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This chapter
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Medical Staff Involved in Medical Investigation and Management
This section seeks to provide guidance on the medical assessment and evaluation of children who may have been abused or neglected, whether they present to community or hospital based staff, the school health service, the Community Dental Service, primary health care or mental health teams. It supports a framework for the medical process from referral to case conference and legal procedures and describes the facilities, equipment and personnel that need to be available.
Every Health Board must ensure that arrangements are in place to allow this guidance to be followed. This will involve the availability of appropriately trained and experienced staff who can give prompt advice to colleagues involved in the referral process and facilitate access to specialist staff and facilities. Medical staff with specialist skills in paediatrics and forensic medicine are required and in many areas these are specially trained consultant community paediatricians and police surgeons. In some Health Board areas the numbers and geographical location of cases will present particular difficulties in setting up local services. Taking into account the exacting level of medical evidence and opinion required by courts, consideration may be given to commissioning some or all of the services from another Trust or Health Board in line with the concept of managed clinical networks as identified in NHS MEL(1999)10. Models of commissioning may include:
Whichever model is commissioned it will result in an explicit and agreed framework for child protection services. This particularly applies to the need to access facilities for video-colposcopy of children, who may have been sexually abused. In determining the way forward careful consideration needs to be given both to meeting the needs of children and their families in the least disruptive way, and ensuring that staff have adequate training, experience and peer support.
In planning services for the clinical investigation of children consideration must be given to the range of other support services that may be required for their full assessment and treatment e.g. orthopaedics, ENT, ophthalmology, radiology, haematology, bacteriology and virology, including in-patient care, and access to mental health services (psychology and child and family psychiatry) in the short or long term. It is important to emphasise that the medical examination in any case of possible abuse or neglect must be a Comprehensive Medical Assessment(CMA) of the child's physical state including a full general examination, measurement of growth, and assessment of developmental status and emotional wellbeing. The examination must not be restricted to the documentation and interpretation of the alleged injuries. A Comprehensive Medical Assessment is not only crucial to ensuring the child receives any treatment he/she requires, but also to the assessment of significant harm that the child may have suffered and the degree of ongoing risk.
Consideration must also be given to the child's emotional and physical needs during what may be a protracted investigation; children may be frightened and bewildered as to what is happening to them and this should be fully explained and support may be offered by paediatric nurses and those working in special child protection units, as well as parents, if appropriate.
Careful and appropriate documentation is required to cover all aspects of the case, especially in the joint paediatric/forensicmedical examination and the subsequent reports for the courts. The use of locally or nationally agreed protocols and proformas is highly recommended to facilitate a standardisation of approach and continuity of care and some examples of case record proformas are given in Annexes H and I.
Clinical Presentation and Identification
Concern that a child may be being abused or neglected can arise from any clinical contact with a child, for example:
Other risk factors that are present in the child or family situation should be taken into consideration, such as domestic violence, substance abuse, mental health problems, disability in the child, post-natal depression and the possibility of Munchausen by proxy.
Where possible, it is good practice for the referring doctor to share his or her concerns with the parent(s) or guardians, when the doctor has decided to refer the child on to the statutory agencies (police or social work) or to a consultant paediatric colleague. Likewise, the consultant may wish to discuss progress with the family doctor. It is important to bear in mind that in some situations this action may place the child or the professional at risk. As the safety of the child is paramount, due consideration should be given to this aspect and in some circumstances it may be more appropriate to refer the child to a paediatric setting, prior to initiating a formal child protection referral.
Doctors should make sure that young people are made aware of their rights with respect to confidentiality and consent and are appropriately informed and involved during any assessments, decisions or treatments.
The issue of confidentiality of the child or parent is often a concern for the referring doctor. (See Chapter 7)
The Planning Meeting or Discussion
When any doctor considers that a child may be the subject of abuse or neglect he or she should make contact with the local social work services. If the doctor is uncertain whether abuse or neglect may be the cause of presenting injuries or symptoms he or she may wish to discuss the case with other specialist advisers, such as the local paediatrician with responsibility for child protection. This discussion may lead to an agreement that the child should be seen either for a second opinion by the receiving general paediatrician or specialist colleague to investigate and exclude an organic cause, or that referral on to the child protection processes through the Planning Meeting or Discussion (PMD) is appropriate. Responsibility for taking the timely referral forward must be agreed within this preliminary discussion, and may be made by the referring doctor where appropriate. However, depending on local arrangements and procedures, it may be appropriate for a general practitioner or community child health doctor (including school health doctors) to refer directly to the statutory organisations in cases of apparent or repeated child abuse, taking full health responsibility within the Planning Meeting or Discussion. Particular attention must be paid to the detailed forensic aspects of each case.
Appropriate advice must be available on a 24-hour basis from suitably trained and experienced hospital or community paediatricians, who have undertaken further training in child protection. These paediatricians will have the appropriate medical experience required to accept this responsibility and will be experienced in inter-agency working and therefore will participate in planning meetings or discussions with colleagues in social work and police.
The referring health professional should contact the duty senior social worker responsible for children and families services. Social workers are also available in all major hospitals during working hours. Out of office hours, local authorities provide a social work emergency service and all GP practices and hospital specialty and A&E departments should have access to the local emergency contact telephone number.
Upon receiving a child protection referral social work services will normally consult with the police. Responsibility for the investigation of the suspected criminal acts rests with the Divisional Detective Chief Inspector or his/her Deputy, who will decide which officer is allocated to the enquiry. Contact can be made directly with the appropriate Divisional Detective Chief Inspector or his/her Deputy or the local specialist police unit which deals with child abuse or sexual assault.
This Planning Meeting or Discussion (PMD) will produce a specific plan for the child protection inquiries.
Account should be taken of the maturity of the child, as well as the chronological age when planning the medical investigation.
A suitably trained police surgeon must be available at all times to discuss the plans for a joint investigation and to co-operate and take part in a joint paediatric/forensic examination where appropriate. There may be occasions where a child is presented directly to the police and is seen by the police surgeon for a medical assessment. Subsequently, if there is a single isolated injury, a fuller examination (i.e. CMA), may not be indicated. The police surgeon may also be available to give advice to paediatric colleagues on the findings at any preliminary medical assessment or examination, especially where the presentation of the case has unusual features which may or may not be the result of child abuse.
In every case of suspected child abuse or neglect a consultant paediatrician or a community paediatrician should be identified as the Co-ordinator of the ongoing medical investigation and management of the child's and family's health needs.
The Need for a Medical Assessment
A Comprehensive Medical Assessment is an essential component in the multidisciplinary assessment of child abuse and should be considered even when information from other agencies showed little or no cause for concern. Children frequently disclose a little information at a time, even over many years. Accurate and comprehensive records made in the medical case records are essential. In cases of sexual abuse, the forensicevidence may be missed or lost and it is essential that the initial joint police/social work interview has a full description of the suspected abuse, supplemented by any previous appropriate health information. In some cases of child abuse there will be no obvious signs or symptoms and some children will require diagnostic procedures only available in a well equipped hospital or clinic.
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The Comprehensive Medical Assessment has five purposes:
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In order to make the most effective contribution, it is important that the examining doctor has clear information about the cause for concern and the known social background of the family, including previous instances of abuse, or suspected abuse.
The findings of the Comprehensive Medical Assessment must be recorded. The use of a standardised proforma to record the medical findings is an invaluable tool in the documentation of evidence. (See proforma at Annex H). This facilitates the sharing of information between the examining doctor, the specialists carrying out any subsequent examination and with social work colleagues taking forward the investigation.
When a child presents directly to an Accident and Emergency Department and there is concern that a child's injuries may be the result of abuse, the casualty officer should regard this medical examination as equivalent to a Comprehensive Medical Assessment. It should be consistent with a formal CMA carried out by non invasive techniques and should not include internal vaginal or rectal examination. The locally agreed proforma should be used (Annex H). Urgent medical treatment will be carried out as appropriate, and the Child Protection Register checked in every case. Subsequent action will be taken depending on the degree of concern existing after the Comprehensive Medical Assessment. Where there is little doubt that abuse has occurred, or it seems likely that it may have occurred, the casualty officer should consult with their consultant and/or the senior paediatrician, social workstaff and the police regarding the process to be followed. When less definite concerns arise discussion with a senior paediatric colleague should be undertaken before the child leaves the Accident and Emergency Department. Procedures should be in place to alert the general practitioner and health visitor to any relevant concerns and gather appropriate background information from the primary care team.
Where records are available, it should be standard practice to compare height and weight (and infant's head circumference) information against these records including the use of centile charts, wherever possible.
Discussion between medical, nursing, social work, and police colleagues should be encouraged at all stages, to facilitate good liaison and the communication of concerns.
Understanding the expertise and roles of each group will ensure that health, police and social workstaff respect the contribution provided by each service.
In planning the medical investigation, it is worth noting that it is the duty of the police to provide best evidence, including medical evidence, to the Procurator Fiscal and the Children's Reporter in appropriate cases. Details of the role of the police are referred to in Chapter 10 and also contained in the inter-agency guidelines Protecting Children - A Shared Responsibility: Guidance on Inter-agency Co-operation (1998).
Once the Children's Reporter is proceeding with an investigation, information may be requested by, or directly passed to, the Children's Reporter. It should be noted that, because Children's Hearings can proceed on a lower standard of evidence compared to criminal proceedings, i.e. the balance of probability rather than beyond reasonable doubt, there are many situations in which the Children's Reporter is able to act, even although it is clear that criminal proceedings cannot be contemplated.
The number of examinations to which a child is subjected must be kept to a minimum and careful planning of the medical component of the examination by experienced medical staff facilitates this. The examining doctor should ensure that the child is kept fully informed of the outcome of all that happens to her or him.
Where the plan is for the child to be 'Looked After', the requirements of the Comprehensive Medical Assessment for Looked After Children should also be fulfilled and the examining doctor should ensure that relevant medical information is recorded and shared with the carers and the child.
Arranging a Medical Examination
The paediatrician, or exceptionally the general practitioner, involved in the Planning Meeting or Discussion should take responsibility for taking the medical assessment forward, agreeing with police and social work colleagues the nature, timing and venue for the examination.
In situations where the referral indicates suspicion that abuse has occurred, the GP or paediatrician should contact the social work service or the police before carrying out a Comprehensive Medical Assessment.
Where information is unclear or uncertain a Comprehensive Medical Assessment may be undertaken to determine the need for a specialist paediatric or joint paediatric/forensic examination. Where it is clear from the referral that a forensic opinion will be required e.g. an allegation or observation of serious physical assault or injury or a disclosure of sexual abuse, the Comprehensive Medical Assessment should be bypassed.
In arranging medical assessments the co-operation and involvement of the parent(s) at all times should be sought even if this may seem difficult or parents are hostile. When a parent or guardian is a suspect, or for some reason not supportive of their child's needs, then their attendance during the examination may not be appropriate. Any exclusion of a parent or guardian should be fully discussed by all the agencies in advance of the examination. The child's views should be taken into account (See Chapter 7 and Annex J).
The Comprehensive Medical Assessment should normally be carried out locally by the family General Practitioner, school doctor or the on-call Community Child Health Doctor for Child Protection at a Child Health Clinic or in the child's school or nursery.
Where the Comprehensive Medical Assessment is bypassed it is important to ensure that appropriate background health information is sought from the Health Visitor, School Nurse, General Practitioner and Community Child Health staff (including school doctor) so that vital information (e.g. a history of previous concerns) is not overlooked.
The child will require to be accompanied by a parent or other trusted adult during this process. A decision about who should accompany the child should be determined by the circumstances of each individual case.
Informed consent must be obtained from the parent or child, as appropriate. See Chapter 7.
The possibility of arranging an admission to a paediatric ward for observation and further assessment should always be remembered in doubtful cases such as non-organic failure to thrive, or where there are other possible medical differential diagnoses, such as thrombocytopenia.
Specialist Paediatric or Joint Paediatric/Forensic Examination
The following circumstances will indicate the need for a specialist paediatric or joint paediatric/forensic examination to be carried out:
In some cases the information gathered from an earlier Comprehensive Medical Assessment may be sufficient together with other supportive evidence (e.g. corroboration of the incident from an eye witness) to enable a conclusion to be reached as to the allegation. In such cases there will be no need for further examination. Photographic evidence may be obtained by the police or medical photographer as part of their investigative procedures, but the examining doctors should assist by ensuring that all significant injuries are recorded.
The decision whether or not to refer the child for more specialist paediatric or joint paediatric/forensic assessment should be a joint decision taken by involved professionals from social work, police and health. Where there is a lack of consensus, this should be resolved by the examining doctor referring the child for a second opinion to a senior paediatric colleague.
This specialist examination provides a comprehensive assessment of the child establishing the need for immediate treatment and ongoing health care as well as ensuring a high standard of forensicevidence to sustain any criminal or care proceedings, and offering reassurance and advice to the child and carers. The examination is intended to encompass both the child's need for medical care and the legal requirement for evidence in a single examination.
The decision whether a joint paediatric/forensic examination or an examination by a single paediatric examiner is appropriate, should be made during the Planning Meeting or Discussion with social work services and the police. This should take place at the time of the referral. The decision on the type of examination depends partly on the need for corroboration of forensic findings and the taking of appropriate specimens for trace evidence including semen, blood, transferred fibres, etc. This decision is ultimately the responsibility of the Procurator Fiscal and in some circumstances it would be appropriate for the examining doctor to contact the police for discussion before proceeding with the examination.
The paediatrician plays the lead role in assessing the child's health and development, while the forensic colleague assists with the interpretation of any injuries in terms of accidental or non-accidental causation, likely timescales, etc. The forensic colleague also oversees the gathering of any samples for forensic analysis (such as swabs of semen and saliva) while the paediatrician takes responsibility for arranging any other investigations (e.g. for sexually transmitted disease, x-rays, clotting studies, etc). Video and photographic recordings are taken in the presence of both doctors. The consultant paediatrician takes responsibility for the medical component and for ensuring that appropriate arrangements are made for further medical investigation, treatment and follow-up. The Police Surgeon is responsible for the forensic element of the examination, and fulfils the legal requirements in terms of e.g. preserving the chain of evidence.
The presence of two doctors in the joint paediatric/forensic examination, each of whom can speak to the physical findings, is not only important for the corroboration of medical evidence in any subsequent criminal proceeding, but is regarded as good medical practice. The co-operation of two doctors from the complementary backgrounds of paediatrics and forensic medicine should achieve a high and consistent standard of medical evidence by ensuring appropriate checks and balances are in place. This is important not only in cases of sexual abuse, but in serious cases of physical assault, for example non-accidental injury or where a baby has been injured by shaking. A single doctor examination by a specialist paediatrician may be appropriate in situations of physical abuse, where the findings at the Comprehensive Medical Assessment appear clear and there is already corroborating evidence available.
The Joint Paediatric/Forensic Examination should normally take place in an appropriately equipped paediatric health facility such as a children's hospital or unit, or perhaps a genito-urinary medicine department, in which appropriately qualified staff are available and where there is access to other services which may be needed for further investigation or treatment. A high standard of consulting accommodation with adequate lighting and video-colposcopy facilities for examination of sexually abused female and male children and young people, must be available. Whatever location is used, the facilities should be child friendly, with access to play materials, food and drink and experienced paediatric nursing staff should be available. The same guidelines for history taking and examination should be followed for all children. A standard proforma should be drawn up ensuring that no important information is overlooked including, for example, gathering a full history of relevant signs and symptoms including bowel habit, menstrual history and use of tampons in the case of girls, including line drawings for the recording of injuries and a section for the documentation of consent and examination technique.
The gender of the examiner should be discussed with the child and a choice made available, wherever possible.
These special examinations should be arranged without undue delay. Suitably trained and experienced police surgeons should be available through a duty rota. The doctor carrying out the Comprehensive Medical Assessment will contact the appropriate paediatrician on call (as determined by local arrangements) to advise about the request for a Joint Paediatric/Forensic Examination and the process will be by local arrangement. The venue and the timing of the Joint Paediatric/Forensic Examination should be fully discussed with police and social workers. Social work services should ensure that the child and parent(s) (and/or any other trusted adult accompanying the child) are fully informed of the plan and likely timescale of the investigation as soon as possible, and are taken to the examination.
Following examination, the doctors should confer immediately, review the video if required and give an immediate statement to the police officers who are in attendance.
Certain children may require early referral for specialist medical services such as neurosurgery, gynaecology, genitourinary medicine, general surgery and orthopaedics and psychiatric and psychological services.
The Timing of Medical Examinations
The timing of the examination should be agreed jointly by the medical examiners and the other agencies involved.
It is important to note that it may not be in the child's best interest to rush to an immediate examination whatever the time of day the disclosure has been made. In a number of cases it may be much more appropriate to wait until the child can be rested and prepared adequately. More information may also become available.
It is expected that in the great majority of cases arising in working hours, a Comprehensive Medical Assessment will be carried out locally and quickly by a doctor who knows the child and/or the family. If difficulty is experienced in arranging a Comprehensive Medical Assessment through normal local contacts, the paediatrician responsible for Child Protection should be contacted.
After normal working hours a Comprehensive Medical Assessment may be arranged by agreement with the family's general practitioner or by discussion with the consultant paediatrician on call, (who may delegate to a member of the junior staff) who can be contacted via the appropriate hospital switchboard. This should be discussed during the inter-agency Planning Meeting or Discussion.
In cases of alleged physical or sexual abuse where the incident(s) has taken place some time previously, the examination should be carefully planned to take place during working hours when the skilled personnel and specialist staff are available. Hasty intervention may prove inconclusive and allow an abused child to remain in continued danger. The decision how best to proceed should always be made in discussion with the other agencies involved. Care must be taken to ensure that in appropriate cases, forensic trace evidence is not lost. Particular care should be taken to retain clothing and avoid bathing.
Consent
A full discussion on this is to be found in Chapter 7 and Appendix J. Medical staff should note that it is the examining doctor's responsibility to obtain informed consent including specific consent to the recording of findings by photograph or video, and the provision of a report to the police. With young children consent must always be obtained from the parent or legal guardian.
With older children who are mature enough to understand fully the nature and type of examination to which they will be subjected and who are prepared to consent to it, additional parental consent is not a requirement. The examining doctors however need to confirm that the child is mature enough to comprehend fully the nature of the clinical examination and investigations. If the doctors cannot confirm this, then parental consent is essential. Where children give their consent parents or carers should also be consulted as a matter of good practice.
It is important to note that children who consent to examination may withhold their consent to certain parts of that examination e.g. the taking of blood or a video recording. Clear notes should be taken of which parts of the process have been consented to and by whom.
When competent consent cannot be obtained, the medical practitioner should obtain legal advice from the social work services and police. In civil Court cases or Children's Hearings, the Children's Reporter will be able to give the necessary advice.
The Report
It is imperative that all medical examinations result in a clear report of the findings and of the doctor's considered opinion speedily submitted within the locally agreed timescale. These reports should be submitted to the Children's Reporter and/or the Procurator Fiscal. If the local authority is seeking a Child Protection or related Order these reports should also be made available to the Court normally through the local authority. Medical samples, if part of the evidence, are the responsibility of the police officer in attendance. In cases where a Child Protection Order has been taken, and is being considered at the second working day hearing, it is important that a sufficiently detailed report is available to meet the Children's Reporter's requirements. Similarly, if the alleged perpetrator has been detained by the police for a court appearance on the first lawful day, the information must be available for the Procurator Fiscal. Written reports may have to serve more than one purpose (e.g. Children's Reporter, Procurator Fiscal or the local authority) and sufficient copies should be made available.
In situations where further information affecting the opinion may become available from investigations requested at the time of examination e.g. x-ray, blood tests, a preliminary report should be provided and care should be taken that a full supplementary report is provided to the Procurator Fiscal and/or Children's Reporter once all the appropriate reports are available.
Where the decision is reached for the child to be Looked After by the local authority, the Comprehensive Medical Assessment should provide the necessary information about health and medical care for the local authority to share with the child's carers. The use of multi-part forms in the Comprehensive Medical Assessment within the child protection procedures which can fulfil both functions facilitates this. The Specialist Paediatric or Joint Paediatric/Forensic Examination should be documented on an agreed standardised proforma, (an example of which is included at Annex I). This facilitates the accurate documentation of the history and clinical findings (including drawings with measurements) and should be completed contemporaneously during the examination by the doctors. This should also include any verbatim statements made by the child during examination (e.g. clarifying terminology for private parts and explanations for specific injuries). These notes will form the basis for the subsequently typed report. The doctors may be asked to produce these or refer to them in the witness box at a later date.
Where an acute sexual assault has occurred, the police will provide sampling equipment in the form of a standard "Physical Evidence Recovery Kit". Both doctors should co-operate in the gathering, labelling and countersigning of all samples. Similarly, the video in such cases should be sealed and signed by the police and the medical examiners and securely stored by the Trust, as it is considered to be part of the health record.
When the examination is complete, a brief verbal report should be made to the attending police and social workers. Care must be taken to include the content of this verbal report in the final written report.
A "soul and conscience" report which may be sworn as evidence and subject to cross-examination in court must contain details of the examination findings and an opinion must be produced for the Procurator Fiscal and/or the police. This should normally be a joint report by the two examining doctors and signed by both. If, however, separate reports are produced, the opinion they contain must be agreed in advance by the two examining doctors. Where difficulty arises reaching an agreed opinion within the reports, the difference of findings and opinions must be stated. Further medical advice must be obtained by either seeking a further expert opinion or through peer review.
A copy of this "soul and conscience" report should be retained by the examining paediatrician and filed alongside the original hand written Joint Paediatric/Forensic Examinationproforma either within the health record or a separate file for reference during any subsequent investigation or legal proceedings. Similar arrangements should be in place for the storage of video evidence. This report is the property of the Procurator Fiscal and may not be copied to other agencies without his or her prior permission.
The paediatrician should take responsibility for producing a medical report for the General Practitioner including all relevant background information, a summary of the procedure and findings and the follow up plan. This will be copied to the hospital and the Community Child Health files.
Follow-Up
Once the investigation is complete, the paediatrician(s) involved have a clear responsibility to monitor the physical and emotional health of the child, and ensure appropriate treatment and management of any identified morbidity is carried out. It is imperative that ongoing care and management includes full discussion with the child, referral to the General Practitioner and the Primary Health Care Team.
These situations often provide an opportunity to ensure the child's attendance at previously defaulted hospital, dental or optician appointments, or for missed routine surveillance and immunisation procedures are addressed.
In cases of sexual abuse or under-age sexual activity, arrangements to follow-up the possibility of pregnancy or sexually transmitted disease and the provision of contraceptive services (including postcoital contraception) may be required. Appropriate services may be accessed through the Primary Health Care Team, young person's advisory services (e.g. family planning clinics) or the local genitourinary medicine or gynaecology clinics, depending on local configuration of services.
Where significant concerns about the child's growth and development have been identified and the child has been placed in a substitute family setting, very careful charting of growth and serial assessments of development may show clear reversal of the worrying trends and be of great value in any subsequent legal proceedings.
Psychological or psychiatric sequelae must not be overlooked and arrangements must be in place to allow ready access to mental health services, which are frequently required at a later stage.