Safeguarding Children and the Anaesthetist

1. Safeguarding Children and the Anaesthetist Alison Mott Consultant Paediatrician Named Doctor Cardiff and Vale UHB Chair Child Protection Special Interest Group

2. Aim • Importance of safeguarding children • Background legislation/ guidance • Role of anaesthetist • Recognition • Response • Record • Training

3. What is Child Abuse? ‘Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Children may be abused in a family or in an institutional or community setting; by those known to them, or, more rarely, by a stranger.’ Safeguarding Children:Working Together Under the Children Act 2004

4. Safeguarding and promoting the welfare of children • Protecting children from abuse and neglect • Preventing impairment of their health or development • Ensuring they receive safe and effective care ..so as to enable them to have optimum life chances

5. Legislation for Child Protection Children Act 1989/2004 U.N. Convention on the Rights of the Child 1991 Human Rights Act 1998 Sexual Offences Act 2003 Safeguarding Children: Working Together Under the Children Act 2004 Child Protection Procedures 2008 (Wales) Child protection and the anaesthetist: safeguarding children in the operating theatre 2007 RCPCH, RCA, APA

6. Health responsibilities • All health professionals play an essential part in safeguarding and promoting children’s health and development • Recognition • Assessment • Ongoing support • Therapeutic intervention • Health professionals often first to recognise families experiencing difficulties • Involves all Service groups not just Child Health Safeguarding Children: Working Together under the Children Act 2004

7. Duties of anaesthetist • To act in the best interests of the child which are always paramount • To be aware of the child’s rights to be protected; • To respect the rights of the child to confidentiality • To contact a paediatrician with experience of child protection for advice (On call paediatrician for CP, Named or Designated Doctor/Nurse) • To be aware of the local Chid Protection mechanisms • To be aware of the rights of those with parental responsibility Child protection and the anaesthetist: safeguarding children in the operating theatre RCPCH, RCA, APA 2007

8. Presentation to anaesthetist of child abuse and neglect • Known child protection concerns • Management of critically ill child e.g. NAHI • Anaesthetise for procedure e.g. genital bleeding • Anaesthetist identifies child protection concerns • Recognition of signs of abuse • Child’s disclosure • Resuscitation of critically ill child

9. Things to look for • Bruises in unusual places • You may notice in anaesthetic room • Resuscitation ?cause • Inconsistent history • Is the story from parent / child consistent with • A) what you were told by others? • B) what you can see?

10. Odd behaviour • Lack of crying • Flinching or shying away • Unusual parental contact / behaviour • Inappropriate affection to staff

11. When to suspect child maltreatmentNICE clinical guideline 2009 • Listen and observe • Seek an explanation • Record • If alerting feature prompts you to • CONSIDER child maltreatment • SUSPECT child maltreatment • EXCLUDE child maltreatment • Record actions/ outcome

12. When to suspect child maltreatmentNICE clinical guideline 2009 • CONSIDER • Look for other alerting features now or historical AND DO ONE OR MORE OF THE FOLLOWING • Discuss concerns with colleague • Gather more information • Review child at appropriate time • SUSPECT • Refer to social services • EXCLUDE • Suitable explanation found • May be after discussion with experienced colleague or after gathering more information

14. When to suspect child maltreatment: physical featuresNICE clinical guideline 2009 • Consider • Serious or unusual injury without explanation • Oral injury without explanation • Suspect • Bruising in non mobile child • Human bite mark (not child) • Rib fractures • Visceral injury

15. Welsh child protection systematic review groupwww.core-info.cf.ac • Bruises • Fractures • Burns • Torn frenum/ oral injuries • Non accidental head injury • Bite marks • Visceral injuries

16. Fractures suspicious of abuse Spiral fracture of humerus Multiple fractures Ribs Femoral fracture in non mobile child Spinal fracture Metaphyseal fracture Skull fracture

17. Torn frenum There is no published evidence to date to confirm the diagnosis of abuse based on a torn labial frenum in isolation Any unexplained torn labial frenum should be fully investigated to exclude the presence of other occult injuries

18. When to suspect child maltreatment: sexual abuse featuresNICE clinical guideline 2009 • Consider • Pregnancy in 13-15 year girl • Gaping anus • Suspect • Genital injury with absent explanation • Pregnancy in 12 year girl

19. When to suspect child maltreatment: NICE clinical guideline 2009 • Neglect • Faltering growth • Severe dental caries • Persistent symptoms eg persistently smelly and dirty, ingrained dirt • Emotional abuse • Domestic violence: If children living in a household with domestic violence, make a child protection referral • Parent or carer – child interactions

20. What should you do? • Appropriate medical care • Be suspicious but open minded • Inform parents unless not in best interests of child • Discuss any concern with • Supervisor or colleague • Paediatrician • Ensure child safety after discharge from your care • Your responsibility to refer if suspect child abuse • Document all discussions

22. Examination under anaesthetic? • Consent issues • Practicalities • Prolonging anaesthetic • ‘visual inspection acceptable of eg skin lesion but any additional or intimate/ invasive examination requires additional consent’ Child protection and the anaesthetist: safeguarding children in the operating theatre RCPCH, RCA, APA 2007

23. Consent and confidentiality • Consent for anaesthetic / surgical procedure only • Need to get consent from carer with parental responsibility for child protection examination

24. The Child Protection Process The six stages of the Child Protection process are: Referral Initial Assessment Strategy Discussion Strategy Meeting Child Protection Section 47 Enquiries by Social Services and/or Police Child Protection Conference

25. Support for anaesthetists • Anaesthetic line manager • Paediatric colleagues • Named professionals • Designated professionals • Safeguarding children structure within Trust/ Board with clear accountability • Local Safeguarding Children Boards

26. Review of the involvement and action taken by health bodies in relation to the case of Baby P Care Quality Commission: Themes Communication between healthcare professionals and partner agencies (police, social services) Training and observation of child protection procedures Staffing and recruitment

27. Child protection training in Haringey trusts 05/06

28. Safeguarding children:A review of arrangements in the NHS for safeguarding children July 2009 • NHS trusts’ boards should urgently review their arrangements for safeguarding children – in particular the levels of up-to-date safeguarding training among their staff. • Their reviews should be completed within six months of this report’s publication

29. Average % up to date on Level 2 safeguarding training • Pharmacists 35% • Surgeons, anaesthetists and theatre nurses who treat children 42% • Dental staff 42% • O&G 55% • Emergency care 58% • Child health 65% • Clinical psychologists 75% Safeguarding children: A review of arrangements in the NHS for safeguarding children July 2009

30. Training for anaesthetists: recommendations • All anaesthetists should complete Level 1 and 2 training in Child protection • Paediatric anaesthetists will need Level 3 training

31. Training levels • DH competence levels • Level 1: all staff working in a healthcare setting • Level 2: clinical and non clinical staff who have regular contact with parents, children and young people • Level 3: all staff working predominantly with children, young people and parents • NPHS Wales levels • College levels

32. Training for anaesthetistsSafeguarding Children and Young People e-learning • Level 1 - Introduction to Safeguarding Children and Young People: A single session that covers the knowledge and competences required for Level 1 Safeguarding  • Level 2 – Recognition, Response and Record: Three sessions that cover the knowledge and competences required for Level 2 Safeguarding • These sessions are now available on e-Learning Anaesthesia (e-LA) to ALL anaesthetists.

33. Training for paediatric anaesthetists • Plan to develop enhanced Level 2 or modified Level 3 with Department of Health for non paediatricians who work predominantly with children

34. Linkman review of safeguarding training November 2009 • 34% Level 1, 52% level 2, 14% Level 3 • 95% mandatory training • 69% training ‘fit for purpose’ • 83% local course • Enhanced level 2 training to include • Undertake local level 1 training for anaesthetic colleagues 60% • Understand forensic procedures/ practice 31% • Report writing 9%

35. Conclusion • Anaesthetists have important role in safeguarding children • Understand the role of anaesthetist • Recognition • Referral process • Record • Training mandatory • Enhanced Level 2 or Level 3 for paediatric anaesthetists • Guidance for anaesthetist

36. References • Child protection and the anaesthetist: safeguarding children in the operating theatre 2007 RCPCH, RCA, APA • When to suspect child maltreatmentNICE clinical guideline 2009 • CQC Review of arrangements within NHS Trusts for Safeguarding children 2009 • Laming Progress against actions 2009 • GMC guidance