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1.3.6 Paediatric Medical Assessments 

RELATED CHAPTER

Section 47 Enquiries Procedure

Conducting a Section 47 Investigation: Use of the Community Paediatric Service and Strategy Discussions Procedure

See also Body Maps

AMENDMENT

This chapter was amended in October 2013 to include links to body map diagrams.


Contents

  1. When a Paediatric Assessment is necessary
  2. Purpose of Paediatric Assessment
  3. Consent for Paediatric Assessment/Medical Treatment 
  4. Arranging the Paediatric Assessment 
  5. Recording of Paediatric Assessment


1. When a Paediatric Assessment is necessary

Strategy Discussions must consider, in consultation with the paediatrician (if not part of the discussion or meeting), the need for and timing of a paediatric assessment. Consideration must also be given as to whether there are any other children in the household who may also require a paediatric assessment.

Paediatric assessments should always be considered necessary where there has been a disclosure or there is a suspicion of any form of abuse to a child.

Additional considerations are the need to:

  • Secure forensic evidence;
  • Obtain medical documentation.

In cases of severe neglect, physical injury or acute (recent) penetrative sexual abuse, the assessment will normally be carried out on the day of the referral, or as soon as practicably possible and agreed by Children's Social Care, Police, and the Medical assessor.

Only suitably qualified health specialists may physically examine the child for the purposes of a paediatric assessment. Other staff should note any visible marks or injuries on a Body Map and document details in their recording. If a child has an acute injury, appropriate medical treatment should be sought. A child should not be presented to the hospital unless there is an urgent medical need.


2. Purpose of Paediatric Assessment

The purpose of a paediatric assessment is:

  • To diagnose any injury or harm to the child and to initiate treatment as required;
  • To document the findings;
  • To provide a medical report on the findings, including an opinion as to the probable cause of any injury or other harm reported;
  • To assess the overall health and development of the child;
  • To provide reassurance for the child and parent;
  • To arrange for follow up and review of the child as required, noting new symptoms including psychological effects.


3. Consent for Paediatric Assessment/Medical Treatment 

The following may give consent to a paediatric assessment:

  • Young people over the age of 14 years who are deemed to be Fraser Competent;
  • A child of under 16 where a doctor considers he or she is of sufficient age and understanding to give informed consent and is "Fraser Competent";
  • Any person with Parental Responsibility;
  • The local authority when the child is the subject of a Care Order (although the parent/carer should be informed);
  • The local authority when the child is Accommodated and the parent/carers 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 Court as part of a direction attached to an Emergency Protection Order, an Interim Care Order or a Child Assessment Order.

Where the child is the subject of ongoing Court proceedings, legal advice should be obtained about obtaining the Court's permission to the paediatric assessment.

It is generally good practice to seek wherever possible the permission of a parent for children under 16 prior to any paediatric assessment and/or other medical treatment even if the child is judged to be of sufficient understanding to give consent in their own right. If this is not considered possible or appropriate, then the reasons should be clearly recorded.

When a child is Looked After and a parent/carer has given general consent authorising medical treatment for the child, legal advice must be taken about whether this provides consent for a paediatric assessment for child protection purposes (the parent/carer still has full parental responsibility for the child). Where the local authority shares Parental Responsibility for the child, the local authority must also consent to the paediatric assessment.

A child who is of sufficient understanding may refuse some or all of the paediatric assessment, although refusal can potentially be overridden by a court.

In emergency situations where the child needs urgent medical treatment and there is insufficient time to obtain parental consent:

  • The medical practitioner may decide to proceed without consent; and/or
  • The medical practitioner may regard the child to be of an age and level of understanding to give her/his own consent and be Fraser Competent.

In these circumstances, parents must be informed as soon as possible and a full record must be made at the time.

In non-emergency situations, when parental permission is not obtained, the social worker and manager must seek legal advice - see Section 47 Enquiries Procedure, Parental Consent.

For additional guidance to doctors, see the GMC Guidance for Doctors Working with 0 to 18 Year Olds and British Medical Association Child Protection Toolkit.


4. Arranging the Paediatric Assessment

Paediatric assessments must take into account the need for both specialist paediatric expertise and forensic requirements in relation to the gathering of evidence. Consultant Paediatricians, Police Surgeons, Paediatric Specialists Registrars, and Paediatric associate specialists may undertake paediatric assessments carried out as part of a Section 47 Enquiry.

There should be only one paediatric examination of the child.

Where child sexual abuse is suspected, usually two doctors with complementary skills will conduct a joint paediatric assessment. A single doctor may carry out the assessment where he or she has the necessary knowledge, skills and experience for the particular case. For further guidance, see Guidance on Paediatric Forensic Examinations in relation to possible child sexual abuse, (Royal College of Paediatrics and Child Health and the Association of Forensic Physicians, 2004).

Consideration should be given to the gender of the examining doctor in consultation with the child and the parents.

Referrals for paediatric assessments should be made by the social worker, who should contact the on call Paediatrician and also make him/her aware of the circumstances of the case. An on call paediatrician is available for consultation during office hours and is contactable: please see Local contacts. An on call paediatrician is available at UHL for emergency situations and is contactable via the UHL switchboard. The police will arrange attendance of a Police surgeon if required. The extent of any questioning of the child by the doctor will depend on the type of abuse and the age and understanding of the child.

In planning the paediatric assessment, the social worker, the manager responsible, the Police Child Protection Unit and relevant doctor(s) must consider whether it might be necessary to take photographic evidence, for example, for use in care or criminal proceedings or where a second opinion may be necessary. Where such arrangements are necessary, the child and parents must be informed and prepared and careful consideration given to the impact on the child.

If the child refuses to be examined or becomes distressed during the examination, consideration must be given to arranging a further examination.


5. Recording of Paediatric Assessment

At the conclusion of the paediatric assessment, the doctor must give a verbal report explaining his or her findings to the social worker/Police officer attending, followed by a written report within 5 working days.

Disclosure of the information contained in the report to the parent(s) of the child and/or the child should be agreed in consultation with the Children's Social Care Service and the Police.

The report should include:

Date, time and place of examination

  • Those present;
  • Who gave consent and how (child/parent, written, phone or in person);
  • A verbatim record of the carer's and child's accounts of injuries and concerns noting any discrepancies or changes of story;
  • Documentary findings in both words and diagrams;
  • Site, size, shape and where possible age of any marks or injuries;
  • Other findings relevant to the child e.g. squint, learning problems, speech problems etc.;
  • Confirmation of the child's developmental progress (especially important in cases of neglect);
  • Time examination ended;
  • Medical opinion of the likely cause of injury or harm.

All reports and diagrams should be signed and dated by the doctor undertaking the examination.

If criminal or family proceedings are instituted, the doctor's written report may be filed and served as well as the doctor's statement of evidence. The doctor's attendance at subsequent Court hearings may also be required.

Where there has been a joint paediatric assessment, the doctors involved should agree which of them will provide the report. If they disagree in their clinical findings and interpretations, they should both provide full reports and usually a further independent medical opinion should be obtained. For further guidance, see Guidance on Paediatric Forensic Examinations in relation to possible child sexual abuse, (Royal College of Paediatrics and Child Health and the Association of Forensic Physicians, September 2004).

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