Safeguarding children

Published on 21/03/2015 by admin

Filed under Pediatrics

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 1054 times

5 Safeguarding children

Ros Proops, Jane Black, Richard Beach

Chapter contents

What is meant by ‘child abuse’?

Physical harm

What might make you suspect a child has suffered a non-accidental injury? 
What should you do if you have child protection concerns?
What should happen once someone has raised the possibility of abuse?

Other types of abuse

Neglect 
Emotional harm
Sexual harm
Fabricated or induced illness

The case conference

Information sharing and confidentiality

The common law duty of confidence 
The Human Rights Act
The Data Protection Act

Every week in the UK one or two children die as a result of child abuse. Many more suffer significant harm at the hands of their parents, carers or someone close to them. Only very rarely is the perpetrator a complete stranger.

High profile cases, including the tragic deaths of Victoria Climbié and ‘Baby P’ (Peter Connolly), have highlighted some important weaknesses in the procedures for safeguarding children in the UK. This has resulted in improved awareness and training for all who are concerned with the care of children and more stringent policies and procedures across institutions. The message is clear – safeguarding children is everyone’s responsibility – and that includes you.

What is meant by ‘child abuse’?

The Children Act 1989 introduced the concept of significant harm as the threshold that justifies compulsory intervention in family life in the best interests of children. Significant harm is defined as:

Physical harm

– including shaking, hitting, poisoning, non-accidental fractures, scalds and burns

Neglect

– described as the persistent failure to meet a child’s basic physical and/or psychological needs likely to result in the serious impairment of a child’s health or development

Emotional harm

– described as the persistent emotional ill-treatment of a child resulting in severe adverse effects on a child’s emotional development. This includes the corruption and exploitation of children.

Sexual harm

– such as forcing a child to take part in sexual activities, whether or not the child understands or is aware of what is happening.

In order to protect children from significant harm, we must all be prepared to think the unthinkable and be prepared to question the information given to us about every child we see.

Physical harm

Case 5.1A A boy with a lump on his head

Jack, a 4-month-old baby boy, was taken to his GP by his mother for a routine immunization. The GP noticed a large swelling on the side of his head. The boy’s mother said she had not previously noticed it and had no idea how the lump arose. The GP sent Jack to the local hospital where a skull X-ray revealed a linear parietal fracture. The paediatrician was concerned that this might have been a non-accidental injury and admitted him for observation and further investigation.

What might make you suspect a child has suffered a non-accidental injury?

1 Factors in the history

• No explanation is given as to how a significant injury might have occurred.

• There are inconsistent or differing stories given about the cause of injury

• The explanation given is inappropriate for the child’s expected developmental level. (‘Those who don’t cruise, don’t bruise’ – immobile children are not likely to accidentally sustain multiple bruises on their legs; by contrast, the shins of most 4-year-olds are covered in bruises.)

• The explanation given is incompatible with the injury sustained, e.g. an 18-month-old child has bilateral fractured femurs, where his mother says the injury happened when he did a ‘roly-poly’ on the kitchen floor.

• There is delay in presentation. The normal reaction when a child is injured is to seek medical advice at once. If a child is presented many hours or days later non-accidental injury is more likely.

There are also a number of risk factors which may make a child more vulnerable to abuse, including having very young parents; those living in poverty; a history of drug and/or alcohol misuse in the parents or carers; and a history of domestic violence in the household. Children with disabilities are also at increased risk. However, it is vital to be aware that child abuse is no respecter of social class and can occur in any household no matter how well off or educated the family concerned.

Sexual abuse may present in a variety of ways, including inappropriate sexual behaviour, psychological disturbance and anogenital soreness or discharge. Detailed physical examination looking for signs of sexual abuse should only be undertaken after specialist training.

2 Factors on examination

If child abuse is suspected the child should be carefully examined from top to toe. Is the child content in the carers company? Do they seem well cared for and appropriately dressed? Are they clean? Height, weight and head circumference should be measured and plotted on a centile chart. Whatever the presenting concern the whole child should be examined for bruises, scars or other injuries.

Bruising is common in active children – but is usually on the shins and perhaps the forehead. Bruising to less accessible sites such as the trunk (especially the back) and the cheeks and ears is suspicious of child abuse.

Although it is impossible to age bruises accurately, a pattern of bruising on different sites and of different colours should cause concern.

Always compare the injury with the history and attempt to reconstruct what might have happened. This can be particularly helpful in assessing burns and scalds.

Linear marks from straps or sticks and circular burns from cigarettes should be identified. On occasion forensic testing can link an injury to the weapon used in an assault.

Be careful about signs said to be diagnostic of abuse. Torn frenulum is a worrying injury often found in children who have died after abusive head injury. Nevertheless it can occur accidentally. Assess each case on its merits.

3 Investigation of suspected child abuse

Investigation like examination should check the whole child looking for unexpected injuries. In younger children a skeletal survey which takes radiographs of all the bones is helpful. Children with possible head injuries should have brain imaging and ophthalmic examination. Investigation should also be used to seek an explanation for symptom. For example, those with bruising require platelet estimation and clotting studies.

As with examination, some injuries detected by investigation are highly suggestive of abusive injury. Metaphyseal fractures and rib fractures on skeletal survey are good examples.

Don’t forget that an injured child needs careful medical attention Remember the possiblity of unsuspected brain or abdominal injury.

Case 5.1B A boy with a lump on his head (cont’d)

Jack’s paediatrician was concerned about his injury and made further enquiries.

Jack’s mother was initially unable to give any explanation as to how the skull fracture occurred. Once on the ward, she mentioned to one of the nurses that her boyfriend sometimes got angry with Jack when he cried.

Further history revealed that the mother was herself only 18 and her boyfriend was not Jack’s birth father. She admitted that he was sometimes violent towards her.

Comment

A skull fracture is a very serious injury in a young baby and may be associated with underlying subdural haemorrhage or other cerebral damage. With no adequate explanation it is highly probable that the cause is non-accidental. A history of domestic violence commonly accompanies non-accidental injury.

What should you do if you have child protection concerns?

1 Accurate documentation is essential

Whenever you take a history, it is vital that you always document what is said to you accurately. This is as essential in child protection cases as in any other area of medicine.

Ideally you should always document:

• When the history was taken – give date and time accurately

• Who gave you the information and who else was present (other relatives, nursing staff, etc.)

• What precisely you are told. Use quotations directly – it can prove very helpful when someone else reviews the history, and will be more accurate than your interpretation of what you have been told. For example, it is better to say ‘Mum told me that “David fell down the stairs and hit his head”’ than just ‘David fell down stairs and hit his head’. After all, did you see it happen yourself?

Document your examination findings clearly and use drawings or body maps to indicate the site and extent of injury. Describe precisely what you have found, not what you are told/think is the cause. For example, a cigarette burn is a round, reddened raised lesion, approximately half a centimetre in diameter – but so might be a spot due to streptococcal infection.

2 Inform your senior colleagues

Always express your concerns with your consultant or other relevant senior colleagues. The key to protecting children is not only to think the unthinkable, but also to share your concerns with those in a position to take further action. They can arrange appropriate investigations and will know who else to inform. Never assume someone else has done this for you. Rarely, if you feel that a child, staff or others may be at immediate risk you should contact the police immediately.

3 Follow your local safeguarding children procedures

Nowadays all NHS organizations are required to have a written safeguarding children policy. Familiarize yourself with its contents and make sure you know where to go for advice if faced with possible safeguarding children concerns. All NHS bodies responsible for children must have a safeguarding team with a named doctor and named nurse available to give advice and support to employees.

All local authorities in Great Britain have a Safeguarding Children Board (a single board covers Northern Ireland), with a designated doctor and nurse, responsible for leading child protection in the locality. This role includes advising local safeguarding boards, working with public health to ensure awareness of safeguarding and related issues, such as domestic violence, providing advice to health providers, and feeding into health commissioning/provision.

Case 5.1C A boy with a lump on his head (cont’d)

Jack was observed on the ward overnight for any clinical effects of head injury. The following day he had a skeletal survey carried out. (This is a type of X-ray that looks at all areas of the body for evidence of any other bony injury. It may well require sedation and the expertise of a specialist radiologist for interpretation.) On this occasion it revealed several healing rib fractures and a healed fracture of the left upper humerus. A CT scan of Jack’s head was reported as normal with no signs of cerebral haemorrhage.

What should happen once someone has raised the possibility of abuse?

Social services must be informed of your concerns, giving clear reasons as to why you feel the child has been, or is at, risk of being significantly harmed. This is usually the responsibility of the consultant in charge, or the GP dealing with the child, if the child presents in general practice and does not attend hospital. The procedures in your hospital will make this clear. However, many other people, including health visitors, teachers and members of the public, can and should notify social services if they are worried that a child might be being harmed.

Once social services are informed of significant concerns about a child, the following usually happens:

• A social worker will carry out an initial assessment of the family situation and the risks to the child/children

• A strategy meeting will be held to decide what further action should be taken. This generally involves key professionals involved in the case

• An initial case conference will be convened at which a decision is made as to whether or not a safeguarding plan should be instituted. This will ensure professional carers and the local authority work together in a planned way to ensure the child’s continuing safety

• The progress of the safeguarding plan is reviewed at a review case conference about 3 months later. Once conference agrees that the child’s safety is assured the plan can be discontinued.

Case 5.1D A boy with a lump on his head (cont’d)

Jack remained well while on the ward, and following a strategy meeting it was agreed that he might be at risk of further harm if discharged home to his mother and her boyfriend. He was therefore discharged from hospital to foster carers.

A case conference took place 10 days later and a safeguarding plan was agreed because of the risk of continuing physical harm. Several months later Jack’s mother left her boyfriend and moved back to live with her parents. Jack was eventually returned to his mother’s care.

Other types of abuse

Neglect

Case 5.2 A girl left on her own

Kelly, a 3-year-old girl, was referred to social services by a neighbour who was concerned that she appeared to be left alone for prolonged periods in the house. She was noted to be extremely dirty and wearing clothes that were badly torn and did not fit.

When medically examined she was found to weigh well below the 0.4th centile for her age, and had marked speech delay. She had no idea what to do with crayons and paper or simple toys, and her behaviour suggested that she had never seen such objects before. She was placed in temporary foster care, where she rapidly gained weight and quickly learned to speak and play, although she had persistent difficulties interacting with other children and adults.

Emotional harm

Case 5.3 A boy who is a nuisance

Andrew, a 4-year-old boy, was constantly told by his parents that he was a nuisance and that they wished they had never had him. He had a favourite teddy bear which was given to him by his grandmother and that was his only real comfort. One day his father became very angry with him and burned the teddy bear in front of him as a punishment.

Sexual harm

Case 5.4 A girl with vulval soreness

Ebony, a 7-year-old girl, was taken to her GP by her mother because of recurrent vulval soreness. The mother was concerned that these episodes coincided with the girl’s access visits to see her father. The GP referred the girl to a consultant community paediatrician and examination showed genital herpes. She later told a social worker that her father regularly asked her to sleep in his bed with him and had been doing so for 3 years since her parents had separated.

Fabricated or induced illness

Fabricated or induced illness (FII) – previously called Munchausen syndrome by proxy – is defined as illness which is fabricated or induced by a parent or carer. The carer, with a story of grave illness, brings the child to medical attention, often persistently. When the child is assessed they are found to be well with no evidence of ill health. The symptoms and signs cease when the child is separated from the perpetrator. The child may be subjected to numerous medical investigations before anyone raises the possibility of abuse. Presentations include seizures, suffocation, non-accidental poisoning and sudden infant death.

FII is never an easy diagnosis to make, and whenever the possibility arises doctors must work closely with other professionals, including the police and social services, to ensure that a detailed assessment is carried out and the case is appropriately managed.

You should consider FII when:

• There is persistent or recurrent illness

• The child looks well in spite of severe symptoms

• Investigations and treatment do not solve the problem

• The parent/carer is excessively attentive and cheerful, and reluctant to leave the child’s bedside.

Clearly all of the above can, and do, arise in children with serious and real pathology. Always consider this diagnosis when a case seems unusual or the facts don’t seem to fit the history given by the parent/carer.

The case conference

Case conferences are arranged by social services and are the place at which decisions are made as to whether or not a safeguarding plan is required and, if so, for what reason – physical harm, neglect, emotional harm or sexual harm.

Key professionals involved in the child’s care are invited, such as the GP, health visitor (or school nurse, depending on the age of the child), paediatrician, teacher, and of course social worker. All are requested to submit a written report stating their involvement with the child to enable those present to make informed decisions about the level of risk to the child.

The parents are also invited and have access to all the reports provided for the case conference – hence the need to be factual and accurate when taking a history and documenting findings in the first place.

Information sharing and confidentiality

Many doctors worry that by providing information for social services they will be breaking their duty of confidence to their patients. However, it is clear that information must be shared between professionals in order to safeguard children. Indeed, sometimes it is only when information from a variety of sources is put together that people then recognize that a child is at risk of significant harm.

In order to understand some of the key issues around information sharing it is helpful to have an understanding of the law in relation to confidentiality. In July 2012, the General Medical Council issued guidance on safeguarding children for all doctors. You need to be aware of:

• The common law duty of confidence

• The Human Rights Act 1998

• The Data Protection Act 1998.

The common law duty of confidence

The doctor–patient relationship is viewed as confidential. However, disclosure of information is allowed under a number of circumstances. These include when the person to whom the duty is owed consents to the information being shared; and when there is an overriding public interest in disclosure, such as the need to protect a child from harm.

The Human Rights Act

This Act recognizes that everyone has the right to privacy and to respect for their private and family lives. However, this right is not absolute, and disclosure of information is justified when it will protect the health and welfare of the child or prevent a criminal offence.

The Data Protection Act

Essentially, this Act lays down requirements about the way personal information, held in computer or paper records, is handled and processed, including disclosure of that information. As with the Human Rights Act, disclosure of information is permitted if there are particular welfare concerns about a child and if it is felt that failure to disclose might result in harm to that child.

So whether you work in general practice, orthopaedics, radiology, obstetrics or paediatrics – or indeed any branch of medicine – safeguarding children really is everybody’s business.

Further reading

Working together to safeguard children. UK: Ministry of Education; 2010.

Child protection companion. Royal College of Paediatrics and Child Health; 2006.

Welsh Child Protection Systematic Review Group. www.core-info.cardiff.ac.uk/

Protecting children and young people: responsibilities of all doctors. http://www.gmc-uk.org/guidance/ethical_guidance/13257.asp

Related posts:

Skin Children’s place in society Pregnancy, birth and the newborn Respiration Congenital and genetic disorders Assessing childhood illness