Lincolnshire Multi-Agency Procedure for Professionals requesting Child Protection Medicals

AMENDMENT

This chapter was updated in October 2024.

1. Introduction

Strategy meetings should be called for all children where there is reasonable cause to suspect that a child is suffering or likely to suffer significant harm. They should be held in line with LSCP guidance (Strategy Discussions) and as specified in Working Together 2023. Meetings should include a local authority social worker, health practitioner and a representative from the police as a minimum. The need for a planned medical assessment with appropriate consent should be considered as part of this meeting.

If it is likely that there will be a need for a medical examination, the on-call consultant Paediatrician should be included in the Strategy Meeting. This meeting must consider, in consultation with the paediatrician (if not part of the discussion or meeting), the need for and timing of a paediatric assessment (child protection medical).

Where the child appears in urgent need of medical attention (e.g. suspected fractures, bleeding, loss of consciousness), they should be taken to the nearest Accident and Emergency department.

If the allegation raises concerns about child sexual abuse, the Lincolnshire Paediatric Sexual Assault Referral Pathway should be followed. The on-call paediatrician at the SARC should be involved in the strategy meeting.

2. When a Child Protection Medical is Necessary

Medical assessments should always be considered necessary where there has been a disclosure or there is a suspicion of any form of abuse to a child. Additional considerations are the need to secure forensic evidence and obtain medical documentation.

Where there are allegations of bruising or other concerning external injury, there should be an assumption that a medical will be required. If it is decided a child protection medical is not necessary, the rationale for this must be recorded. The absence of visible marks should not be a reason, without consultation with a paediatrician.

For bruising in babies and children who are not independently mobile, please refer to the relevant LSCP policy at Bruising in Babies and Children who are Not Independently Mobile.

Only paediatricians with appropriate experience should physically examine the whole child for the purposes of a child protection medical. It is not appropriate to send a child to their GP for a child protection medical.

3. Arranging the Medical

Once the decision to undertake a child protection medical has been made, reference should be made to the Appendix 1 flowchart. Please do not contact the paediatric ward to arrange a medical.

For children who are to be seen at Lincoln, the on-call consultant paediatrician is contacted via Lincoln County Hospital Switchboard.

For children who are to be seen at Boston, any in hours cases (i.e., Monday to Friday 09.00 to 17.00) are to be arranged by contacting the paediatric secretaries. Out of hour cases are arranged by contacting the on-call paediatrician via Boston Pilgrim Hospital switchboard.

4. Purpose of the Medical

A paediatric medical assessment is an essential component of a child protection investigation. It is a comprehensive holistic assessment that includes clinical history and examination. It should include a developmental assessment (particularly below the age of 5 years). The assessment should include obtaining any relevant investigations, arranging aftercare, and writing a report with an opinion.

The purpose of a medical assessment is to:

  1. Identify the child's health needs, initiate treatment, and arrange any necessary follow up as required;
  2. To help to reduce the physical and psychological sequelae of such abuse;
  3. To determine the likelihood of child abuse on the balance of probability;
  4. To facilitate the police investigations of a possible crime by documentation of clinical findings, including injuries and taking samples that may be used as forensic evidence in a police investigation relevant to all types of abuse;
  5. To contribute to the multiagency assessment through sharing of information.

Parents/carers should be informed that it may be necessary for their child to be admitted to the ward as an in-patient, until any relevant assessments and investigations are completed.

The following may give consent to a child protection medical:

  1. A young person aged 16 and over;
  2. A child aged under 16 where a doctor considers he or she is of sufficient age and understanding to give informed consent and is "Fraser Competent";
  3. Any person with Parental Responsibility;
  4. The local authority when the child is the subject of a Care Order (although the parent/carer should be informed);
  5. The local authority when the child is accommodated, and the parent/carers have abandoned the child or are physically or mentally unable to give such authority;
  6. The High Court when the child is a Ward of Court;
  7. A Court as part of a direction attached to an Emergency Protection Order, an Interim Care Order, or a Child Assessment Order.

It is generally good practice to seek wherever possible the permission of a parent for children under 16 prior to any child protection medical and/or other medical treatment even if the child is judged to be of sufficient understanding to give consent in their own right. If this is not considered possible or appropriate, then the reasons should be clearly recorded.

Where the child is the subject of ongoing court proceedings, legal advice should be obtained about obtaining the court's permission for the child protection medical.

When a child is Looked After and a parent/carer has given general consent authorising medical treatment for the child, additional consent must be sought for a child protection medical. Where the local authority shares Parental Responsibility (PR) for the child, the local authority must also consent to the child protection medical.

If the adult with PR refuses to give consent and the local authority wishes an examination to take place, the paediatrician should consider the case in its entirety and decide if the examination is in the child's best interest and/or there is a public interest, then the paediatrician should refer to the local authority to obtain consent by court order. The local authority would need a court order to override the refusal of the party with PR. If one adult with PR consents but another person who holds PR refuses consent, the paediatrician should consider the case in its entirety and if they decide the examination is in the child's best interest and/or there is a public interest, then the paediatrician should refer to the local authority to obtain consent by court order. However, consent from one party with PR is usually sufficient.

A child who is of sufficient understanding may refuse some or all of the child protection medical, although refusal can potentially be overridden by a court. The child may agree to a limited examination and the process may be adapted. The paediatrician should offer information about the consequences of refusal and offer a further opportunity. Any risks to the child may be discussed with experienced colleagues, and clearly documented in the notes.

In emergency situations where the child needs urgent medical treatment and there is insufficient time to obtain parental consent:

  • The medical practitioner may decide to proceed without consent; and/or
  • The medical practitioner may regard the child to be of an age and level of understanding to give her/his own consent and be Fraser Competent.

In these circumstances, parents must be informed 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 seek legal advice.

6. Medical Assessment

The examining clinician should have information available from the child's previous hospital attendances, wherever possible.

The examining clinician should obtain a thorough and comprehensive history including any explanations given by parents/carers for the injury and perform a complete clinical examination of the child/young person including an assessment of development and a broad understanding of the child's cognitive ability.

Any visible marks or injuries should be charted on a body map and documented in detail in case notes. Where possible, photographs are taken of all significant visible findings, in line with the acute trust's medical photography policy.

The medical assessment should be done in accordance with RCPCH's standards for such assessments, and such assessments are subjected to peer review.

A skeletal survey needs to be considered when a child presents with a physical injury and abuse is suspected. (Royal College of Radiologists: The radiological investigations of suspected physical abuse in children - November 2018). A second skeletal survey is then undertaken 10 to 14 days later. When gaining initial consent for the Child Protection Medical, it must be explained why a second skeletal survey is required. Should the parent refuse to present the child for the second skeletal survey, this should be discussed between the local authority and paediatrician, and consideration be given to seeking legal advice.

7. Recording of the Medical Assessment

At the conclusion of the child protection medical, the doctor must give a written summary of initial findings and an opinion explaining his or her findings to the social worker/police officer attending, followed by a written report within 5 working days.

In cases where a second skeletal survey is required, or other ongoing medical investigations, a further written report will be provided within 5 working days of the results becoming available. Should these results or the findings during peer review change the initial opinion or safety plan, this must be communicated to the social worker within 24 hours. The social worker needs to provide the details of any police officer they have discussed the case with.

Disclosure of the information contained in the report to the parent(s) of the child and/or the child should be agreed in consultation with the Children's Social Care Service and the Police.

The report should include:

  • Date, time, and place of examination;
  • Those present;
  • Who gave consent and how (child/parent, written, phone or in person);
  • A verbatim record of the carers and child's accounts of injuries and concerns noting any discrepancies or changes of account;
  • Site, size, shape and where possible age of any marks or injuries;
  • Other findings relevant to the child e.g., squint, learning difficulties, speech problems etc.
  • Confirmation of the child's developmental progress (especially important in cases of neglect);
  • Summary;
  • Medical opinion of the likely cause of injury or harm.

All reports and diagrams should be signed and dated by the doctor undertaking the examination.

If criminal or family proceedings take place, the doctor's written report may be filed and served as well as the doctor's statement of evidence. The doctor's attendance at subsequent Court hearings may also be required.

The medical report is written for Children's Services. With appropriate consent, it should also be copied to:

  1. The GP;
  2. The health visitor (for children of reception year or younger);
  3. Police (where there has been involvement);
  4. Named nurse for the acute trust.

The parents/carers can ask for a copy of the medical report from the social worker.

8. Timescales

All child protection medicals should be carried out within the timescales appropriate to the type of abuse and the requirement for collection of evidential samples.

For all child protection medical referrals, the doctor should decide the timing of the examination, and where the examination should take place.

It is essential to keep the best interest of the child central to the decision making.

Factors influencing the decision may include:

  1. Age of child;
  2. Type of abuse;
  3. Severity of injury;
  4. Safety of the child and any siblings;
  5. Availability of an appropriate doctor;
  6. Multi-agency child protection process.

Appointments within 24 working hours

  1. Physical Injury;
  2. Severe neglect with medical implications.

Siblings associated with an acute physical injury should be discussed regarding appropriateness for a medical.

Appointments within 10 working days

The child protection medicals below can be undertaken within a maximum of 10 working days. Their urgency is dependent on the results of a strategy discussion and any clinical or non-clinical need.

  1. Court requested examinations;
  2. Long standing neglect or emotional abuse;
  3. Abandonment where there is a need for early assessment e.g., for court advice;
  4. Self-harming behaviour with child protection concerns;
  5. Old physical injury;
  6. Cases where there is time to plan for an assessment;
  7. Sibling examination where there is no immediate need;
  8. FGM where there are non-urgent child protection concerns.

9. Transfers between Hospitals and Discharges

If a child is transferred between hospitals and there are safeguarding concerns, this must be discussed prior to transfer and also documented in the written communication accompanying the child. The safeguarding process up to the point of transfer should be clearly stated and any transfer arrangements must be agreed by police, social worker and health.

A child should not be discharged from a hospital to a home environment without agreement of the Paediatric consultant, police and Children's Services. It is best practice for there to be a pre discharge planning meeting to address all of the issues including appropriate follow up. A discharge letter should be written ensuring the appropriate professionals are informed - this should include the GP, health visitor and social worker, even if a more detailed medical report is to follow.

For more information, consider the following policy: Discharge Planning from Physical Healthcare Hospitals when there are Safeguarding Concerns about a Child.

Appendix 1: Child Protection Medical Pathway

See Appendix 1: Child Protection Medical Pathway.