3.12 Medical Examinations
SCOPE OF THE CHAPTER
To provide guidance for the medical examination of children and young people who may have been abused/harmed.
This chapter is currently under review.
The purpose of this document is to:
- Advise practitioners from all agencies about when a medical examination may be helpful in the assessment of a child or young person about whom there are safeguarding concerns;
- To provide advice for practitioners about what type of medical assessment will ensure that the child or young person’s medical needs are appropriately addressed. This advice will assist practitioners in identifying who to request a medical assessment from and, if in doubt, how to obtain advice about the type and scope of assessment required;
- To guide practitioners from all agencies in determining the urgency of an assessment.
The objectives of a medical examination are:
- To assist in determining whether a child who may have been subjected to any form of intentional harm requires immediate medical attention;
- To assist in establishing whether or not there is evidence of physical or emotional harm.
A medical assessment alone is rarely proof that a child has been intentionally harmed and should be undertaken only to decide whether the child needs treatment or as part of a multi-agency assessment.
A medical assessment alone should never be requested to determine whether a multi-agency investigation is required.
A medical assessment may be of value when:
- A child may have experienced some form of intentional maltreatment and may require medical attention;
- A child or young person may have physical or emotional evidence that may assist partner agencies with their assessment of a child and family;
- When there is a possibility of gathering forensic evidence (e.g. specimens or photographs);
- In order to provide reassurance to a young person and their immediate family members or carers.
Consent to examine a child or young person must be obtained prior to undertaking a medical examination. It is the responsibility of the examining doctor to ensure that consent for the examination has been obtained.
This consent may be given:
- By a young person who is assessed as Gillick Competent to give consent (a young person is said to be Gillick competent if they are under 16 years of age but of sufficient age and understanding to consent to medical treatment). (Fraser Competence refers only to capacity to consent to matters relating to contraception and consensual sexual intercourse);
- By a parent or carer who holds Parental Responsibility;
- By the Local Authority if the child is subject to a Care Order, but the parent should be informed;
- By the High Court if the child is a ward of court;
- By the Family Proceedings Court as part of a direction attached to an Emergency Protection Order, an Interim Care Order or a Child Assessment Order;
- When a child is looked after under Section 20 and a parent has given general consent authorizing medical treatment.
Consent for an examination cannot be given by an accompanying adult who does not hold Parental Responsibility, e.g. step-parent, grandparent or foster carer. Parental Responsibility is a legal term and is defined by the Children Act 1989 and 2002. It relates to the powers, duties and responsibilities that an adult may hold over a child.
If the medical team feel that the child or young person is in need of urgent medical attention this may override the requirement to obtain consent.
Separate consent is required for any photo-documentation.
In order to undertake a medical assessment the doctor will need information about the child’s past medical history and illnesses. The child should therefore ideally be accompanied by an adult who is able to give information about the child’s current and previous health.
The professional seeking the assessment should always have a discussion with the paediatrician prior to the medical assessment to ensure that the paediatrician is aware of their concerns.
A record of the past medical history may be gathered from:
- The general practitioner’s record;
- From the record of previous visits to hospital in the hospital medical record;
- Some children have complex health needs and will have records in several hospitals;
- Younger children may have important medical information held by the community health team which may include the health visitor and school nurse.
It is especially important that injuries (even those for which there appears to be a plausible explanation) are considered in the context of that child’s previous health and developmental needs.
There is not a single medical assessment or health record that encompasses an overview of all of a child’s medical and developmental needs.
A medical assessment should include:
- A comprehensive history of the child’s medical, social and developmental needs, taken from parent or carer;
- A history of the current episode;
- An examination of the child including an assessment of height and weight. This examination will include an inspection of the child as well as examination of the presenting injury. This examination should be undertaken in a manner that is sensitive to the emotional and cultural needs of the child;
- Accurate documentation of all findings and use of body maps where appropriate;
- Preliminary analysis of findings;
- Plan including referral for additional tests and assessments;
- Plans for medical follow up;
- Record of who the findings of the assessment are to be shared with;
- It is good practice to document both positive and negative findings and to provide non medical practitioners with information about the limitations of the significance of physical findings.
There are 3 acute paediatric units in Norfolk. Each hospital has different practice with regard to seeing children who may have been maltreated. It is important to liaise with the paediatric team on call in the area in which the child is located.
Where practitioners wish for additional advice about who should be asked to see and assess a child they can also discuss this with the Designated Doctor or Nurse for Norfolk or the Named Doctor within the appropriate hospital
If a child or young person is unwell and has urgent medical needs these needs should be addressed with the same degree of urgency as is the case for any other acute medical illness. The child should be seen in a place and by professionals who have facilities and skills to assess acutely unwell children. Usually this will be in an accident and emergency department or an acute paediatric ward in a hospital.
Any non-mobile baby or child who is unable to move independently because of a physical disability who sustains any injury should be referred to an acute paediatric consultant for assessment (in hospital).
When children (who are fully mobile) have minor physical injuries and a forensic opinion is unlikely to be required, their general practitioner may agree to see them.
Any child or young person who presents with bruising to the face, buttocks, genital area or trunk should be referred to a paediatric consultant for assessment.
Independently mobile children and young people who have sustained injuries for which there is an inadequate or inconsistent explanation should be seen by their own general practitioner who may wish to seek a second opinion from a consultant paediatrician.
When a child or young person less than 18 years of age discloses, or concern is expressed by a carer, parent or other agency that the young person may have been sexually harmed a forensic examination may be required. In these circumstances it is especially important that an appropriately trained medical practitioner undertakes the relevant assessment since this will ensure that the child is not subjected to repeated examinations (which may in itself be distressing) and that forensic evidence, both photographic and samples can be obtained. There are several clinical pathways depending on the age and needs of the young person.
Children less than 13 years of age who may have been sexually harmed should be examined by a specialist paediatrician. In Norfolk and north Suffolk this service is provided by the consultant paediatrician on call via the Norfolk and Norwich University Hospital (NNUH). Request for Examinations should be coordinated via the Multi-Agency Safeguarding Hub (MASH) who will liaise with the Sexual Assault Referral Centre (SARC, the harbour centre).
Young people who are 13 and over will normally be examined by a forensically trained physician. These examinations must be organised by the MASH via the SARC.
Children who have physical or learning needs and are over 12 years of age should be examined by a paediatrician together with a Forensic Medical Examiner (FME). Young people and their families should, when possible, be offered a choice of gender of examiner.
Adherence to best practice ensures that the conclusions drawn by paediatricians in Norfolk following medical assessments are peer reviewed and informed by current evidenced based literature.
With the exception of situations where the health of a child or young person is of immediate concern there are a number of guiding principles about the timing of medical assessments.
Practitioners must determine the purpose and scope of the medical examination. Normally this will require that the child and family will have been seen by a member of Children Services Social Care staff. This assessment will determine the urgency and type of medical assessment required.
When it is anticipated that there may be forensic specimens there should be consultation with the SARC (Harbour Centre – 01603 276381) manager with regard to the timing of the examination.
Unless there is an overriding urgency to examine a child then the examination should be undertaken in a place and at time that is sensitive to the developmental and cultural needs of the child.
Examination in locations that are not specifically adapted to the needs of children e.g. an Accident and Emergency department or where it will not be possible to undertake a full examination because facilities in that location fall short of basic requirement should not be undertaken.
Times when a young child would normally be sleeping or an older child should be e.g. taking an exam in school should be avoided
The weight of a child as a single measurement and in isolation from other parameters of growth is not a helpful indicator of wellbeing. Any professional who has a concern about a child’s weight or development should in the first instance discuss with Health Visitor (if child under 5) or the child’s GP for a child over 5 years.
Information about the child’s assessment is gathered on a proforma that is included in the child’s hospital medical record.
The paediatrician will prepare a report based on the findings recorded in the proforma. This report is shared with the referrer, the child’s GP, health visitor and in some circumstances the child’s family. It is also included in the child’s hospital and electronic record.
The referrer may wish the report to be written as a witness statement. In this case the referrer may request that the statement is not shared with all parties. However it will be included in the child’s medical record and with the GP unless the referrer specifically requests that it is not.
When the referrer requests an assessment that is in the form of a report for the court it is anticipated that the report will be included in the child’s medical record unless the referrer specifically requests that it is not.
When a referrer specifically requests that the report is not shared it is important that there is a full record of safeguarding concerns in the medical record and it is documented when the child was examined and by whom.