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Contents

1. Introduction
2. Roles of Community Paediatric and Hospital Paediatric Teams
3. Nature of Child Protection Medical Assessment
4. Other Forms of Medicals in Social Care Context
5. Referral Procedure
6. Medical Examination Following Acute Sexual Assault
7. Medical Examination When Sexual Abuse is Suspected in a Child Presenting With Possible Sexually Transmitted Infection
   
   Appendix: 1 (Procedure for CP Medical Assessment)

1. Introduction

In some cases when children are referred to Children's social care (CSC) or the police with concerns relating to any form of abuse or neglect, specialist medical opinion is required to:

• Identify unmet medical or developmental needs
• Identify a management plan
• Analyse known medical or developmental concerns and interventions in the context of abuse & neglect and advise on their significance
• Examine and assess to provide evidence for statutory, civil or criminal proceedings as required.

This service is denoted here as Child Protection Medical Assessment (CPMA).

In addition, a CPMA may be requested by health professionals where a child protection concern may arise solely from the medical presentation in a case where a second opinion may be needed before making a referral as child protection. Foe example a suspicious bruise without any allegation, a suspicious anal or genital sign discovered during the course of a routine medical examination for constipation or genital soreness without allegation etc.

2. Roles of Community Paediatric and Hospital Paediatric Teams

A well qualified, specifically trained and experienced team of Community Paediatricians based at The Edwin Lobo Child Health & Development Centre (ELC) undertake this assessment during normal working hours.

For the medical assessment of alleged sexual abuse, the ELC is equipped with a Colposcopic facility, which provides magnification, illumination and image capture for a second opinion when needed without the need for a repeat medical examination.

Paediatricians at the Luton & Dunstable Hospital are trained to undertake  medical examinations for child abuse and neglect but not for child sexual abuse. Therefore, the arrangement in place is that hospital paediatricians will cover for all 'out of hours' examinations and provide opinion on cases of suspected physical abuse but not sexual abuse (Refer to para 5.3.1 & 5.3.2).

However, hospital paediatricians will manage cases requiring medical investigation, medical treatment and observation where sexual abuse is suspected out of hours and can not weight until next working day. Where an 'out of hours' forensic sampling or medical opinion is required, the police should instruct their own forensic medical practitioners. In non-urgent cases, the Community Paediatric Team will undertake this examination during normal working hours.

3. Nature of Child Protection Medical Assessment

3.1	A medical assessment is based on a combination of history, examination, investigation when needed and observation to formulate an opinion on the presenting problem from a forensic perspective. It will consist of evidentially weighted precise nature of the findings, In addition, attempts are made to assess for other forms of abuse or neglect which may co-exist. However, if there is an indication of sexual abuse from a non-genital examination (e.g. bruising or bite to thighs or buttock), an examination for sexual abuse will not be undertaken without the approval of the investigating professionals and the agreement of the child and carers as appropriate. Where a medical treatment, review or further referral for emotional support is needed these will be discussed and instigated.
3.2	An examination for sexual abuse is not an internal examination unless specifically indicated, in which case it will be explained and further consent sought. The examination consists of an external examination of genitalia and the anal area when tissue changes are identified.  A Colposcope maybe used. The Colposcope, which is basically a microscope, provides magnification, illumination and facility for image capture. This can be used where a second opinion or peer review is required.
3.3	A joint examination with a Genito Urinary Specialist maybe arranged on a planned basis. This usually takes place within a week for cases with a sexually transmitted infection with suspicion of sexual abuse (Appendix 1).

4. Other Forms of Medicals in Social Care Context

	In addition to a CPMA, the following medical examinations, opinions or assessments are also conducted which are at the ELC which may be confused with the CPMA:-
4.1	Looked After Child Medical - This is a medical assessment provided to Children Looked After by the local authority. This is a comprehensive medical assessment to ensure well being and health and not a CPMA. Where abuse or neglect is identified, a specialist evaluation will be needed. The examining doctors have the option to either refer for a Child Protection Medical Assessment or undertake the full CPMA if  they have the competencies needed.
4.2	Adoption Medical - This is a comprehensive assessment which may not pick up on the subtle features of abuse or neglect. Where abuse or neglect are factors, always refer for a Child Protection Medical Assessment.
4.3	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. The assessment may not necessarily cover examination for sexual abuse however, if the examining doctor perceives the need, it will be discussed and planned. It involves a more in-depth medical assessment of health, developmental, medical and environmental factors, ascertain how much is due to abuse or neglect and how it impacts on the child. It is often requested by the social worker to inform their core assessment, independent chair of the child protection conference, legal team or the family courts.
4.4	Examination and opinion by a GP or other medical professionals. An initial description of medical signs (e.g. bruise) described by a GP at the time of a referral to CSC or the Police would not automatically constitute specialist medical opinion, unless the doctor or other medical professional has the  requisite training and has been practicing in that field.

5. Referral Procedure

5.1	Sources of Referrals
	Referrals are accepted mainly from childcare social workers, police and some times from health professionals (GPs, HV, SN, and Hospital Doctors etc).
5.2	Normal Working Hours (Monday To Friday, 09.00hrs Till 17.00hrs):
	All referrals should be made to - The Edwin Lobo Child Health & Development Centre (ELC), 633 Dunstable Road, LUTON LU4 8QR. Tel: 01582 700300. Fax: 01582 700299.
5.2.1	Referral mode - Referral by phone is acceptable. The Receptionist will take some details and consult with the doctor on call. She or he will come back to the referrer to give an appointment time. Any directly relevant document should be faxed to us in line with Data Protection principles or brought to be shared with the doctor at the time of examination.
5.2.2	Presentation for appointment - Referred by Social Worker / Police - We would expect either a social worker or police officer who knows about the case to accompany the child to the appointment. The professional must be sufficiently knowledgeable to tell us about the case as well as the status of consent by parent/carer, if they are not present to authorise the examination. Referral by health professionals - Parents/carers should be informed (unless discussed otherwise with the examining paediatrician) about the nature of the examination. The referrer should ensure that the child has attended, If not, it is the referrer's responsibility to inform investigating agencies (social care or police) of the non attendance.
5.2.3	Consent - Consent will always be sought from parents/carers if present at the time of examination and the child if appropriate. However, where the parent(s) do not accompany the child, then the accompanying police officer or social worker must state that parent/s are in agreement or if not, they must authorise the examination. Accurate recording of who provided 'consent' must be recorded. In cases of examination for sexual abuse, additional consent for use of the colposcope must be obtained or authorised. Parents/carers must be advised that it will be used for second opinion and peer review and some times for training.
5.2.4	The Examining Team - A team of community paediatricians operate from The Edwin Lobo Centre (ELC) and undertake a range of paediatric work. Part of their work involves undertaking Child Protection Medical Assessments (one afternoon a week on a rota basis). Children, on occasions, can be seen during the morning if feasible.
5.2.5	Waiting time - At the ELC there is a team of community paediatricians on call each afternoon, during normal working hours. Wherever possible, most cases are seen on the same day. It is always helpful if the ELC are advised of possible  referrals early in the day to facilitate planning in the day's schedule. During 'out of hours', where an examination cannot wait for the next day, hospital paediatricians will undertake examinations for physical abuse (see para 2 above).
5.2.6	Outline of examination procedure - We recognise that it is often a very stressful time for children and their carer/s therefore, we collectively try to make the whole experience as stress free as possible. All our medical and non-medical staffs are trained to handle this aspect of the work sensitively. The procedure is explained to the carer and child in order to allay, as far as possible, any anxiety or fears. To plan the assessment, information regarding context and points of sensitivity are obtained from the police and social worker. The history of the case is obtained from the parent(s)/carer(s) where present. Information is taken from the child without being interrogative, in order to give them the opportunity to express their views and feelings. Leading questions are not asked, especially if the child has already been interviewed. In the event that a child refuses or protests, then the examination would not be carried out. 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 examination. For a sexual abuse examination, an instrument called Colposcope is used in line with standards set by the Royal College of Paediatrics & Child Health. This is basically a microscope mounted on a stand and also attached to a recording device and a light source to give better illumination. The part being examined is viewed through it without direct contact. Joint examination with Genito Urinary Specialist will consist of taking swabs from the anal and genital area for signs of infection. It may also be necessary for sexual abuse examination by the Community Paediatrician if signs of infection are discovered during the course of the examination. During joint examination with the Police surgeons similar swabs will be taken for forensic purposes. Findings and provisional opinion are conveyed at the conclusion of examination orally followed by a written report within a week. In cases where findings are not clear, a second opinion may need to be obtained before forming a firm opinion. If this is sought internally it will take no longer than a week, external opinion will take longer.
5.2.7	Follow up examination or referrals - Arrangement for follow up examination or referral to other services should be discussed and agreed with accompanying social worker or police as such children may be cared for at a different location after initial examination.
5.3	Out Of Hours, Bank Holidays and Weekends
5.3.1	Referrals may be made to the Paediatric Team at the L & D Hospital and asking for Paediatric Registrar on call.
5.3.2	A Range of services are available at the hospital during 'out of hours'. These include - Medical attention or treatment for injuries suspected to have occurred non-accidentally; Where injuries are suspected to have occurred non-accidentally and specialist medical opinion is required at the time to safeguard the child or where signs of injuries may fade away, resulting in loss of evidence while waiting for the next available ELC appointment. Any medical emergency, e.g. starvation or non-accidental head injury etc. Suspected sexual abuse, where there is a need for medical attention or treatment for acute genital or perineal injury. This will not include a specialist forensic medical opinion. Please see para 2 above. For observation in mutually agreed circumstances.
5.3.3	Mode of referral - Referral should be made by telephoning the hospital and asking for the Paediatric Registrar on call. The details and nature of the case should be explained, if it falls within their remit, the referrer would be advised where to present, with the child.
5.3.4	Consent - Same as 5.24.

6. Medical Examination Following Acute Sexual Assault

	In cases where a child or young person is sexually assaulted within a familial setting or considered as a child protection issue rather than stranger rape and a time frame of 72 hours to obtain forensic samples has not been exceeded, the following support can be offered to the police:
6.1	Where assault occurred, for example, on a Sunday, the examination can wait until the next available ELC Service when a joint examination with Police Surgeons and a Community Paediatrician can be arranged. The Police have access to Police Surgeons and should phone the Edwin Lobo Centre (01582 700300) to engage the Community Paediatrician on call that day to co-ordinate the joint examination. The Police Surgeon will obtain forensic samples and join the Community Paediatrician in eliciting and interpreting medical signs of abuse/assault as per their expertise.
6.2	If timing does not allow for a joint examination then examination by the Police Surgeon should proceed. If a Community Paediatric opinion is still needed this can be arranged as above.
6.3	If the child was admitted to the hospital for the injuries, then again either 6.1.or 6.2 would be applicable.

7. Medical Examination When Sexual Abuse is Suspected in a Child Presenting With Possible Sexually Transmitted Infection

See Appendix 1.

Click here to view the Referral Pathway Diagram

Appendix: 1 (Procedure for 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

End