Child protection

1. Child protection Fiona Finlay Simon Lenton

2. Objectives Update Think �child protection� Best practice Respond to your concerns Who to contact locally

3. Topics NICE Guidelines GMC Guidance 0-18 years: guidance for all doctors Working Together Rapid Response + Child Death Overview Panels Serious Case Reviews Competencies + Training Local arrangements + Staff

4. Scenarios

5. Scenario 1 You health visitor calls at a local family home to find 2 young children �home alone�. The baby is screaming in his cot, feeling cold and looking �rather scrawny�. His 4 year old sister, who answered the door has some bruises on her face and legs and what looks like a bite mark on her left arm. She phones you for advice What would you say? What should happen next?

6. NICE GUIDANCE

7. NICE Guidance When to suspect child maltreatment Issued July 2009 Reissued December 2009 It provides a summary of the alerting features associated with child maltreatment

8. NICE GUIDANCE It is good practice to follow this process : Listen and observe Seek an explanation Record Consider, suspect or exclude maltreatment Consult if unsure Record

9. Record Record in the child or young person�s clinical record exactly what is observed and heard from whom and when Record why this is of concern Date and time and signature

10. Alerting Features Consider (one possible explanation) Suspect (serious level of concern) Physical abuse Sexual abuse Emotional abuse Neglect FII

11. Fabricated or induced illness reported S+S are only observed by, or appear in the presence of, the parent or carer an inexplicably poor response to treatment new symptoms are reported as soon as previous symptoms stop despite a definitive clinical opinion being reached, multiple opinions are sought child�s normal daily activities are limited, or they are using aids to daily living more than expected

12. Obstacles Obstacles that should not stop acting to prevent harm include: fear of losing positive relationship with a family divided duties to adult and child patients and breaching confidentiality losing control over the child protection processand doubts about its benefits stress, personal safety, fear of complaints

13. Scenario 2 A 13 year old girl comes to the surgery asking for contraception. She confides that her boyfriend is 18 and that she first met him in an internet chat room. She says that you must not tell her mum � �What do you think? What would you do?

14. GMC Guidance0-18 years: guidance for all doctors

15. GMC Guidance Respecting patient confidentiality is an essential part of good care If a child or young person does not agree to disclosure there are still circumstances in which you should disclose information: a. when there is an overriding public interest b. when you judge that the disclosure is in the best interests of a child or young person c. when disclosure is required by law

16. Public interest disclosure a child or young person is at risk of neglect, sexual, physical or emotional abuse the information would help in the prevention, detection or prosecution of serious crime a child or young person is involved in behaviour that might put them or others at serious risk If you judge that disclosure is justified, you should disclose the information promptly to an appropriate person or authority and record your discussions and reasons

17. GMC Guidance A risk might only become apparent when a number of people with niggling concerns share them. If in any doubt about whether to share information seek advice e.g. from colleague, named/designated doctor, defence organisation or GMC You will be able to justify raising a concern, even if it turns out to be groundless, if you have done so honestly, promptly, on the basis of reasonable belief, and through the appropriate channels

18. GMC Guidance You should participate fully in child protection procedures, attend meetings whenever practical and co-operate with requests for information about child abuse and neglect You should share relevant information, even when a child or young person or their parents do not consent, or if it is not possible to ask for consent

19. GMC Guidance You should usually share information about sexual activity involving children under 13, who are considered in law to be unable to consent (Bichard)

20. GMC Guidance You should usually share information when: big differences in age, maturity or power between sexual partners a young person's sexual partner has a position of trust force or the threat of force, emotional or psychological pressure, bribery or payment, is used drugs or alcohol used to influence a young person to engage in sexual activity when they otherwise would not

21. Scenario 3 You are doing a late shift at the local minor injuries unit. 2 boys arrive one of whom has an infected laceration on his shin. They speak very limited English but you deduce they are from Afghanistan. They are unable to give an address or GP What would you do? What might happen next?

22. Working Together There are new sections in respect of: Children in contact with the youth justice system clarifying the role of the YOTs Children who go missing from education Children with families whose whereabouts are unknown

23. Working TogetherSupplementary Guidance Safeguarding Children from Abuse Linked to a Belief in Spirit Possession (2007) Safeguarding Children who may have been trafficked (2007) Safeguarding Children in whom illness is Fabricated or Induced (2008) Safeguarding Disabled Children � Practice Guidance (2009)

24. Working Together The Right to Choose: Multi-agency statutory guidance for dealing with Forced Marriage (2009) Safeguarding Children and Young People from Sexual Exploitation (2009) Safeguarding Children and Young People who may be affected by Gang Activity (2010)

25. Private fostering Children are looked after in a carer�s own home for 28 days or more The carer is not a parent or close relative Arrangement is made without the involvement of the local authority � but it is the duty of the carer or parent to notify the authority Then it is the duty of the LA to satisfy themselves that the welfare of the children is safeguarded and promoted Social worker will visit and provide support as needed In Victoria Climbie�s case she was looked after by her great aunt and partner, with no notification to the LA

26. Scenario 4 Kirsty born at 34 weeks gestation, spend 9 days on NICU �feeding and growing�. Now 6 weeks of age, she is found not breathing at 06.00 when dad got up to go to work. She had been co-sleeping as mum fell asleep after midnight bottle feed. Ambulance called, brought to A+E, resuscitation unsuccessful. You had seen her twice in the precious 48 hours with �snuffles� What will happen in the next 6-8 weeks?

27. Child Death Overview Panels and Rapid Response Teams

28. Rapid Response Teams Joint police + health visit Multi-agency investigative process Health - gathering information, bringing specific paediatric skills through history taking, examination and medical investigations Contribute to the support offered to bereaved parents, by providing information, answering questions, and arranging emotional support Feedback following post mortem and final case discussion

29. Child Death Overview Panels Statutory requirement since April 2008 Consider information from each child death in their area to ascertain cause of death Learn what could have been done to prevent the death where possible Disseminate findings and prevent future deaths

30. Focus Potentially avoidable Deaths Deaths from abuse or neglect Accidents Traffic, home, playground Suicides Deaths from natural causes not normally fatal Consider parental care; medical responses; other factors Deaths of disabled children Particular patterns of deaths Ethnic or demographic variation Certain services

31. Child Death Overview Panels Director of Public Health Coroner or Coroner�s Officer Consultant Paediatrician Children�s Social Care Police Child Abuse Investigation Unit Child Health Nurse /Midwifery Themed panels with appropriate expertise

32. Factors Contributing to Childhood Deaths Agencies involved in child protection will be familiar with The assessment triangle which can prove a helpful tool in evaluating individual child deaths. This can be used whatever the underlying cause of death. Agencies involved in child protection will be familiar with The assessment triangle which can prove a helpful tool in evaluating individual child deaths. This can be used whatever the underlying cause of death.

33. Scenario 5 Tasha a 15 year old girl, is found hanging by her mother. You had recently seen her and were concerned about her mood and non school attendance. You referred her to CAMHS but she failed to attend the appointment. The family are well known to social services - Tasha and her 4 younger siblings have CP plans for neglect. The SW has tried to visit 3 times recently but has not managed to gain access to the house In addition to a rapid response visit and child death overview panel review, what else needs to be considered? �

34. Serious Case Reviews

35. Serious Case Reviews Conducted by LSCBs where a child dies and abuse or neglect is known or suspected A serious case review must also be considered where: a child sustains a life-threatening injury or serious permanent impairment to health or development through abuse or neglect a child has been subject to particularly serious sexual abuse the case gives rise to concerns about inter-agency working

36. Serious Case Reviews The purpose of a serious case review is: to establish whether there are any lessons to be learned about inter-agency working to identify clearly what these lessons are, how they will be acted upon and what is expected to change as a result LSCBs are required to send the completed review to Ofsted for evaluation

37. Learning fromSerious Case Reviews The children�s families domestic violence, mental health problems, drug and alcohol misuse chaotic and complicated lives, making it difficult for professionals to obtain a clear picture of the family�s circumstances and dynamics agencies were found to have held important information about the family circumstances, but too often this was not shared early enough

38. Learning fromSerious Case Reviews Health services In many cases health practitioners had noted the signs and symptoms of possible abuse but had not acted on them Poor communication among primary care practitioners Information for assessments of risk during the pre-birth period and in the early months of life had not been collated Responses to the signs and symptoms of abuse in very young children, especially non-ambulant babies, were frequently inadequate. Parents� explanations for facial bruising and other injuries were too readily accepted

39. Learning fromSerious Case Reviews DNA�s - Referrer assumed that a service was being provided and, in turn, the provider assumed that when a DNA the service was not needed When parents were given responsibility for making appointments for their children they did not always do so, especially parents of disabled children Providers of specialist health services for adults, eg. substance misuse and mental health services, did not always take sufficient account of the service users� role as parents and whether the parents were likely to place children at risk. Some had not received safeguarding training

40. The SCR panel is of the view that all staff in every agency involved with Peter and his family were well motivated and concerned to play their part in safeguarding him and supporting Ms A to improve her parenting They were deemed to be competent in their safeguarding and child protection roles. They had the appropriate qualifications and experience for their roles and were no less qualified and no less experienced than staff in similar roles in other places. However, they did not exercise a strong enough sense of challenge when dealing with Ms A and their practice, both individually and collectively was completely inadequate to meet the challenges presented by the case of Baby Peter Baby P

41. Baby P The uncooperative, anti-social and even dangerous parent/carer is the most difficult challenge for safeguarding and child protection services. The parents/ carers may not immediately present as such, and may be superficially compliant, evasive, deceitful, manipulative and untruthful The interventions were not sufficiently authoritative by any agency. The authoritative intervention is urgent, thorough, challenging, with a low threshold of concern, keeping the focus on the child

42. Khyra Ishaq The death of a 7 year old girl who starved to death could have been prevented Khyra Ishaq was mistreated by her mother at a house in Birmingham and weighed just 16.5kg when found The SCR found there were a catalogue of missed opportunities by professional agencies. Better assessments and more effective communication could have stopped her death Some professionals "lost sight" of their responsibilities to protect Khyra and focused on the rights of the her mother and partner SWs did not listen to concerns of school staff and information from two worried members of the public was not acted on

43. Shannon Matthews Social workers could not have foreseen the abduction of Shannon Matthews by her mother, a serious case review has concluded Shannon�s disappearance in February 2008 sparked a �3m police operation and a nationwide search that ended when she was found hidden in the base of a divan bed in a flat about a mile from her home in Dewsbury Her mother, Karen, was jailed for 8 years for her part in what a judge described as a "truly despicable" plot with Michael Donovan, in whose flat she was found The Kirklees LSCB review ruled there was "little leeway" for social services and other agencies to intervene before Shannon was abducted

44. Shannon Matthews The review concludes that the family's history was characterised by "neglectful parenting interspersed with periods of adequate parental care" This case starkly demonstrates the difficulty of responding effectively to families where parenting is characterised by low-level neglect which at times escalates into inadequate parenting with detrimental consequences for children's wellbeing

45. Scenario 6 Over morning coffee you mention that you have seen a 4 year old girl with genital warts and your colleague says he has seen another 4 year old with what he suspected was genital herpes Should you be worried about either, neither or both? What would you do?

46. Competencies and Training

47. Professor Sir Ian Kennedy Despite the increased awareness in the NHS of the need to safeguard children, it is acknowledged that, on occasions, the NHS fails to provide a safe and supportive environment. Eg, young people are reluctant to tell health professionals about abuse, for fear that they will not be believed or that no action will be taken NHS trusts need to ensure that clinical staff are trained to the necessary level and must ensure that they keep safeguarding under regular review, rather than merely respond to serious incidents All those involved in providing services for children and young people, should receive training according to a common curriculum, developed with the involvement of the Royal Colleges and other professional bodies, to enable professionals to understand each other�s roles and work together

48. Intercollegiate Document Safeguarding Children and Young People:Roles and Competences for Health Care Staff

49. Level 2:clinical and non-clinical staff who have regular contact with parents, children and young people Competency: Be able to recognise child abuse Be able to document concerns Know who to inform Understand next steps in child protection process

50. Level 2 Knowledge: Understand who is at risk Know who to inform/seek advice from Know how to share information Know who to share info with/when � individual, organisational, professional Know what to record, storage, disposal

51. Level 2 Skills: Be able to document concerns, differentiating fact and opinion Know when further support is needed, involve managers, supervisors

52. Level 2 Criteria for assessment: Demonstrate appropriate referral Demonstrate accurate documentation of concern

53. Level 2 Method: Multidisciplinary training Update refresher training at regular intervals � minimum 3 yearly, with written briefing of any changes in legislation and practice minimum of annually

54. GP Self Assessment Tool Practice policies and procedures Staff recruitment and training Patient records systems Information for patients

55. Scenario 7 When looking at a 1 year olds notes you realize that you have received 3 letters from 3 different local hospitals regarding possible apnoeic spells What would you do?

56. Local Arrangements and Staff

57. Local Procedures South-west child protection procedures http://www.swcpp.org.uk/

58. On-call Rota and staff Community paediatrician always on call 9am � 5pm contact community child health department 5pm � 9am contact RUH switchboard Fiona Finlay, Tom Hutchinson, Rosemary Jones, Simon Lenton, Stuart Murray, Neil Simpson

59. Staff BaNES Designated doctor Simon Lenton Named doctor Fiona Finlay Designated nurse Mary Lewis Named Nurse Jill Chart Wiltshire Designated doctor Fiona Finlay Named doctor Paul Jakeman Designated nurse Cecelia Wrigley Named nurse Kate Larard

60. Any Questions?