SAFEGUARDING CHILDREN IN SUFFOLK

GUIDANCE FOR GENERAL PRACTITIONERS, PRIMARY CARE AND OUT OF HOURS STAFF

INTRODUCTION

General Practitioners have a vital role in all stages of the child protection process. They are in a position to identify when a parent has problems which may mean they pose a risk to a child. Their contribution may be essential, recognizing that the welfare of the child is paramount.

WHAT TO DO

New GMC guidance has been issued and sent out in July 2012 entitled Protecting Children and Young People , the responsibility of all Doctors.

All children and young people* are entitled to protection from abuse and neglect.

Good Medical Practice places a duty on all doctors to protect and promote the health

and well-being of children and young people. This means all doctors must act on any concerns they have about the safety or welfare of a child or young person.

Child protection is a difficult area of practice that can involve making decisions that are emotionally challenging, complicated by uncertainty and sometimes go against the wishes of parents. Doctors should work with parents and families, where possible, to make sure that children and young people receive the care and support they need. But in cases where the interests and wishes of parents may put the safety of the child or young person at risk, doctors must put the interests of the child or young person first.

Failure to act when a child or young person is at risk can have serious consequences for both the child and their family.

Key points

Be aware of risk factors that have been linked to abuse and neglect and look out for signs that a child or young person may be at risk. If you are treating an adult patient, consider whether your patient poses a risk to children or young people.

Keep an open mind and be objective when making decisions. Work in partnership with families where possible. If you are not sure about whether a child or young person is at risk or how best to act on your concerns, ask a named or designated professional or a lead clinician or, if they are not available, an experienced colleague for advice.

Consider whether to make a referral to Children’s Social Care or to ask for a second opinion where there are features of abuse, neglect, domestic violence, or concern about sexual abuse. Any disclosure of an acute sexual assault in a young person 13 or over should be immediately referred to the Sexual Abuse Referral Centre, (tel 01473 668974) where Police and Social Care will be involved and the young person assessed and treated by a Forensic Medical Examiner

In cases where sexual abuse in a prepubertal child is suspected, because there has been an allegation by a parent or carer, or the child has made a disclosure, a referral to Social Care should be made. In these cases GPs are advised not to examine the child, but refer to the Consultant Community Paediatrician. However if the family is concerned about symptoms, without any allegation, the child should be examined and relevant swabs/investigations taken.

If you would like a second opinion, contact the Consultant Paediatrician on call by phone or if a child requires treatment /admission , send the child to hospital.
Do not send the family to A/E without contacting the paediatricians in case they do not attend.
In general, babies and those requiring investigation and treatment should be referred to the hospital, those with bruising, potential sexual abuse or more minor injuries will be seen by the Community Paediatricians .

Always consider the safety of any children in the household where there is evidence of domestic violence, or any of the carers have mental health problems

Avoid confronting the family but explain that you are concerned and are referring for a second opinion

All NHS Trusts have a Named Doctor and Named Nurse for safeguarding.

There are also Designated Doctors and a Nurse who work across the County and can be contacted for advice through the Safeguarding Department on 01473 264357.

www.suffolkscb.org.uk

NORTH SUFFOLK / EAST SUFFOLK / WEST SUFFOLK
The on call Paediatrician through James Paget Switchboard
01493 452452 / The on call Paediatrician through Ipswich Hospital Switchboard 01473 712233
Consultant Community Paediatricians
01473 321209 / The on call Paediatrician through WSH Switchboard
01284 713000
Consultant Community Paediatricians
01284 775075
T

Paediatricians expect and welcome discussions with all referral agencies regarding concerns about children and provide a 24-hour on call Service across the County. Out of hours, contact the Hospital Switchboard for access to the on call Paediatrician.

SHARING INFORMATION—GMC GUIDANCE JULY 2012 :

You should normally discuss any concerns you have about a child’s or young person’s safety or welfare with their parents. You should only withhold information about your concerns, or about a decision to make a referral, if you believe that telling the parents may increase the risk of harm to the child or young person or anyone else. If this is difficult to

judge, or you are not sure about the best way to approach the situation, you should ask for advice from a designated or named professional or a lead clinician or, if they are not available, an experienced colleague.

When discussing your concerns with parents, you should explain that doctors have a professional duty to raise their concerns if they think a child or young person is at risk of abuse or neglect. You should explain what actions you intend to take, including if you are contacting the local authority children’s services.

You should give the parents this information when you first become concerned about a child’s or young person’s safety or welfare and throughout a family’s involvement in

child protection procedures.

You must work with and communicate effectively with colleagues in your team and organisation and with other professionals and agencies. This includes health visitors, other nurses, social workers and the police.

You should understand and respect the child protection roles, responsibilities, policies and practices of other agencies and professionals and cooperate with them. You must be clear about your own role and responsibilities in protecting children and young people,

and be ready to explain this to colleagues and other professionals.

You must tell an appropriate agency, such as children’s social care services, or the police, promptly if you are concerned that a child or young person is at risk of, or is suffering abuse or neglect unless it is not in their best interests to do. You do not need to be certain that the child or young person is at risk of significant harm to take this step. If a child or young person is at risk of, or is suffering, abuse or neglect, the possible consequences of not sharing relevant information will, in the overwhelming majority of cases, outweigh any harm that sharing your concerns with an appropriate agency might cause.

When telling an appropriate agency about your concerns, you should

provide information about both of the following:

a the identities of the child or young person, their parents and any other person who may pose a risk to them

b the reasons for your concerns, including information about the child’s or young person’s health, and any relevant information about their parents or carers.

The GMC booklet gives clear guidance about issues of confidentiality and consent and your duties and responsibilities in this respect. There is also guidance on assessing capacity and determining who has parental responsibility for the child.

1. INDICATORS FOR CONCERN
§  Any unexplained bruise or mark in a non-mobile baby
§  An episode of cyanosis or collapse
§  Disclosure of abuse to GP either by child or parent
§  Injuries inconsistent with the history given, or unexplained injuries
§  Recurrent injuries
§  Unexplained failure to thrive
§  Features of neglect or emotional abuse
§  Allegations or medical findings suggestive of sexual abuse
§  Premature birth/young parents/multiple births
§  Actual or suspected multiple episodes of domestic violence
§  Parental drug and alcohol misuse
2. FACTORS IN THE HISTORY WHICH SHOULD AROUSE SUSPICION
§  Inappropriate delay in seeking medical advice
§  Multiple and mixed injuries
§  Complicated history
§  Apparent fabrication of symptoms
§  Variable history
§  Inappropriate parental reaction
§  Abnormal interactions between child and parent
§  Unusual degree of hostility or over-friendliness to staff
§  Concerning comments made by the child
3. PARENTAL INDICATORS THAT MAY LEAD YOU TO HAVE CONCERNS REGARDING THE SAFETY OR WELFARE OF A CHILD
§  Mental health difficulties
§  Learning disorder difficulties
§  History of sexual offending
§  History of violence
§  History of previous children being referred for child protection concerns or being removed under care order
§  Parental fabricated illness
§  Frequent visits to health professionals for advice – could be a cry for help
PHYSICAL ABUSE
Findings on examination which should arose suspicion and prompt referral
§  Bruising of different ages in places where accidental causes are unlikely i.e. soft tissues/flexor surfaces of limbs
§  Linear bruising/imprint bruising
§  Scalds and burns which do not look accidental
§  Bite marks
§  Mouth injuries/torn frenulum
§  Bilateral eye or ear injuries
§  Head injuries incompatible with history obtained i.e. fall from low surface
§  Abdominal bruising or injuries
§  Genital bruising or injuries
§  Any bruise in non-mobile baby which is unusual or unexplained
Always refer non-mobile babies with unexplained bruises for a Paediatric opinion as they may have more serious underlying injuries
NEGLECT
In the infant: / In the pre-school child: / In the school child: / In the teenager:
Physical / Failure to thrive
Significant weight loss
Unexplained bruising
Severe nappy rash
Frequent hospital admissions
Recurrent and persistent infections / Failure to gain weight/height
Physical features of FTT
Poor hygiene / Failure to gain height/weight
Poor hygiene / Failure to gain height/weight or obese
Poor general health
Delayed puberty
Poor hygiene
Developmental / General delay / Delayed language
Poor attention
Socially immature / Learning difficulties
Lack of self esteem
Poor coping skills
Emotional immaturity / School failure
Behavioural / Attachment disorder: anxious, avoidant
Socially unresponsive / Food scavenging
Overactive
Aggressive and impulsive
Indiscriminate friendliness
Seeks Physical comfort from strangers / Food scavenging
Poor relationships
Overactive
Aggressive
Withdrawn
Unusual patterns of defecation or urination
Destructive / Truancy
Smoking
Alcohol and substance misuse
Sexual promiscuity
Destructive behaviour

PATTERNS OF EMOTIONAL ABUSE

Rejecting:
Isolating:
Terrorising:
Ignoring:
Corrupting:
The following age specific guidelines can be used:
0 – 1
1 – 3
3 – 6
6 – 12
12+ / The child’s needs are not acknowledged
The child is excluded from normal social interaction
The chills is verbally assaulted
The child is deprived of essential stimulation
The child is stimulated to engage in destructive anti-social behaviour
Sleep/feeding problems, irritability, apathetic, dull, anxious attachments
As above + overactive, aggressive, attention deficit, language delay, indiscriminate affection, fearful and anxious, inability to play, anxious and ambivalent attachments
As above + peer relationship difficulties, attention seeking, clingy, school failure, poor social skills
As above though sleep and feeding problems may resolve inappropriate attachment to carers, rejected by peers, development of delinquent behaviours, truanting, wetting, soiling, stealing, bullying
As above + depressions, escalated aggression, anxiety, self-harm, poor self-image, psychosomatic illness, drug and substance misuses, criminal activities

SEXUAL ABUSE - Levels of concern:

Low Suspicion:

Medium Suspicion:

High Suspicion:

/

Recurrent UTIs · Recurrent abdominal pain, headaches or other psychosomatic features · Isolated observation of sexualised behaviour · “Eccentric” sexual patterns of family interaction without other observable or reported symptoms

Perineal itching, soreness, pain on micturition, discharge · anal warts · child hinting that there are secrets he/she cannot talk about · psychiatric disturbances, mutism, anorexia nervosa, attempted suicide or deliberate self harm · concern about inappropriate behavioural patterns with other children or adults

Semen in vagina, anus or external genitalia · pregnancy in a minor where identity of father is unknown/concealed · signs of STDs · repeated and frequent sexualised behaviour · bruises, scratches or other injuries to genital or anal areas, or areas such as breast and lips · laceration or scarring of anal mucosa into perianal skin

Flowchart for Professionals working with
Sexually Active Under 18’s

WHAT TO DO FOLLOWING A DISCLOSURE

OF DOMESTIC VIOLENCE

SUFFOLK SAFEGUARDING CHILDREN BOARD

INJURIES TO NON- MOBILE INFANTS

ADVICE FOR GENERAL PRACTITIONERS AND HEALTH VISITORS

DON’T DELAY IF YOU ARE CONCERNED

Version 4 dated July 2012