Haringey Community children s Health Service CARE PATHWAY FOR SECTION 47 PAEDIATRIC ASSESSMENTS WHERE THERE IS SUSPECTED OR ACUTAL PHYSICAL ABUSE, EMOTIONAL ABUSE, SEXUAL ABUSE AND/OR NEGLECT The follow is a description of the care pathway offered by the Community Paediatric service in Haringey by Whittington Health for a child who is referred because of concerns about abuse or neglect. Ideally a strategy meeting is held between children s social care, the police and the paediatrician, and when agreed, will lead to a paediatric assessment. This assessment will be provided by a senior paediatrician, or when done by a registrar, then a senior clinician will be available on site for further advice. At the end of the paediatric assessment a hand written summary with recommendations is given to the referrer and a typed report is produced and circulated within 2 weeks. All Section 47 paediatric assessments are discussed in the weekly departmental supervision session to provide a second opinion and quality assurance. As a result of the supervision discussion, details in the report and the recommendations may be modified to reflect the views expressed at supervision. 1. STRATEGY MEETING The need for a paediatric assessment is a key decision from the initial strategy meeting. Where possible paediatricians should be involved in the strategy meeting where there are concerns around physical abuse, emotional abuse, sexual abuse and/or neglect. Such strategy meetings may take the form of a conference call to facilitate communication. If it is agreed that the child would benefit from a paediatric assessment then the timing of this will be agreed. Consideration will also be given in the strategy meeting for other children in or outside the family, who may also benefit from a paediatric assessment. Other issues such as whether or not the parent(s) should be present at the assessment and issues of consent should all be discussed and resolved as part of the strategy meeting. When an Achieving Best Evidence (ABE) interview is needed, this is normally arranged by the police before the paediatric assessment, unless there are circumstances where the strategy meeting concludes that medical input is required prior to ABE. This will be discussed as part of the strategy meeting. A paediatrician is on call 9 am to 5 pm, Monday to Friday, to take referrals for children for Section 47 paediatric assessments. The children will be seen in the afternoons which will allow time for social care to put in place practical arrangements for all necessary people to attend the medical, and to ensure that any other issues, e.g. consent or an ABE interview, Section 47 pathway for medical assessment 26th Aug 2011 Page 1 of 7
are dealt with. The paediatrician who will see the children will be a senior clinician (consultant or associate specialist) or a registrar. When it is a registrar there will always be a senior clinician on site and working closely with the registrar. 2. CONSENT The issue of consent is addressed in paragraphs 7.9.7 to 7.9.15 of the London Child Protection Procedures - 4th edition (Apr 2011). The following outlines who can give consent for a paediatric assessment: A child of sufficient age and understanding (Gillick competent or Frazer ruling competent) Any person with parental responsibility, providing they have the capacity to do so The local authority when the child is the subject of a care order even so the guidance is clear that the parent should be informed and where possible their consent should be secured, even when the child is the subject of a care order. To fail to ask for consent when a parent is contactable is poor practice. To go against parental wishes and go ahead with a paediatric assessment should only be done with very good reason and preferably with a court direction. The local authority when the child is accommodated under s20 of the Children Act 1989, and the parent/s have abandoned the child or are physically or mentally unable to give such authority The High Court when the child is a ward of court A family proceedings court as part of a direction attached to an emergency 3. PAEDIATRIC MEDICALS Making a referral To arrange a Section 47 paediatric assessment contact the Child Protection Administrator, Monday to Friday, 9 to 5, on: Tel: 0208 887 2493 Fax: 0208 887 2712 Location For Haringey children Section 47 Community Paediatric Assessments are conducted at the: Paediatric Assessment Unit North Middlesex University Hospital NHS Trust Sterling Way London N18 1QX The Paediatric Assessment Unit is a white flat roofed building situated next to the old A&E department at the north east corner of the block of land occupied by the hospital. Entry to the unit is gained via a ramp along the side of the building. Appointments Section 47 paediatric assessments take place in dedicated rooms in the Paediatric Assessment Unit between 1pm and 5pm Monday to Friday, with the exception of bank holidays. Section 47 pathway for medical assessment 26th Aug 2011 Page 2 of 7
We have capacity for 2 to 3 new cases per day depending on the complexity of the case and the number of children being seen as part of a family group. If the numbers of children being referred in a family exceeds 3, or if there have been a number of other cases already accepted, then it may be necessary to see some of the children on the following day. This will be discussed at the time of referral and priorities agreed as to who needs to be seen first and who can wait to the following day. For follow up appointments and some of the new referrals deemed as not needing to be seen on the day of referral or soon after, there is a weekly clinic on a Tuesday morning for this purpose. These clinics are held in the paediatric outpatient department of the main hospital at the North Middlesex Hospital (NMH). Urgent referrals received between 4-5pm If a child is referred after 4 pm then the paediatrician will discuss this with the referrer and depending on the priority, the child will be referred onto colleagues in the nearest hospital (typically the NMH or the Whittington Hospital) or arrange for them to be seen the following day. If it is agreed that a referral to an acute setting is needed, the paediatrician taking the referral will contact the on-call registrar to hand over the case. Out of Hours For agencies who need to referral a child after 5 pm: If the child is evidently in need of urgent medical care to call: London Ambulance 999 If the child is in need of, or potentially in need of medical care, but is not urgent, then to contact the appropriate acute hospital and speak to the on-call paediatric registrar on one of the following numbers: NMH 020 8887 2000 Whittington Hospital 020 7272 3070 Wherever possible attendance at A&E should be avoided and the child referred to the community service the next working day. A&E visits can involve considerable waits and the child may have a relatively brief assessment. For those children who are seen in A&E, consultant cover is always available for advice and supervision of the report writing. Referrals for repeat medicals by the community service following A&E attendance will not generally be accepted. 4. SEXUAL ABUSE Acute sexual assault Acute Initial sexual abuse medical examinations are not undertaken at the Paediatric Assessment Unit. An acute sexual assault is one that has occurred: In the past 72 hours for any girl under age 13 years or a boy of any age In the past 7 days for any girl over 13 years of age In cases of acute sexual assault the social worker or police to make an urgent referral one of the Haven Clinics: Whitechapel 0207 247 4787 Section 47 pathway for medical assessment 26th Aug 2011 Page 3 of 7
Paddington 0207 886 1101 The research behind the timings that define what is an acute sexual assault or not is based on the likelihood of recovering forensic evidence in the different age groups. In all cases there is a decreasing chance of recovering forensic evidence with every hour that passes, so speed is vital. In all circumstance the child or young person should be advised not bathe or wash themselves before being seen at the Haven. For some the Haven may recommend follow up locally and if so they will refer children to this service. Non-acute or historic sexual abuse For concerns such as marked inappropriate sexualised behaviour or an alleged assault that has occurred outside of the above times that defines acute sexual abose, the Social Worker should contact the Child Protection Administrator on 0208 887 2493 and give referral details. The paediatrician will return the call and discuss the case with the social worker. One option will be for a referral to Dr Hodes, Consultant Paediatrician, at University College Hospital clinic for further assessment and follow up. PLEASE NOTE that the CONSENT POLICY also applies to cases of sexual abuse. Section 47 pathway for medical assessment 26th Aug 2011 Page 4 of 7
CLINICAL CARE PATHWAY Suspicion/Concern/Allegation of abuse/neglect reported to Social Services/Police if at this (or any subsequent time) the child is deemed to be in need of urgent medical care (e.g. fracture, head injury, etc) then the professional working with the child should call London Ambulance on 999 If the child does not required urgent medical attention, the Social Worker/Police should contact Child Protection Administrator, at North Middlesex Hospital on 0208 887 2493. Fax 0208 887 2712 CP Administrator: to take the child(ren)'s and referrer's details and an outline of the reason for the referral. They will then contact the on-call doctor to set up conference call, locate any existing notes and prepare the notes for the assessment. Initial Strategy Meeting: social worker, police and paediatrician to discuss the case (via a conference call). If the strategy meeting has already taken place, then the paediatrician will discuss the case with the social worker and possibly the police. Paediatric assessment: From whatever discussions take place, if a paediatric assessment is agreed then timing, who will attend and arrangements for consent should be discussed. Consideration will be given in these discussion as to the safety and need for paediatric assessment of other children/siblings (See Note 2 below). If possible the ABE will take place before the paediatric assessment wherever possible. All appointments will be confirmed directly by phone with the SW or their Team Manager only. No messages or emails advising of appointments/cancellation/rescheduling to be left. Social Worker to provide any missing referral information to the CP Administrator and fax through all relevant documents (See Note 1 below). No child will be seen without a social worker their attendance is mandatory unless exceptionally agreed Child Abuse Investigation Team officer will be present. Paediatric Assessment report: Full assessment to include recording all injuries and marks on body map and photography where indicated (See note 5). For registrar conducted paediatric assessments, the supervising consultant will support the assessment by seeing any relevant injuries, assisting with summary report and agreeing opinion/recommendations The summary report and body maps to be given/faxed to social worker (and police if requested) on same day The doctor will dictate the full report, including the recommendations, any plans for follow up and the copy list, and pass on to CP administrator for typing. Section 47 pathway for medical assessment 26th Aug 2011 Page 5 of 7
CP administrator to ensure that report is typed, corrected, signed and sent to social services (and police if requested), and others on the copy list within 10 working days. If urgent this may need to be faxed earlier (See Note 3 below). Non Urgent Follow up: When follow up is planned the CP Administrator will book the child into weekly Child Protection Community Clinic or copy report to Looked after Children s Nursing Team if in care. Notes 1. Information gathering: In order to reduce the time taken gathering information Paediatricians have asked for as much information as possible to be provided in writing beforehand. It is agreed that the basic referral information sent to the police from CYPS can be copied to paediatricians together with copies of any useful background information e.g. disclosure reports, genograms, previous initial/core assessments or CAF forms. This will include strategy minutes. This should reduce the time it takes to accept a referral and conduct the interviews. 2. Parental consent: Only in exceptional circumstances can a paediatrician undertake a medical assessment without parental consent. The strategy meeting should discuss the appropriateness of one or both parents attending the medical. It is agreed that Social Workers and Police will support paediatricians in seeking consent for the medical in writing, if parents are not attending and try to arrange for paediatricians to speak to parents by phone as well if they are unable/ unwilling to attend (See also Consent Policy). In conjunction with CAIT and the allocated Social Worker, Paediatricians will consider whether it is appropriate for the parents to be present during the medical and whether they should be spoken to in a different area to the child. Where parents have only supervised access to the children, arrangements will need to be agreed to supervise the waiting area. 3. Paediatric report: Social Workers will be provided with a hand written report at the end of the medical. This will be followed by a full typed report within 2 weeks. A note has been added to the handwritten summaries saying a typed report will follow. It is important that the full type written report is filed with the courts where proceedings are initiated. Paediatricians will make all efforts to ensure this is ready for the initial hearing, if appropriately advised. If only the hand written report is available at the initial hearing, then leave should be sought to file the subsequent typed report. 4. Follow up: Some children may be assessed as requiring follow up at the community clinic. This will be highlighted in the typed report although the date of the next appointment may not be available and may be some months in advance. Where a child is made subject of a plan, the need for ongoing health review should be detailed in the paediatrician s report to conference and be part of the Child Protection Plan. Where the child becomes looked after this information will be shared as part of the paediatric assessment report which is reviewed as part of the Initial Looked After Child Health Review. Responsibility then lies with the Looked After Child Nursing team to discuss where this follow up work takes place and to advise the Paediatricians that the child is in care. Where the review medical is over 4 weeks after the initial medical Paediatric Administration will check FWI at the time of sending out the appointment to ascertain who the allocated social worker is. If the case is closed to CYPS the support for parents to attend the subsequent appointment will be via the school nurse/ Health visitor or GP. (See also CP Community Clinic Process) Section 47 pathway for medical assessment 26th Aug 2011 Page 6 of 7
5. Photography: this is provided by the Hospital Medical Photographer in normal working hours. If he is away or if medical is conducted out of hours, police will be responsible for providing photography. Social Care and Police can request copies of medical photographs, by contacting Ian Abernethy on 0208 887 2559 and quoting the reference number given in the typed medical report. Similarly, police will make their photographs available to the doctors on request. L Hayman 26 Aug 2011 T Wheeler 29 Sep 2001 Section 47 pathway for medical assessment 26th Aug 2011 Page 7 of 7