Locality GPs Training Cumbria NHS

1. Locality GPs Training Cumbria NHS Dr K Balachandran Consultant Community Paediatrician Alder Hey 26th January 2012

2. Case Scenario 1 • You (or a G.P. colleague) are involved in seeing a teen age girl with her elder sister when she discloses that the step dad has been trying to sleep with her in the same bed. She has not been able to discuss it with her mother because she will not believe her story. The elder sister confirms that the same man has abused her in the past and again this has been kept as a secret and not being reported to any one. • The girl does not want you to share this information with anyone, and especially with her mother, who happens to be a social worker in another locality.

3. Case Scenario 1 Safeguarding Issues • Risk of sexual abuse • One of the girls already been subjected to sexual abuse on the basis of the information given • Risk of STD • Unwanted pregnancy • Family relationship issues

4. Case Scenario 1 Safeguarding Issues • Stress within the family • Alcohol or drug misuse • Domestic violence • Possibility of “invisible male” – what information do we have on step father’s past background and life style issues • Mental health issues – parents and/ or other members

5. Case Scenario 1 Professional/Patient Relationship Issues • Listen to the information from both girls and take necessary details including the duration of the concerns • Check regarding mother and daughter relationship/s • Brief check on academic attainments – name of the school that the girl attends and peer pressure issues • Her understanding and knowledge on sexual health matters • Enquire about general health including physical and emotional well being etc • Check consent/confidentiality and capacity to consent

6. Case Scenario 1 Interagency Communications • Ensure that both girls understand that due to the serious nature of the allegation that you will not be able to preserve confidentiality and keep the information as secret and not act on it. Avoid making promises that you can not keep. • Ensure that the girls understand that you may consider speaking to the mother in their presence to bring to her attention about their worries. • Ensure that both girls understand that you will have to speak to other professionals within the health to seek expert advice and guidance before making any referrals to outside agency such as social care to visit the family • Emphasise the benefit of sharing information with the relevant agency or other colleagues to get the right kind of help and support to prevent further risks to both girls • Refer to Child Protection – a tool kit for doctors – BMA RCGP Tool Kit and GMC Guidance on Consent and Confidentiality

7. Case Scenario 1 Referrals to Other Services/Professionals • Consider discussion with the named or designated professional/s • Look at what the SENCO/ school report say about the girl having obtained the necessary consent • Speak to the school nurse to see if she has any additional information either about the girl or the family • You need to ascertain whether the family has already been known to social care under child protection plan or child in need

8. Case Scenario 1 Working Together • Risk assessment and professional decision about a future course of action • Wherein doubt consult senior colleagues for advice – expert paediatrician and/or designated doctor • Consider consent and the capacity to consent by the girl before taking the next step

9. Case Scenario 1 Cumbria LSCB Procedure/s • Check Cumbria protocol on “possible risk of sexual abuse” • How best to protect the girls from coming to harm in the future

10. Case Scenario 1Record Keeping and Documentation • Good record keeping and documentation of the entire consultation • Document your action plans and future follow-up arrangements as required • There will be no need to subject the girls for a medical examination unless there is an acute episode of abuse suspected. • Let your colleagues in the surgery know of your actions • Keep in mind RCGP Tool Kit on the subject • Refer to the “ 7 Golden Rules” of information sharing as detailed in the Govt Guidance, Information Sharing: Pocket Guide – which is also detailed in RCGP Tool Kit

11. Case Scenario 2 • You (or a G.P. colleague) are concerned over the growth and nutrition of a toddler who has also failed several of his appointments at the surgery for routine health checks and immunisations. You receive a telephone call from the school that the elder boy has been frequently absenting from school due to ill health but you have no record of this in the boy’s surgery notes. • You meet the mother at the surgery that afternoon when she smells of alcohol and she has couple of bruises on her face and neck. She expresses her serious concerns about the elder boy being very active and stubborn making it difficult for her to manage. She believes that he has an underlying medical condition like ADHD and that he refuses to attend school.

12. Case Scenario 2Safeguarding Issues • Concerns over toddler’s weight gain, inadequate protection against common illnesses/failure of developmental follow-ups • Possibility of inadequate parenting versus “good enough parenting” • Possible “neglect” issue/s • Older sibling with poor school attendance and alleged to be frequently ill.

13. Case Scenario 2Safeguarding Issues • Older sibling with possible behavioural issues • Mother smelling alcohol • Possibility of volatile family relationship • “Child in Need” scenario

14. Case Scenario 2Professional/Patient Relationship Issues • Ensure that the mother is made aware of the school’s concerns about the elder boy. • Keep assuring her that you are trying to get help for the boy while you are also concerned over the younger child’s non-attendance and poor weight gain/developmental issues • Ask her about the family relationship and get her talk to you about her alcohol consumption in day time as well as her injuries

15. Case Scenario 2Professional/Patient Relationship Issues • Ask her about the support received from other family members or agency workers including benefits agency etc • Check whether there any chronic or mental health issues amongst family members

16. Case Scenario 2 Interagency Communications • Get full picture of what is going on – check all records in the surgery about the children and the family members • Seek the views of the health visitor and school nurses • Check whether the child and family are known to other services or agency workers or previously been on child protection plan • Speak to school to know about the elder child’s academic progress and other issues such as possible victimisation

17. Case Scenario 2 Interagency Communications • Inform mother that you will be contacting agency workers in both health and outside agencies to get the optimum help and support to the children and family • obtain consent and discuss confidential sharing of information under the terms of WT and Tool Kit for doctors • Risk assessment to decide the category of CIN process – Universal/Vulnerable/Complex child

18. Case Scenario 2 Referrals to Other Services/Professionals • Family health visitor • School Nurse • School SENCO or class teacher for more information • Social care to see whether the family is already known to them either under child in need or child protection • Speak to named or designated doctor or nurse for further advice and support

19. Case Scenario 2 Working Together • Welfare of the child is of paramount importance • Child In Need • CAF • Escalate to section 47 if the children are at acute risk of coming to significant harm

20. Case Scenario 2Cumbria LSCB Procedure/s • Familiarise yourself with Child In Need procedure • CAF • Threshold/s of intervention – child in need of child protection – escalation to section 47 from section 17

21. Case Scenario 2Record Keeping and Documentation • Document your entire consultation and discussion with other agency workers • Check both children for physical examination including growth and developmental checks – chart all growth parameters • Check the nutritional status of the children and where indicated carry out base line blood tests – look for iron deficiency status • Opportunistic completion of immunisation programme

22. Case Scenario 2Record Keeping and Documentation • Monitor progress with a clear action plan following each consultation either by the GP or Health Visitor/School Nurse • Attend CAF meetings as required or forward written reports or complete the health section updates • Confident and professional approach at all stages of assessment/reassessment is crucial • Consider developing a practice based policy about non-attendances or failed follow-ups if there is none in place. • Share your approach with other doctors in the practice • Use RCGP Tool Kit regarding documentation of Child Protection Incident Reporting from and/or significant event monitoring – a way of reflective learning for the practitioners

23. Case Scenario 3 • The mother of a 14 year old girl came to see you (or a G.P. colleague) at the surgery raising concerns over the volatile relationship between the father and daughter which at times have resulted in father thumping the girl as witnessed by the mother. She has also informed you that her husband is currently going through some stressful situation at work and his anger gets worse while he has had a drink. • You have made a note in the surgery notes that the mother has been victim of abusive behaviour at the hands of her partner about 2 or 3 years ago. They have a younger son of primary school age. • Both parents are professionals and the mother is a Head Teacher at a local school and the father is a local police officer. The family is requesting some form of therapeutic counselling. • Father is registered with a different GP practice whereas the mother and the children are registered with your practice.

24. Case Scenario 3 Safeguarding Issues • Family relationship issues • Domestic abuse and its impact on parenting ability • Stress related to work • Consideration of alcohol, drug/substance misuse/chronic medical conditions/mental health issues • Professional status of parents and the implications in safeguarding children

25. Case Scenario 3Professional/Patient Relationship Issues • How best to acquire an accurate picture of what is going on within the family. • What is the family composition and are there other children who may be at risk of abuse/ witness to domestic violence • How to ensure that all relevant family members are involved in the subsequent consultations • How to deal with the father who is registered with another GP

26. Case Scenario 3Professional/Patient Relationship Issues • What next in respect of supporting the family and protecting the teen age girl from coming to harm – emotional/physical or other forms of abuse. Consider as well the sibling’s reaction to the situation • Keeping such sensitive information confidential from working places and at the same time ensuring that family and child are supported • Children’s exposure to parental conflict, even where violence is not present can lead to serious anxiety and distress (WT) • Correlation between Domestic abuse and child abuse • Risk assessment is crucial before deciding the next step

27. Case Scenario 3 Interagency Communications • Important to acknowledge that removal from an abuser does not automatically mean safety for a child. • Listen to what the child /mother says • Explain the need to make sure that the child and others in the family are safe • Discuss consent and confidentiality in respect of protecting children – refer to “Tool Kit for Doctors” and GMC guidance on the subject

28. Case Scenario 3 Interagency Communications • Seek advice of a named or designated doctor/nurse • Look at Cumbria DV policy • This will mean sharing information with relevant agencies – local social care, local DV advocacy services, local police community safety units, NSPCC child protection helpline • Understand your locality Multi-agency risk assessment conference protocol (MARAC)

29. Case Scenario 3 Referrals to Other Services/Professionals • Familiarise with the local policy about DV • Local Social care • Local DV advocacy services • Local police community safety units • NSPCC child protection helpline • MARAC

30. Case Scenario 3 Working Together • Act in the best interest of the child • Think Family practice when dealing with issues of possible dysfunctional family. • Children at risk of poor outcomes where there is evidence of volatile relationship/domestic violence

31. Case Scenario 3 Working Together • Professional standards to be maintained - Promotion of good professional practice • Provide advice and expertise for fellow professionals • Appropriate training to understand the impact of Domestic violence on Parenting ability and the child’s welfare and promotion of health

32. Case Scenario 3Cumbria LSCB Procedure/s • Look at Cumbria LSCB procedures – website • Take appropriate action in safeguarding the child and supporting the family

33. Case Scenario 3Record Keeping and Documentation • Good record keeping • Look at previous entries about DV • Look at previous CP plans if any • Discuss with the HV/School Nurse and document your discussion • Make sure your practice colleagues are aware of your actions. • Refer to RCGP Tool Kit relevant to the case scenario

34. Thank You