CHILD SAFEGUARDING

1. Introduction to Child Safeguarding

What is child safeguarding?

Child safeguarding is not defined in law but has been described as; “Arrangements to take all reasonable measures to ensure that risks of harm to children’s welfare are minimised.”[1]

It has two components;

  • protecting children from maltreatment
  • preventing impairment of children’s health or development

Child protection is the term used to refer to the activity taken to protect children who are suffering or at risk of suffering significant harm[2].

There are four categories of abuse:

  • Physical abuse includes hitting, shaking, kicking, punching, scalding, suffocating and other ways of inflicting pain or injury to a child. It also includes giving a child harmful substances, such as drugs, alcohol or poison. If a parent or carer reports non-existent symptoms of illness in a child, or deliberately causes illness in a child, this is also a form of physical abuse.
  • Sexual abuse is when a child or young person is pressurised, forced or tricked into taking part in any kind of sexual activity with an adult or young person.
  • Neglect is the persistent lack of appropriate care of children, including love, stimulation, safety, nourishment, warmth, education and medical attention. It can have a serious effect on a child's physical, mental and emotional development
  • Emotional abuse is when a parent or carer behaves in a way that is likely to seriously affect their child's emotional development. It can range from constant rejection and denial of affection, through to continual severe criticism, deliberate humiliation and other ways of verbally "terrorising" a child.

Whose responsibility is it to safeguard children?

All agencies coming into contact with children have a safeguarding responsibility – it is a shared responsibility. General practice is well-placed to discharge its responsibility but is not responsible for making a diagnosis of child abuse and neglect; rather it is required to share concerns appropriately and refer onto the relevant agency responsible for carrying out an assessment and arranging medical examinations, as appropriate, to help determine whether or not child abuse has occurred[3]. The competencies expected of healthcare staff are set out in intercollegiate guidance[4], and summarised in Appendix A.

Responsibility for co-ordinating the activity in regards to safeguarding and protecting children rests with the Local Safeguarding Childrens Board (LSCB) – there is one in each local authority area. They have a particular role in developing policies and guidance, in providing training, and in undertaking Serious Case Reviews. The local Childrens Social Care department have the responsibility for responding to concerns about a particular child, and if necessary commencing child protection proceedings. This may lead to the child being made subject to a child protection plan (previously they were placed on the child protection register) if they are thought at risk of significant harm.

What role do GPs play in safeguarding children?

  • Virtually all children are registered with a GP
  • GPs remain the first point of contact for most health problems in children
  • A GP may be the first to recognise parental and/or carer health problems, or someone whose behaviour may pose a risk to children and young people
  • The primary health care team may be the only professionals to have contact with infants and pre-school children

The long-term effects of abuse are widely documented and include a range of psychological, emotional and social effects[5], but most abuse is preventable[6]. In order to achieve the optimum life chances for children and young people, early detection and intervention is paramount, and GPs are well-placed to perform this role.

Key Messages

  • Child safeguarding is about more than child protection – it seeks to identify and resolve problems early, preferably before child protection procedures are required
  • Abuse of children has long-term psychological, emotional and social effects, but most abuse is preventable.
  • GPs have a responsibility to help safeguard children, but it is a responsibility they share with other agencies, and they are not expected to make ‘diagnoses’ of abuse but rather to share their concerns so that appropriate action can be taken.

2. Suspicious Bruising in Babies and Children

Bruising is the commonest presenting feature of physical abuse in children[7],[8].Patterns of bruising that are suggestive of physical child abuse are:

  • Bruising in children who are not independently mobile – those who don’t cruise rarely bruise(in one study of healthy babies less than 6 months of age only 0.6% has a bruise - and only 1.7% of those aged 6-8 months – compared to 18% of cruisers and 52% of walkers[9])
  • Bruises that are seen away from bony prominences
  • Bruises to the face, back, abdomen, arms, buttocks, ears and hands
  • Multiple bruises in clusters
  • Multiple bruises of uniform shape
  • Bruises that carry the imprint of implement used or a ligature[10]

In keeping with typical characteristics of NAIs generally,

  • the explanation for the bruise(s) may be inconsistent, vague or not compatible with the mechanism of injury given, or there may be no explanation at all
  • there may have been a delay in reporting or in seeking treatment, if treatment is required
  • the child may have already been taken to hospitals or doctors on a number of past occasions with similar ‘unexplained’ injuries
  • parents may not mention previous injuries known to have occurred

A bruise should never be interpreted in isolation and should always be assessed in the context of medical and social history, developmental stage, explanation given, and full clinical examination[11].

Responding to a suspicious bruise

Immediately;

  • document the explanation of the child’s condition verbatim, and log all injuries in detail using a body chart,
  • be open and honest with the parents about your concerns – do not try and admit the child to hospital under false pretences (e.g. ‘bleeding disorder’ even if this is a possible if not unlikely diagnosis)
  • advise the parents of the need totelephone Children’s Social Care (CSC), who will arrange a medical examination if required – CSC may choose to escort the child to the hospital and ask you to ensure the parents are not left alone with the baby/child until they arrive
  • you may also choose to speak to the paediatrician who will be doing the medical examination to explain your concerns and ensure they have all the relevant information
  • record all discussions, decisions and actions, and confirm your referral to CSC in writing within 48hrs

Things to avoid;

  • DO NOT do nothing - if you are uncertain about what to do when presented with an injured child/baby then you must at the very least share your concern immediately, either with a colleague, an experienced paediatrician, the local safeguarding team or the initial response service at CSC – remember you can discuss the case without revealing patient identifiable information at this stage. If you remain concerned following these discussions then you should follow the steps outlined above.
  • DO NOT admit to paediatric care directly without first discussing with CSC, unless there is an urgent medical need to do so. CSC are best placed to arrange an appropriate medical examination, and they have the responsibility for making sure the baby/child gets to the hospital.
  • DO NOT allow the parents to leave the surgery with the child before CSC arrive if CSC have advised that they wish to escort the child to hospital themselves – inform the parents of the advice you have received but if they are adamant they want to take the child from the surgery unsupervised then inform them that you will have to the call police if they do (and do so should they actually leave with the baby/child). If you have concerns about the personal safety of yourself or any of your staff in these situations then you should call the police immediately.

For further advice about Suspicious Bruising in Babies and Children;

  • contact your local safeguarding representatives
  • go to for expert guidance on interpretation of injuries, including bruising

Key Messages

  • Bruises are the commonest sign of physical abuse in children
  • Babies who don’t cruise rarely bruise
  • Bruising needs to be assessed in context
  • Suspicious bruising requires an immediate respond, following local procedures

3. Domestic Violence

What is domestic violence?

Any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners or family members, regardless of gender or sexuality.

Who are the victims/perpetrators of domestic violence?

Domestic violence is rarely a single event, and is mostly but not exclusively experienced by women and perpetrated by men. Children are often victims too, even if not directly assaulted themselves (90% of children in households in which DV occurs are either in the same or the next room).

How DV affects children

  • Over 3 million episodes of DV are witnessed by children every year in the UK
  • 40% of DV cases also involve physical or sexual abuse of the child by the perpetrator. The term ‘family violence’[12] is sometimes used to reflect this.
  • 80% of runaways are fleeing DV (22,000 children under 11 runaway from home every year) but children are seldom asked about DV.
  • Children from DV households are often ‘looking for love’ and become esp vulnerable young people and adults who fall into physically and sexually abusive relationships.
  • DV is a factor in 60% of children being subject to child protection plans
  • Children who witness violence between parents have emotional and behavioural difficulties that mirror those of children who have actually been abused themselves

Solutions

  • Changing attitudes: Traditionally the police response to a callout for DV was to ask the women there and then if she wanted the man arrested and was she willing to go to court, and that was all that was offered. She frequently said no. Now there is support, even if she does not wish to pursue charges.
  • The abusive partner is ‘the problem’, and needs to be dealt with – mention of ‘an abusive relationship’ suggests a shared responsibility for the violence. The women like the child is a victim/survivor of DV and DV services should focus on increasing safety for both.
  • Routine enquiry at new patient registration and antenatal bookings can help identify women suffering from DV
  • Freedom Programmes can help women leave abusive relationships
  • Male perpetrators present to GPs more often than to anyone else. Perpetrators programmes can engage with the father in a way that social workers often fail to, and can produce longterm benefits (research shows that 4 years after starting a PP 75% of men have not been violent in the previous 2 years)
  • Services for children with complex needs or at high risk of serious harm or death should encompass multi-agency risk assessment and safety planning through;
  • MARAC (multi-agency risk assessment conferences), and
  • MAPPA (multi-agency public protection arrangements)

Key Messages

  • Children in households experiencing DV are at very high risk of abuse
4. Information Sharing in Child Safeguarding

Introduction

Information sharing is essential to enable early intervention and preventative work, for safeguarding and promoting welfare and for wider public protection[13]. Its importance in ensuring children are adequately protected cannot be overstated. In cases where children have been abused or even killed at the hands of those expected to care for them inadequate information sharing has frequently been cited as a major contributory factor[14] - it could reasonably be described as the Achilles heel of effective safeguarding.

However, information sharing raises legal and professional concerns as it may seem at odds with usual best practice that stresses the importance of confidentiality. Striking the balance between sharing information and maintaining confidentiality is a particular challenge for every clinician involved with the protection of children and young people.

Information Sharing – General Principles

The ‘Seven Golden Rules’ of information sharing are set out in the government guidance, Information Sharing : Pocket Guide[15]. This guidance is applicable to all professionals charged with the responsibility of sharing information:

1)Remember the Data Protection Act is not a barrier to sharing information[16] but provides a framework to ensure personal information about living persons is shared appropriately.

2)Be open and honest with the person/family from the outset about why, what, how and with whom information will be shared and seek their agreement, unless it is unsafe or inappropriate to do so.

3)Seek advice if you have any doubt, without disclosing the identity of the person if possible.

4)Share with consent where appropriate, and where possible, respect the wishes of those who do not consent to share confidential information. You may still share information without consent, if, in your judgement, that lack of consent can be overridden by the public interest – you will need to base your judgement on the facts of the case.

5)Consider safety and well-being: Base your information sharing decisions on considerations of the safety and well-being of the person and others who may be affected by their actions.

6)Necessary, proportionate, relevant , accurate, timely and secure: Ensure that the information you share is necessary for the purpose for which you are sharing it, is shared only with those people who need to have it, is accurate and up to date, is shared in a timely fashion, and is shared securely.

7)Keep a record of your decision and the reasons for it – whether it is to share information or not. If you decide to share, then record what you have shared, with whom and for what purpose.[17]

These rules, although generic, serve as a good guide for clinicians who are asked to share information in child protection scenarios. However, the duty of confidentiality warrants closer scrutiny, since it is this issue that most vexes GP when asked to release information without consent.

Information Sharing and the Duty of Confidentiality

Release of information without consent is permitted in certain situations, such as;

  • disclosure in connection with judicial or other statutory proceedings:
  • by law – such as notification of communicable disease
  • to courts or in connection with litigation
  • to statutory regulatory bodies
  • disclosures in the public interest[18]

Disclosure in connection with judicial or other statutory proceedingsmay be relatively straightforward since the terms of such release may be set out explicitly. Public interest considerations may be more subjective although (fortunately) they often run hand-in-hand with child protection concerns. The GMC lists scenarios where public interest disclosures are permitted, including when;

  1. a child or young person is at risk of neglect or sexual, physical or emotional abuse
  2. the information would help in the prevention, detection or prosecution of serious crime, usually crime against the person
  3. a child or young person is involved in behaviour that might put them or others at risk of serious harm, such as serious addiction, self-harm or joy-riding[19].

Furthermore, in child protection scenarios, GMC guidance is clear where the doctor’s duty lies:

Your first concern must be the safety of children and young people. You must inform an appropriate person or authority promptly of any reasonable concern that children or young people are at risk of abuse or neglect, when that is in a child’s best interests or necessary to protect other children or young people.[20]

Information sharing can also be done without the consent of either the child or any adult involved:

Children, young people and parents may not want you to disclose information about them ……. but you must not delay sharing relevant information with an appropriate person or authority if delay would increase the risk to the child or young person or to other children or young people.[21]

And of further note, there is reassurance that the threshold for sharing without consent it set quite low and that even if concerns prove unfounded the action to share would still be supported:

You may share some limited information, with consent if possible, to decide if there is a risk that would justify further disclosures. A risk might only become apparent when a number of people with niggling concerns share them…… You will be able to justify raising a concern, even if it turns out to be groundless, if you have done so honestly, promptly, on the basis of reasonable belief, and through the appropriate channels.[22]

So even a ‘niggling’ concern can and should be shared. Indeed, the GMC are clear that the practitioner is more likely to be asked to justify why such a concern was not shared than why it was[23].

GPs should be greatly reassured by this guidance. It indicates that the sharing of a concern, or of information in light of a concern, where the aim is the protection of a child, is permitted (and required) in the public interest without the consent of parents if consent is not forthcoming.

Breeching confidentiality

Complaints about breeches of confidentiality may have some legitimacy not for the fact that information has been shared without consent but because of the manner in which it was done. By following correct procedures the risk of such adverse outcomes can be minimised.

The usual rules of confidentiality and information sharing (including the Seven Golden Rules[24]) should be applied, in that;

  • patients (or when appropriate those with parental responsibility for the patient) should usually be informed and consent sought prior to release of information, and clear documentation made of steps taken and reasons for release without consent[25];
  • release of information should be proportionate and on a need-to-know basis. Where outside agencies request information the clinician should be satisfied that the concern warrants release of information without consent – it isn’t sufficient for information to be handed over ‘because the social worker wants it’. The clinician needs to understand the concern, from where they are able to determine whether the concern is sufficient to meet the threshold of a public interest disclosure (which may mean release without consent);
  • clinicians should not feel compelled to release information without first having the opportunity to seek patient consent, where practicable and if time permits, or without seeking further advice if required before doing so (although in urgent situations there should be no delay if such a delay increases the risk to the child);
  • release of information in the public interest may include releasing information without even seeking consent, and this may be particularly pertinent to scenarios presented through MARAC (multi-agency risk assessment conference) processes. In such cases the seeking of consent may be considered impractical because the patient has been or may be violent[26].

Responsibility to parents

The damage to the doctor-parent/carer relationship from investigation of child protection concerns is a source of anxiety to clinicians, especially, of course, if the concern subsequently proves to be unfounded. Although there will inevitably be some negative fallout from such events, the doctor’s legal and professional position should be protected if proper procedures have been followed. In a recent court case, the House of Lords made it clear where the responsibility of the doctor lies: