North Yorkshire and York Safeguarding General Practice Guidance

North Yorkshire and York Safeguarding General Practice Guidance

Hambleton, Richmondshire and Whitby CCG

Harrogate and Rural District CCG

Scarborough and Ryedale CCG

Vale of York CCG

Safeguarding -

General Practice Guidance:

Coding and Management of Safeguarding Information

Version / Date / Purpose of Issue/Description of Change / Review Date
1 / February 2017 / Standard guidance for General Practice North Yorkshire and York. / February 2020
or earlier to reflect new national guidance
Scope / North Yorkshire and York
Author / Dr J Shacklock Named GP HaRD CCG
Dr S Tyrer Named GP HRW CCG
Dr N Wells Named GP VoY CCG
Dr P Billingsley Named GP SR CCG
Jacqui Hourigan Nurse Consultant Safeguarding Adults and Children Primary Care / Date
February 2017
Approval and/or
Ratification Body / YOR Local Medical Committee Limited North Yorkshire and York / February 2017

Contents:

Guidance Document / Page
Processing and Storing of safeguarding Information in general practice / 2
Recommend safeguarding codes to use in North Yorkshire – Emis and systm 1 / 7
MARAC meetings – how to manage correspondence from these in general practice / 9

Processing and storing of Safeguarding Information in Primary Care

There is one overriding basic principle:

Safeguarding Information needs to be immediately obvious on a patient’s notes to all health practitioners* who may access those medical notes.

*Health Practitioners may include GPs, Practice nursing staff and health care assistants, Locums (GPs or nursing staff), Trainees (for example FY2s, GP Registrars), A+E staff, GP OOH staff, midwives, health visitors and school nurses.

ALL Primary Care staff (clinical, secretarial, and administrative) has an equally important role in ensuring Safeguarding information is stored correctly on medical records.

Information coming into the practice

This can include:

• Invitations to Strategy meetings, Child Protection Conferences, Adult Safeguarding conferences
• Child Protection Conference Reports
• Adult Safeguarding Conference reports
• Referrals to Children’s or Adult Social care made by Primary Care staff
• Safeguarding information held within patient’s notes who are new to the practice which is identified by administrative staff when summarising these notes
• MARAC minutes
• MAPPA minutes
• Channel Panel minutes

Each practice will have their own unique way of how they handle information coming into the practice. However, it is good practice to have a small team of staff who deal with all of the Safeguarding Information to ensure consistency.

It is ideal to have one administrative person within the practice who is responsible for the coding and summarising of new notes coming into the practice and who codes all the incoming Safeguarding information. This staff member will work closely with the Practice Safeguarding Lead.

It is important that all* Safeguarding Information is coded as Major, Active Problems so that all Health Professionals can be immediately aware when they access notes that this child/family/adult has particular vulnerabilities.

*the exception to this can be cases of Domestic Abuse in some circumstances. The specific challenges of recording Domestic Abuse is discussed later in this document.

When coding and recording any Safeguarding Information good questions to ask yourself are:

1. Would someone who doesn’t know this family, e.g. a locum or A+E doctor, be instantly aware from first glance at the notes/Summary Care Record that there are Safeguarding Concerns for this child/family/adult?
2. Would a member of the administrative team who is printing out a complete set of this patient’s notes for an insurance company be instantly aware that there is sensitive Safeguarding information that should not be included? E.g. Child Protection Conference Reports or MARAC reports – these DO NOT BELONG TO PRIMARY CARE and therefore Primary Care do not have authorisation to share these notes with anyone
3. If this patient moved practice, would the new Primary Care team be able to instantly identify from the summary that there are Safeguarding Concerns?

If your answer is ‘no’ to any of these questions then you may need to rethink how that information is currently recorded.

Specific situations

Children (born or unborn) on Child Protection Plans

The following groups of people need appropriate codes added to their notes as Major Active Problems:

A child (born or unborn) on a Child Protection plan.

A short note should also be added as to what category they are on a plan for i.e. Emotional Abuse, Sexual Abuse, Physical Abuse, and Neglect. If the child is not yet born something should be added to the mother’s notes and then added to the child’s once born.

When a child is taken off a Child Protection Plan the appropriate code needs to be added as a Major Active Problem.

Siblings

It is often the case that all siblings in the family are also on the same Child Protection Plan so will have this information coded on their notes. However, if the siblings are not on a Child Protection Plan they also need appropriate codes on their notes as a Major Active Problem also.

A short note should be added as to who the sibling is that is on a Child Protection Plan (name, D.O.B) and what category they are on a plan for.

Parents/Step-parents of children on a Child Protection Plan

Parents/Step-parents or any other adult living in that household also need a code on their notes as a Major Active Problem.

Again a short note should be added with the name of the child/ren and the D.O.Bs and what category they are on a plan for.

Child Protection Case Conference Invitations and Reports

Child Protection Case Conference invitations and reports should generally be scanned into ALL the notes of the family/household members – there will be some exceptions to this which need to be judged on a case by case basis.

Recording family groups/relationships

It is very important that where possible family/household members are linked on the Medical Records.

Child in Need

Any child who is classed as a ‘child in need’ also needs appropriate coding as a Major Active Problem

Looked After Children

The following groups of people need codes added to their notes as Major Active Problems:

• Children who are Looked After/ Child in Care / Fostered.
• Parents/carers who have had their child removed from them or their child is being looked after / child in care / fostered.
• Siblings of the child who is being looked after / child in care / fostered but they themselves are not looked after.
• Adults who are the Foster Parents.
• Other children/adults in the household where the child is being looked after.

In each of the above situations a short note should be added with the code to give details of name, DOB of child who has been looked after / fostered.

When a child is no longer Looked After, the appropriate code needs to be added to their notes (this can happen when either the child is returned to their parents or the child turns 18 years old).

Adult Safeguarding Information

There are far fewer codes available to use to record Adult Safeguarding Information compared with Children’s Safeguarding Information but an appropriate code should be added for any adults for which there are safeguarding concerns.

Consideration should be given to other adults/children in the household of the adult for whom there are safeguarding concerns, as to whether something should be recorded in their notes also – this will need to be done on a case-by-case basis.

Adult Safeguarding Conference Invitations and Reports

These should be added onto the patient notes and consideration given as to whether they should be scanned onto any other patient’s notes e.g. family members, children, partners.

Information gained through consultations or from other professionals

For clinicians

Through the course of a consultation you may become aware of Safeguarding concerns from information given by the patient, or you may be contacted by third parties e.g. family members with concerns, other professionals with concerns e.g. social workers, other health professionals.

It is important that this information is recorded and coded in the notes in the same way as safeguarding information coming into the practice.

Consideration needs to be given to whether it is appropriate to record the information in other patient’s notes such as family members.

Drug and Alcohol Problems and Mental Health Problems/Learning disabilities

It is important to remember ‘the child behind the adult’ and ‘the adult behind the child’

If you are aware that a parent/carer/household member has a drug/alcohol problem or significant Mental Health Problem (including Learning Disabilities) it needs to be considered whether that information should be recorded in their child’s notes (or equally any vulnerable adult within the household). A code should also be added to parents/carers of children/vulnerable adults with learning disabilities.

Domestic Abuse

Coding Domestic Abuse on patient’s notes is a rather more complex issue. What to code and how to code will need to be done on a case by case basis depending on the circumstances.

There is a real risk of ‘unintended harm’ when recording domestic abuse in medical records. For example, if a perpetrator of domestic abuse requested his child’s records and when looking at these the perpetrator was able to find out that the mother of his child had disclosed domestic abuse without the perpetrator’s knowledge; this could put the mother and the child at increased risk of serious harm.

Questions to ask yourself when coding Domestic Abuse:

1. Will any health professional who accesses the notes be able to readily identify that there is Domestic Abuse in this household?
2. Is the information recorded in a way that it will be obvious to a member of the admin team that it needs to be redacted should a request for a full set of records be received?

There are a number of different codes available to use for Domestic Abuse – see below.

There is further guidance regarding domestic abuse / MARAC information – see below

Perpetrators of Domestic Abuse

What to record in perpetrator’s notes is again a very complex issue and very case dependent.

If you are absolutely sure that the perpetrator is aware of the allegations of domestic abuse, then this can be coded in the notes.

Situations where you will be absolutely sure that the perpetrator is aware include:

• The perpetrator has disclosed this to you
• There is an ongoing Child Protection Process due to Domestic Abuse and the perpetrator has attended the Child Protection Conferences and is therefore aware of the allegations
• The perpetrator has been convicted of domestic abuse

If you are not sure that the perpetrator is aware of the allegations then it may not be safe to record anything in the perpetrator’s notes. This will need to be judged on a case by case basis with the Practice Safeguarding Lead and, if appropriate, clinicians within the practice who know the family well.

Processing / storing of safeguarding information in primary care – Codes

The codes below are a selection of possible codes to use in safeguarding. It is hoped that by practices using similar codes it will facilitate easier identification of safeguarding concerns for staff who may work in multiple practices, and for when patients transfer surgeries locally. These are the codes the safeguarding team are recommending for use in North Yorkshire.

EMIS / SYSTMONE
CHILDREN
Child Protection
Unborn child subject to child protection plan / 13Iv0 / XaYs9
Subject to a child protection plan / 13Iv / Xa0nx
Child removed from protection register / 13I0 / 13I0
Family member subject to a child protection plan / 13Iy / XaPkF
Family member no longer on child protection register / 13IPO / XaeDf
Child Protection Category Neglect / 13WT4 / XaYLy
Physical / 13WT2 / XaYM2
Sexual / 13WT3 / XaYLz
Emotional / 13WT1 / XaYM1
Children In Need
Child in Need / 13IS / XaI08
Child no Longer in Need / 13IT / XaI07
Looked After Children
Looked after Child / 13IB1 / XaXLt
No longer subject to looked after child arrangement / 9NgF / XaXMD
Own child has been fostered / 8GE71 / 8GE71
Approved Foster Parent / 133N / XaFOD
Member of foster family / No code / UaOHw
Miscellaneous Codes for children
Child is cause for safeguarding concern / 13WX / Xa2Js
Family is cause for concern / 13Ip / Ub1Go
Referral to safeguarding childrens team / 8Hkh / XaXIf
Child at risk / 13IF / 13IF
Vulnerable child / 13IF-1 / 13IQ
ADULTS
Adult safeguarding concern / 9Ngj / XaXP4
Adult no longer safeguarding concern / 9Ngk / XaXP7
Referral to safeguarding adults team / 8Hkc / XaQok
Safeguarding adults protection plan agreed / 8CSC / XabzB
Vulnerable adult / 133P / XaKXv
CASE CONFERENCES
If attended a conference for adults or children use the 2 codes below: / - / -
Initial Case Conference / 387A / XaXH9
Review Case Conference / 3879 / XaXHB
Child protection conference report submitted / 9Eq / Xaedm
Conference Report (when filing the report) / 9Ee01 / XaX2k
DRUG / ALCOHOL MISUSE
Family history of alcohol misuse / 12X0 / XaN28
FH: Drug Dependence / 1283 / 1283
MENTAL HEALTH / LEARNING DISABILITY
Family history of mental and behavioural disorder / ZV1A / 128
Maternal Postnatal Depression / 12K8 / Xaeft
Paternal / Maternal learning disability / 12L5/12K6 / Xaec5 / Xaec7
Family history of learning disability / 12W1 / XM1Je
Carer of a person with learning disability / 91BW / XaKBe
Parent of / 133E / 133E
DOMESTIC ABUSE
(Victim of) domestic abuse / X70xr / X70xr
History of domestic abuse / 14XD / XaN21
Alleged perpetrator of domestic violence / 14XC / XaLVG
Domestic abuse victim in household / 13Wd / XaaUL
Subject of MARAC / 13Hm / XaX96
Referral to MARAC / 8T0b / Xacv1
At risk of violence in the home / 13VF / 13VF
FGM
History of FGM / K578 / Xab25
Family history of FGM / 12b / Xab24
PREVENT
No Codes available yet for either system – suggest use vulnerable adult or vulnerable child (see above for these codes)

MARAC Meetings – how to manage minutes from the meeting

A MARAC (Multi Agency Risk Assessment Conference) is a local, multi agency victim-focused meeting. Individuals considered to be at risk of significant domestic abuse are discussed with a view understanding the level and nature of the risk and establishing a safety plan. These meetings are minuted and involve multiple different agencies with the police taking a lead in organising these meetings. Increasingly one of the outcomes of the MARAC meeting is to share the minutes of the meeting with the relevant GP surgery. The content of MARAC meetings is highly sensitive and confidential. The information below provides guidance for practices on how to manage this information when they receive MARAC minutes. It highlights key issues to be aware of but it is for each practice to develop their own system alongside their other safeguarding systems, in particular their system for recording domestic abuse (see earlier) Key points include:

-Receipt of minutes: On receipt of MARAC minutes a practice needs to share this information with relevant individuals within the practice. Each case needs to be assessed on its own merits to ascertain how best to handle it. It may be the first time the practice is aware that domestic abuse is an issue. In most cases it is advisable to summarise the minutes and then destroy them given their very sensitive nature. Occasionally it may be appropriate to scan the minutes on to the notes. If scanned the minutes from the MARAC meetings are highly confidential and are not to be shared outside the practice without the consent of the chair of the meeting.

-It is important to ensure this information is visible to those who need to see it, whilst ensuring there is a system in place to ensure this information is not in inadvertently shared or viewed. As previously discussed this is particularly important in domestic abuse due to the potential risk of inadvertently causing more harm to the victim / children.

-Confidentiality: Whether the minutes are summarised, or occasionally scanned each practice needs to ensure they have a system in place to ensure this information is not shared outside the practice (eg insurance reports), or with patients. Unlike with child protection reports, whilst in most cases the victim consents to the MARAC meeting they normally get feedback about the MARAC from their key worker and they do not normally get site of the minutes. There are various ways to ‘flag’ the notes to ensure the fact that sensitive information is in the notes is visible to all staff members. Examples may include coding the notes as containing third party information, or using the confidentiality option, or using major message alerts (available in EMIS).

-Coding: Each case will need to be judged on an individual basis by the practice to decide whether to code domestic violence and in whose notes. As discussed previously a balance needs to be struck between ensuring the information is easily accessible to anyone providing care whilst also ensuring it is not inadvertently shared / viewed. As well as potentially highlighting the victim’s notes it is important to consider risks to children or other vulnerable adults in the household and consideration should be given to recording something in their notes as well. Remember that domestic abuse perpetrators can also simultaneously be victims and therefore have their own vulnerabilities and may need these highlighting in some way.

-Patient Access: When coding domestic abuse or MARAC information it is important to ensure online patient access is switched off for these individual codes to ensure there is no risk that the perpetrator sees that a disclosure has been made. Caution is also needed when patients request access to or copies of their notes to ensure this information doesn’t potentially cause more harm than good. The principles of the data protection act need to be followed.

Examples to illustrate guidance:

Case Example 1:

-30 year old female victim discussed at MARAC. Minutes demonstrate clear past history of male partner perpetrating violence against previous partners. Currently they are still in a relationship. He is unaware of the disclosure and MARAC meeting. He is also registered at the practice. The victim has consented prior to the meeting. She has 1 child (4 year old – the perpetrator is not the father).

-On receipt of the minutes the practice should discuss / share the case so that relevant clinicians are aware. The minutes should be summarised and then destroyed (or occasionally scanned). Anything coded / written in the victim’s notes needs to be blocked from online access in case of coercion. Something should also be written in the child’s notes advising of domestic abuse in the household. This should also be blocked from online access. There is minimal risk in this example that the perpetrator will gain access to the child’s notes given they have no parental rights. The information recorded needs flagging in some way to ensure practices don’t share it inadvertently. There is a clear distinction between victim and perpetrator and in this case when the perpetrator is unaware of the disclosure nothing should be recorded in his notes.