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Comprehensive Medical Assessment (CMA)
It is important to note that the planning meeting or discussions may lead to a joint decision that no further investigation is required or that a "Comprehensive Medical Assessment" (or other form of medical intervention) is required before that decision can be made. In some situations presenting to health professionals the child may have already had a medical evaluation through direct presentation to the Accident and Emergency department, or to the general practitioner's surgery.
The role of doctors in this comprehensive medical assessment is detailed in Chapter 8.
Immediate Management
In situations where the child's immediate clinical condition is causing serious concern, the child should be referred immediately to the appropriate local hospital for emergency care. Where the primary care team have suspicions that the child has been deliberately injured they should make a clear request to the receiving senior clinicians to initiate child protection procedures and alert the local social work service.
In situations where the general practitioner is unsure whether the clinical presentation is due to abuse or illness, for example in a child with unexplained severe bruising which could be due to a haematological condition, referral to the hospital for a second opinion prior to initiating inter-agency discussions may be indicated. This would not be regarded as the formal planning meeting or discussion but a request for a paediatric second opinion. It is important that the primary care team provide the hospital paediatricians with any available social background and previous medical history, which may suggest that the differential diagnosis of abuse is possible.
It is also important for clinicians to note carefully any explanations given for injuries and be aware of giving away information to possible abusers about the medical causes for injuries, so that these explanations can then be incorporated by possible abusers into later explanations and statements given by them.
The child should be kept appropriately informed of the medical findings and should be supported throughout the process.
Once child protection inquiries are under way, the progress of the health component will take place in parallel to other aspects of the police and social work enquiries. It is therefore fundamental to the success of the process that health professionals ensure that their colleagues in other agencies are kept closely informed of their progress and findings, including their provisional conclusions so that decisions particularly relating to the child's immediate protection from further harm may be made appropriately. Medical staff should keep careful notes of any examinations and findings and provide written reports of these at an early stage to the police and local authority if the child's case is the subject of court proceedings or a Children's Hearing.
Health Staff Involvement in Child Protection Case Conferences
A Child Protection Case Conference (CPCC) may be called by the social work service at the conclusion of inter-agency child protection inquiries to gather all relevant information from the involved professionals and make an assessment of the probability that abuse or neglect has occurred and of the ongoing risk to the child and any siblings. In order to achieve this effectively it is vital that health professionals in the primary care team and any other medical or health staff involved in inquiries attend to describe and interpret medical findings and relevant background information. It may also be relevant for the health professionals involved in the secondary care of the child to attend.
Health professionals must be prepared to be open and honest about their views even in the presence of the parents who may also be their patients. Appropriate training, information and support to professionals in this aspect of their work should be made available. In some situations the practitioners may wish to be accompanied by a more senior member of staff but in general only those actively involved with the child and family should attend. Health professionals should normally provide written reports of their involvement and any assessment and findings to the child protection case conference.
A Child Protection Case Conference may have a number of objectives; it will undertake some or all of the following tasks:
The Child Protection Case Conference is the mechanism for deciding that a child's name be placed on the local authority Child Protection Register. Any agency or professional may ask for such a conference but the social work service is responsible for its organisation.
The removal of a child's name from the register offers agencies more flexibility (see Protecting Children - A Shared Responsibility paragraph 3.10 page 22), but support may still be needed.
Children and Parents' Involvement in Child Protection Case Conferences
Professionals should actively seek to develop partnerships with parents and be honest and sympathetic towards parents, but without losing sight of the child's needs. Parents may need to bring someone to support them when they attend a case conference and written information about child protection case conferences should be made available to children and parents, in the form of local leaflets or national public information.
Case conferences should take account of children's views and feelings, having regard to their age and understanding. Whenever children are able to express their wishes and feelings and are able to contribute to assessment, planning and review, they should be invited to attend the case conference, if this is consistent with their welfare. The child should also be told that he or she can ask for someone to be present for support at the conference. If a child does not wish to attend, or if this is inappropriate, the professionals working with the child should make sure that the conference has information, in writing, about his or her views. The keyworker should make sure that the child knows about the plans for him or her.
The Child Protection Register
The Child Protection Register is maintained by the social work service. It is held separately from agency records or case files, in secure conditions. The social work service appoints a person to maintain and manage the Child Protection Register - generally known as the Keeper of the Child Protection
Register. The Keeper of the Register should make sure that all agencies know how to obtain access to information from the Register at any time. There should be 24-hour access to the Register for all professional staff who need to make an enquiry about a child as it provides a central point of rapid inquiry.
The Scottish Executive Children and Young Persons Group maintains a list of current Keepers of Child Protection Registers in Scotland, and contact points for Child Protection Registers in other parts of the UK. (Telephone Number: 0131 244 5486). All professional staff should notify the Keepers of local Registers of any changes in the details about children named on the Register.
When a health professional makes an inquiry of the Register by telephone, the Keeper will confirm the person's identity by calling them back at their place of work, before giving out information. The inquirer should be given the name, office address and contact telephone number of the child's keyworker, so that the inquirer can obtain relevant information directly. If the child about whom an inquiry has been made is not registered, but has the same address as another child named on the Register, the inquirer should be given the same information about the keyworker. In such circumstances the Keeper should also contact the keyworker to find out if there is a need to revise registration information, or for the local authority to make further inquiries. Where the keyworker is unlikely to be available, for example out of office hours, the social work service should make arrangements for minimum information to be disclosed directly to inquirers at the point of inquiry.
A note should be kept of all inquiries. The Keeper is responsible for notifying other local authorities of the need to transfer records when a family/child moves into, or out of, their area. The Keeper will also be responsible for attempting to trace a registered child whose whereabouts becomes unknown (see page 24, Missing Families on the Child Protection Register).
Consideration should be given to the automatic flagging of records pertaining to young children who are on the Register when accessing health services, especially accident and emergency services.
The decision to place a child's name on the Register should be taken by a Child Protection Case Conference, or the chair of the conference, when there are reasonable grounds to believe or suspect that a child has been suffering abuse or neglect, or the child is at risk of suffering abuse or neglect, and an inter-agency agreement is needed to protect the child. A child's name should be placed on the local Child Protection Register when:
The following minimum information about a registered child should be recorded:
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Outcome of the Child Protection Case Conference
Where child abuse or neglect is confirmed or strongly suspected and the child's name placed on the register, the CPCC will also put together a Child Protection Plan and appoint a keyworker.
Health professionals should make their views on the proposed plan clearly known and should ensure that appropriate colleagues are aware of the tasks or actions required. If they should subsequently find themselves unable to fulfil the agreed plan they must immediately alert their manager and the social work services.
All attending health professionals should receive the case conference minutes and must check these carefully, alerting social work to any errors and ensuring that, in particular, any dissension is clearly minuted.
Where a decision is made by the CPCC to refer the child on to the Reporter further written reports may be required.
Where it appears that information about the mental health of a family member may be relevant to considering the well-being of the child, a psychiatrist or other member of the mental health service should be invited to attend or give written advice, as appropriate.
Child Protection Plan
When the decision has been made to place a child's name on the Register, the Case Conference will proceed to draw up a Child Protection Plan identifying the services and appropriate support which will be required in order to protect that child and the ways in which that child's well-being will be monitored. Health professionals have a vital part to play in this process. Protection, treatment and other services for the child and family should be based on a comprehensive assessment of the child's and family's needs, including an assessment of the level of risk to the child. All cases in which a child's name is placed on the Child Protection Register require a comprehensive assessment. The keyworker is responsible for ensuring that a comprehensive assessment is undertaken. This is fully explained in Protecting Children - A Shared Responsibility: Guidance for Inter-agency Co-operation (1998) (pages 36-38).
These situations often provide an opportunity to complete surveillance and immunisation programmes, follow through hospital referrals such as ophthalmology or ENT appointments or treatment, as well as offering an important supervisory health role. The local authority should inform the child's parents or carers and, if he or she is of sufficient age and understanding, the child orally and in writing about the information held on the Child Protection Register and who has access to it. If a parent is concerned that information held on the Child Protection Register is inaccurate, they should be given an opportunity to discuss this with a manager in the social work service. Child Protection Committees should consider a local mechanism enabling parents to challenge decisions taken by an inter-agency Child Protection Case Conference, if they believe the decision is based on inaccurate or partial information or assessment or other objective grounds. (See 4.48 of Protecting Children - A Shared Responsibility: Guidance for Inter-agency Co-operation (1998))
When a registered child moves from one local authority to another, the child's name should be placed on the new authority's Child Protection Register pending a review case conference to discuss the child's new circumstances. The local authority in whose area the child was registered should retain responsibility for the management of the case until a review case conference has been held and arrangements agreed for the transfer of the inter-agency Child Protection Plan to agencies in the receiving local authority's area. However, the child may present to health professionals in the new area before that process is complete and health recordsshould therefore be transferred rapidly to the new area with a clear alert to the primary health care team and community child health service that a registered child has moved to their area. Procedures must be in place to facilitate this.
The transferring local authority should provide the receiving local authority with comprehensive information in writing about the registered child(ren) and their family, and should include a social and family history, minutes of the last Child Protection Case Conference and a copy, or written details, of the Child Protection Plan. If a family in which a child has previously been named on the Child Protection Register moves to another local authority area, the transferring local authority should give the receiving local authority written information about previous concerns and previous and current inter-agency involvement. Both authorities should consider together whether the family's new circumstances increase the likelihood of any risk to the child recurring, or whether the child and family may be in need of support. Health professionals in the area to which a registered, or previously registered, child has transferred should make early contact with the local social work service to find out whether there is a current Child Protection Plan and a keyworker with whom they should liaise.
Missing Families on the Child Protection Register
There should be a procedure in place which ensures that when a health professional is the first to become aware that a family with a child(ren) on the Child Protection Register disappears the senior medical and nursing personnel with child protection responsibilities are notified immediately and checks are made to ensure that all local contacts have been approached and all other action to trace the family locally has been taken. Contact with other agencies, e.g. the social work services and police should be made promptly. The enquiries made must be recorded in professional records.
If a new local address is obtained in the same Health Board, the named nurse should contact the designated or named nurse in that district, ask for it to be verified, and then make arrangements for the child's records to be forwarded as appropriate. In cases where the child or children have specific health needs or disability, the lead doctor for the child protection service should be informed so that appropriate contact may be made with paediatric services in the new area.
When the family moves to another Health Board there should always be an agreed system for the rapid transfer of all records of children whose names are on the Child Protection Register between Trusts and a Health Board and to Trusts in other Health Boards.
The Local Authority Keeper of the Child Protection Register is responsible for attempting to trace a registered child whose whereabouts become unknown.
In circumstances where health professionals have early concerns, exacerbated by the disappearance of the family, the responsibility would rest with the Health Board or Trust to make a decision on disseminating information to other Health Boards/Trusts, or other agencies about a family who have gone missing.
Section 30(1) and (3) of the Data Protection Act 1998 allows flexibility as to how the Act applies to information gathered for health and social work related functions.
Since 1 April 1999, all Health Boards, Special Health Boards and NHS Trusts have appointed a Guardian of personal health information, in order to safeguard patient confidentiality within their organisation. These Guardians will be charged with promoting the highest standards for safeguarding patient information and responsibility for developing clear rules about disclosing information to other agencies or organisations.
Personal information disseminated by Health Boards/Trusts about missing families should be clearly justified on the basis of the individual case, and subject to scrutiny by the Guardian; a mechanism should be in place to ensure this.
From the practical point of view, knowing who and how to contact personnel from within and across agencies is crucial to effective working. A contact list should be available to staff. A guide is available in Appendix F.
Decision to Remove a Child's Name from the Child Protection Register
When the professionals who are working with the child and family decide that the risk to the child has been reduced, the local authority should remove the child's name from the Child Protection Register. A decision to remove a child's name should normally be made by a review Child Protection Case Conference with representation or views from all the agencies working with the child. If an agency does not think a child's name should be removed, this should be noted in writing, in the minutes of the Case Conference which considers de-registration. Child Protection Committee procedures should describe how these disagreements may be resolved.
Removal of a child's name from the Register should not necessarily lead to a reduction or withdrawal of services or support to the child or family by any or all of the agencies. The risk of child abuse or neglect may have been reduced but the child may continue to be a child in need, and require a variety of services from any or all of the agencies to safeguard and promote his or her welfare.
Legal Measures for the Protection of Children at Risk
The legal framework for child care in Scotland has the Children's Hearings System at its heart. Any person may refer a child to the Children's Reporter. The Children's Reporter examines the case impartially and decides whether or not to refer the case to a Children's Hearing. Children's Hearings comprise volunteer lay members drawn from a local Children's Panel, who will discuss a child's difficulties with the child and his or her family and determine how best to meet his or her needs. The Hearing may make a supervision requirement placing the child under the supervision of the local authority. If the child and/or his parents do not accept the grounds for the child's referral to the Hearing, a Sheriff will hear evidence and decide whether the grounds exist. The child and the parents may also appeal against a Hearing's decision disposing of the case, or keeping the child in a place of safety on a temporary basis. A further appeal to the Sheriff Principal, or Court of Session is available to the child, the parents or the Children's Reporter. (Children (Scotland) Act 1995, Chapter 2, Sections 39-51).
In some cases local authorities must take urgent action to protect a child from significant harm. In some cases a child's parents may agree to the local authority providing the child with accommodation and looking after him or her, until concerns about the child's safety, or allegations of abuse or neglect, can be clarified. The local authority might also consider whether others in the child's extended family or social network could look after the child whilst agencies carry out further inquiries or assessment. However in some cases the risk of significant harm befalling the child may make it necessary for agencies to take legal action for his or her protection. Any person may apply to a Sheriff for a Child Protection Order (CPO) (Section 57 Children (Scotland) Act 1995), or the local authority may apply for an Exclusion Order (EO) (Section 76 Children (Scotland) Act 1995). The CPO authorises the applicant to remove a child from circumstances in which he or she is at risk, or retain him or her in a place of safety. The EO requires the removal of a person suspected of harming the child from the family home. A Justice of the Peace may also, in certain circumstances, authorise the removal of the child for a short period if a Sheriff is unavailable and, in limited circumstances, a police constable may take the child to a place of safety (Section 61 Children (Scotland) Act 1995).
The responsibility to take any urgent action to protect a child rests with the local authority within whose boundaries the child is located when such action is deemed necessary, even if the child does not normally live within that local authority's area. Other agencies or professionals may need to apply to a Sheriff for a CPO or to a Justice of the Peace, where a Sheriff is not available, for authority to remove a child where emergency protection is necessary. Any health professional contemplating such action should contact the local authority social work service for advice. If a local authority or any other person is considering emergency action to protect a particular child, the need for similar action to ensure the safety of any other children in the household should be considered at the same time.
The Children (Scotland) Act 1995 also makes provision for the local authority to apply for a Child Assessment Order (CAO) if it has reasonable cause to suspect that a child may be suffering or is likely to suffer significant harm and the parents or carers are refusing to allow the local authority to see the child (Section 55 Children (Scotland) Act 1995). The CAO requires the parents or carers to produce the child and to allow any assessment needed to take place to help professionals to decide whether they should act to safeguard the child's welfare. The authority may ask, or the Sheriff may direct, someone else such as a GP, paediatrician or psychiatrist to carry out all or any part of the assessment. Professionals must assist in carrying out these assessments when asked to do so and local procedures should make provision for this.
More detailed guidance on the provisions in the 1995 Act is contained in Scotland's Children: Children (Scotland) Act 1995 Regulations and Guidance - Volume 1 Support and Protection for Children and their Families.
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