Doctors’ responsibilities in child protection cases
Guidance from the Ethics Department
June 2004
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Part one: introduction
- Summary
- General principles
- General Medical Council’s guidance
- BMA guidance
- Terminology
- Child abuse – definitions
- Children’s rights
- Scope of medical involvement in child protection cases
Where doctors have concerns about a child who may be at risk of abuse or neglect, it is essential that these concerns are acted upon, in accordance with the guidance in this note, or other local and national protocols. The best interests of the child or children involved must guide decision-making at all times. Where suspicions of abuse or neglect have been raised, doctors must ensure that their concerns, and the actions they have either taken, or intend to take, including any discussion with colleagues or professionals in other agencies are clearly recorded in the child or children’s medical record. Where doctors have raised concerns about a child with colleagues or with other agencies and no action is regarded as necessary, doctors must ensure that all individual concerns have been properly recognised and responded to. When working with children who may be at risk of neglect or abuse, doctors should judge each case on its merits, taking into consideration the likely degree of risk to the child or children involved. Disclosure of information between professionals from different agencies should always take place within an established system and be subject to a recognised protocol. This guidance applies equally to both information about children who may be subject to abuse, a well as to information about third parties, such as adults who may pose a threat to a child.
General principles
- In child protection cases, a doctor’s chief responsibility is to the well being of the child or children concerned, therefore where a child is at risk of serious harm, the interests of the child override those of parents or carers.
- All doctors working with children, parents and other adults in contact with children should be able to recognise, and know how to act upon, signs that a child may be at risk of any form of abuse or neglect, not only in a home environment, but also in residential and other institutions.
- Efforts should be made to include children and young people in decisions which closely effect them. The views and wishes of children should be therefore be listened to and respected according to their competence and the level of their understanding. In some cases translation services suitable for young people may be needed.
- Wherever possible, the involvement and support of those who have parental responsibility for, or regular care of, a child should be encouraged, in so far as this is in keeping with promoting the best interests of the child or children concerned. Older children and young people may have their own views about parental involvement.
- When concerns about deliberate harm to children or young people have been raised, doctors must keep clear, accurate, comprehensive and contemporaneous notes.
- All doctors working with children, parents and other adults in contact with children must be aware of, and have access at their place of work to, their local Area Child Protection Committee’s Child Protection Procedure manual.
The GMC also emphasises the importance of listening to the patient but gives specific advice about young patients who lack the ability to give valid and unpressured consent to disclosure.
“If you believe a patient to be a victim of neglect or physical, sexual or emotional abuse and that the patient cannot give or withhold consent to disclosure, you should give information promptly to an appropriate responsible person or statutory agency, where you believe that the disclosure is in the patient's best interests. You should usually inform the patient that you intend to disclose the information before doing so. Such circumstances may arise in relation to children, where concerns about possible abuse need to be shared with other agencies such as social services. Where appropriate you should inform those with parental responsibility about the disclosure. If, for any reason, you believe that disclosure of information is not in the best interests of an abused or neglected patient, you must still be prepared to justify your decision.”[Go to reference 1]
BMA guidance
In January 2003, Lord Laming published his report of the inquiry into the circumstances surrounding the death of Victoria Climbié. [Go to reference 2] Among much else, the report drew attention to a number of serious failings in the provision of child health services for this extremely vulnerable girl. As a result of the inquiry, the government published revised guidance for all professionals directly involved in child protection, What to do if you’re worried a child is being abused. [Go to reference 3] This replaced the existing guidance for doctors, Child protection: medical responsibilities. [Go to reference 4] The BMA has developed this subsequent guidance note in order to highlight the particular ethical responsibilities that doctors have when working with children who may be at risk of harm or neglect. It aims to augment and expand upon the government’s guidance, and is based in part on enquiries to the BMA’s Ethics Department from doctors. Doctors and health care workers who require more detailed clinical information about assessing the needs of vulnerable children should refer at the outset to the government’s publication Framework for the assessment of children in need and their families. [Go to reference 5]
Working with children and families where there are concerns about neglect or abuse is difficult and demanding. No two cases are identical, and the needs of children and families vary from case to case. Decisions about how best to respond when there are concerns about harm to a child necessarily involve a degree of risk – at the extreme, of leaving a child for too long in a dangerous situation, or of removing a child unnecessarily from its family. In each case, these risks need to be weighed and advice may need to be taken from other professionals and local agencies such as the Area Child Protection Committee (ACPC). To protect patient confidentiality in cases where the evidence for suspicion may be uncertain, doctors can discuss their concerns with colleagues on a no-name basis. Nevertheless, a guidance note cannot provide a substitute for the development of sensitive professional judgement based on a sound assessment of the child’s needs, the parents’ capacity to respond to those needs, and the wider developmental context. This note aims rather to provide some general ethical pointers to assist doctors in their practice in this area. It draws heavily on the government’s wide-ranging 1999 guidance Working together to safeguard children. [Go to reference 6]
The guidance in this document applies equally to those doctors directly involved in providing care to children, and to those doctors working with adults whose illness or condition may have an impact on the health or well being of a child.
Terminology
For the sake of ease of use, ‘child’ also includes young people up to the age of 18. As is stressed throughout however, due recognition must be given to the capacity of the child or young person to make decisions on his or her own behalf. ‘Doctor’ includes both GP and hospital doctor, and although this guidance note is principally directed toward doctors, much of the information is applicable to other health care workers. Unless expressly indicated otherwise, ‘parent or carer’ refers to those individuals with parental responsibility for the child or young person. (The BMA has produced a separate guidance note on the meaning of ‘parental responsibility’. [Go to reference 7])
Although the terms ‘abuse’ and ‘neglect’ are sometimes used interchangeably, different responses are frequently called for if the child is suffering actual abuse, or is being neglected due to family stresses or other parental problems. As is emphasised throughout this guidance, the appropriate response for each child will have to be based on an assessment of the facts of the individual case.
The Children Act 1989 introduced the concept of ‘significant harm’ as the threshold for intervention under the Act. As is discussed in part 3 of this guidance, there are no absolute criteria by which significant harm can be judged. Decisions in this area will however involve weighing up the effect of any ill-treatment on the child’s overall physical and psychological well being.
Child abuse – definitions
‘Child abuse and neglect’ is a generic term that includes all ill treatment of children including serious physical and sexual assaults as well as cases where the standard of care does not adequately support the child’s health or development. Children can suffer abuse or neglect through the direct infliction of harm, or through the failure to prevent harm occurring. Abuse can occur in a family or institutional setting and the perpetrator may or may not be known to the child.
In its guidance note Working together to safeguard children, the government defines four broad categories of abuse, and these are given below. [Go to reference 8]
Physical abuse
Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer feigns the symptoms of, or deliberately causes ill health to a child whom they are looking after. This situation is commonly described using terms such as factitious illness by proxy or Munchausen syndrome by proxy.
Emotional abuse
Emotional abuse is the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate or valued only in so far as they meet the needs of another person. It may feature age or developmentally inappropriate expectations being imposed on children. It may involve causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of ill-treatment of a child, though it may occur alone.
Sexual abuse
Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative or non-penetrative acts. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways.
Neglect
Neglect is the persistent failure to meet a child’s basic physical or psychological needs, likely to result in the serious impairment of the child’s health or development. It may involve a parent or carer failing to provide adequate food, shelter and clothing, failing to protect a child from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.
Children’s rights
The United Kingdom ratified the United Nations Convention on the Rights of the Child in 1991. The Convention places a duty on the state and its actors to promote the well-being of all children in its jurisdiction. The Convention sets out standards that should be reflected in health care. Article 3 of the Convention states that any decision or action affecting children, either as individuals or as a group, should be focussed on their best interests.
In addition to these Convention rights, doctors should bear in mind that the rights of children and parents under the Human Rights Act 1998 will be engaged by child protection proceedings. Where these rights are in tension, they may need to be traded against each other. Of particular importance here are Article 2, the right to life, Article 3, the prohibition of torture, inhuman or degrading treatment of punishment, Article 6, right to a fair trial, and Article 8, respect for private and family life.[Go to reference 9]
Discussion of children’s rights in relation to health care can be complex. It can introduce an adversarial or confrontational element into an area that has traditionally focussed on consensual care. Societal attitudes are also generally more complex here than in relation to adults’ rights, as society tends to have a vested interest in ensuring that children’s health is not avoidably put at risk, even though a young person may want to refuse medical treatment. In cases of abuse, for example, it may be necessary to override the wishes of a competent young person and refer concerns about significant harm to an appropriate body. The following are generally regarded as children’s basic health rights:
Children have rights:
- to child-centred health care
- to be looked after appropriately, without discrimination of any kind
- to be encouraged in every possible way to develop their full potential
- to take opportunities to be involved, from the beginning, and to choose not to be involved in decision-making
- to receive clear information about matters closely affecting themselves and about the right to decline detailed information at a particular time
- to have opportunities to express opinions without pressure or criticism
- to ask someone else to decide a particular issue
- to receive an explanation of the reasons when their preference cannot be met
- to confidentiality – subject to certain constraints; and
- to redress – where appropriate – through a fast, accessible complaints procedure.[Go to reference 10]
All health professionals, both in the NHS, the private sector, and those working for other agencies have a role to play in ensuring that children and families receive the care, support and services they need in order to promote children’s health and development. Because of the universal nature of health provision it is likely that health professionals will be among the first to have contact with children or families in difficulty. In addition to the direct provision of clinical services to children, both in primary care and in hospitals, medical participation in child protection encompasses a range of activities. These can include:
- recognising children in need of support or protection, and parents who may need extra help in bringing up their children
- contributing to enquiries about a child or family
- assessing the needs of children and the capacity of parents to meet their children’s needs
- planning and providing support to vulnerable children and families
- participating in child protection conferences
- planning support for children at risk of significant harm
- providing therapeutic help to abused or neglected children and parents under stress
- contributing to case reviews
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