This is an official Northern Trust policy and should not be edited in any way Admission, Care and Discharge (Acute Services) of Children/Young People (0-18 yrs) where there are safeguarding concerns Reference Number: NHSCT/11/380 Target audience: This policy is aimed at all professional staff within acute services specifically All qualified medical, nursing and midwifery staff All qualified allied health professionals All qualified children s social work staff in Antrim Hospital Sources of advice in relation to this document: Cecil Worthington, Director of Children s Services Valerie Jackson, Director of Acute Hospital Services Amber McCloughlin, Named Nurse Safeguarding Children Alison Livingstone, Desinated Doctor Safeguarding Children Replaces (if appropriate): N/A Type of Document: Trust Wide Approved by: Policy, Standards and Guidelines Committee Date Approved: 15 December 2010 Date Issued by Policy Unit: 3 March 2011 NHSCT Mission Statement To provide for all, the quality of service we expect for our families, and ourselves.
Admission, Care and Discharge (Acute Services) of Children/Young People (0-18 yrs) where there are Safeguarding Concerns
Contents Page Introduction 1 Purpose of the Policy 1 Target Audience 1 Roles and Responsibilities 2 Equality, Human Rights and DDA 2 Alternative Formats 3 Sources of Advice in relation to this Policy 3 Responding to Safeguarding Concerns 3 Admission / Documentation 4 Specific Responsibilities of Staff working in 6 Emergency Departments Referral to Social Services 7 Medical Assessment 8 Requests for Information 9 On-going care of the Child and Family whilst 9 an Inpatient Discharge from Hospital 9 Page Transfer to Another Hospital 11 Appendices 13-24
1.0 Introduction Admission, Care and Discharge (Acute Services) of Children/Young People (0 18 yrs) where there are Safeguarding Concerns 1.1 In 2003, Lord Laming produced a report concerning the death of Victoria Climbie which contained 108 multi-agency recommendations (The Victoria Climbie Inquiry Report, Laming, 2003). Trusts have undertaken selfassessment audits to ensure compliance and a number of local and regional processes have addressed these recommendations. Some of the recommendations relate to the admission and discharge, to/from acute services, of children/young people where there are safeguarding concerns. 1.2 This policy should not be read in isolation, but in conjunction with: Area Child Protection Committee Regional Child Protection Policy and Procedures (ACPC, 2005), and subsequent amendments (2008) Understanding the Needs of Children in Northern Ireland (UNOCINI) Guidance. (DHSSPSNI), 2008) Co-Operating to Safeguard Children (DHSSPSNI, 2003) 2.0 Purpose of the Policy 2.1 The purpose of the policy is to provide clear guidance for acute services staff within the Northern Health and Social Care Trust (NHSCT) regarding the admission, care and discharge of children/young people where there are safeguarding concerns. A child or young person relates to persons aged 0-18 years 1. For the remainder of the document, the term child will be used to include young persons as described above. 2.2 This is an overarching policy. In order for it to be fully implemented, each ward or department will need to agree local systems and processes given variations in clinical settings across the Directorates. 3.0 Target Audience 3.1 This policy is aimed at all professional staff within acute services 2 specifically All qualified medical, nursing and midwifery 3 staff All qualified allied health professionals All qualified children s social work staff in Antrim Hospital. 1 In maternity services, this applies to both the baby and parent where the latter is also a young person. 2 Acute services applies to any hospital department including adult wards, maternity wards, outpatient and emergency departments including those acute settings that are within the Children s Directorate. 3 The term nurse will be used in the remainder of the policy to denote nurse or midwife where relevant. 1
3.2 Reference is made to interface issues with community services, and in that context, the policy also applies to those staff. 3.3 This policy does not apply to the admission, care and discharge of children with a disability unless there are additional safeguarding concerns. 4.0 Roles and Responsibilities 4.1 Directors are responsible for the dissemination and implementation of this policy within the Directorates. 4.2 Line managers are responsible for ensuring that staff have a working knowledge of, and adhere to, the policy. They are also responsible for agreeing systems, processes and any operational guidance that may be required to ensure local implementation, given variations in clinical settings across the Directorates. 4.3 Staff are responsible for familiarising themselves with, and adhering to, this policy. 4.4 Staff are required to be familiar with Co-operating to Safeguard Children (DHSSPSNI, 2003) and ACPC Regional Child Protection Policy and Procedures (2005). Chapter 3 of the latter document details individual roles and responsibilities. Additionally chapter 8 refers to the medical assessment of children/young people. Chapter 9 provides specific guidance on admission and discharge to hospitals. 4.5 Staff are also required to adhere to Trust and professional guidance in relation to safeguarding children. 4.6 Safeguarding children is everybody s responsibility; the very nature of child protection may evoke profound personal feelings in staff that are involved in caring for children and their families. It is essential for the welfare of the child that staff seek to discuss any concerns that they have and to have an understanding of the best way to manage personal feelings. In the first instance it is usual to discuss concerns with the line manager. The Named and Designated safeguarding children professionals are also available for staff to consult with. 5.0 Equality, Human Rights and DDA 5.1 This policy has been drawn up and reviewed in light of Section 75 of the Northern Ireland Act (1998) which requires Trust to have due regard to the need to promote equality of opportunity. It has been screened to identify any adverse impact on the 9 equality categories and no significant differential impact were identified, therefore, an Equality Impact Assessment is not required. 2
6.0 Alternative Formats 6.1 This document can be made available on request on disc, larger font, Braille, audio cassette and in other minority languages to meet the needs of those who are not fluent in English. 7.0 Sources of advice in relation to this policy 7.1The policy authors and responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. Policy Statement 8.0 Responding to Safeguarding Concerns: 8.1 If a child discloses, or there is a suspicion regarding abuse, it is imperative to listen carefully to what he/she says. Staff should avoid using leading questions and a verbatim record of what the child says should be made. The child should be reassured that attempts will be made to help to stop the abuse with support from other people, but promises should not be offered. Promises of confidentiality should not be made. 8.2 If any member of staff raises a safeguarding concern, this must be discussed with the relevant line manager / nurse in charge and the consultant in charge to agree appropriate actions. Following this it may be appropriate to discuss these concerns sensitively with the parents unless to do so would put the child at further risk. 8.3 If staff are unsure about, or cannot agree on, whether to refer a child to social services the relevant line manager, child protection nurse specialist, where available, and/or Named/Designated Doctor for Safeguarding Children must be consulted. 8.4 Where there are dissenting views a discussion must take place between all those professionals involved. The outcome of the discussion and actions required should be documented in the child s record / each professional record. 8.5 A consultant paediatrician must be informed about all children (who would normally fall into the age range managed by paediatricians) who are brought to hospital where there is a child protection concern. 8.6 A consultant paediatrician should not normally be informed for children who do not fall into the age range managed by paediatricians within the hospital. The Named / Designated Paediatricians are, however, available for advice to medical staff. 8.7 If a medical examination/assessment for child abuse is required then Northern Trust guidance should be followed: 3
How to Request a Paediatric Medical Assessment for Investigation of Possible Child Abuse: Guidance for Social Workers/PSNI/General Practitioners Appendix 1 When to Request a Paediatric Medical Assessment for Investigation of Possible Child Abuse Appendix 2 8.8 Although this guidance is written for social workers / Police Service of Northern Ireland (PSNI) and general practitioners, it equally applies to medical and nursing staff in the hospital setting. 9.0 Admission/Documentation 9.1 A child protection checklist should be initiated and completed for all children subject to a child protection investigation (whether admitted to the ward or seen on the Paediatric unit as a ward attender). See Appendix 3a and 3b. 9.2 A copy of the completed checklist must be sent to the Designated Doctor for Safeguarding Children, for audit purposes 9.3 Nursing staff are required only to complete admission documentation for those children who are formally admitted to the ward i.e. occupy a bed following an assessment by the consultant. 9.4 The Child Protection Register should be checked by ward staff if not already done so by emergency department staff. (The nurse in charge of the emergency department must be informed of occasions where children s names have not been checked, who are admitted via the department.) Where staff do not have direct access to the Child Protection Register, checks may be made by contacting the relevant social work team, including Out Of Hours arrangements (see appendix 6). 9.5 Checking the Child Protection Register is part of a process informing assessment and decision making. A Soscare check should also be made to ascertain if the child is currently, or was, historically known to social services. It is important to note that these two processes do not definitively guide any further action. Any concerns will require appropriate action including a referral to social services. Likewise, any difficulty accessing the Child Protection Register or Soscare should not deter appropriate action. 9.6 Nurses must ensure that the following basic information is recorded: The child s name The child s date of birth and gender The child s address The name of the child s primary carer / parents or those holding parental responsibility The name of the child s general practitioner The name of the child s school if relevant The name of the child s social worker (if applicable) and contact details The name of the child s health visitor (if applicable) and contact details. 4
9.7 Any gaps in this information must be reported to the nurse in charge and the child s consultant and appropriate action initiated. This will include further exploration with the parents / carers and may necessitate a referral to social services for further assessment. 9.8 When a child about whom there are concerns of possible harm/neglect is being admitted to hospital the doctor and nurse admitting the child should enquire whether there has been any previous admissions to hospital. It is the responsibility of medical staff to obtain all relevant information regarding these admissions. 9.9 In cases where deliberate harm is suspected the nursing plan of care must include those concerns. The nurse in charge must ensure that all nursing staff on duty are aware of those children who are the subjects of concern and the nursing plan of care should take full account of this diagnosis/ assessment. 9.10 A comprehensive and contemporaneous written record must be kept on the child s case notes (multi disciplinary and / or individual, professional records) of: All information gathered about the child and family All discussions held, including nursing/medical/social work/allied health professional handover, face-to-face discussions and telephone conversations relating to the care of a child about whom there are concerns of deliberate harm The decisions made and action taken on the basis of available information The identity of the person(s) responsible for agreed actions, completed tick boxes indicating that agreed actions have been completed and who actually completes them. The name of the consultant responsible for the child protection concerns. This must be clearly identified on the child protection checklist in the child s notes. Relevant observations of the child/family/visitors. These must be factual, concise and detailed. 9.11 Consideration should be given to having a single set of records kept within a given location from which all health professionals work. 9.12 Each child s record must contain an up-to-date chronology of action(s) taken or decision(s) made. 9.13 Staff working in circumstances where case notes are not immediately available, should record all discussions/examination/ observations relating to concerns about deliberate harm contemporaneously and transfer these records to the case notes at the earliest opportunity. 5
9.14 Where child protection concerns exist consideration must be given to the most appropriate area that the child should be cared for within the hospital ward / department. The preferred option would be in an open bay if medically possible. A specific written plan/decision regarding the details of contact between the child and parents/carers whilst an in-patient must be made jointly by social services/nursing/medical staff/allied health professionals and any other relevant persons for example the Police Service of Northern Ireland (PSNI). This will be recorded in the child s record by the social worker. 10.0 Specific Responsibilities of Staff Working in Emergency Departments 10.1The admitting nurse must ensure that full demographic details of the child are recorded on the emergency department record. The child s name The child s date of birth and gender The child s address The name of the child s primary carer / parents and those holding parental responsibility The name of the child s general practitioner The name of the child s school if relevant 10.2 Any gaps in this information must be reported to the nurse in charge and the child s consultant and appropriate action initiated. This will include further exploration with the parents / carers and may necessitate a referral to social services for further assessment. 10.3 When any child presents with injuries a detailed history must be taken, a full examination carried out and the information recorded accurately. 10.4 When a child presents to the emergency department where there are concerns of possible deliberate harm/neglect, it is the responsibility of the examining doctor to discuss these with a consultant paediatrician (either directly or via the middle grade doctor on call) as per the guidance in Appendix 1 and 2. 10.5 If there are safeguarding concerns regarding a child attending any Northern Trust emergency department a Child Protection Register check should be undertaken. It is the responsibility of the nurse, in the emergency department, assessing the child to make sure that the register has been checked and the child s registration status recorded on the child s case notes before the child leaves the department. Checking the Child Protection Register is part of a process informing assessment and decision making. A Soscare check should also be made to ascertain if the child is currently, or was, historically known to social services. It is important to note that these two processes do not definitively guide any further action. Any concerns will require appropriate action including a referral to social services. Likewise, any difficulty accessing the Child Protection Register or Soscare should not deter appropriate action. 6
10.6 When an adult presents to the emergency department, consideration must be given to any child in the household or community whose welfare may be at risk. If there are concerns identified that may impact on parenting/caring responsibilities or the adult may pose a risk to children, (consider risk factors included in Appendix 4), a discussion between the attending doctor and nurse must take place and a referral made to social services, when necessary. This discussion will be initiated by the professional who identifies the concern. The adult must be made aware of professionals concerns and included in discussions about a referral, unless this would place additional risk of harm to a child. 10.7 All conversations about a child must be recorded on the emergency department records. 10.8 Children, who are frequent attendees, should be discussed with the consultant in emergency medicine and subsequent action agreed and recorded. 11.0 Referral to Social Services 11.1 Staff should work together and discuss cases before referring to the Gateway Team or the Children s Social Work Team in Antrim Hospital using a UNOCINI referral document. All verbal referrals must be followed up in writing within 24 hours, also using the UNOCINI referral document. 11.2 In the majority of cases, when making a referral to social services the parent /carer should be informed. In certain situations, usually where a child would be at increased risk of harm, a decision could be taken not to inform the parent /carer about the referral. This must always be discussed with the nurse in charge/consultant/line manager and the reason must be clearly documented in the child s records. 11.3 Medical staff should aim to ensure that when a professional diagnosis/opinion is provided to social services/other agencies that it is explicit and not likely to be misinterpreted. 11.4 Medical/nursing staff must directly contact social services/other agencies if they become aware that a professional diagnosis/opinion provided by them has been misinterpreted so that concerns or misunderstandings can be promptly rectified. They should clarify this in writing and forward to the relevant agency/discipline at the earliest opportunity. 7
12.0 Medical Assessment 12.1 There needs to be a systematic and rigorous approach to the investigation and management of a case of possible deliberate harm/neglect by health professionals on a par with other potentially fatal diseases. 12.2 A fully documented physical examination must take place within 24 hours of a child s admission. The only exception to this is if the examining doctor feels that the child s emotional, or physical well-being would be compromised. 12.3 Consideration must be given to the child s developmental needs, parental capacity and environmental factors. 12.4 There must be direct communication with parents/carers and their views must be recorded on the child s notes. 12.5 There must be direct communication with the child taking into account his/her age, understanding and development and the child s views must be recorded in the case file (if appropriate). Medical staff should not be discouraged from speaking to children directly or seeing children alone, without a parent or carer present, solely on the grounds that this might compromise future joint investigations. The examining doctor should consider if it is in the best interests of the child to take a history directly from the child. 12.6 When a decision to take a history from a child directly has been made by the examining doctor the history should be taken even when the consent of the carer has not been obtained. The reason for dispensing with consent must be fully documented and placed on the child s case notes by the examining doctor and countersigned by a senior doctor. 12.7 For those children whose first language is not English, consideration must be given to using a professional interpreter (who is not related to the child). 12.8 During the course of a ward round when concerns about deliberate harm are raised, the doctor conducting the ward round should review and take into account all available information before taking any decisions on the future management of the child s case. They should consider whether to seek information from parents / carers, primary care staff, social services and education staff. 12.9 When a child has been examined by a doctor and concerns about deliberate harm/neglect have been raised, no subsequent appraisal of these concerns should be considered complete until each of the concerns has been addressed, accounted for and documented i.e. explanations and assessment of each injury observed. In such cases if the examining doctor s opinion is that there is an alternative explanation for the presentation they must seek the opinion of a second consultant (a paediatrician) regarding the case and that consultant must record their opinion in the child s notes. 8
12.10 When differences in medical opinion occur in relation to the diagnosis of possible deliberate harm to a child a recorded discussion must take place between the persons holding the different views. When the deliberate harm of a child has been raised as an alternative diagnosis to a purely medical one, the diagnosis of deliberate harm must not be rejected without full discussion and if necessary obtaining another opinion from either a Named or Designated Doctor for safeguarding children. 12.11 Where consent is required from the child s parent /carer for investigating possible deliberate harm, or for treatment of injuries, this must be sought by a consultant or middle grade doctor. 13.0 Requests for Information: 13.1 All staff invited to a child protection case conference must prepare a written report where possible. The child protection nurse specialist, where available, will support nursing staff in the preparation their report and attending the case conference. 13.2 Medical staff must discuss any medical reports with a second consultant or, preferably, the Named or Designated Doctor for Safeguarding Children. 13.3 All other staff should discuss their reports with the relevant line manager. 13.4 Staff should follow existing Trust Guidance (General Procedures for Processing of Personal Information (POPI), NHSCT, 2009) regarding any other information request. 14.0 On-going care of the Child and Family Whilst an Inpatient: 14.1 Every effort should be made to work in partnership with parents/carers and to provide care to the child and support parents/carers without prejudice. 14.2 The consultant in charge of the child s care should review all information known about the child, from whichever source, when making decisions about the child s future care and management. 14.3 Any differences of opinion regarding the plan of care for a child or the support available to the parents must be directed to the line/ward manager, the child s consultant and documented. 15.0 Discharge from Hospital: 15.1 Consultation must take place between medical, nursing and relevant, professional staff regarding discharge. 15.2 The purpose of discharge planning is to: Allow the child to leave hospital safely as soon as medical condition permits 9
Ensure all necessary safeguarding arrangements are in place Ensure all appropriate persons are informed of discharge arrangements Ensure appropriate liaison between disciplines, both within and outside the hospital Ensure implementation of the discharge plan prior to discharge 15.3 Permission to discharge a child, where there are child protection concerns, can only be given by the relevant consultant or a consultant paediatrician (preferably the consultant responsible for the child protection case). 15.4 A safe discharge plan should be informed by a coordinated multi disciplinary assessment by the key professional staff and should involve communication with the parents and child (if age appropriate). Children and their families should be kept fully informed about the discharge procedure and any meetings being arranged to plan this. Consideration should always be given to involving parents in discharge planning / associated meetings unless there is a specific documented reason that it is inappropriate to do so. 15.5 It is social work responsibility to ensure that either, a strategy discussion, professional meeting or Child Protection Case Conference takes place before discharge. The nurse in charge and the child s consultant as well as any other relevant professional, should attend any meeting. 15.6 In Antrim Area Hospital, the dedicated Children s Social Work Team will co-ordinate the relevant meeting. Any requests for a multi disciplinary meeting prior to discharge should be requested via this team. In Causeway Hospital, the Northern Gateway Team will arrange any relevant meetings. 15.7 The Children s Social Work Team, Antrim Hospital/Gateway Team will identify the key personnel involved, both in hospital and in the community. Invitations will be issued, usually by telephone given the short notice involved. A venue will be arranged, usually hospital based to suit hospital based staff and parents if attending. 15.8 Each professional invited will ensure they come to the meeting prepared with all relevant information. The parents will either be invited to the meeting or receive feed back at the end depending on the nature of the meeting and the circumstances of the case. Parents will always be advised of any meeting taking place in relation to their child. 15.9 In situations where there is uncertainty about the medical opinion regarding an injury, the consultant should inform the Named or Designated Doctor for Safeguarding Children who should also be involved in the relevant meeting. The discussion and outcome must be recorded in the child s record at the earliest opportunity and before going off duty that day. 10
15.10 The minutes of any meeting will include the decisions and plan for discharge and any follow up arrangements. The senior social worker in Children s Social Work Team, Antrim Hospital/Gateway Team will ensure minutes are taken and circulated to all attendees with a copy to parents. 15.11 A parent cannot be prevented from leaving the ward with their child. However, where a parent wishes to discharge the child from hospital against medical advice and there are concerns for the child s welfare, social services must be contacted immediately. If the child is in urgent need of protection, the Police Service of Northern Ireland (PSNI) should be contacted directly by the relevant staff member. 15.12 No child about whom there are concerns of deliberate harm should be discharged from hospital without an identified general practitioner. The nurse must inform the relevant consultant and arrangements should be put in place to ensure registration with a general practitioner. 15.13 Where there are child protection concerns, there must be a documented plan of care on discharge detailing arrangements which should be in place to safeguard the child s welfare on return to the community and including any follow up arrangements. Prior to discharge, the Children s Social Work Team, Antrim Area Hospital/Gateway Team, will liaise with the relevant social work team in the community to ensure all plans agreed at any discharge meeting have been activated and are in place. An agreed action plan including the timing of discharge will promote effective continuity of care on return to the community. 15.14 It is the responsibility of the nurse in charge at the time of discharge to ensure that follow up arrangements for the child s health needs have been clearly documented. It is the responsibility of the child s consultant to ensure that discharge summaries including any concerns about the child s welfare, as well as medical issues, are documented. The consultant should forward a copy of any discharge letter and follow up arrangements to the relevant social worker. 15.15 Follow up arrangements must include documentation about what to do if a child fails to attend outpatient s appointments or any other health appointments. 15.16 A discharge check list must be completed the nursing staff (paediatric wards only) and filed in the child s record (see Appendix 5). 16.0 Transfer to Another Hospital 16.1 Where there are safeguarding concerns and a child is being transferred to another hospital, medical staff must agree which consultant will have ongoing responsibility for the child protection aspects of the case. This will include which consultant will initiate a social services referral where this has not yet been undertaken. This must be clearly documented. The consultant in the transferring hospital should ensure that the concerns are passed verbally 11
and in writing to their counterpart taking responsibility for the child s care where relevant. 16.2 Where the Children s Social Work Team, Antrim Hospital or the Gateway Team have been informed/involved, they should liaise with their colleagues in the hospital where the child is being transferred to. They should ensure that all the child protection concerns are highlighted and any safeguarding arrangements are continued in the new hospital e.g. supervised parental contact. Any minutes of meetings should be forwarded and included in the child s case record. 16.3 The nurse in charge and all other professionals will liaise with his/her counterparts in the receiving hospital. 12
Appendices Appendix 1- How to Request a Paediatric Medical Assessment for Investigation of Possible Child Abuse: Guidance for Social Workers /PSNI/General Practitioners Appendix 2 - When to Request a Paediatric Medical Assessment for Investigation of Possible Child Abuse: Guidance for Social Workers/ PSNI/General Practitioners Appendix 3 a) Child Protection Checklist admitted b) Child Protection Checklist-ward attenders Appendix 4 - Risk factors Appendix 5 - Safeguarding Children Discharge Checklist Appendix 6 - Key Contacts 13
Appendix 1 How to Request a Paediatric Medical Assessment for Investigation of Possible Child Abuse: Guidance for Social workers/police SERVICE OF NORTHERN IRELAND (PSNI)/General Practitioners This guidance must be read in conjunction with ACPC Regional Policy and Procedures 2005 Purpose of the Guidance: This guidance provides information to agencies (POLICE SERVICE OF NORTHERN IRELAND (PSNI)/SW/GENERAL PRACTITIONER) on how to request a Paediatric Medical Assessment following a decision made to seek such an assessment in cases of possible child abuse. The guidance in general refers to children/young people below the age of 15 years. In some cases e.g. young people with particular vulnerability 1 factors it may be appropriate to extend the age limit for paediatric medical assessment to 18 years. (Those who do not have vulnerability factors aged 15 years and above should usually be assessed by an FME but this decision should be made following a strategy discussion involving FME/SW and POLICE SERVICE OF NORTHERN IRELAND (PSNI)). The geographical catchment area includes Larne, Carrickfergus, Newtownabbey, Antrim, Ballymena,Magherafelt Cookstown,Coleraine, Ballymoney and Moyle i.e. Northern Trust area. 1Vulnerability factors e.g. learning difficulty, deliberate self-harm, prostitution, looked after child, runaway 1) Physical Injury Antrim Hospital During normal working hours (9am-5pm) Antrim Hospital Paediatric Department operates a Ward Chief system (i.e. Consultant paediatrician of the week on call) SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER staff should contact Ward A2 (Tel: 944242363 or 944244266) to establish who the relevant consultant is. Contact can then be made to request/discuss assessment by phoning either that Consultant s secretary or contacting the Consultant paediatrician via switchboard. Outside normal working hours there will always be a Consultant available on call. SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER staff should initially phone Antrim Hospital switchboard (Tel: 94424000) and ask them to bleep the 14
Paediatric Middle Grade Doctor on call to discuss the case. That doctor will then discuss the assessment with the Consultant on call and make arrangements for the child to be seen (informing the referrer). NB: In the event of a child sustaining an injury requiring treatment they should be taken to the A&E Department for initial assessment AND SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER staff should also contact a Paediatrician as detailed above. Causeway Hospital During normal working hours (9am-5pm) SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER staff should contact the Hospital switchboard (Tel: 70327032) and speak to the Consultant on-call or another available consultant. The on-call consultant may not be immediately available but there will always be a Consultant paediatrician in the hospital. Outside normal working hours there will always be a Consultant paediatrician available on call. SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER staff should phone Causeway Hospital switchboard and ask them to bleep the consultant on-call. NB: In the event of a child sustaining an injury requiring treatment they should be taken to A&E Department for initial assessment AND SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER staff should also contact a Paediatrician as detailed above. 2) Sexual Abuse During normal working hours in the Northern Trust area (outside Causeway) SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER can contact Dr Alison Livingstone or Dr Kim Troughton by phoning their secretaries in Antrim Hospital (Tel: 94424000) or at Child Development Clinic, Antrim (Tel: 94415729 or 94415725) or asking switchboard, Antrim Hospital, to bleep them. Either Consultant will endeavour to facilitate a joint examination with FME if requested. If it is not possible then they will be advised that an FME will need to be requested to conduct the examination singly. In Causeway contact the hospital as above and speak to the consultant on-call that day or another available consultant. Outside normal working hours if it is decided that examination is urgently required there may not be a Consultant paediatrician available 15
with the necessary knowledge, skills and experience. SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER staff are advised to contact the Consultant paediatrician on call via either Hospital switchboard to discuss the possibility of a joint examination. If it is not possible then they will be advised that an FME will need to be requested to conduct the examination singly. NB: If a joint examination is to be carried out by two professionals they will need to determine in advance of the assessment what skills they bring to the examination and who will undertake which component. This may require direct discussion at this stage between the Consultant paediatrician and FME. NB: Cases of alleged or suspected sexual abuse should never be taken directly to A&E for assessment unless they are acutely unwell and in need of urgent medical attention. In the event of a child sustaining an injury requiring treatment they should be taken to A&E Department for initial assessment AND SW/POLICE SERVICE OF NORTHERN IRELAND (PSNI)/GENERAL PRACTITIONER staff should also contact a Paediatrician as detailed above. 3) Neglect/Emotional Abuse/Fabricated or Induced Illness (FII) Cases of suspected chronic neglect/emotional abuse/fii can usually be seen in a planned manner by contacting Consultant Community Paediatricians (Dr Livingstone or Dr Troughton) in Antrim or the on-call paediatrician in Causeway. NB: In cases of severe neglect requiring urgent assessment the guidance for physical injury detailed above should be followed. 16
Appendix 2 When to Request a Medical Assessment for Investigation of Possible Child Abuse: Guidance for Social workers/police SERVICE OF NORTHERN IRELAND (PSNI)/General Practitioners This guidance must be read in conjunction with ACPC Regional Policy and Procedures 2005 (especially relevant Chapter 3 & 8) Purpose of the Guidance: This guidance provides information to those professionals who are presented with, or asked to assess children, where signs or symptoms may be suggestive of possible abuse. Attached is an appendix entitled How to Request a Paediatric Medical Assessment for Investigation of Possible Child Abuse: Guidance for Social workers/police SERVICE OF NORTHERN IRELAND (PSNI)/General practitioner s * which will be referred to throughout the guidance. NB: In cases where joint protocol procedures have been initiated (i.e. police and social services investigation) and medical assessment is required the aim should be to carry out a paediatric forensic medical assessment (i.e. usually FME and senior paediatrician jointly). There may be exceptions to this decided via Strategy discussion. In such cases Strategy discussion must therefore take place involving FME/senior paediatrician/sw and POLICE SERVICE OF NORTHERN IRELAND (PSNI) to decide the following*:- a) Who is required to carry out the examination i.e. senior paediatrician or FME or both jointly? b) Where the examination should be carried out? c) When the examination should be carried out? Physical Injury If the referring agency/professional suspects the injury is strongly suggestive of deliberate physical injury e.g. cigarette burn/ slap mark or there is an allegation of abuse then they should request a Paediatric Medical assessment *rather than GENERAL PRACTITIONER assessment. 17
GENERAL PRACTITIONER s may be requested to carry out an assessment of minor physical injury by another agency/professional e.g. bruising in a child (other than that discussed above). If GENERAL PRACTITIONER assesses a minor physical injury possible conclusions may be as follows:- a) Injury compatible with history given (no concerns) liaise with referrer b) Injury not compatible with history - possible deliberate physical injury or underlying medical disorder c) No history given possible deliberate physical injury/underlying medical disorder d) Injury compatible with history (history given by carer of deliberate physical injury or suggestive of neglect issues) Action:- GENERAL PRACTITIONER should discuss with a senior paediatrician for b, c and d (see Guidance for how to request a Paediatric Medical Assessment for Investigation of Possible Child Abuse*). For cases b, c and d above the GENERAL PRACTITIONER should discuss with a senior paediatrician if referral should be made to Social Services at this stage and a decision made as to who will refer (i.e. GENERAL PRACTITIONER or Paediatrician). NB: Send to A+E only if clinical condition indicates but also inform senior paediatrician as per guidance* At the stage where any medical assessment confirms the likelihood that abuse has occurred the doctor carrying out this assessment (who may be either GENERAL PRACTITIONER or senior paediatrician) must refer the case without delay to Social Services. Sexual Abuse In cases of a disclosure of sexual abuse, when abuse has been witnessed or when a referring agency strongly suggests sexual abuse the child will require a paediatric forensic examination (in order to collect any available forensic evidence if relevant, to assess for anogenital signs of abuse and to provide a holistic paediatric assessment and arrange for on-going follow up whilst reducing the need for further examinations). This may require examination by a senior paediatrician(s) or FME or both jointly depending on the specific core and case dependent skills of the professionals available and the child s circumstances and this must be decided via Strategy discussion involving FME/senior paediatrician/sw and POLICE SERVICE OF NORTHERN IRELAND (PSNI) (see above*). 18
NB: Allegation/strong suspicion of acute sexual assault i.e. within last 72 hours it is vital that urgent contact is made with POLICE SERVICE OF NORTHERN IRELAND (PSNI)/SW to facilitate contact with FME in order to consider collection of any potential forensic (perpetrator DNA) evidence as soon as possible. Children may present to the GENERAL PRACTITIONER with signs and symptoms which may be specifically suggestive of sexual abuse or there may be an allegation or disclosure of such abuse. Action:- The GENERAL PRACTITIONER must immediately contact Social Services to initiate a Strategy discussion regarding further assessment/investigation. Any examination which is undertaken by a GENERAL PRACTITIONER should only be for the purpose of establishing the need for immediate investigation and treatment NB: Send to A+E only if clinical condition indicates but also inform senior paediatrician as per guidance* Specific Medical Conditions to consider:- 1. Unexplained bleeding PV sexual abuse must always be considered as part of the differential diagnosis and if abuse has occurred then forensic evidence may be available for a limited time only. Discuss case without delay with senior paediatrician. 2. Vulvovaginitis/vaginal discharge sexual abuse is within the list of differential diagnoses. If any associated features are present suggestive of abuse discuss the case without delay with a senior paediatrician*. Otherwise refer for out-patient assessment in accordance with usual practice. 3. Ano-genital warts sexual abuse must always be considered. Discuss case without delay with a senior paediatrician*. Neglect/Emotional Abuse/Fabricated or Induced Illness (FII) At any stage if a GENERAL PRACTITIONER/Paediatrician confirms it is likely such abuse has occurred they must refer the case to Social Services. If requesting a Paediatric Medical Assessment refer to Guidance * 19
Appendix 3a Child Protection Checklist (To be completed for all children undergoing a Child Protection Investigation/Assessment admitted to the Paediatric Unit) Name DOB Address Hosp no: Action Date Signed Designation Comments Name of Consultant Responsible (for CP episode) Child Protection Nurse Specialist informed (nursing staff) Nursing Care Plan Initiated (nursing staff) SW informed (nursing staff) SOSCARE check (social work team) CPR check (social work/medical/nursing team) Written referral to SW (medical staff) Enquire re previous admissions/a&e Attendances (medical staff) Request/review previous medical notes (as appropriate) (medical staff) Request /review siblings medical notes (as appropriate) (medical staff) Document consent in notes for blood tests, relevant x-rays (medical staff) Consider need for siblings to be medically examined (medical staff) Inform HV by phone (nursing staff) Inform HV in writing (nursing staff) Inform GENERAL PRACTITIONER (medical staff) Consider request for second Consultant opinion (medical staff) Discharge letter sent (medical staff)-detail to whom NB: Copy this form to Designated Doctor for Child Protection (consultant at sign-off) Revised Sept 2010 20
Appendix 3b Child Protection Checklist (To be completed by Consultant paediatrician for all children undergoing a Child Protection Investigation/Assessment attending but not admitted to the Paediatric Unit) Name DOB Address Hosp no: Action Date Signed Designation Comments Name of Consultant Responsible (for CP episode) SW informed (as appropriate) SOSCARE check (as appropriate) CPR check (as appropriate) Written referral to SW (as appropriate) Enquire re previous admissions/a&e Attendances Request/review previous medical notes (as appropriate) Request /review siblings medical notes (as appropriate) Document consent in notes for blood tests, relevant x-rays Consider need for siblings to be medically examined Inform GENERAL PRACTITIONER/HV in writing Consider request for second Consultant opinion Medical Report sent (detail to whom) NB: Copy this form to Designated Doctor for Child Protection (consultant at sign-off) Revised Sept 2010 21
Appendix 4 Risk Factors Suspicions that should trigger or lead to a consideration of a referral to Social Services for further investigation: A disclosure or allegation of abuse or neglect by a child Unexplained injury Injuries inconsistent with the explanation, or explanation which is unconvincing Explanations for injuries that vary between parent/carers or change with time Unexplained delay in presentation of a serious injury Any injury not compatible with the child s developmental stage Fractures in a child who is not independently mobile Mouth injuries torn frenulum Genital injuries bruising, bleeding or discharge Burns or scalds with demarcation lines, cigarette burns Bruises on buttocks, pelvic area, face, ears, head, cheeks, neck, around mouth, black eyes, finger tip bruises, especially if bilateral, multiple or excessive bruises which are not obviously due to a single impact caused by a plausible accident Bruises with a straight edge such as a belt, stick or ligature, or slap marks Any unaccountable bruising/injury in a pre-mobile child Multiple injuries following a reported moderate fall Severe head injuries in babies or toddlers Other injuries discovered on examination which are undisclosed Neglect failure to thrive, thought to be due to neglect Child s behaviour which is over friendly to strangers, sexualised, unduly apprehensive Child exhibiting gaze aversion apathy, frozen watchfulness, wariness of either male or female staff Frequent attendance at accident and emergency department Children/ young people presenting with self harm, expressing suicidal intent Refusal of parent or carer to allow proper treatment or admission to hospital Children of school age not attending school Abnormal parental behaviour, such as intoxication or aggression Parents or carers with mental health problems, drug and/or alcohol problems or misuse or learning disabilities Very young or socially isolated parents Domestic violence Children with special needs, and children born very pre-term This is not a comprehensive list and there may be other signs or no obvious signs. Further Guidance regarding signs, symptoms and risk factors may be found in appendix 2 of Area Child Protection Committee Regional Policy and Procedures (ACPC, 2005) 22
Appendix 5 Safeguarding Children Discharge Checklist Discharge Checklist Details Signature Date Address and details of parent/carer where the child is being discharged to Date of next out patient appointment and any other follow up arrangements Name of CPNS informed and date Name of Health Visitor notified and date Name of Social worker notified and date Name of Community Children s Nurse notified (if applicable) and date Parent held record completed Name of GENERAL PRACTITIONER notified and date Discharge Summary (completed by medical staff) This discharge checklist must be completed by nursing staff prior to discharge and filed in the child s record on completion. 23
Appendix 6 Key Contacts Child Protection Nurse Specialist Bridget Burnside (For Antrim Hospital) Tel: 028 2531 3169 Bleep for urgent advice only: 028 9442 6511 Designated Doctor for Safeguarding Children (Trustwide) Dr Alison Livingstone Antrim Hospital Tel: 028 9442 4000/ 028 9441 5725 Trust Named Doctors for Safeguarding Children:- Dr Deirdre Walsh (Causeway area) Consultant paediatrician Causeway Hospital Dr Kim Troughton (outside Causeway) Consultant paediatrician Antrim Hospital Tel: 028 9442 4000/ 028 9441 5725 Children s Social Work Team Antrim Hospital Tel: 028 9442 4000 Northern Trust Gateway Teams: Central Gateway: 028 7965 1020 Northern Gateway: 028 7032 5462 South Eastern Gateway: 028 9334 0165 Out of Hour s Social Services Arrangements: All day weekends, public holidays and between the hours of 5pm and 9am Tel: 028 9446 8833 24