Alison Mott Consultant Paediatrician Named Doctor Cardiff and Vale UHB Chair Child Protection Special Interest Group

 Importance of safeguarding children ◦ Background legislation/ guidance  Role of anaesthetist ◦ Recognition ◦ Response ◦ Record  Training

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

 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

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

 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

 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

 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

 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?

 Lack of crying  Flinching or shying away  Unusual parental contact / behaviour  Inappropriate affection to staff

When to suspect child maltreatment NICE 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

When to suspect child maltreatment NICE 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

When to suspect child maltreatment: physical features NICE 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

 Bruises  Fractures  Burns  Torn frenum/ oral injuries  Non accidental head injury  Bite marks  Visceral injuries

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

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

 Consider ◦ Pregnancy in year girl ◦ Gaping anus  Suspect ◦ Genital injury with absent explanation ◦ Pregnancy in 12 year girl

 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

 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

 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

 Consent for anaesthetic / surgical procedure only  Need to get consent from carer with parental responsibility for child protection examination

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

 Anaesthetic line manager  Paediatric colleagues  Named professionals  Designated professionals  Safeguarding children structure within Trust/ Board with clear accountability  Local Safeguarding Children Boards

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

GOSHWhittingtonNMUH Day care nurses 63%83%100% Consultant anaesthetists 18%88%No data Consultant surgeons 35%75%13% Emergency care nurses NA23%100%

 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

 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

 All anaesthetists should complete Level 1 and 2 training in Child protection  Paediatric anaesthetists will need Level 3 training

 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

 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.

 Plan to develop enhanced Level 2 or modified Level 3 with Department of Health for non paediatricians who work predominantly with children

 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%

 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

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