GPs – Vital Role in Safeguarding Children Dr Junaid Oluseyi Solebo Associate Specialist in Paediatrics Named Doctor for Safeguarding Children BHRUT Feb 2010

Introduction GPs have a vital role in the protection of children Be aware of their responsibilities As care provider, be able to recognise and respond to CP Shift of responsibility for child protection to PCTs Government’s determination to change things for children for the good and for good

Key Position GPs Enjoy an enhanced role in health provision Provide majority of child health surveillance See significant proportion of childhood illness Have extensive knowledge of the family background First point of Contact for most health problems Unusual for a child not to be registered with a GP GPs, well placed at surgery’s consultation, home visits, treatment rooms sessions, child health attendance and have information from other staff (HV, Midwifes, Practice Nurses)

Local Procedure and Policy Be aware of local procedures Referral pathways Documentation Named/lead Professionals for Child Protection How to contact Named/Lead Professionals How to contact Social Workers/other agencies

Obstacles to identifying child maltreatment (These must not stop healthcare professionals from acting to prevent harm to the child) Concern about missing a treatable condition Fear of losing a positive relationship with a family Discomfort of disbelieving, thinking ill of, suspecting or wrongly blaming a parent or carer Divided duties to adult/carers and breaching confidentiality Understanding of the reason why maltreatment have occurred and no intention to harm child Losing control over child protection process and doubts about its benefits Stress personal safety Fear of complaints

The Scale of The Problem Research showed if all forms of injury in childhood are analysed, then NAI is common. 7% of children experienced serious physical abuse – by parents/carers 1% , sexual abuse by parents/carers 3%, sexual abuse by another relative 11%, sexual abuse by people unrelated, but known to the children 5%, sexual abuse by stranger 6%, serious absence of care at home 6%, severe emotional abuse 16%, severe maltreatment by parents/carers 55% of fatally abuse have been seen within the previous month by a healthcare Non-accidental head injury, more common in babies and toddlers 36 per 100,000 in <6 mth of age, 14-24 per 100,00 in < 1 yr and 0.3-3.8 in 1 -2 yrs. Standard for Radiological Investigations of suspected NAI. RCPCH March 2008

CHILD FATALITIES Between 1995 and 1997, 78% of these children were less than five years old, while 38% were under one year of age. Deaths 44% of deaths resulted from neglect, 51% from physical abuse, 5% from a combination of neglectful and physical abuse 41% of these deaths occurred to children known to child protection service agencies as current or prior clients

Some Statistics 570,220 referrals to social services in England in 2003 4,109 reported offences of cruelty or neglect of children 2002/3 Every year, 30,000 children names ‘Registered’ in England 2500 in Wales, and 2000 in Scotland NSPCC Information Briefings April 2004 Hobbs estimates At least 150,000 children a year suffer sever physical punishment likely to cause harm to their development 100,000 children a year have potential harmful sexual experience Hobbs C , Physical Abuse In Protecting Children from Abuse and Neglect in primary Care,2003

RCPCH Research Division –march 2003 of 3879 practicing/just retired paediatricians 536 (13.6%)-complaints related to Child Protection 79% of complaints dealt with locally 8% went to independent review 11% referred to GMC Yet we must act firstly in the best interest of child and secondly the family

GPS LOTH TO REPORT CHILD ABUSE BMJ 1999 (16TH JANUARY) Doug Payne in Dublin found that of the five GPs interviewed in depth not one had a copy of the health department’s child abuse guidelines and that two “were completely unaware of their existence”. Of the 72 referrals for abuse, only 4 had been made by GPs, and in all cases the GPs were only passing on concerns OF the children’s parents. GPs also expressed reluctance to become involved with Social Workers, Police, or others engaged in the system

Essential aspects of child protection Accurate diagnosis Timely Intervention Appropriate Intervention 50% chance of repeated abuse if no intervention 31% chance of repeated abuse within 3 years following intervention Arch Dis Child Jan 2004

Every Child Matters (Integrated working is the key focus) Five outcomes for children: Be healthy Stay safe Enjoy and achieve Make a positive contribution Achieve economic well-being

Child Protection Training GPs should take part in child protection Have regular updates as part of their postgraduate education GPs as ‘employers’ to ensure that others attend training

Safeguarding Children Training Level 1 All staff working in healthcare settings (clinical and non-clinical) should be trained to this level. They should: • Understand what constitutes child abuse. • Know the range of physical abuse, emotional abuse, neglect and sexual abuse. •Know what to do when they are concerned that a child is being abused

Level 2 All clinical and non-clinical staff who have regular contact with parents, children and young people should be trained to this level. They should: Be competent at level 1. • Be able to recognise child abuse. • Be able to document their concerns. • Know who to inform. • Understand the next steps in the child protection process

Level 3 All staff working predominately with children, young people and parents should: Be competent at level 2. • Have knowledge of the implications of key national documents/reports. • Understand the assessment of risk and harm. • Understand multi-agency framework/assessment/investigation/working. • Be able to present child protection concerns in a child protection conference. • Demonstrate ability to work with families where there are child protection concerns. • Be able to put into practice knowledge of how to improve child resilience and reduce risks of harm. • Understand forensic procedures/practice. • Where appropriate, be able to undertake forensic procedures. • Be able to advise other agencies regarding the health management of child protection concerns. • Be able to contribute to serious case reviews or equivalent process.

3 ways to be involved Direct contact with a child or his/her careers. Approach by social services to provide information about a child Asked to carry out a specific type of assessment

The Victoria Climbié Inquiry (Jan 03) Health Analysis Information was known but not recorded Recorded information was not shared Information was passed verbally and not recorded Actions were agreed without making anyone responsible for carrying them out Actions were put off and not completed Actions were assumed to be complete but not checked Actions were recorded but ignored i.

Summary of the contact that health professionals had with Baby P 6 visits by to an acute hospital. 14 visits to the GP practice 1 to the child health service, 5 visits by a health visitor 6 visits to the child health clinic 2 visits to walk-in centres 1 contact with the midwife

Review after Baby P (March 09) Systemic failings in a number of areas leading up to the death of Baby P, in particular: Poor communication between health professionals and between agencies, leading to a lack of urgent action with regard to child protection arrangements, and no effective escalation of concerns. Lack of awareness among some staff about child protection procedures, and a lack of adherence, by some staff, to these procedures. Poor recruitment practices combined with lack of specific training in child protection, leading to the risk of some staff being inexperienced in the arrangements to protect the safety of children. Shortages of staff,, leading to delays in seeing children. This included shortages in consultants, nurses and administrative staff. Failings in governance in the trusts concerned. Care Quality Commission: Review of the involvement and action taken by health bodies in relation to the case of Baby P 36

Care Quality Commission – Core Standards The core standards relevant to this report for all health organisations are: 1. Safeguarding children: To protect children by following national child protection guidance within their own activities and in their dealings with other organisations (standard C2). 2. Recruitment and training: Ensure that staff are appropriately recruited, trained and qualified for the work they undertake (standard C11a). 3. Mandatory training: Ensure that staff participate in mandatory training programmes (standard C11b). 4. Professional development: Ensure that staff participate in further professional and occupational development (standard C11c). 5. Public health partnerships; Promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by cooperating with each other and with local authorities and other organisations (standard C22a)

National Review of health services for children The Healthcare Commission’s (now called Care Quality Commission) review of services for children in hospital use the following criteria for review. Children have access to child-specific services. Children have access to care that is local to their homes. Services are staffed by appropriate levels of trained staff. Staff have child-specific training. Staff have the opportunity to maintain their skills

Key Documents to support The role of Primary Care in the protection of children form abuse and Neglect. RCGP 2002 Laming. The Victoria Climbie Enquiry. 2003. Recommendations Every Child Matters. 2003 What to do if you ‘re worried a child is being abused. 2003 The children Act 2004 The National Service Framework for children, Young People and Maternity. 2004 Working together to safeguard children. DoH 1999, 2006, 2010 Child Death Review Panel. April 2008

Aims of Policies Raising Standards Improved information sharing More effective working between professionals A more child and family sensitive service Supports for children Common core skills for all who work with children Improved accountability and integration of services

Issues for all Confidentiality and Sharing Information (BMA, Human Rights Act, 1998. Working Together 1999. 2004) 1. Patients are entitled to confidentiality 2. A doctor’s legal and ethical duties to maintain confidentiality 3. A doctor in possession of information relating to a third party who might pose a continuing risk to child Disclosure of such information will be justified in the public interest in relation to protecting a Child.

Issues for all - Referral If the child is in immediate danger, 1. Child’s safety is paramount 2. Consider hospital admission 3. Involve Community Based Services 4 Always communicate with parents/carers 5. YOUR RESPONSIBILTY includes verbal referral, followed within 2 working days in writing

Issues for all - Referral If Child is not thought to be in immediate danger Inform parents/carers unless this would compromise the child safety Obtain a full history Record the information, where possible, verbatim Check with the community based Services. Consult as appropriate with colleagues (Designated paediatrician) Still refer if child is at risk

Referral Should be made by telephone to the appropriate Access or Assessment Team Should be followed in writing within 2 working days Document reason for a decision NOT to proceed/refer If unsure MUST REFER

Issues for all - Record Keeping Copy of Referral Form should be in child’s medical record Ensure records are Timed, Dated and Accurate. Good practice to keep records of incident/allegation, any discussion and reason why action was taken Report on the examination, indication where, when and why child was examined, details of injuries Best Practice to include child’s full name, dob, address, main carer, school, GP’s name.

Issues for all – Attendance at Child Protection Conference Information sharing with community based services when enquires are made about a child To be involve in child protection plan If attendance is not possible, to submit a written report

Important Areas Recognition Procedures Communication and Partnership Record Keeping

Where to seek advice/Guidance Designated Doctor Designated Nurse Named Doctor Named Nurse Team Manager, Children’s Service

For Every Case A full history Documentation of the history (verbatim from informant) An examination of the whole body, inc weight and height A Register check Discuss with other relevant professionals Seek advice and consult with Named/Designated doctor A Decision on if injury or observed symptom could be abuse A Decision on further action Referral, verbal followed by written

Discussions (in groups) Symptoms in a child suggesting abuse Symptoms in parents that could lead to child abuse Barriers to information sharing and reporting Barriers to further engagement

Areas of Potentially Serious Concerns Failure to thrive Failure to attend immunisation/hearing test without explanation Failure to attend hospital outpatient appointments Inappropriate use of out of hours service or A & E Troubled/Multiproblem Families – chronic health, poor housing, long term unemployment, petty crime, domestic violence, some addictions and substance abuse. Acutely distressed families – struggling but coping until some final overwhelming incident precipitated child abuse. Single parent, immature parents, physical illness or disability.

Questions Thank you