Paediatric Safeguarding Medicals

1. When a Paediatric Safeguarding Medical is Necessary

If a child has an acute injury, appropriate medical treatment should be sought. A child should only be presented to the hospital if there is an urgent medical need.

Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer, Significant Harm there should be a Strategy Discussion involving children's social care, the Police, health and other relevant bodies such as the referring agency. This might take the form of a multi-agency meeting or phone calls and more than one discussion may be necessary. A Strategy Discussion can take place following a referral or at any other time, including during the assessment process.

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 Safeguarding Medical. Consideration must also be given as to whether there are any other children in the household who may also require a Paediatric Safeguarding Medical.

If a medical practitioner has already seen the child, they must be included in, or consulted as part of the Strategy Discussion.

Paediatric Safeguarding Medicals 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 or physical injury, the assessment will normally be carried out on the day of the referral, or as soon as practicably possible in agreement with Children's Social Care, the Police, and the Paediatric Medical assessor.

The same applies to acute (recent) penetrative assault where the discussion will be between Social Care, Police and the clinician at the designated Sexual Assault Referral Centre ("SARC").

Where the Paediatric Safeguarding Medical is not considered urgent, and cannot be carried out the same day, a safe place must be sought for the child until the Medical can take place. Social care may need to seek legal advice regarding steps that can be taken at the time.

Only suitably qualified health specialists may physically examine the child for the purposes of a Paediatric Safeguarding Medical. Other staff should note any visible marks or injuries on a Body Map and document a description in their records.

2. The Purpose of Paediatric Assessment

The purpose of a Paediatric Safeguarding Medical 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 clarity for the child and parent;
To arrange for follow up and review of the child, referring to appropriate health services as required.

The following may give consent to a Paediatric Safeguarding Medical:

A child of under 18 years 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 for the child;
The local authority when the child is the subject of a Interim or Full 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 prevented from providing the child (whether or not permanently, for whatever reason) from providing them with suitable accommodation or care;
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 on-going Court proceedings, legal advice should be obtained about obtaining the Court's permission to conduct the Paediatric Safeguarding Medical.

It is generally good practice to seek, wherever possible, the permission of a parent for children under 18 prior to any Paediatric Safeguarding Medical 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 Safeguarding Medical 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 Safeguarding Medical.

A child who is of sufficient understanding may refuse some or all of the Paediatric Safeguarding Medical, 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 Involvement and 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 Safeguarding Medicals

Paediatric Safeguarding Medicals 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 Safeguarding Medicals as part of a Section 47 Enquiry.

There should ideally be only one paediatric examination of the child.

Requests should, in the first instance, be referred to the Community Paediatric Consultant or Associate Specialist, who provide a clinic during office hours (09:00 – 17:00hrs, Monday to Friday, excluding Bank Holidays) for paediatric medical assessments, and are available for advice during this time. They can be contacted on 0116 2951370. A referral should be made by the social worker at the earliest opportunity to ensure the child can be booked in to be seen at the earliest possible appointment. It should be noted that the last available appointment of the day is 16:00hrs.

For out of office hours cases where it is felt the child may have an Acute medical need, an initial discussion should take place with the Paediatric Specialist Registrar on call for the Children's Assessment Unit at the Leicester Royal Infirmary, who should be called via the University Hospitals of Leicester NHS Trust switchboard on 0300 303 1573. They in turn will contact the on-call Paediatric Consultant for advice as required.

A place of safety must be found for the child, until a paediatric medical assessment can take place. This must be agreed as part of the Strategy Discussion safety plan. Social care may need to seek legal advice in such circumstances.

If the child becomes unduly distressed during the examination, in accordance with best medical practice, consideration may be given to deferring the examination.

Paediatric Safeguarding Medicals where Sexual Abuse is Suspected

Where sexual abuse is suspected, the medical forensic examination should be undertaken by the commissioned specialist Sexual Assault Referral Centre ("SARC"). Responsibility for organising this lies with the Police, following agreed actions from the initial Strategy Discussion.

Children should only be managed in hospital if a disclosure or suspicion arises in a child already admitted, or if a child has genital (or other) injuries requiring emergency medical treatment, or they otherwise need emergency medical care that can only be provided in hospital. The medical practitioner should keep any examination to a minimum in order to limit distress to the child and preserve potential forensic evidence.

For further guidance, see Guidelines on paediatric forensic examinations in relation to possible child sexual abuse (PDF) - published May 2012, developed in partnership with RCPCH.

5. The Medical Investigations

5.1 Photographs

As part of the initial Strategy Discussion to decide if a Paediatric Safeguarding Medical is required, the social worker, the manager responsible, the Police Child Abuse Investigation 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. Consent for photographs must be sought by the lead consultant, Associate Specialist or nominated deputy at a minimum Specialist Registrar level from the person with parental responsibility.

The Police will make arrangements for photographs to be taken if evidential photography is required in community medicals, whilst those children in University Hospitals of Leicester NHS Trust may be photographed by the Medical Illustration team.

5.2 Radiological Imaging

In accordance with Royal College of Radiologists Guidance (The radiological investigation of physical abuse in children), has been jointly produced by The Royal College of Radiologists (RCR) and the Society and College of Radiographers (SCoR), with input and endorsement from the Royal College of Paediatrics and Child Health (RCPCH) 2017, the following actions must be considered:

All Children <1year:
- A full skeletal survey;
- CT head scan.
All children aged 1-2 years;
A full skeletal survey;
A CT head scan if clinically indicated;
Children aged over 2 years:
- A skeletal survey may be indicated in older children. This should be considered on a case-by-case basis;
- This may include children with communication, or learning difficulties who may be unable to give a history of physical abuse or children where there is a clinical suspicion of skeletal injury.

5.3 Bloods

In children less than two years of age, blood tests should include the following:
- Full blood count (FBC) including platelets;
- Liver function tests (LFT);
- Calcium, Phosphate, Alkaline phosphatase, Vitamin D;
- Coagulation screen to include PT, APTT and ratios, Fibrinogen level and thrombin time in all cases;
- Consideration given to performing an extended clotting screen (Consultant decision).
The decision to perform an extended screen is a Consultant decision;
Consider whether other tests like U&E, creatinine, CRP, copper and Vitamin C are indicated.

5.4 Ophthalmology

In children less than 2 years of age, ophthalmic screening should take place as part of the acute medical assessment.

5.5 Follow up radiological imaging:

No paediatric medical examination is complete where a child has had initial imaging, until follow up imaging has been performed.

This should ideally be 11-14 days and no later than 28 days after the initial skeletal survey. This includes all cases, even when the initial imaging has shown no evidence of any fractures or breaks. Details of this follow-up appointment will be shared by the hospital at the follow-up Strategy Discussion.

6. Recording of Paediatric Safeguarding Medicals

At the conclusion of the Paediatric Safeguarding Medical, the doctor must give a verbal report explaining his or her findings to the social worker or 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;
Documented findings in both words and diagrams;
Site, size, shape 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 possible cause of injury or harm, if any present.

All reports and diagrams should be signed, dated and timed 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 Safeguarding Medical, 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 Guidelines on paediatric forensic examinations in relation to possible child sexual abuse (PDF) - published May 2012, developed in partnership with RCPCH).

7. Siblings

Consideration should be given to the need for medical assessments of siblings of those subject to a Paediatric Safeguarding Medical. This must be specifically considered in the Strategy Discussions.

8. Follow Up Appointments

Following the Paediatric Safeguarding Medical, some children will require follow up assessments and appointments with medical staff. This should be clearly communicated and shared with the social worker prior to leaving the clinical area.

9. Further Strategy Meetings

Following the paediatric medical assessment, a further strategy meeting must be convened to share the findings of the assessment, allow any questions of the findings to be presented to the clinicians, and for further medical investigations to be explained to social care and, where appropriate, the Police.

10. Resources

See Child Protection Evidence – Bites Royal College of Paediatrics and Child Health.

Appendix 1: A Quick Guide to Accessing Paediatric Safeguarding Medicals

Click here to view Appendix 1: A Quick Guide to Accessing Paediatric Safeguarding Medicals.