The GMC states that “doctors play a crucial role in protecting children from abuse and neglect”. Child maltreatment includes neglect and physical, sexual and emotional abuse. The following frequently asked questions are designed to advise MPS members what to do and who to contact, should they suspect children are at risk of, or are experiencing, harm.
1. The police have asked me for a three-year-old patient’s medical records, whom they suspect has been physically abused. Can I share the records without parental consent?
Usually it would be advisable to seek a parent’s consent prior to disclosing a child’s medical records; however, if asking them is likely to prejudice a police investigation, eg, if the parents were alleged to have abused the child, you will need to consider whether you can explain and justify a disclosure without consent.
The GMC, in 0–18 Years: Guidance for All Doctors, states that: “You should disclose information if this is necessary to protect the child or young person, or someone else, from risk of death or serious harm. Such cases may arise if a child or young person is at risk of neglect or sexual, physical or emotional abuse.” In such an instance, it is acceptable to share a child’s medical records, particularly if there are other children within the family. The GMC states that: “The risk of harm must, in your opinion, outweigh the privacy interests of your patient.”
In these circumstances, you need to ensure you have all of the relevant information to allow you to make an informed decision. If you do not feel that you have enough information, then you can contact the police to ask for further details. It is also important to document your decision and the reasoning behind it.
2. Patient F, a seven-year-old boy, visited the surgery with a bad cough. When examining his chest, I came across some unusual burn marks and scarring. I felt a niggling sense of unease. What should I do?
NICE guidelines, When to Suspect Child Maltreatment, divides the alerting features of child abuse into two different categories:
You must be able to justify a decision not to share any concerns you may have. Even if you raise a concern that later becomes groundless, you can justify your decision so long as you have acted reasonably and through the appropriate channels.
- If you consider child abuse, you should discuss your concerns with a more experienced colleague, a community paediatrician, child and adolescent mental health service colleague, or a named or designated doctor for child protection.
- If you suspect child abuse, you should refer the child to children’s social care, following Child Protection Committee procedures.
3. Patient A, a 12-year-old girl, comes into the surgery to request emergency contraception – can you prescribe without telling anyone?
Concern about confidentiality is the biggest deterrent to young people asking for sexual health advice. Doctors need to make their own assessment of the situation in the first instance. However, you must contact the police if you suspect child abuse or that the patient has been forced into sexual activity. If this seems unlikely, but you are still concerned, you should speak to your local child protection lead.
The GMC states: “You should usually share information about sexual activity involving children under 13, who are considered in law to be unable to consent. You should discuss a decision not to disclose with a named and designated doctor for child protection and record your decision and the reasons for it.”
Doctors should also be mindful of NICE guidance, When to Suspect Child Maltreatment (2009), which states that “sex with a child under 13 years is unlawful. Therefore pregnancy in a girl of this age means that she has been maltreated.”
4. A mention of possible sexual abuse some 15 years ago, which was investigated and later dropped by social services, is documented in a vulnerable patient’s records. She has requested it to be removed – can I do this?
Patients have the right, under the Data Protection Act (DPA), to ask for factual inaccuracies in the record to be rectified. The Act does not, however, give them the right to ask for entries expressing professional opinions to be changed, although a patient’s comments can be added to the record to ensure they reflect the patient’s opinion.
The Information Commissioner’s Office has produced guidance on best practice in these circumstances. They advise that an addendum be added to any factual inaccuracy to ensure that this is corrected. They recommend that the error remains in the records to explain any possible unforeseen consequences. For example, if a result or diagnosis is acted upon and then removed it may subsequently be difficult for third parties, reading the records, to identify why a particular course of action was taken. This could have serious medicolegal implications.
5. A child’s parents have repeatedly failed to bring him to the surgery for a vital health assessment. Is this neglect?
NICE guidance defines neglect as “the persistent failure to meet the child’s basic physical or psychological needs, that is likely to result in the serious impairment of their health or development, which may or may not be deliberate”.
It can be difficult to identify neglect, but the child should be placed at the centre of all assessments. If you suspect neglect, or you are concerned that the child is not getting the treatment available to them that they need, you should discuss your concerns with the appropriate persons named above.