TRUST POLICY FOR THE MANAGEMENT OF CHILDREN, YOUNG PEOPLE AND NEONATES WITH SUSPECTED MALTREATMENT. Final

Transcription

1 TRUST POLICY FOR THE MANAGEMENT OF CHILDREN, YOUNG PEOPLE AND NEONATES WITH SUSPECTED MALTREATMENT Reference Number CL-CH PROT Version / Amendment History Version: 1 Status Final Version Date Author Reason V1 September 2010 Jane O Daly Author: Safeguarding Children Trust Named nurse Following CQC inspection and working together Intended Recipients: All clinical and medical staff. Associate Directors, Service Managers, Quality Improvement Leads, Heads of Nursing, Operational Managers and Senior Matrons/ Senior Midwives, Facilities Managers and Therapy staff. Training and Dissemination: Safeguarding Children training is compulsory for all Medical, Nursing and Allied Health Professionals in line with Trust training policies and joint agreements with other statutory agencies involved in Safeguarding Children. Dissemination will be via the intranet. To be read in conjunction with: Trust Safeguarding policy In consultation with and Date: Safeguarding committee Procedural Documentation Review November 2010 Group Assurance and Date Approving Body and Date Approved Safeguarding Committee July 2010 Date of Issue November 2010 Review Date and Frequency November 2013 Contact for Review Executive Lead Signature Jane O Daly Safeguarding Children Trust Named Nurse Director of Nursing Approving Executive Signature Director of Nursing Extension agreed by Management Executive until 31 st March

2 Contents Section Introduction Purpose and Outcomes Definitions Used Key Responsibilities/Duties Management of child protection concerns Page /4 4 Child protection medical examinations for nonaccidental injuries Management of ano-genital injuries Monitoring Compliance and Effectiveness References Appendices /15 2

3 TRUST POLICY FOR THE MANAGEMENT OF CHILDREN, YOUNG PEOPLE AND NEONATES WITH SUSPECTED MALTREATMENT 1. Introduction 1.1 The abuse or neglect of a child or young person, whether as a one off event or as part of a pattern, can have a long term impact on their ability to achieve health and well being and lead to serious injury or death. 1.2 The quality of professional response to abuse or neglect is of crucial importance in the ability of services to adequately safeguard and protect children and young people. 2. Purpose and Outcomes To ensure that appropriate and adequate investigations into maltreatment of a child or young person are carried out in accordance with local safeguarding children procedures and in such a manner as to facilitate Children s Social Care (CSC) and the police in the exercise of their investigative function. To guide staff with regard to the need to address safeguarding concerns and child protection concerns in accordance with Derby and Derbyshire Safeguarding Children Board (SCB) Safeguarding Children Procedures 3. Definitions used Safeguarding Concerns: Concerns indicating that a child or young person may not achieve the 5 outcomes in Every Child Matters (Be Healthy; Stay Safe; Enjoy and Achieve; Make a positive Contribution; Achieve Economic Well-being) without support and services being provided. Child Protection Concerns: Suspicion that a child is at risk of, or has experienced, significant harm, neglect or abuse. Children and Young People: Defined in the Children Acts (1989 and 2004), a child or young person is anyone who has not yet reached their 18th Birthday or 21yrs if disabled or in Local Authority Care (LAC). Issues of neglect as defined in Working Together 2010 can apply to the unborn baby. 4. Key responsibilities/ Duties 4.1 All services within the Trust seeing children and young people as patients and/or visitors. 3

4 4.2 Chief Executive The Chief Executive is ultimately responsible for ensuring that the Health contribution to safeguard and promote the welfare of children is discharged effectively and that there is a process in place to ensure that staff are aware of and follow the policy. 4.3 Director of Nursing The Director of Nursing is the Lead Executive for Children and Safeguarding (delegated responsibility to the Deputy Director of Nursing) and is responsible for ensuring that commissioning arrangements are linked to Local Safeguarding Children Boards. As the appropriate representative on Derby/Derbyshire Safeguarding Children Board, they have the responsibility to ensure that Health Services and Health Care Workers contribute to the multiagency working arrangements in order to safeguard and promote the welfare of children. 4.4 Safeguarding Committee Oversees the implementation of Safeguarding processes throughout the Trust and reports the Trust s performance in Safeguarding Children to the Quality Review Committee on a bi monthly basis. Provides a focus for the establishment of safeguarding infrastructures and processes within the Trust. Oversees the Trust s attainment of required standards of training and development for Safeguarding Children. Oversees appropriate Trust responses to the findings of serious case reviews. Connects with the wider Health community through the Named Professionals and receives reports from them to ensure that the Trust acts upon actions agreed within these community groups. 4.5 Safeguarding Link Group The membership of this group includes identified staff representation from each area within the Trust and is chaired by the Named Nurse for Safeguarding. 5. Management of child protection concerns There are two main ways by which maltreatment concerns are raised within the Acute Trust setting: - Concerns are raised by staff members of the trust about a child or young person visiting or admitted to the wards - Concerns are raised outside the trust and a referral from Children s Social Care is made for a Child protection medical examination by the paediatric team. 5.1 Concerns raised within the Trust Where concerns about maltreatment of a child or young person are raised by members of staff, the following flow chart should be followed: 4

5 Concerns may be discussed with: The Line Manager. Senior colleague. Named Nurse for Safeguarding. Named Doctor for Safeguarding. Named Midwife. Middle grade paediatric doctor on call. Consultant Paediatrician on call. Children s Hospital bleepholder. Emergency Department staff will escalate to the Consultant where relevant. Safeguarding Link Group member Where there are concerns, staff can additionally contact CSC to enquire as to whether there is any involvement by CSC, or relevant history known to them. 5

6 Following discussions if staff still have concerns they should invoke the Safeguarding Procedure and refer directly to CSC. It is best practice to tell the family that you have concerns about their child and that you have a legal duty to inform CSC about your concerns and to manage medical investigations into potential causes concurrently with other agency investigations. Staff are required to follow up telephone referrals to CSC in writing, by using the appropriate documentation (Form WPH1362). The referral form must be completed prior to calling CSC as this will structure thoughts and concerns and ensure that significant concerns are not omitted. It is important to ask CSC: 1 What their plans are following your referral and document this, 2 To clarify arrangements regarding the need for supervised access of parents to the child at this stage 3 Where they want the family to go to (e.g. to stay and be met on hospital premises to organise a medical examination, or to go home and be assessed later) and document this. The WPH1362 forms can be obtained from all wards and departments within Children s Services, Maternity Services, the Emergency Departments and from the Safeguarding Children Team office in Children s Hospital Reception. All available relevant information must be added in order to aid CSC to make their assessment of the child/young person s needs. On completion of the form and following telephone referral, the copies must be distributed as follows; White copy to appropriate CSC duty team (faxed prior to posting) Blue copy to Management Offices, 3 rd Floor, Children s Hospital Pink copy to be filed in the child s Health Records. 5.2 Concerns raised outside the Trust Where a child or young person is referred by CSC for a Child Protection medical examination the following should already have happened: 1. CSC should have gained consent from the guardian for the medical examination 2. CSC should have contacted the paediatric registrar about the case and been told where to go to by the paediatric registrar (out of hours this will be CED, in hours this could be CED or COPD whichever the paediatric registrar doing the examination prefers) 3. CSC should be told that out of hours there is no appointment system and they will wait their turn as clinical priorities dictate. When they arrive with the family they should ensure that a member of staff is informed and asked to let the paediatric registrar know that they are here to avoid unnecessary delays. 6

7 The acute trust have responsibility for performing non-accidental injury (NAI) Child Protection medical examinations for any child under 18 months old and out of hours for all age groups. (There is a community paediatric rota Monday to Friday 9am to 4pm where over 18 month old children can be examined for NAI. This rota should be used as a first line for children where concerns are first raised outside the trust.) Child sexual abuse examinations are not performed by acute trust professionals (see later). 5.3 Child protection medical examinations for non-accidental injuries A child protection medical examination should be completed by a paediatrician trained in child protection and above the level of ST2 (i.e. on the middle grade rota or above). The history, examination and conclusions should be documented using the Child Protection Medical Examination proforma (see appendix 1) provided. The checklist should be completed on the proforma to ensure that all aspects of the medical have been completed thoroughly. (Useful information is available in the NICE Clinical guideline When to suspect child maltreatment (see appendix 2) and RCPCH Child protection companion 2006 (see appendix 3)) A second opinion should be sought before any child or young person is discharged from hospital. In the vast majority of cases this will be the registrar discussing the case with the paediatric consultant. If a consultant sees the child for the medical then they may discuss the case in hours with the named doctor; Out of hours the police surgeon or the community consultant paediatrician on the rota for child sexual abuse are available as the second opinion. The purpose of this discussion is to agree on the medical opinion of the findings and the management plan for the child It is important not to hypothesize with the parents / carers regarding likely causes of the injury as the parent or carer may then adopt the same as their subsequent explanation for the injury Investigations The RCR/RCPCH Guidance Standards for radiological investigations of suspected non-accidental injury states that: Skeletal survey - In children under the age of 2 where physical abuse is suspected, a full skeletal survey should always be performed. If it is decided not to perform a skeletal survey, the reasons for this should be detailed in the patient s notes. - In children over the age of 2, the decision to perform a skeletal survey will be guided by clinical and social history and physical findings. - Follow-up radiographs may be of significant value in cases of NAI providing in some cases confirmatory evidence and in others contributing to the exclusion of the diagnosis. It is recommended that they are obtained 11 to 14 days after the original skeletal survey to achieve optimum detection of healing. 7

8 Neuroimaging Neuroimaging should be obtained for: - any child under the age of one where there is evidence of physical abuse; - any child with evidence of physical abuse with encephalopathic features or focal neurological signs or haemorrhagic retinopathy. - Schedule of neuroimaging depends on clinical presentation: o Day 1 post injury o Day 3-5 post injury cranial CT if initial CT scan abnormal or child continues to have neurological signs despite normal CT scan then arrange Cranial MRI scan including DWI. Strongly consider imaging spine at this stage. - if MRI abnormal arrange for follow-up scan in 3-6 months to aid prognosis Ophthalmology The same indications for neuroimaging apply to obtaining a formal ophthalmological opinion, looking specifically for retinal haemorrhages and congenital abnormalities. A consultant ophthalmologist with a particular interest in paediatrics will perform the examination as soon as practically possible from the onset of the concerns. The pupils will need to be dilated for this examination. Coagulation tests for bruises Coagulopathies are not common and NAI can co-exist with disorders of coagulation. When a child or young person presents with bruising suspicious of NAI, a bleeding history should be documented: - bleeding from gums, - significant epistaxis (more than 5 episodes or lasting longer than 10 minutes), - menorrhagia, - prolonged bleeding post-operatively (e.g. dental extraction), - poor wound healing (e.g. Ehlers-Danlos syndrome) - use of NSAIDs (may cause platelet dysfunction). When a coagulopathy needs ruling in or out the RCPCH Child protection companion, 2006 suggests performing the following screening tests: APTR INR Fibrinogen level Thrombin time FBC (to look at platelet count) Coagulopathy screening is advised in all cases where NAI is the most likely diagnosis for the cause of the bruising or if the diagnosis of the bruising is uncertain. If the decision is made not to perform the screening tests then the reasons should be clearly documented. 8

9 5.4 Report writing (see also Communication below) A verbal report should be given to Social Worker at the time of the medical and a written report should be available within 5 working days. The report should be clear with regard to the opinion of the professional in relation to the likelihood of the injuries being more likely to be accidentally or non-accidentally caused. (Further advice on report writing is available in the RCPCH Child protection companion 2006 (see appendix 3)) 5.5 Communication After a child protection medical examination, the allocated social worker should be informed of the findings away from the family to ensure that a clear uninhibited conversation has taken place. The conversation between social care and the medical professional needs to be documented and include: - whether the findings indicate NAI is more likely than accidental injury, - whether in the absence of any significant findings, the history alone is significant to warrant further child protection investigations due to the level of risk to the child/young person, - the need to examine siblings or other children in the care of the family, - the immediate safeguarding of the child and other siblings The child and family should then be informed of the findings and the plan. This responsibility is shared between the health professional and social care. The formal report should be dictated that day and be sent to social care within 5 working days from the examination. When a child is admitted to hospital with safeguarding concerns, as well as the formal medical examination report, a discharge summary should be available to CSC. The discharge summary should include results of any investigations not mentioned in the previous medical report, any positive or negative parenting reports from the ward staff, and any discharge planning meeting outcomes.any concerns or incidents which occur during the admission should be documented and shared with CSC. The sharing of information should be clearly documented in the notes. 5.6 The opinion of the consultant in charge of the case should be the opinion offered to CSC to avoid confusion. If there is a difference of opinion as to mechanism of injury, then agreement should be established within the health team before contradiction is expressed to other agencies (e.g. CSC or Police) as this can hinder the investigation. Peer review is a useful opportunity to seek opinions from others within the health team. 5.7 For children and young people admitted to hospital where there are concerns regarding child protection or there are complex safeguarding concerns, there should be a discharge plan agreed with CSC, community 9

10 health colleagues and the Police. A strategy meeting can be arranged at short notice by the safeguarding team to facilitate discharge planning. 5.8 Management of ano-genital injuries A history of genital symptoms or injuries must be treated with care. Concerns regarding sexual abuse should not be discussed with the parent / carer before discussion with police and / or CSC Where clinical concern or suspicion of abuse exists (e.g. a disclosure of abuse), there should be immediate referral to CSC and followed up in writing using the WPH1362 form. The on-call hospital consultant must be made aware of the case Where sexual abuse is clearly suspected it is important that health professionals do not inadvertently destroy or alter evidence that the forensic team would require; e.g. washing the perineum during nappy changes, asking for a urine sample, MSU etc. The child should only be examined once and this should be in the context of a forensic examination. (Note: the acute trust do not have the responsibility or skills to perform the forensic CSA examination.) If CSC accept the referral then they will arrange a Child Sexual Abuse medical with the community paediatric consultant on the CSA rota (out of hours this rota is located in CED along with the telephone numbers of the community paediatricians; hospital staff should not give out the telephone numbers to CSC but should take the CSC telephone details and pass on to the on-call community paediatrician). If CSC refuse the referral as they do not feel the threshold for a forensic examination and investigation has been met then the on-call hospital consultant should be informed. If the hospital paediatric team still have concerns regarding sexual abuse then a discussion will take place between the hospital paediatric team and the community consultant paediatrician to decide a path of action. (see flow chart section 7.5). Where the health professionals dispute the threshold adopted by CSC the LSCB policy regarding escalation of concern should be followed. Communication of information with parents / carers regarding concerns of sexual abuse must also be agreed with CSC Where sexual abuse is less strongly suspected, as assessment by the hospital paediatric team should take place, including inspecting the perineum (e.g. looking for inflammation, threadworms, lichen planus etc). Swabs of the perineum and an MSU should be taken unless during the examination it becomes clear that sexual abuse is more likely than originally thought (e.g. thigh bruising, vulval injuries not disclosed in the history) The following flow chart has been created to help establish the responsibilities of the hospital and community paediatricians in these cases. 10

11 6 Monitoring Compliance & Effectiveness Monitoring Requirement : Process for ensuring that policy is acted upon throughout the organisation Monitoring Method: Random case file audit from child protection cases 11

12 Reports by: Prepared Named Doctor for Safeguarding Children Report presented to: Trust Safeguarding Committee and Womens and Children Directorate Governance Board Frequency Report of Yearly 7. References Learning lessons from Serious Case Reviews: Improving Safeguarding Practice; Study of Serious Case Reviews The Victoria Climbie Inquiry Report (2003) Lord Laming HMSO Derby & Derbyshire Safeguarding Children Board Safeguarding Children Procedures (2007) Working Together to Safeguard Children (2010) DOH The Children Acts (1989 and 2004) RCR/RCPCH Guidance Standards for radiological investigations of suspected non-accidental injury (2008) NICE Clinical guideline When to suspect child maltreatment (2009) RCPCH Child protection companion,

13 Appendix 1 Medical proforma for Child protect medical examinations available in CED / paediatric wards Printed on pink paper. (front page only reproduced here) 13

14 Appendix 2 Available at CG89 When to suspect child maltreatment: quick reference guide 14

15 Appendix 3 RCPCH practical guidance for paediatricians working in the field of safeguarding Full copy available at 15