Missing the signs

Child maltreatment is under-recognised and inconsistently reported to children’s social care services. Sara Williams explores the vital role that doctors play in safeguarding children

D was five when his mother was referred for psychiatric help after she presented to her GP claiming she could not look after her son. Her psychiatrist wrote back to the GP stating what treatment had been pursued.

A couple of years later D appeared at the same surgery and was seen by a nurse. The nurse wrote that this child looked unwell, so an appointment was made to see the GP. D’s mother did not keep the appointment.

The child was not seen again for a significant number of years, by which time his problems were compounded – he had received no education. When the GP was later spoken to about his failure to refer the child to children’s services, he said he thought that by making the mother better, that would be the answer.

Had the GP or psychiatrist made a referral in the first instance, or followed it up, the issues for the child may have been dealt with swiftly and future problems may not have occurred.

Child maltreatment is inconsistently reported to children’s social care by healthcare professionals. The death of Baby P saw the Care Quality Commission (CQC) single out health professionals for criticism. Baby P had 34 contacts with health professionals, including 14 at a GP practice, before he died in Haringey, North London, in August 2007. Clinicians were accused of not attending child protection conferences and failing to interact with child protection services, contributing to the systemic failings that led to his death.

What is child protection?

“Doctors play a crucial role in protecting children from abuse and neglect.”¹

Doctors play a crucial role in protecting children from abuse and neglect

The NSPCC reported that more than 21,500 sex offences against children were recorded last year.² Child maltreatment historically includes neglect and physical, sexual and emotional abuse, and fabricated or induced illness. Children may present with both physical and psychological symptoms and signs that constitute alerting factors.

Subtle forms of abuse were only recognised in the 1960s, when Dr Henry Kempe published his paper on the “battered baby syndrome”. He ripped through perceptions that broken bones were due to them being excessively brittle and forced people to believe that parents could break children’s bones.

In the context of a doctor’s work today, child protection means preventing the impairment of a child’s health or development, ensuring they are growing up in circumstances consistent with the provision of safe care, thus giving them optimal life chances.

Why doctors play such an important role

A GP’s role in safeguarding children starts as soon as there are concerns about a child’s wellbeing, not just when there are questions about possible harm

Kim Doyle is a barrister and a sessional expert in child protection for the Department of Health national support team for response to sexual violence. She has been involved in a number of committees focusing on safeguarding children. She says that doctors are frontline, which makes them key players. “The old view that child protection belongs to social workers is redundant; everyone involved with children has a responsibility to keep their eyes open.

“Doctors who are treating young people with sexual health, behavioural or mental health problems are in a key place to identify sexual exploitation, neglect or abuse early. It’s not just when treating children; while treating parents, guardians and carers, they may hear something that raises concerns, so are well placed to identify where help is needed or who the perpetrators are.”

Ms Doyle stresses that a GP’s role in safeguarding children starts as soon as there are concerns about a child’s wellbeing, not just when there are questions about possible harm. “It is important to be familiar with the Common Assessment Framework – Every Child Matters. GPs need to understand how to complete the assessment themselves, or how to contact someone who can complete it on their behalf.”

Recent guidance from the Home Office identified child sexual exploitation and grooming as a huge problem.³ This can take many forms, from the seemingly "consensual” relationship where sex is exchanged for attention/affection, accommodation or gifts, to serious organised crime and child trafficking. It is characterised by a serious imbalance of power, where the perpetrator holds some kind of power over the victim.

Social media have changed the mechanics of child grooming. Where previously a potential perpetrator may have loitered outside a school to access children, now they can spin a web around them remotely using social networking sites. This abuse is harder to spot, as children are often complicit in what is happening.

GPs may be best placed to identify these new forms of abuse, eg, knowledge that a child had a pregnancy terminated combined with other information might suggest that they are being exploited.

The role of hospital doctors is different. In hospital, paediatricians and emergency medics are in a prime position to pick up signs of abuse or violence and refer to other agencies when young people present with injuries, or signs of grooming when young people present with alcohol or drug related issues.

If they suspect abuse, they should highlight their concerns to the designated lead for child protection in their unit. The role of clinicians is to take the medical history, perform an appropriate examination and, having highlighted the potential risk of abuse, refer appropriately.

Most children present as a result of chronic abuse, so the forensic evidence is limited. The best practice is for a child to be examined by both a paediatrician and a forensic medical examiner (FME). This may include documentation and photographs of physical injuries and a video recording of anogenital findings using the colposcope. In the acute setting, forensic evidence may also be taken.

What you should be aware of

• The frameworks for assessing children and young people’s needs 
• The work of Local Safeguarding Children Boards and Child Protection Committees 
• Policies, procedures and organisations that work to protect children.

The law deals with child protection in a broad way under the Children Act (1989): 

• Section 17 – children who are in need of services, whose development might be impaired if services are not sought 
• Section 47 – children who are at risk of suffering significant harm, such as physical, sexual, emotional abuse or neglect.

How to diagnose child abuse

A study by Kemp et al looked at different skeletal fractures in child abuse. Their conclusion was that the site of an injury or type of fracture could never in itself distinguish between abuse and accident.⁴

So how is abuse diagnosed? The diagnosis is made based on the presence of injuries and the absence of a compatible history given by caregivers. Abusers can be devious, eg, Baby P’s parents smeared chocolate on his face to hide the bruising.

NICE has produced guidance on how to identify child maltreatment:

• Listen to and gather information to create a full picture 
• Seek an explanation in an open manner 
• Record in the child’s medical notes what is observed and heard from whom and when 
• Discuss your concerns with a colleague or MDO.⁵

How doctors go about diagnosing abuse is crucial. Ms Doyle is aware of a case involving a paediatrician who unwittingly tainted evidence. “There were two children involved; one had made a disclosure of abuse. Their paediatrician sat them down together and asked questions. This tainted the children’s evidence for the purposes of criminal proceedings, because they had not made free disclosures in the absence of each other. It is perfectly acceptable to ask what happened, but not to start your own investigation.”

Ms Doyle says that normal clinical practice can have a real impact on outcomes and working together is the only way to avoid this. “Children’s services are not a doctor’s area of expertise. Lord Laming was clear: work is always tackled on a multi-agency basis; there is a need for joined-up working from the bottom to the top. Doctors need to move away from the perception that it is the next person’s job to deal with it. In order to be effective, doctors must understand the role other people play and how sharing information with them will help.

“Visualise a jigsaw. If you put all the information together, the jigsaw would become clear, but if each person involved holds a little bit and doesn’t do anything with it, the picture may never become clear. Doctors should ask themselves: ‘If I pass on information, what is it going to mean for that child?’”

How to raise concerns

“The best interests of a child and his parent normally march hand-in-hand. But when considering whether something does not feel “quite right”, a doctor must be able to act single-mindedly in the interests of the child.”⁶

This 2005 case judgment states that if you have a gut feeling that something is not right, act on it: your actions should not be hampered by the possibility of such doubts being unfounded, and potential exposure to a distressed parent. When the child is the patient, their doctor is charged with the protection of that child, not the parent. Above all your actions must be carried out in good faith.

The Department for Children, Schools and Families (DCSF) has detailed the processes involved when making a referral:

• Any concerns about child abuse should be referred to the appropriate persons in children’s social care or the police. 
• If you make a referral by telephone, confirm it in writing within 48 hours. 
• Ask the social worker to fax a request for a report from the medical records – and include consent from the carer unless it would put the child at increased risk. Fill it in and return it as soon as possible. 
• If the enquiry is urgent you can give details over the phone, but always follow this up with a written report. 
• Be guided by the principles of proportionality and “need to know”, when sharing information. 
• Agree with the recipient of the referral what you will say to the child and parents. 
• Talk to the child about your concerns, with their parents present, unless you feel that this would increase the risk to the child. 
• Each PCT or local health board should have access to a paediatrician with responsibilities for advising on child protection.^{7 8}

Should you choose not to share concerns you must be able to justify your actions. So record any discussions, concerns and reasons.

When should you breach confidentiality?

When deciding whether to share information, you need to consider the legal obligations. Where there is a duty of confidentiality, you may lawfully share information if you have appropriate consent, or if it is in the public interest. Where there is a significant risk of harm to the child, the public interest defence will most certainly be satisfied, and a failure to take action would be unacceptable.

The GMC says you should consider the views of the child on why you should not disclose, but should disclose information if it is necessary to protect the child from the risk of serious harm, or the child is involved in behaviour that might put others at risk.⁹

Any disclosure should be proportionate to the risk of harm. A risk may only become apparent when a number of people share niggling feelings, so you may share some information to decide whether there is a risk that would justify further disclosures.

What happens then?

Other agencies will take on the investigation, but may come back to you for access to records, etc. If a child makes a disclosure of an abuse in a familial setting, there will be a joint investigation. Children’s services will look at this as a safeguarding issue and the police will look at it as a criminal investigation against a perpetrator. These two will sit in the middle of the investigation; sitting around them will be other agencies that hold a lot of material – one of these will always be health.

According to Ms Doyle, one of the frequent complaints made against health services during an investigation might be that they are not always available to supply information, or they don’t send everything that is needed. On the flip side, health services often complain that they feel excluded and not involved. She reiterates that understanding each other’s roles will avoid these common misperceptions.

How to protect yourself

At last year’s MPS GP conference, Dr Clare Gerada, Medical Director of the Practitioner Health Programme (PHP), gave a presentation touching on why doctors fail. She identified certain personality types that can hinder best practice – the evangelist (if not me then who), the maverick (I don’t need rules), the arrogant (I know best), the incompetent (blind spots) and the unlucky (slightly poor practice). Doctors demonstrating behaviour under any one of these headings may fail to pick up on the signs. You can protect yourself by being alive to the possibility of abuse.

Secondly, by communicating well – which involves both listening skills and knowing what questions to ask and when to stop asking them – progress can be made on all fronts. Thirdly, good records evidencing your actions and concerns will form the basis of your defence if you are criticised. On a wider scale, a criticism that is often levelled at GPs – which was highlighted by the Baby P case – is the failure to attend case conferences.

Although it can be difficult for GPs to get there, it is a GP’s duty to make sure that any relevant information they hold is put across in the best possible way, eg, organise for the liaison health visitor to share the facts in their place. Sending a written report doesn’t always get the important facts across.

Responsible doctors

The presence of high profile cases, driven by the media, have caused doctors to feel vilified and singled out for the part they allegedly played. This has created a culture of paranoia, self-consciousness and shyness surrounding child protection. But doctors should fight against this and remember what a difference they can make to a child’s life by raising concerns. As one emergency medic said: “The responsibility stays with us and we cannot ignore it.”

Useful links

• Every child matters guidance
• Royal College of Paediatrics and Child Health (RCPCH) 
• Department for Children, Schools and Families
• MPS factsheet, Safeguarding Children
• Faculty of Forensic and Legal Medicine 
• Professor Yvonne Carter and Dr Michael Bannon developed a strategy for GPs on child protection called Keep Me Safe.

References

1. GMC, 0–18 Years: Guidance for All Doctors, par 56 (2007) 
2. BBC, 60 children a day abused – NPSCC – www.bbc.co.uk 
3. Home Office, Safeguarding Children and Young People from Sexual Exploitation (2009) 
4. Kemp AM et al, Welsh Child Protection Systematic Review group. Is this fracture due to abuse? A systematic review of the patterns of skeletal fractures in child abuse, BMJ (2008) 
5. NICE, Clinical guidance 89, When to Suspect Child Maltreatment (July 2009) 
6. JD (FC) v East Berkshire Community Health NHS trust and Others (2005) 
7. DCSF, What to Do if you are Worried a Child is Being Abused (2006) 
8. Londonwide LMCs, Doctors’ Responsibilities in Child Protection (2007) 
9. GMC, 0-18 Guidance, pars 49-50 (2007)