protocol are: Luton Borough Council & South Central Bedfordshire (Dunstable, Houghton Regis & Leighton Buzzard) part of Central Bedfordshire Council.

Providers – Cambridgeshire Community Services, Department of Community Paediatrics (Edwin Lobo Centre) and Luton & Dunstable University Hospital NHS Trust

Named professionals:

Dr Adele Humphrey, Consultant Community Paediatrician, Named Doctor for Safeguarding Children, CCS

The Edwin Lobo Child Development Centre
Redgrave Gardens
Luton
LU3 3QN

Tel: 01582 700 300 or 345 924

Dr Vana Gandhi, Consultant Paediatrician, Named Doctor for Safeguarding Children, LDUH

Luton & Dunstable University Hospital
Lewsey Road
Luton
LU4 0DZ

Tel: 01582 496 699.

(For Bedford & Rest of the Central Bedfordshire see Child Protection Paediatric Examination (Bedford CCG, Bedford Community and Bedford Hospital Procedure)).

AMENDMENT

In October 2017, an updated version of Appendix 2: Multi-Agency Referral Pathway for Child Protection Medicals for children 0-18 years living in Luton or Central Bedfordshire (South) was added and an addition of Appendix 4: Child Abuse Medical Pathway .


Contents

  1. Introduction
  2. Referral Procedure for Child Protection Medical Assessment

    Appendix 1: (Procedure for Joint GUM & Paediatric CP Medical Assessment)

    Appendix 2: Multi-Agency Referral Pathway for Child Protection Medicals for children 0-18 years living in Luton or Central Bedfordshire (South)

    Appendix 3: Bedfordshire and Luton - Suspected Cases of Sexual Abuse, Child & Young Person Pathway Acute (up to 3 weeks)

    Appendix 4: Child Abuse Medical Pathway


1. Introduction

In some cases when children are referred to Children's Social Care or the Police with concerns relating to any form of abuse or neglect, a Child Protection Medical Assessment (CPMA) and specialist medical opinion is required to:

  • Perform medical evaluation and documentation of signs of abuse or neglect to provide evidence in the child protection investigation and in some cases for subsequent legal proceedings;
  • Identify unmet medical or developmental needs;
  • Analyse known medical or developmental concerns and interventions in the context of abuse & neglect and advise on their significance;
  • Contribute to a multi-agency management plan.

Although cases can present with a variety features, bruising is the most frequent presentation (either as suspected physical abuse or mixed forms of abuse or neglect).

Refer to Management of Bruises, Bites and Suspicious or Unexplained Marks on Children.


2. Referral Procedure for Child Protection Medical Assessment

The following procedures are in line with Appendix 3: Bedfordshire and Luton - Suspected Cases of Sexual Abuse, Child & Young Person Pathway Acute (up to 3 weeks).

The strategy discussion and decision on the need for a child protection medical should always involve a health professional, preferably the on-call community paediatrician if available (see below). This will also ensure that the child is assessed in the most appropriate setting.

2.1 Normal Working Hours

Referral to the Edwin Lobo Centre (Community Paediatrics)

The Edwin Lobo Centre is open Monday To Friday 9am to 5pm (except bank holidays).

In order that medical assessments can be completed by 5pm, the latest appointment time offered is 4pm.

The on-call community paediatrician can be contacted for advice during normal working hours up to 5pm on 01582 345945 and can liaise with the paediatric team at the Luton & Dunstable Hospital if necessary if it is more appropriate for the child to be seen in hospital. If the child cannot be seen at ELC on the day it may be possible to arrange the examination for the following day (rather than referring to the hospital out of hours) if the child is considered to be in a safe place overnight. All such cases should be discussed with the on-call doctor.

Note: Hospital admission will be required if the child is unwell and/or requires urgent medical/surgical treatment - for severe physical injuries, head injuries requiring neuro-imaging (including all infants under 1 year with suspected abusive head trauma), severe neglect or acute sexual assault.

The ELC no longer provides medical assessment for suspected sexual abuse. Sexual abuse referrals should be made directly to Bedford SARC (Emerald Centre).

Waiting in premises after hours: It is important to note that ELC closes at 5pm and It will not be possible to wait in the premises once the examination has been completed and feedback has been given by the paediatrician. Should the child require an urgent removal from the home, the premises cannot be presumed “a temporary place of safety” for the child while arrangements are made and must be vacated.

Referral mode

Referrals from Children’s Social care to the Edwin Lobo Centre for a Child Protection medical examination must be made electronically using the ELC referral form to the secure email address (see below). The referral form should be completed as thoroughly as possible and if strategy meeting minutes are available these should be attached. It is particularly important to provide details of any previous surnames of the child, correct date of birth, person(s) holding parental responsibility and the person who will be providing written consent for the examination. Once the referral has been sent via the secure email, it is essential to inform the ELC team immediately by phone on 01582 345945 to ensure that this has been received. Failure to do this will result in delay in the referral being processed which may not allow sufficient time for an appointment to be made on the day. The referral will then be passed on to the on-call paediatrician to agree a time for the medical appointment as appropriate. The paediatrician may need to contact the referrer for additional information or further discussion of the case.

Referral by health professionals – If a child is suspected to have suffered harm and a child protection medical assessment is required a referral should be made to the Social Care Rapid Intervention and Assessment Team who can refer to the ELC as above. Health professionals may contact the on call doctor or Named Doctor for advice about a referral if required.

Contact details:
The Edwin Lobo Child Health & Development Centre
Redgrave Children & Young People’s Centre
Redgrave Gardens
Luton
LU3 3QN

Tel (reception): 01582 700300
Child Protection referral Tel: 01582 345945
Fax: 01582 346013 (Safe Haven)
Email: CCS-TR.ELCCPMedicals@nhs.net

Presentation for appointment

All children will need to be brought to the Edwin Lobo CDC by 4 pm at the latest. Late arrival may result in the appointment being rescheduled.

A social worker and/or police officer who knows about the case is expected to accompany the child to the appointment. The attending professional must be sufficiently knowledgeable to provide full details about the case. The parent/carer should be present wherever possible to provide informed consent (see below) for the examination and to provide the medical and developmental history on the child (to ensure holistic assessment).

Interpreting services: It is the responsibility of the referrer to arrange for an interpreter where this is required. It may not be possible to assess the child if an interpreter is required but not present.

Consent

Child protection medical assessments will only be conducted when there is written informed consent to do so. It is expected that the parent(s) or other person who holds parental responsibility (PR) will attend the assessment to give written consent, or the child/young person may give written consent if they have the capacity to do so. If the parent(s) or person holding PR is unable to attend and the child/young person does not have capacity to consent, the social should seek to obtain written consent beforehand, or ensure that the parent/guardian is available by telephone for discussion with the examining doctor. In exceptional circumstances, for example if the parent cannot be contacted or refuses consent and the examination is deemed essential to safeguard the child, the social worker or police must provide written consent for the examination to take place. Written consent is also sought for the use of photography and other investigations where appropriate. (Note: ELC Consent Form 2 for social workers/police can be obtained electronically from the Edwin Lobo CDC in advance if required).

Medical Personnel

Child Protection Medical Assessments (for children living in Luton and South Central Bedfordshire) are carried out by the experienced team of community paediatricians at The Edwin Lobo Centre on a rota basis. Due to general clinical commitments, most CP medicals take place in the afternoon, however on some days morning assessments may be possible. The majority of examinations take place on the day of referral when appropriate. Examinations may be carried out by two doctors where appropriate or by a doctor plus a chaperone. On some occasions a trainee paediatrician may be present, observing or assisting in the case, for which consent is obtained where appropriate.

Outline of examination procedure

The ELC medical and supporting staff members are trained to handle this aspect of work sensitively. The requirement and nature of the medical assessment are explained to the parent/carer/child/young person and written consent is obtained. Information regarding context and background information is obtained initially from the accompanying social worker and/or police. The history of the case is obtained from the parent/carer(s) where present. Information is taken from the child in a sensitive manner, avoiding leading questions if developmentally appropriate. The assessment consists of interpretation of available historical data, observation of child and child-carer/parent interaction, an estimation of development (in younger children) and comprehensive physical examination. If the child/young person refuses or resists examination despite reassurance, this will not be pursued, however examination at a later date can be considered if required/appropriate.

Photo-documentation

It may be necessary for the examining doctor to photograph any injuries seen and any images taken will form part of the child’s medical records. This may be arranged through the hospital medical photography department Photographs may also be used to obtain a second opinion, for peer review and training purposes and for submission as evidence in court. Written consent will be obtained in all cases. In some cases the examining doctor may request that photographs are taken by the police.

Medical reports

Findings and provisional opinion are conveyed orally to the social worker at the conclusion of the medical examination followed by a written report usually within 3 working days. In cases where findings are not clear, a second opinion may need to be obtained before forming a final conclusion. It is therefore possible that the conclusion in the written report may differ from the initial medical opinion given at the time of assessment.

Other medical assessments

Paediatric Assessments - These are often conducted on a planned basis in cases of chronic neglect (with or without other forms of abuse) where more complex medical issues may be involved. It involves a more in-depth medical assessment of health, developmental, medical and environmental factors in the context of suspected chronic abuse or neglect and how it impacts on the child.

2.2 Out of Hours, Bank Holidays and Weekends

Service provided by the Luton & Dunstable University Hospital

Referral mode

Referrals should be made to the on-call paediatrician at the Luton & Dunstable Hospital by phone on 01582 497401 or bleep 733 via switchboard on 01582 491166). Arrangements for seeing the child will be made over the phone. Children should not be taken to the Accident & Emergency Department without prior discussion with the on-call paediatrician.


Appendix 1: (Procedure for Joint GUM & Paediatric CP Medical Assessment)

Protocol for Joint GUM & Community Paediatric Examination in Children referred for suspected STI (Sexually Transmitted Infection) & concern about sexual abuse

Description: This protocol is for examination of children referred with symptoms of sexually transmitted infection where there is concern about possibly possible sexual abuse. Originally operational since March 2004, reviewed in October 2008 and operational since January 2009.

Covers children and young people under the age of 18.

Principle

Sexually transmitted infections (STI) have varying levels of significance in relation to sexual abuse of children, some are more strongly associated with sexual abuse, others less so. Where presence of STI alone may not be enough to prove sexual abuse and hence safeguard a child, simultaneous finding of medical signs of sexual abuse makes the case evidentially stronger and reported in our publication (ref 1). This protocol addresses both aspects of management - medical and child protection.

Background

It was developed through a series of multi-disciplinary and multi-agency meetings including GUM, Community Paediatrics, Microbiology, Police & Luton Social Care and reviewed in 2008 by Consultant in GUM & Consultant Community Paediatrician.

Referral

Referral can be made by a hospital doctor, a GP, or a nursing colleague who is concerned that presenting symptoms of genital or anal infection may be due to sexual abuse. Referral should be made to the Consultant Community Paediatrician who is on call on the day for child protection over the phone (Tel: 01582 700300) followed by a faxed referral for processing (Fax: 01582 700299). It may take a few days to organise.

Where a child is already known to a social worker or the police and there is such concern, a referral can be made to the Edwin Lobo Centre as any other case of child protection. If other agencies e.g. education or school are concerned, they could either access this service through the GP or if sexual abuse perceived to be more probable, through children's social care or the police.

Health Professionals dealing with children in the community

Any child with ano-genital symptoms or signs of STI should be carefully evaluated both for medical signs and socio-environmental factors. If there is need for specialist opinion on medical grounds alone (no concern about abuse or welfare), a referral need be made to the secondary care discipline of suitable for the case (Paediatrician in hospital, GUM Specialist or Dermatologist) depending up on clinical situation.

However, if there is suspicion of any form of abuse or neglect or if there is welfare concerns, it should be referred to The Edwin Lobo Centre (ELC) for a joint medical examination between a community paediatrician and a GUM specialist.

Secondary Healthcare Professionals dealing with children

Any specialist doctor during the course of dealing with such cases discovers that the organism grown has higher specificity for sexual transmission and hence raises the probability of sexual abuse, should consider -

  1. Withholding treatment and taking a fresh sample maintaining chain of evidence if that was not the case when initial sample was taken or consider referral for joint examination at The ELC after discussion with carer/s. Referral to social services needs to be made after such a diagnosis is confirmed by the laboratory;
  2. Explaining its implication to carers and the child (if applicable) and explain the process and management plan;
  3. If treatment cannot be withheld for medical reasons, then having explained the child protection implications to the carer/s a referral to children social care should be made;
  4. Cases of ano-genital warts are pretty obvious clinically (without virological studies) and may be considered for joint examination at the outset under some circumstances.

Joint Examination

  1. Venue: These examinations will normally be conducted at the ELC;
  2. Objective: Simultaneous examination for medical signs of sexual abuse, evidence of other abuse (physical, emotional or neglect), clinical examination for STI, collection of appropriate biological samples maintaining chain of evidence, transportation of the samples to the laboratory. Treatment of the condition, support to the child and the carer/s and appropriate follow up. Taking measures to safeguard the child where indicated by referral to the children's social care or the police;
  3. Conduct of examination:
    1. Explain to the child and carer/s the nature and conduct of examination, including use of colposcope if applicable.
    2. Obtain their consent for examination and photo documentation;
    3. Discuss the findings after examination and discuss the management plan;
    4. Examination: As for examination for sexual abuse (Community Paediatrician).
      Examination for STI, obtaining appropriate samples and transporting these to the laboratory maintaining chain of evidence up to that point. Treatment and follow up (GUM Specialist).

References/Bibliography:

  1. Child sexual abuse and sexually transmitted infections: review of joint GUM & paediatric examination practice. Kawsar, Long & Srivastava; International Journal of STD & AIDS; 2008; 19: 349 - 350;
  2. National guidelines on management of suspected sexually transmitted infections in children and young people. BASHH website;
  3. RCPCH Child Protection Companion;
  4. RCPCH Physical signs of child sexual abuse 2008.


Appendix 2: Multi-Agency Referral Pathway for Child Protection Medicals for children 0-18 years living in Luton or Central Bedfordshire (South)

Click here to view Multi-Agency Referral Pathway for Child Protection Medicals for children 0-18 years living in Luton or Central Bedfordshire (South).


Appendix 3: Bedfordshire and Luton - Suspected Cases of Sexual Abuse, Child & Young Person Pathway Acute (up to 3 weeks)

Click here to view Bedfordshire and Luton - Suspected Cases of Sexual Abuse, Child & Young Person Pathway Acute (up to 3 weeks)


Appendix 4: Child Abuse Medical Pathway

Click here to view Appendix 4: Child Abuse Medical Pathway.

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