Doctors’ responsibilities in child protection cases
June 2004
Part two: initial concerns
- Where a doctor has concerns about a child
- Local procedures
- Confidentiality and suspected abuse
- Sharing information
- The General Practitioner and the primary health care team
- Hospital-based doctors
- Medical note keeping
- Communicating with children
- Involving parents and carers
As outlined in the basic principles above, where a doctor has a reasonable belief that a child is at serious risk of immediate harm, he or she should act immediately to protect the interests of the child, and this will almost always involve contacting one of the three statutory bodies with responsibilities in this area: the police, the social services or the NSPCC, and making a full report of concerns.
The precise action taken should be governed by the procedures set out by the local Area Child Protection Committee. In some cases, however, signs of abuse or neglect are not straightforward or clear-cut. Patterns of behaviour or of symptoms develop over time, neglect can shade into abuse, and children and adults can become adept at masking difficulties and misleading professionals.
Doctors are therefore often forced to make difficult decisions on the basis of fragmentary and ambiguous evidence. Where doctors believe, however, that there may be genuine grounds for concern, it is important that they do not ignore any early warning signs, even where they may consider the evidence too uncertain to warrant the immediate commencement of child care proceedings. In these circumstances, doctors should initially consider discussing the matter with other colleagues and health care professionals and should also seek the advice of trained professionals with experience in child protection. Where uncertainty exists, it can be extremely helpful for doctors to test out hypotheses in this way, without necessarily disclosing identifying data about the patient. It is also important that the option of talking to the carers or family at an early stage is not ruled out. Obviously this needs to be sensitively done and is not feasible in all cases, but it may indicate opportunities to work constructively with parents to improve parenting skills.
It is difficult to over-emphasise the importance of documented professional discussion and support in this area.
Local procedures
All doctors who are likely to come in contact with children in a professional capacity should familiarise themselves with local procedures for promoting and safeguarding the interests of children. Every area is obliged to identify a senior paediatrician, and a senior nurse with a health visiting qualification (designated senior professionals) to take a lead on all relevant aspects of child protection. These professionals are a key source of advice on child protection matters. Ordinarily therefore, a doctor with suspicions of potential child abuse or neglect should consult with a designated senior professional within the area.
Confidentiality and suspected abuse
A frequent area of difficulty for doctors involves the extent to which they should respect the wishes of children who they suspect may be being abused but who do not want the information disclosed further. Children may also try and elicit a promise of confidentiality from adults to whom they disclose abuse. At the time of writing, the government was considering introducing statutory duties on professionals working with children to report certain kinds of information.[Go to reference 11] Until clear legal guidelines exist, doctors will need to make judgements based on the facts of the individual case, bearing in mind that their primary duty is the protection of the child.
As with all other patients, children at risk of neglect and abuse are entitled to have their confidentiality respected. Where there is a risk of significant harm, however, either to the patient, siblings or to others, doctors have a duty to take action, including, where necessary, the disclosure of relevant confidential information (‘significant harm’ is the threshold that triggers assessment under the Children Act 1989). Doctors should not therefore promise to keep information about child abuse confidential, but should explain to the child or young person their general rights in this area, and also point out that such rights are not absolute.
Where doctors believe that, in the interests of the child or others, it is important that action is taken, they need to discuss disclosure with the child, and, if possible, the child should be given sufficient time to come to a considered decision. If the child cannot be persuaded to agree to voluntary disclosure, and there is an immediate need to disclose information to an outside agency, he or she should be told what action is to be taken, unless to do so would expose the child or others to increased risk of serious harm. It can also be helpful in certain circumstances if professionals arrange a ‘safe’ way to contact the child. [Go to reference 12]
Sharing information
Although both the rights of children to have their confidentiality respected, and the existence of limits to this right are clear, a frequent grey area for doctors is the extent to which this respect for confidentiality needs to be balanced against the requirement to share information with other professionals in the interests of the child. Doctors are also unsure sometimes as to whether they can be breach the confidentiality of other patients, such as a child’s relatives, on the basis of an unconfirmed suspicion or hearsay reports. Clearly each case must be considered on the available evidence, but the Climbié report made it clear that keeping children safe from harm requires professionals and others to share information. Often it is only when information is pieced together from a number of sources that it becomes clear that a child is at risk or is suffering harm.
The difficulty for doctors here is that they may have some initial concerns about a child but are uncertain whether the appropriate threshold of severity has been reached to justify a disclosure of information without consent. As already mentioned, at the time of writing, the government had indicated that it may change the law in relation to the release of information in child protection cases. Until such time as the law is changed, doctors should recognise that personal information that is held about children and families is confidential and should not normally be released without the consent of the subject. However, both the law and the GMC permit the disclosure of information where it is necessary to protect a child against a risk of harm. In these cases, the public interest in protecting children overrides the public interest in maintaining confidentiality.
It is sometimes the case that both the abused or neglected child, and the person suspected of responsibility for the abuse or neglect, are registered with the same doctor. Doctors in these circumstances have sometimes reported feeling a sense of divided loyalty, as they have professional responsibilities to both parties. In these circumstances, the doctor’s primary responsibility is to the child, as the more vulnerable party, and where the interests of the child and the suspected abuser conflict, the latter’s interests should always give way to the child’s. Doctors should, however, treat all parties sensitively and professionally, and try and respect both party’s wishes, in so far as this is conducive to promoting the best interests of the child or children concerned.
The general practitioner and the primary health care team
Although these guidelines are intended to apply to all doctors who have professional contact with children, or with adults whose circumstances may have an impact on the well being of children, there are inevitably going to be differences of emphasis between, for example, GPs and doctors working in hospitals.
General practitioners and the wider primary health care team are likely to be among the first professionals to come in contact with children who are either at risk, or who are in need of additional support. Consultations, home visits as well as information from health visitors, midwives and practice nurses can all help to build up a picture of a child in difficulty. GPs and all members of the local primary health care team should know how to act on concerns they may have about a child, and, in particular, what steps to take when a child is considered to be at risk of significant harm. All members of the primary health care team should therefore be familiar with both local procedures, and the names and contact details of colleagues with experience in child protection procedures, such as the designated professionals within their trust. GPs are also well placed to recognise when a parent or other adult carer has problems which may affect their ability to look after a child. While GPs have responsibilities to all their patients, the welfare of children at risk must be their primary concern.
Health visitors play a particularly important role in the protection of vulnerable children. Their knowledge of individual children and families, combined with their expertise in monitoring and assessing child health and development means that they have an important role to play in all stages of family support and child protection. Midwives, as a result of their involvement with the mother throughout pregnancy and with the mother and child during the months after birth, are also well placed to identify any problems during pregnancy, birth and the child’s early care. It is important that doctors collaborate closely with all members of the primary care team to secure the safety and well being of children.
Hospital-based doctors
Partly as a result of the extremity of Victoria Climbié’s injuries, problems arising in her hospital care were at the centre of the health care recommendations of the Climbié report, and these recommendations are reflected in the guidance below.
It is frequently the case that SHOs in Accident & Emergency Departments or Paediatrics are the first point of contact in a hospital and many non-accidental injuries or cases of neglect are presented to these junior doctors first. It is crucial that these doctors receive training in how to identify injuries which need further investigation, how to spot warning signs, and how to raise concerns with appropriate colleagues and professionals in other agencies.
Continuity of care
Summary of points:
- Wherever a doctor sees a child who may be at risk, he or she must ensure that systems are in place to ensure follow-up care
- As full a picture as possible of the circumstances of a child at risk must be drawn up
- Where a child presents at hospital, inquiries must be made about any previous admissions
- Where a child is admitted to hospital, a named consultant must be given overall responsibility for the child protection aspects of the case
- Any child admitted to hospital about whom there are concerns about deliberate harm must receive a thorough examination within 24 hours unless it would compromise the child’s care or well being
- Where a child at risk is to be discharged from hospital, a documented plan for the future care of the child must be drawn up
- A child at risk must not be discharged from hospital without being registered at an identified GP
- All professionals must be clear about their own responsibilities, and which professional has overall responsibility for the child-protection aspects of a child’s care
Where a health professional has contact with a child about whom there are child protection concerns, it is important that as full a picture of the child’s situation as possible is developed. Where a child presents at hospital, this must include inquiring about any previous hospital admissions, and efforts must be made to gain access to all relevant notes and records. Where children are admitted to hospital, a named consultant must be given overall responsibility for the child protection aspects of the child’s case. The identity of this consultant must be clearly marked in the notes.
Any child admitted to hospital about whom there are concerns about deliberate harms must receive a thorough, carefully documented examination within 24 hours of their admission, except when doing so would, in the opinion of the examining doctor, compromise the child’s care or the child’s physical and emotional well being.
Doctors should not discharge children about whom child protection concerns have been raised until a discussion has taken place with the local social services department, and appropriate medical and social follow up has been arranged. Although it may prove difficult in some cases, such children must not be discharged without their being registered at an identified GP. Decisions relating to discharge should ordinarily be made by the consultant in charge of the child’s care, or by another senior trained paediatrician. Where social care and other agencies are also involved in continuing care, it is important that individual areas of responsibility are clearly demarcated, and all professionals involved are clear about both their own responsibilities, and about which professional has overall responsibility for the child-protection aspects of the child’s care.
Health staff, particularly those working in A&E departments should also be alert to carers who seek medical care from a number of sources in order to conceal the repeated nature of a child’s injuries. A child’s GP or primary health care team should be informed of any visit to an A&E department, and appropriate records kept.
Differences of medical opinion
Where there are disagreements between health professionals in relation to a diagnosis of possible deliberate harm to a child, it is important that a full discussion takes place between those with differing views, and the substance of the discussion is recorded in the child’s medical record. Where deliberate harm has been raised as a possible diagnosis, it must not be rejected without proper consideration and, if necessary, the securing of a second opinion.
Should children be retained in hospital?
The BMA has received inquiries from doctors in the past about whether they should ever keep children in hospital when concerns about child abuse or neglect have been raised. Where children are competent to make the decision, their own wishes will normally be determinative. Where children are not competent, those with parental responsibility will need to consent on their behalf. Where doctors are concerned that parents are either responsible for neglect or abuse, or are unable to protect their children from abuse, then an assessment must be made of the risks to the children concerned. Where doctors reasonably believe that there is a risk to the life of a child, or a risk of serious immediate harm, the police or social services should be contacted immediately and emergency protection procedures should be initiated. Police have powers, for example, to remove children to a place of safety for up to 72 hours. Where there is no immediate risk of serious harm or death and parents wish them to be discharged, but health professionals do not believe it to be in their best interests, legal advice should be sought as a matter of urgency. Doctors should discuss the matter with parents and explain why they believe that further clinical supervision would be advisable. Where children are competent, but seem to be making decisions that are significantly at odds with their best interests, legal advice should again be sought. It needs to be recognised that hospitals are not ideal environments for children unless they have serious health problems which require hospital admission.
Weekend admission
Difficulties with inter-agency working, general communication and timely referral can be exacerbated when children are admitted over the weekend. It is often much more difficult for doctors to gain immediate access to necessary information, to liaise with other agencies, and to arrange examinations by an appropriate specialist. There is no straightforward solution to these administrative difficulties. Nevertheless, the fact that a child about whom child protection concerns have been raised is admitted over the weekend should not be allowed to interfere with an assessment of his or her needs, and of any risks of harm. It may be the case, for example, that where admitting doctors have concerns that a child is at risk but cannot secure an immediate assessment from a specialist, the child should be encouraged, with discussion with those with parental responsibility where appropriate, to remain in hospital for supervision. Clearly, where there is a risk of serious harm to the child, emergency protection proceedings should be commenced immediately. All local authorities have a social services officer permanently on call with access to the child protection register. He or she can also take referrals if concerns are raised about a child who is not on the register. Doctors with concerns about child protection can contact this officer even out of hours.
Where children are admitted over the weekend, it is clearly important to ensure that full notes of relevant findings are made, with clear indications of any future referral and follow-up that are required. Responsibility for any actions that are to be taken should be clearly marked. It is important that children who at risk of serious harm should not be allowed to ‘slip through the net’ as a result of weekend admission.
Medical note keeping
The Climbié report identified a number of problems in the keeping of medical records, and its subsequent recommendations reinforced established best practice. When doctors are concerned about a child or children being exposed to abuse or neglect, they must ensure, in keeping with GMC guidance, that accurate, comprehensive and contemporaneous notes are made. Where the child is unknown to the doctor, detailed factual information about the child should be recorded at the point of contact, including information about those with parental responsibility and any primary carers, if these are different. This information should be verified at appropriate intervals. When making notes, it is important that doctors record all their relevant concerns, without venturing into speculation that cannot be justified, and that a record is kept of any discussions about the child, including telephone conversations, any decisions that are made, and the reasons behind the decisions. Where doctors are working in situations in which case notes are not available, any relevant information should be entered into the notes as soon as is practicable.
Notes should clearly show the difference between information given by the child or carers, the health care worker’s own direct observations, and any subsequent interpretation or assessment of the situation. Notes should also record any action that has been taken or will be taken, as well as any action by, or intended by, other relevant parties.
It is good practice for GPs and hospital doctors to have a clear means of identifying in records those children (together with their parents and siblings) about whom child protection concerns have been raised, although due consideration will have to be given to ensuring that the means of identification remains confidential. The tagging of medical records should only be considered where other systems that involve less likelihood of inadvertent disclosure cannot be used. Ordinarily, tagging should only be used with the consent of the individual concerned. Where young children’s records are tagged, permission will usually come from the parent until the child is able to decide for him or herself.
Communicating with children
It is imperative that doctors listen to children and take their views into account as far as possible, even where the doctor believes that the child or young person concerned does not have the capacity to fully engage in any decision-making process. Children can have a very clear idea of what needs to be done to ensure their safety and well-being. Communicating sensitively with children, and establishing sufficient trust to enable them to be open about distressing information and experiences takes considerable skill, and doctors who are likely to be involved in child protection work require special training in this area.
Doctors need to ensure that children understand the extent and nature of their own involvement in decision-making. They should be helped to understand how child protection processes work, how they can be involved, and that they can contribute to decisions about their future to the extent that their age and understanding allows. Doctors should make it clear, however, that children, particularly young children, will not necessarily have the final say in decisions concerning their welfare, and that decisions may have to be taken based upon information contributed by a number of professionals and carers.
It is vital that doctors attempt, as far as possible, to develop a relationship of trust with children they believe to be at risk, and it would be difficult to exaggerate the importance of good communication in this process. Although in practice this may be difficult, as their trust in adults may have been abused in the past, doctors should work towards establishing as far as possible, a positive professional relationship with children. At whatever stage in their development, children should be encouraged to talk openly to health professionals about their experiences, and be assured that confidential information will only be revealed if it is absolutely necessary and in their best interests. Doctors should use methods of communication that are appropriate to the age, understanding and needs of the child, particularly where the children are young, disabled or with a limited understanding of English. As mentioned previously, translators from outside the family may be needed in some cases. Wherever possible, medical professionals with expertise in caring for children should be involved, either directly or through consultation.
When children are first involved in discussions about potential abuse or neglect, the extent of any possible harm, or whether criminal acts have been committed may not be obvious. It is important that even initial discussions with children are conducted in a way that minimises any distress caused to them, and increases the likelihood that they will provide accurate and complete information. It is important, wherever possible, to have separate communication with a child. Children may need time, and more than one opportunity for discussion, in order to develop sufficient trust before they can begin to discuss their experiences, particularly if they have communication difficulties, are very young or have learning or mental health problems. (For further information on potential criminal proceedings, see part 3 below.)
Doctors and other health care workers should be honest and open with children and families about professional roles and responsibilities. They should be clear about what professionals can offer in the way of services, and on the limits of their powers. Doctors should take care that children are clear about any legal and professional restrictions they operate under, such as in relation to confidentiality.
Involving parents and carers
Doctors sometimes express considerable uncertainty about the extent to which parents or carers should be involved in decisions relating to children who may be victims of intentional harm. Decision-making in this area can be difficult, particularly where children are not competent to make decisions on their own behalf. Generally speaking, where children are competent to make decisions, their views are very influential although, exceptionally, decisions that are clearly contrary to their best interests can be challenged. [Go to reference 13] Ordinarily, where children cannot make decisions for themselves, those with parental responsibility have a legal right to make decisions on their behalf. Such rights, however, are not absolute, and when children are at risk of avoidable harm, professionals involved in caring for them have a clear duty to take appropriate action. Where children lack the competence to make decisions, those with parental responsibility should therefore be involved, provided it is in the best interests of the child or young person concerned. Parents or carers should not be involved where there is a reasonably found belief that it would put a child at further risk of harm. Reasons for such a decision might include situations where there is a possibility that a child would be threatened or otherwise coerced into silence; where there is a strong likelihood that important evidence would be destroyed; or that the child in question does not wish the parent to be involved at that stage and is competent to make that decision.
When harm or neglect is identified as a possible diagnosis by a doctor, he or she should consider whether taking a history directly from the child is in that child’s best interests. Where it is, the history should be taken even when the consent of the carer has not been obtained, with the reasons for dispensing with consent recorded in the medical record.
A decision to exclude an individual with parental responsibility is obviously a serious one, and, if time allows, it should be made in consultation with colleagues with expertise in this area. Doctors should bear in mind that almost all children about whom child protection concerns are raised either remain with, or are returned to their families. Involving the family in child protection processes, to the extent that it promotes the interests of children, is therefore likely to be productive.
Doctors need to bear in mind that family structures are increasingly complex. In addition to those adults who have daily care of a child, a variety of other adults such as estranged parents, grandparents or other family members may play a significant part in the child’s life. Some children may also have been supported by adults outside the family during periods of difficulty, depending on their age and maturity. Children may themselves be able to identify adults who provide a supportive influence in their lives.