3.13 Medical Examinations

SCOPE OF THE CHAPTER

To provide multi-agency guidance for professionals regarding the medical examination of children and young people when abuse or harm is suspected. Individual agencies should review their own procedures. Paediatricians and Forensic Medical Examiners should consult the RCPCH Child Protection Companion and Purple Book.

Contents

1. Introduction
2. Why is a Medical Examination required?
3. The medical assessment: Aid to decide whether a medical assessment is required and who to ask?
• Physical injury
• Concern re: sexual assault
• FGM
• Neglect
What is a Medical Assessment?
Timing and Location of Examination
4. Consent
5. Information Gathering and Sharing
6. Appendices

1. Introduction

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 when there are safeguarding concerns;
  • To provide advice for practitioners about what type of medical assessment will address the child or young person’s medical needs. The response will vary between professions and within professions particularly with regard to clinical assessment;
  • 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.

2. Why is a Medical Examination required?

The objectives of a medical examination are:

  • To identify the child’s health needs;
  • It is an important component of a child protection investigation to assist in determining whether or not there is evidence of physical harm, neglect or emotional harm;
  • To document clinical findings including injuries and (rarely) taking samples that may be used as evidence in a Police or Children’s Services investigation, relevant to all types of abuse.

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 has experienced some form of harm where the cause is uncertain and an intentional cause is a possibility;
  • A child or young person may have physical, developmental 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.

3. The Medical Assessment: Aid to decide whether a medical assessment is required and who to ask and what it involves:

3.1 For all professionals wanting advice regarding safeguarding concerns:

If there are safeguarding concerns about a child it is advisable to consult within individual organisations initially and to follow the organisations’ safeguarding protocols.

If as a result of this consultation concerns remain then the Norfolk Multi-Agency Safeguarding Hub (MASH) is contactable Monday–Friday 09:00 to 17:00 on 0344 800 8020 and out of hours though the Emergency Duty Team (EDT) on 0344 800 8020. It is important to seek informed consent from the person(s) with parental responsibility unless seeking consent would put the young person at greater risk of harm.

The MASH is the single point of contact for any referral regarding any form of abuse. The MASH can review information from Health, Education, Children’s Services and Police and will make a decision regarding further action. This will usually involve an initial strategy discussion.

For children living on the borders of Norfolk contact may be with the relevant county MASH (refer to their LSCB policies).

If it is apparent that a medical assessment is required the MASH will contact the relevant paediatric team (see below Appendix 2/4) to involve them in a discussion prior to the medical assessment. This is to ensure that the most appropriate decision is made in respect to who, where and when the medical assessment should take place.

3.2 For Health Practitioners wanting advice prior to contacting MASH

If Medical Practitioners (Doctors in primary or secondary care, Nurses or Health Visitors) need initial advice with a Health Practitioner about a potential safeguarding medical assessment of a child during working hours they can discuss this with:

  • The Named Doctor or Nurse within their hospital or community trust.

For GP’s

  • GP Practice Safeguarding Lead
  • The Designated Safeguarding Team (Named GP’s, Designated Doctor or Nurse) for Norfolk and Waveney – 01603 257164
  • The duty community Paediatrician for Central Norfolk – 01063 286286 / 01603 508969
  • West Norfolk duty community Paediatrician – 01553 668556

Where a family lives on the borders of Norfolk as long as they are within the Norfolk border please use contacts as above. If in Suffolk or Cambridgeshire please refer to local LSCB policies.

3.3 If it is apparent that a safeguarding medical assessment is required the MASH will contact the relevant Paediatric Team, see algorithm Appendix 4

All safeguarding referrals should go via MASH. There may be an initial brief strategy discussion within the MASH. The case will be referred onto an allocated Social Worker who will arrange a more comprehensive strategy discussion with relevant professionals depending on where the child or young person lives which will include a Paediatrician if it is considered the child will need a medical assessment.

There are three acute units covering Norfolk (James Paget University Hospital, Norfolk and Norwich University Hospital, Queen Elizabeth Hospital) (Appendix 2). If there is consideration that a medical examination is required, the assessing clinician will be contacted by a Senior Social Worker to be part of that strategy discussion. If the child is already in hospital the strategy discussion would include the treating clinicians and other professionals as deemed necessary.

A decision regarding the best person to see the child will depend on the child’s presentation and age see below.

3.4 Acute severe injury

If there is a medical emergency the child should go to the nearest acute hospital and their acute medical 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 an appropriate place and by those professionals who have the facilities and skills to assess acutely unwell children. Usually this will be in an Emergency Department or an acute Paediatric Department within a hospital and any safeguarding concerns should be clearly communicated at the time of referral.

3.5. Acute physical injury

3.5.1 Non-mobile baby with any injury or an infant under 1 year with an injury with no credible or verifiable explanation (See appendix 1).

This should be discussed with the acute Paediatric Consultant on-call regarding an assessment in hospital. In most cases the infant would be seen immediately at the hospital, although there may be circumstances where immediate assessment is not indicated, this would be by mutual agreement between the referrer and the acute Paediatrician. The professional identifying the injury (bruising/fracture/thermal) should complete a referral to MASH and should confirm this with the acute Paediatric Consultant. It is the responsibility of the referring clinician to ensure the child arrives in hospital.

3.5.2 Children over one year of age

If any child presents with an unexplained injury that raises suspicion of physical abuse (i.e. bruising to the face, ears, buttocks, genital area, trunk or has an unusual number or pattern of bruising/fractures, thermal injury, head injury), or if the child is unable to move independently because of a physical disability and sustains an unexplained injury, the professional identifying the injury/bruising should complete a referral to MASH both by telephone and written confirmation. This list is not exhaustive and any pattern of bruising or injury that is of concern should be referred.
The MASH will convene a strategy and decide with the appropriate clinician where and when the child should be seen. The MASH may ask the referring practitioner to contact the duty Paediatric Team (see table below), if the level of concern is such that it cannot wait for a strategy discussion.

Central 09:00-17:00 Duty Community Paediatrician 01603 508969
Central Out of Hours Acute Paediatric Consultant who will decide where and when the child will be seen 01603 286286
West Norfolk 09:00-17:00 Duty Community Paediatrician 01603 508969 or 01553 668556
West Norfolk Out of Hours Acute Paediatric Consultant who will decide where and when the child will be seen 01553 613613
East Norfolk Anytime Acute Paediatric Consultant 01493 452452

3.5.3 Children over a year of age with minor physical injury

Children over a year of age with minor physical injury may require a medical examination. There may have been an inadequate or inconsistent explanation of the injury, but it is not a serious injury and is unlikely to require a forensic opinion or an opinion as to causation. It is important that there is documentation in the child’s health record of the injury or mark seen and any explanation given.

In this situation the strategy discussion within MASH with a Paediatrician may suggest the child can be seen by their own General Practitioner rather than a Paediatrician. In this situation the General practitioner should be contacted to explain the situation. Should the General Practitioner be involved and wish to seek a second opinion they should contact relevant Paediatrician listed in table above.

3.6 Disclosure of sexual assault

When a child or young person under the age of 18 discloses sexual assault or a concern is raised by a parent, carer or other agency that the young person may have been sexually harmed then the first point of contact is the MASH – Monday–Friday 09:00 to 17:00 on 0344 800 8020 and out of hours though the EDT on 0344 800 8020 or the Police on 101 or 0845 4564567.

The MASH Practitioners will then need to convene an initial strategy discussion before any decision is made about an examination. This should include a Health representative with relevant experience (either a Paediatrician (under 13 years) or Forensic Nurse Examiner (13 years and over) in order to help the decision as to whether an examination is required and if so when this should take place. To identify the relevant person to be part of the strategy – see algorithm Appendix 3 and 4.

A strategy discussion will decide if, when and where the young person should be assessed and these decisions will be based on the information available at the time of the referral. Children may be presented to Educational Services, Children’s Services, Police or Health Services. The information below is a guide to help decide on the urgency of an assessment and where this could be done.

3.6.1 When to consider child or young person is at high risk of CSA:

Acute assault: This is an assault that has occurred within the previous 72 hours (pre pubertal) to 7 days (post pubertal)

If there is a clear disclosure by a child or more often by a young person, who has given a clear description of events that indicates the child or young person has been sexually assaulted this would suggest a high risk for CSA. The nature of the assault may involve touching and/or attempted or successful penetration. The forensic window for specimens depends on the nature of the assault and varies from 2 days up to 7 days.
In this case:

  • The child/young person will usually require a forensic examination to obtain forensic evidence (digital images (still or moving) and samples). (See SARC pathway appendix 3).
  • This examination will take place at the SARC within the forensic window. It should be convened as soon as reasonably possible, preferably within 24 hours. There is no forensic out of hours service in Norfolk and thus children will be seen as soon as is possible the next working day for forensic examinations.
  • Examinations should be avoided at night unless it is agreed jointly between Health, Police and Children’s Social Care that it is in the child’s best interests to do so. This will depend on the nature of the assault and age of the child/young person.
  • Achieving Best Evidence (ABE) interview should preferably be undertaken before an examination. This should be as soon as possible after the disclosure so that information from the child can be obtained. This will provide the most important evidence because examination, particularly in younger children is usually normal. A younger child’s memory of events may be affected by those around them. This may not be possible if a registered intermediary is required. In 13-18 year olds the ABE may be done before or after the examination.
  • The decision regarding ABE should be taken on a case by case basis as the ABE may not be achievable within a short timeframe due to the need for trained intermediaries. There may be an agreement to examine the child or young person before the ABE if there is a chance that the forensic window may be missed, or it is agreed that it is in the child’s best interest to have an earlier examination.
  • If there is a significant injury the child will need to go to the local Paediatric Assessment Unit to be assessed. They may require examination under an anaesthetic. In this situation the on-call Community Paediatrician in-hours (<13yrs) or Forensic Medical Practitioner ( >13 yrs and/or out of hours) should be contacted to consider forensic sampling.
  • The young person may require a Sexually Transmitted Infection (STI) screening depending on the clinical assessment. In those over 13 this will be arranged through Integrated Contraception and Sexual Health Services (ICASH) but for those under 13 this will be arranged via the examining Community Paediatrician. Consideration should also be given to toxicology screening if history suggestive.

3.6.2 Historic assault: This is an assault that has occurred more than 72 hours ago in pre pubertal child or more than 7 days ago in a post pubertal young person

If there is a clear disclosure by a child or more often by a young person, who has given a clear description of events that indicates the child or young person has been sexually assaulted this would suggest a high risk for CSA. The nature of the assault may involve touching and/or attempted or successful penetration and the last alleged assault is outside of the forensic window for specimens.
In this case:

  • Achieving Best Evidence (ABE) interview should preferably be undertaken before an examination. This should be as soon as possible after the disclosure so that information from the child can be obtained. This will provide the most important evidence because examination, particularly in younger children is usually normal. A younger child’s memory of events may be affected by those around them. In 13-18 year olds the ABE may be done before or after the examination. This may not be possible if a registered intermediary is required.
  • If it is agreed that a CSA examination is required, then the examination will be arranged within working hours at the SARC. Images may be obtained (digital, still or moving) but no forensic samples (DNA) will be required however the young person may need STI screening as above. (See SARC pathway appendix 3).

3.6.3 When the presentation indicates an uncertain risk of CSA/uncertain benefit from forensic medical examination

There may be a history of contact with a separated parent and the child has said something unusual which may worry the other parent or may report they are sore or parent thinks genital area looks red. A child may report ‘something’ to a third party.

When taking the history from a parent it is important to note that children do not usually have a good understanding of their genital anatomy thus are less likely be able to give as clear a description of events than older children. Unless the child is able to give a clear description of a potential assault, a report from a parent should be assessed in the context of the child’s developmental stage and events surrounding their concerns. A parent may misinterpret what their child says out of context.

If the parent presents a child as above to a clinical service i.e. to their General Practitioner or to an acute service the clinician should examine the child as part of their assessment including examination of the genitalia. The clinician may want a second opinion but should not feel inhibited from an initial examination as for any clinical condition. An examination can identify medical causes for symptoms and/or reassurance of no injury but cannot rule out whether the child may have experienced some form of abuse as young children rarely have clinical evidence of sexual assault.

In cases of alleged CSA, examination is usually normal. A recent review of children (see Appendix 5) and young people aged 0-17 years indicated that 93% have normal findings, mean age of those seen was 6-7 years. The median age of those with abnormal findings was age 13 and associated with clear disclosure and recent event.

In this case the priority should be evidential interview rather than examination.

If there is no clinical reason and history does not suggest that CSA is likely, there may be no need for a further formal medical examination. Otherwise follow guidance as above.

3.6.4 Presentation suggests low risk of CSA (may or may not require strategy discussion)

There would be a low risk of CSA if there has been no clear disclosure but the child is brought to the attention of medical care (GP, A & E, Paediatric Department) with symptoms but no specific safeguarding concern from a parent.

Whilst it is important to ask a parent or carer whether they have any concern that the child may have been intentionally harmed and important to ask the child, it is important also to consider the presentation and history given. When the child is pre-school it will be more difficult to ask them directly whether they have been harmed.

They may be presented by their parents or by their Educational setting, Police or Children’s services with history of:

  • Soreness in genital region
  • Redness
  • Bleeding
  • Discharge
  • Accident/Straddle injury

If there are symptoms the child will need a clinical examination to assess for vulvo-vaginitis, infection (Group A Streptococcus), lichen sclerosis, normal physiological discharge, straddle injury or urinary tract infection (UTI).

This may be referred to the child’s GP (if not initially presented to GP) or the Paediatric Team in the child’s local area. The concerns from another agency (Children’s services/Police) should always be discussed with the examining clinician so they are aware of the circumstances and can agree that they are the best person to examine the child.

If the examining clinician is uncertain re their findings they can discuss and refer on to the Community Paediatrician on call.

3.7 Female genital mutilation (FGM)

In cases where it is suspected a child may be at risk of FGM an immediate referral to MASH or Police is mandatory. A new mandatory duty was introduced via the Serious Crimes Act in October 2015, which requires all regulated professionals (Health, Teachers and Social Workers) to report all known cases of FGM in girls under the age of 18, who are identified in the course of their professional work directly to the Police (Call 101). This is a personal duty and cannot be transferred to anyone else although failure to report is not a criminal offence it may lead to local disciplinary proceedings.

Once reported, a risk assessment according to the Government guideline ‘Multi-agency Practice Guidelines: Female Genital Mutilation (HM Government 2014)’ will then be followed. Decisions about whether a medical assessment is required will be made by the multi-agency team which should include the Paediatrician with specialist expertise of FGM. Any decisions will require a careful and considered response and a medical examination is not an emergency. Please see NSCB FGM policy.

3.8 Neglect

Any professional who has concerns about a child who may be subject to neglect should make a referral to MASH in accordance with the NSCB Neglect Strategy. A Community Paediatrician should be involved in the strategy discussion and consideration given to whether a medical assessment is required.

3.9 What does a Medical Assessment involve?

3.9.1 A medical assessment should be undertaken by a Medical Practitioner with the relevant qualifications and competencies (Level 3 training) for the type of medical examination required.

  • The assessment should include a comprehensive history of the child’s medical, social and developmental needs taken from parent or carer and access to their health records.
  • A history of the current episode including the context in which an injury has occurred.
  • 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 developmental and cultural needs of the child.
  • Accurate documentation of all findings and use of body maps where appropriate.
  • It is important that injuries, even those for which there appears to be a plausible explanation are considered in the context of the child’s previous health and developmental needs.
  • Preliminary analysis of findings and an opinion.
  • Plan including referral for additional tests and assessments if required.
  • Plans for medical follow up if required.
  • 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.
  • Record of who the findings of the assessment are to be shared with.

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 be accompanied by an adult who is able to give information about the child’s current and previous health, unless there are exceptional circumstances that mean the parent cannot attend.

Additional information about the past medical history may be obtained from:

  • The GP’s record.
  • Previous visits to the hospital within the hospital medical records.
  • 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, these will be available on SystmOne.
  • Community child health records are electronic (SystmOne). It is important to ensure access to all units within SystmOne i.e. Health Visiting, School Nursing, Looked After Children (LAC), Disability and Specialist Health and Primary Care as all are under separate provider units. There may also be paper records for children born before 2010.

There is not a single medical assessment or health record that encompasses an overview of all of a child’s medical and developmental needs. The MASH Health Practitioners currently have access to SystmOne only and this will only provide a limited view if the GP uses a different system i.e. Vision or EMIS. The hospitals have access to their own hospital records only. Within hospitals some departments keep separate records and clinicians should be aware of this i.e. A&E attendances are recorded separately.

Adherence to best practice ensures that the conclusions drawn by Paediatricians and Forensic Nurse Examiners in Norfolk following medical assessments are informed by current evidenced based literature, discussed with a colleague and usually subject to consensus peer review.

3.9.2. Timing and Location of Examination

The timing of the examination depends on the health needs of the child/young person, the gathering of evidence and the legal requirements.

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’s Services Social Care staff and may also have been seen by the Police. This initial assessment will determine the urgency and type of medical assessment required. This will have been agreed as part of the strategy discussion at MASH. It may be that the child is seen with Social Care staff and /or the Police at the time of the medical assessment.

Medical assessments must be pre-arranged and agreed as part of a strategy discussion with a Paediatrician. Medical assessments should usually be arranged within 24 hours of the referral. Children should not be brought unannounced to A&E or Paediatric Department unless there is a need for urgent medical treatment. If there is a serious injury the child should be managed by the acute hospital team.
The timing and location of a medical assessment should take into account the medical urgency, the safety of the child and the developmental and cultural needs of the child. This requires discussion between the referrer and the Paediatrician. Consideration should be given for instance to the child’s need for sleep and the educational commitments of the older child.

Examination should only be undertaken in settings and locations that are adapted and sensitive to the needs of children. Locations in which facilities fall short of recommended requirements for assessments of children should not be used e.g. A&E.

For children where there is an alleged sexual assault (whether or not it is anticipated that there may be forensic specimens) a decision will be taken at the strategy meeting/discussion with the clinician undertaking the examination and in consultation with SARC Manager on 01603 276381 with regard to the timing of the examination (See section 3.6). The examinations should usually be done within working hours, however if due to the circumstances of the allegation, the loss of the forensic window and the wishes of the child /young person it may be agreed that it is in their best interests to examine the child out of hours, although there is no out of hours forensic service for under 13 year olds in Norfolk currently.

4. Consent

Consent to examine a child or young person (under 16) must be obtained prior to undertaking a medical examination. You must be satisfied and the person giving consent is fully informed. It is the responsibility of the examining Doctor to ensure that consent for the examination has been obtained. (See GMC guidance, RCPCH Child Protection Companion).

This consent may be given:

  • By a young person over 16 years of age.
  • By a young person who is under 16 years of age but of sufficient maturity and understanding to make the decision (assessed as Gillick Competent).
  • By a parent or carer who holds parental responsibility.
  • By the Local Authority if they have joint parental responsibility. It is good practice to inform the parent if it is safe to do so.
  • 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 (LAC) under Section 20, their parent will have given general consent authorising medical treatment but it would be important to obtain consent for any non-routine assessment. Young people and children assessed as competent can consent themselves.

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 which relates to the powers, duties and responsibilities that an adult may hold over a child.

The Children Act states ‘the interests of the child are paramount’ thus 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 immediate consent.

A separate consent is required for any photo evidence obtained and would be given by a parent or carer at the time of the examination.

A person with parental responsibility should attend any medical assessment with the child or young person unless there are exceptional circumstances and these should be discussed with the clinician undertaking the examination.

5.  Information Gathering and Sharing

Information about the child’s assessment is gathered on a pro-forma that is included in the child’s hospital medical records. It should also be documented on the child’s electronic record that an examination has taken place, the pro-forma should be scanned and saved onto the child’s electronic record.

The Paediatrician will prepare a medical report based on the findings recorded in the pro-forma. This report is shared with the referrer i.e. Health, Children’s Services, Police, 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. This report may be used if the case goes to Court with the consent of the report writer.

In some circumstances a report may be withheld if the child’s interests may be jeopardised by circulating the report or where criminal proceedings may be jeopardised.

If a Court orders an assessment, the resulting assessment is the property of the Court and would only be circulated to those named in the Court’s instructions. However, these reports would also be kept in the child’s medical record. If someone else requests a report that may be included as part of a submission to Court, the standard arrangements for any medical report would apply.

6.  Appendices

  • Medical Examinations Appendix 1 – Injury to non-mobile babies and children
  • Medical Examinations Appendix 2 – Contact details
  • Medical Examinations Appendix 3 – SARC Referral Pathway
  • Medical Examinations Appendix 4 – MASH decision pathway
  • Medical Examinations Appendix 5 – References
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