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1.8.3 Child Protection Medical Assessments: Bedfordshire Protocol

SCOPE OF THIS CHAPTER

The areas covered by this protocol are: Bedford Borough Council and Central Bedfordshire Borough Council. Due to geographical considerations, some Bedfordshire children will need to be assessed by the paediatricians in Luton. Local Authorities who need this service from Luton will need to consult the Luton Child Protection Medical Policy.

Providers - South Essex Partnership Trust Community Services, Department of Community Paediatrics, Bedford General Hospital.

This does not cover acute sexual abuse/assault cases where forensic sampling is needed nor cases of historic sexual abuse. For this please refer to the SARC protocol.

Enquiries about this service to:

  1. Dr. Rishi Arora, South Essex Partnership NHS trust;
  2. Dr. Oseiwa Kwapong, Bedford General Hospital NHS Trust.

This chapter was added in November 2016.


Contents

  1. Introduction
  2. Roles of Community Paediatric and Hospital Paediatric Teams
  3. Nature of Child Protection Medical Assessment
  4. Referral Procedure
  5. Out Of Hours, Bank Holidays and Weekends
  6. Genito-urinary management

    References / Bibliography


1. Introduction

Liaison will be needed between partner agencies in those cases when children are referred to Children’s Services Social Care (CSSC) or the Police, with concerns relating to any form of abuse or neglect and a specialist medical opinion is required to:

  • Perform a medical evaluation of signs of abuse or neglect. These need to be at a forensic standard (i.e. precise) to provide evidence in investigation for abuse and neglect. It must be borne in mind that some of these cases may become the subjects of a legal proceedings;
  • 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.

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, or as a result of an undiagnosed medical condition.

General Guidance for all cases where ‘bruising’ is a feature:

  • Only 0.6% babies who are not crawling (under 6 month age) have accidental bruising.
    Less than 1% of children who are not walking have accidental bruising;
  • Accidental bruising observed in children who are not walking is very rare and for those who are not yet crawling, it is even more rare. Therefore, Professionals should exercise a high level of suspicion when seeing bruising on children in these age groups. It is strongly advisable to seek a specialist opinion or refer to Childrens Social Care or the police in such cases; the old adage is that ‘if you don’t cruise, you don’t bruise’;
  • In all ages where bruising raises a suspicion of abuse or neglect, a specialist opinion must be sought from a Paediatrician skilled in this area. Opinion from a child’s GP cannot be a substitute for this. Access to a Child Protection Medical Assessment (CPMA) is ideally done through referral to the investigating agencies (children social care or the police and in some cases the NSPCC).

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, or in a case where a second opinion may be needed before making a referral for child protection. Examples may include 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 and Hospital Paediatric Teams

Community Paediatricians at the Child Development Centres (Hill Rise and Union Street) will undertake this assessment for all forms of abuse, including neglect; the exception is for alleged sexual abuse, whereby medical examinations are undertaken by specialist professionals at the Sexual Assault Referral Centre (SARC). The paediatricians work during normal working hours.

Paediatricians at Bedford Hospital are able to undertake medical examinations for physical abuse and neglect but not for child sexual abuse. For sexual abuse examinations and for cases of FGM there are separate pathways. The arrangement in place is that Bedford Hospital paediatricians will cover for all non-mobile children i.e. up to the age of two years and for 'out of hours' examinations for older children when it is deemed essential for the examination to be done urgently and “out of hours”, and provide opinion on cases of suspected physical abuse but not sexual abuse (Refer to para 5.3.1 & 5.3.2). However, they will still be able to offer management of acute medical or surgical problems associated with any form of abuse, including observation where needed.

Examination for suspected sexual abuse where forensic sampling is needed, are outside the scope of this procedure. They are dealt with under the SARS protocol with the police leading the process.


3. Nature of Child Protection Medical Assessment

3.1 A medical assessment is based on a combination of history, physical examination, investigations when deemed to be necessary, and for observation. These are necessary to formulate an opinion about neglect or abuse from a forensic (precise evidence) perspective. It will consist of eliciting evidentially weighted and precise information in nature and associated 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 with the appropriate professionals and instigated.
3.2 An examination for sexual abuse cannot be undertaken by the paediatricians. This service is currently undertaken by Mountain Health Care. There is a separate flow chart for this process.


4. Referral Procedure

4.1 Sources of Referrals

Referrals are accepted from various professionals, but predominantly from childcare social workers, police and sometimes from health professionals (GPs, HV, SN, and Hospital Doctors etc).

4.2 Normal Working Hours (Monday To Friday, 09.00hrs Till 17.00hrs)

All referrals should be made to:
Bedfordshire
Union Street Clinic
Bedford
Tel: 01234315818 (Child Protection Medicals number)

4.2.1 Referral mode

Referral by phone is acceptable where you will be asked to complete a referral form. The medical secretary will take some details and consult with the doctor on call. She or he will come back to the referrer with an appointment time. Any directly relevant documents, such as notes of a Strategy Discussion if available, should be brought to or faxed to Union Street, to be shared with the doctor at the time of examination. The referrer should telephone to advise of a fax being sent and to ensure that any information faxed has been received.

4.2.2 Presentation for appointment

Referred by Social Worker / Police – it is expected that 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 inform the examining doctor 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. If the referrer is not attending with the child, 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. All children will need to be brought to Union Street or Child Development Centre, Kempston by 15.30 at the latest. Usually an appointment will be given at the time of referral.

4.2.4 The Examining Team

A team of community paediatricians operate from Union Street and the CDC at Kempston undertakes a range of paediatric work. Part of their work involves Child Protection Medical Assessments. These are available daily with two appointments per day in the afternoon.

4.2.5 Waiting time

At the Union Street and CDC, 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 Union street team are advised of possible referrals early in the day to facilitate planning 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 if considered urgent. Referring agencies will need to appreciate that whilst an appointment time is given for hospital paediatric assessments, there may be a delay if the consultant is otherwise involved in treating a sick child. Clinical priority will have to be given to sick children.

4.2.6 Outline of examination procedure

Doctors recognise that it is often a very stressful time for children and their carer/s, and therefore they collectively try to make the whole experience as stress free as possible. All 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.

4.2.7 Follow up examination or referrals

Arrangement for follow up examination or referral to other services should be discussed and agreed with the accompanying social worker or police as such children may be cared for at a different location after initial examination.


5. Out Of Hours, Bank Holidays and Weekends

5.1 Referral

Referrals should be made to the Paediatric Team at Bedford General Hospital by telephone (01234 355 122) asking the operator (switch board) to ‘bleep’ the Paediatric Registrar on call. Arrange the details of the examination with the Registrar. Children should not be brought to the Emergency Department (Accident & Emergency) unless there is a medical need for treatment ahead of any Child Protection Medical.

A Range of services are available at the hospitals 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, where signs of injuries may be lost due to the passage of time e.g. bruises fade away, while waiting for the next available community paediatric appointment;
  • Any medical emergency, e.g. extreme starvation or 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;
  • For observation in mutually agreed circumstances.

5.2 Consent

The medical team will need consent from an adult with parental responsibility to allow the clinician to carry out a physical examination. It is the duty of the social worker to facilitate this consent. The clinician has the right to delay or refuse to carry out the examination, if s/he is not satisfied with the quality of the consent. In the case of children deemed to be Gillick competent, the child may consent to the examination.


6. Genito-urinary management

There is an established pathway with the GUM clinic in the Luton and Dunstable Hospital for management of children needing this service if it is needed.


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 2015.

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