2.1 Arrangements for Medical Assessment of Children in Cases of Suspected Abuse and Neglect: Procedure

The purpose of this document is to provide practitioners within health, social care and the police with simple guidelines to follow when presented with a child who may need a medical assessment in cases of suspected non-accidental injury, sexual abuse and neglect. It does not apply to children who may need a psychiatric assessment. It has been produced by safeguarding children professionals across the health economy in Buckinghamshire, in consultation with colleagues in Children’s Social Care and the police. The document has been reviewed by the Local Medical Council and the Buckinghamshire Safeguarding Children Partnership.

This guidance details agreed procedures and decision-making pathways to ensure that when a child or young person is alleged or suspected to have suffered significant harm, the child will be medically assessed by a doctor with appropriate skills and expertise following multi-agency agreement/strategy discussion that a medical assessment is appropriate.

When a child has an unexplained or suspicious injury, has symptoms and signs of neglect, or is a suspected victim of child sexual abuse, a medical assessment is usually an essential part of the multi-agency investigation.

The majority of children should be seen during the daytime. Examination of children out of hours is rarely needed other than in cases of acute assault, either for medical or forensic necessity.

Why medical assessment may be needed:

• to establish what immediate treatment and support the child may need
• to secure any ongoing medical care, support, monitoring and treatment the child may require
• to provide information which will support or dismiss a diagnosis of child abuse in conjunction with other assessments made, so that agencies can initiate further enquiries without delay
• to provide information or evidence, if appropriate, to sustain criminal and/or care proceedings.

Even when there is multi-agency agreement that a medical assessment is appropriate, consent is sought and the medical is only undertaken with the agreement of the child.

Where the child appears in urgent need of medical attention s/he should be taken to the nearest Accident & Emergency (A&E) department, regardless of age, explanation of injury or any other factor.

A&E staff will contact the on-call paediatric registrar to assess the child if non-accidental injury (NIA), abuse or neglect is suspected. The paediatric registrar will inform the consultant on call.

The paediatrician will refer to Children’s Social Care and the police via telephone on 101 or 999 at the earliest opportunity and then complete a Multi-Agency Referral Form (MARF) within 24 hours.

In cases of suspected non-accidental injury, the GP or other health professionals in primary care should:

• document the explanation of the child’s injury and log all injuries using a body map (see Appendix B)
• consider the need to speak to the on call paediatrician to discuss concerns, who may suggest a medical examination to be arranged following the referral to social care
• note that it is the responsibility of the social care team to arrange a medical assessment by contacting the on call paediatric consultant
• advise the parents of the need for the healthcare professional to refer to Children’s Social Care/police, who will arrange a medical examination if required
• Contact social care First Response Team 01296 383962 / Out of Hours 0800 999 7677. Record all discussions, decisions and actions and complete a MARF and confirm within 24 hours. (In some cases it may be necessary to contact police/social care without parental knowledge, for example if it is believed that the carer is suspected of causing the injury or it is felt that the child may be put at further risk).

Except for in cases of child neglect, paediatricians do not accept referrals directly from GPs.

GPs can seek advice from the named doctor during normal working hours from Monday to Friday or from the paediatrician on call out of hours.

                        Named Doctor: Dr Ash Joshi, 01296 566055 /56

                        Designated Doctor: Dr Lesley Ray, 07342 064612

                        Clinical Director Thames Valley Sexual Assault Service (Forensic Doctor):

                        Dr Sheila Paul, 07899 870679

Buckinghamshire Safeguarding Children Partnership (BSCP) procedures state that medical assessments must be considered when there is a suspicion or allegation of child abuse and/or neglect involving:

• any injuries to children under one year
• a suspicious or serious injury (thought to be non-accidental or an inconsistent explanation)
• suspected sexual abuse or assault (if information indicates, an intimate examination may be needed)
• serious neglect.

Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm there should be a strategy discussion involving local authority Children’s Social Care, the police, health and other agencies as appropriate.

The strategy discussion will plan the medical assessment, deciding what the objectives of the assessment are, when it needs to take place, who should conduct it and where is the most appropriate venue.

Consideration will be given to the need for any other children in the household to be assessed.

A specific and detailed record must be made of the decision about whether to undertake a medical assessment and its rationale clearly stated.

The strategy discussion must plan what will be explained to parents/carers so that they understand the reason for assessment.

If a criminal prosecution is considered by the police to be a possibility, a statement for court by the paediatrician may be required.

If a criminal investigation is urgent, police action may be taken prior to a full strategy meeting.

The following may give consent to a paediatric assessment:

• a child of sufficient age and understanding (Gillick competency/Fraser guidelines)
• any person with parental responsibility, providing they have the capacity to do so
• the local authority when the child is the subject of a care order (though the parent should be informed) – the local authority may seek legal advice to support obtaining a medical examination where this is in the child’s best interests in cases where parental consent is deemed to be unsuitable or impossible
• the High Court when the child is a ward of court
• a family proceedings court as part of a direction attached to an emergency protection order, an interim care order or a child assessment order.

When a child is looked after under section 20 and a parent has given general consent authorising medical treatment for the child, legal advice must be taken about whether this provides consent for paediatric assessment for child protection purposes (the parent still has full parental responsibility for the child).

A child of any age who has sufficient understanding (generally to be assessed by the doctor with advice from others as required) to make a fully informed decision can provide lawful consent to all or part of a paediatric assessment or emergency treatment.

A young person aged 16 or 17 has an explicit right (s8 Family Law Reform Act 1969) to provide consent to surgical, medical or dental treatment and unless grounds exist for doubting their mental health, no further consent is required.

A child who is of sufficient age and understanding may refuse some or all of the paediatric assessment, though refusal can potentially be overridden by a court.

Wherever possible, the permission of a parent should be sought for children under 16 prior to any paediatric assessment and/or other medical treatment.

Where circumstances do not allow permission to be obtained and the child needs emergency medical treatment, the medical practitioner may:

• regard the child to be of an age and level of understanding to give their own consent
• decide to proceed without consent where this is deemed to be in the best interests of the child. (Where consent has not been gained, the reasons for this should be clearly documented and signed by two professionals at consultant level to say the medical examination is in the best interests of the child. Legal advice should also be sought. In these circumstances, parents must be informed by the medical practitioner as soon as possible and a full record must be made at the time.)

In non-emergency situations, when parental permission is not obtained, the social worker and manager must consider whether it is in the child's best interests to seek a court order.

If the child does not require urgent medical care, contact Children’s Social Care First Response Team 01296 383962 / Out of hours 0800 999 7677.

The social worker will contact the on-call consultant paediatrician by ringing the following number and asking the operator for the consultant paediatrician on call:

• North of county 01296 315000 bleep 593
• South of county 01494 526161 Ext 5506 (Children Day Unit) and ask for consultant paediatrician on call.

The consultant will discuss the case with social worker – see above strategy discussion. A suitable time and place for the child to be seen will be arranged. This may not be on the same day as the discussion.

If the child does not require urgent medical care, contact Children’s Social Care First Response Team 01296 383962 / Out of hours 0800 999 7677.

Telephone the community paediatrician on number below and ask to speak to doctor on call for neglect cases:

• North of county 01296 566046
• South of county 01494 426602

If the community paediatrician is not available, the social worker’s contact details will be taken and the doctor will return the call within 4 hours or before 5pm, whichever is sooner.

Following a strategy discussion with the social worker, the paediatrician will decide when and where the medical is to take place. These medicals are not urgent but should take place within a timely manner ideally before the initial case conference and definitely before the first review conference. Younger children may need to be seen more quickly.

The appointment for the medical should be sent to the parents/carers, social worker and school nurse/health visitor as appropriate. In cases of neglect all children in the family may be seen for medical assessment.

Local policy with regard to examination in cases of suspected sexual abuse is underpinned by the Guidelines on Paediatric Forensic Examination in relation to Possible Child Sexual Abuse produced by the Royal College of Paediatrics and Child Health (RCPCH), and the Faculty of Forensic and Legal Medicine (FFLM).

The Thames Valley Sexual Assault Referral Centre (SARC) is run by Harmoni for Health and has been named ‘Solace’. The contact number for Solace is 0300 1303036.

In all cases, medical needs are paramount and come before forensic needs if necessary. If the child requires urgent medical treatment they should be taken to the nearest A&E department.

If the child does not require urgent medical care, contact Children’s Social Care First Response Team 01296 383962 / Out of hours 0800 999 7677.

The timing of the medical depends on the time of the sexual assault (acute or historic) and the pubertal status of the child.

If an urgent forensic medical examination is required, the police should contact Solace who will arrange an appointment with the duty forensic doctor on the SARC rota. If that doctor does not have all the core and case dependent skills required to examine the child, the forensic medical examination should ideally be carried out by a forensic doctor experienced in paediatric examination or, if not available, jointly by the duty forensic doctor and a consultant paediatrician on call.

Professionals can call Solace directly for advice on any sexual assault case regardless of age on 0300 130 3036. They should also contact police/social care as per the flow chart (Appendix A).

Cases of acute sexual assault in pre-pubertal children (aged usually less than 12 years) are rare. These cases require an urgent forensic examination as soon as practicable so that forensic evidence is not lost. Persistence data reveal the opportunity of up to three days to collect samples for foreign DNA from a pre-pubertal child, depending on the type of sexual assault. Research shows this is often reduced to 13 hours in practice.

Cases of acute sexual assault, within the last 7–10 days, in post-pubertal children (usually aged more than 12 years) need an urgent forensic medical examination. The timing of a medical examination needs to balance the welfare of the child with the need to secure forensic evidence. More evidence is likely to be secured the sooner a medical examination takes place, but in achieving this effort should be made to minimise the distress to child. The timing depends on the disclosure but always as soon as possible and usually the same day or night, so that forensic evidence is not lost and distress is minimised. The examination should be carried out by the duty forensic doctor on the SARC rota and should be arranged through the police.

It is important to recognise that urgent examinations to capture forensic evidence such as healing injuries, or provide appropriate treatment such as emergency contraception, may be needed outside the persistent data time scales and this is reflected in the FFLM and the RCPCH service specification for the clinical evaluation of children and young people who may have been sexually abused. In this document it is emphasised that acute examinations may be needed for the above reasons up to 21 days post-alleged event.

Pre-pubertal (children aged usually less than 12 years) and post-pubertal (usually aged more than 12 years) cases where there is delay in reporting sexual abuse (abuse occurred usually more than 21 days) are non- acute cases that do not need an urgent out of hours examination. Police should make arrangements with the forensic doctor.