Medical Assessment of Alleged or Suspected Child Abuse

1. Purpose of Assessment

Medical advice should always be sought as part of the investigative process of alleged or suspected child abuse.

The general purpose of a medical assessment is threefold:

• To assist with the inter-agency assessment as to whether abuse has occurred;
• To ensure that any evidence which is collected and presented is of a high quality thus ensuring that the child/young person has the optimum level of protection and support;
• To ensure that the wider healthcare needs of the child/young person are fully identified and arrangements made to meet these needs.

The welfare of the child/young person must remain paramount when a medical assessment is undertaken.

Medical assessments in cases of alleged or suspected child abuse will achieve their purpose if undertaken collaboratively, ensuring that children/young person are not subjected unnecessarily to repeated medical assessments for evidential purposes. The specific purposes of a medical assessment are to:-

• Ensure appropriate diagnosis, and treatment, if necessary;
• Provide advice, support and reassurance (where possible) to the child/young person and carers in a manner that will assist the process of recovery;
• Exclude the possibility that there are other injuries which were not immediately apparent;
• Assess for any other conditions, as clinically indicated, which may be suggestive of other types of abuse;
• Provide a medical opinion on the nature of the abuse, its likely cause and compatibility or otherwise with any history given;
• Obtain any forensic evidence available, if indicated.

2. Who Should Undertake the Assessment?

Children/young people who may have suffered abuse can be presented to doctors in a variety of ways e.g. by the police, social services, hospital/community Paediatrician, hospital outpatient department (including Accident & Emergency), GUM and Community clinics, e.g. family planning clinics, out-of-hours GP centres, primary care staff or AHPs. The nature of the abuse may vary from minor to life-threatening concerns or injuries. Consequently, the question of who should carry out the examination should be determined by the situation, the clinical circumstances and the age of the child/young person but may include a GP, senior Paediatrician and/or an FMO.

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 joint medical assessment (the FMO and senior Paediatrician). There may be exceptions to this arrangement but these should be decided by a strategy discussion.

In cases of alleged or suspected sexual abuse, if a medical assessment is required this should be undertaken by a senior Paediatrician and/or an FMO who between them, or individually, have the necessary core and case-dependent skills required as defined in "Guidance on Paediatric Forensic Examinations in relation to possible Child Sexual Abuse" (RCPCH and APS April 2002).

Any medical practitioner carrying out an assessment should be aware of the skills needed, the possible consequences of the examination and the need for accurate, detailed and contemporaneous notes.

The examining doctor(s) should attend any Child Protection Case Conference or strategy meetings about the child/young person, to which they are invited. If unable to attend, a written report should be sent to the Chairperson, ideally at least 2 days prior to the meeting.

If two medical professionals are involved in a joint assessment they should agree in advance of the assessment who will undertake which component of that examination.

Medical practitioners who have examined a child/young person for suspected abuse and disagree in their findings and/or conclusions should discuss their reports and resolve their differences where possible; in the absence of agreement they should identify the areas of dispute, recognising that their purpose is to act in the best interests of the child/young person.

3. Location and General Considerations

The venue for the examination should, ideally, be determined at a strategy discussion, where one has taken place.

The examination should be carried out in a child-friendly environment. Facilities or equipment e.g. colposcope, camera and video recorder which may be needed should be available or readily accessible. The child/young person should be accompanied by an appropriate supporting adult during the examination. A chaperone should be available for the examination.

If a child/young person has any form of communication difficulty, or if English is not their first language, special consideration should be given to the need for assisted communication or the use of an interpreter.

4. Consent

The doctor(s) must obtain consent for examination in accordance with the Fraser Principles. DoH guidance is available on the internet at www.health-ni.gov.uk/. Doctors can also seek information on consent from their Trust/employing organisation or professional body.

5. Medical Assessment of Alleged or Suspected Physical Abuse

History, Examination and Investigation

• Record person(s) present at the assessment and his (their) relationship to the child/young person. Record those with parental responsibility and from whom consent was obtained. Record date, time and venue;
• Record a full paediatric history, including explanations of the abuse from the child/young person (where possible), carer, and/or other relevant person(s) present. Document when abuse was reported to have occurred. Record both times and details;
• The examining doctor(s) should consider the appropriateness or otherwise of taking certain details of the history from an adult in the presence of the child. Alternative arrangements should be available to accommodate the child separately if required;
• The examining doctor(s) should consider whether taking a history directly from the child is in that child`s best interest. The child/young person should be offered privacy to give this history if required;
• On occasions, dispensing with consent for taking a history directly from the child/young person may be considered by the doctor to be in that child/young person`s best interest. In such cases the examining doctor(s) should clearly record the reasons for dispensing with consent;
• The general history should include (where possible) antenatal, neonatal, developmental, social, family and educational history (including current school or pre-school placement);
• Record parent's/carer's expressed concerns about the child/young person e.g. behaviour, health and development;
• Document the previous medical history with specific enquiry about previous admissions/injuries. Previous hospital/community medical records should be reviewed. Consideration should be given to accessing previous information from A&E Departments, if possible;
• Consider in detail the whole child/young person; the full examination should include measurement of growth parameters with the use of relevant, properly completed centile charts (recommended charts are available from the Child Growth Foundation), assess nutritional status, general appearance and level of hygiene, signs of neglect, overt signs of sexual abuse, emotional / behavioural disturbance, development including language and social skills. The interaction of the child/young person with parent, carer and examining doctor(s) should be commented on;
• Diagnosis of physical abuse involves the assessment of lesions visible to the unaided eye. Accurate documentation should be achieved by means of words, drawings with measurements and photographs supplemented, where appropriate, by x-rays;
• Examination and investigations may include some or all of the following:
  • A full physical examination (always required);
  • Taking of appropriate blood samples;
  • Photographs obtained with specific written consent;
  • X-rays with access to an appropriately trained radiologist for advice e.g. full skeletal survey under 2 years of age (with follow-up chest X ray 2 weeks later). Consider isotope bone scan in the older child/young person;
  • Ophthalmological assessment;
  • Dental assessment;
  • Orthopaedic assessment;
  • Other expert professional opinion, as required.
• There is also a need to consider if a CT brain scan should be included routinely with the skeletal survey in suspected non accidental injuries for all pre-mobile children/young people. It is recommended that a CT brain scan is considered for all small children in whom non accidental injury is suspected, if CT is judged to be not worthwhile or indicated in that individual case, it is advisable that this be documented in the notes;
• The outcome of the medical assessment should be clearly verbally communicated immediately by the examining doctor(s) to Social Services (where appropriate) and the Police (if involved). This should be followed up with a written report as soon as practicable (and where possible within 72 hours) being sent to Social Services and Police (on request);
• The child/young person's general practitioner, health visitor and any other relevant health professional should be notified of the examination;
• The examining doctor(s) should make arrangements for treatment and follow-up health care of the child/young person as necessary;
• The examining doctor(s) should attend any Child Protection Case Conference or strategy meeting about the child/young person to which they are invited. If unable to attend, a written report should be sent to the Chairperson, ideally at least 2 days prior to the meeting.

6. Medical Assessment of Alleged or Suspected Sexual Abuse

• The necessity for a medical examination, its timing, and who is/are the most appropriately trained and experienced doctor(s) to carry out the examination should be discussed immediately with social services and/or police i.e. at a strategy discussion;
• The paramount consideration must be the welfare of the child/young person, however, the need to gather forensic and/or other criminal evidence must be considered. This will occasionally necessitate an immediate Out-of-Hours response and it is essential local protocols/procedures are in place to enable this to occur;
• If two doctors are involved in a joint assessment they need to determine in advance of the examination who will undertake which component of that examination;
• The medical examination of suspected sexual abuse should never be undertaken in an Out-of-Hours GP centre;
• Children/young people should not be unnecessarily subjected to repeated medical examinations solely for evidential purposes although repeat examination may be required in some circumstances e.g. to obtain samples for investigation of sexually transmitted infections or follow-up as medically indicated;
• The outcome of the medical assessment should immediately be verbally communicated by the examining doctor(s) to social services (where appropriate) and the police (if involved) using clear, unambiguous language. This should be followed up with a written report as soon as practicable (and where possible within 72 hours) being sent to social services and police (on request);
• In any communication, well-recognised anatomical terms should be used to describe ano-genital structures;
• Notification of the medical assessment should be forwarded to the child/young person's GP, health visitor and any other medical consultants involved in the care of the child/young person;
• Screening for sexually transmitted infections should take place at an appropriate stage, if clinically indicated, with suitable arrangements for a chain of evidence. Post-exposure prophylaxis for Hepatitis B and HIV should be administered if clinically indicated;
• The significance of infection needs careful interpretation;
• Arrangements should be made for the supply of emergency contraception, if indicated, and with consent obtained in accordance with the Fraser Principles;
• The examining doctor(s) should make arrangements for any further medical follow-up and management of the child/young person where necessary;
• Appropriate arrangements should be made for the security and storage of medical notes, photographs and videos;
• The examining doctor(s) should attend any strategy meeting/Child Protection Case Conference about the child/young person to which he is invited. If unable to attend, a written report should be sent to the Chairperson ideally at least 2 days prior to the meeting.

6.1 Colposcopy and Photo-Documentation

• Photo-documentation of all visible findings in abuse is recommended as a standard of good practice. The colposcope provides optimal light and magnification to assist with detailed examination of the ano-genital area and enables photography and/or a video recording of the findings. Full written consent is required. Written consent should also be sought for the purposes of peer review, teaching or publication, if appropriate. Information must be given to the parent/carer and where appropriate the child/young person that photographs will be used to document the findings in the medical record and may be seen by other doctors who are asked to provide opinions. In legal proceedings, other medical experts may be involved who usually accept good quality photographs as evidence without the need to re-examine the child/young person. On rare occasions, and only after comprehensive consultation with all relevant parties, re-examination may be deemed appropriate;
• Where digital photographs are used consultation with the police in advance is strongly advised. A clear audit trail is required, including arrangements for logging all photographs taken and subsequent retention of images to maintain their integrity pending appeals, retrials and/or civil claims.

7. Medical Assessment of Alleged or Suspected Neglect, Failure to Thrive (Growth Faltering), Emotional Abuse or Fabricated or Induced Illness

The medical assessment of suspected cases of failure to thrive (growth faltering), neglect, emotional abuse and fabricated or induced Illness is complex and should always be referred to a senior Paediatrician for assessment and management. Whilst the comprehensive assessment will be inter-disciplinary and/or inter-agency, the medical component may include the following:

• A full history being taken from carers. This should include antenatal, perinatal, postnatal history and include previous medical history (including admissions), social, family and educational history. Enquiries about previous injuries, concerns or attendance at hospital or community clinics;
• Document person(s) with parental responsibility and any information about previous court orders or social services involvement;
• Review any hospital (including A&E) or community medical records and liaise with other professionals e.g. health visitor, school nurses and AHP's;
• Record history, examination and investigations;
• The findings of the medical assessment should be forwarded to social services, and police (if applicable) as soon as possible, recognising that often these complex diagnoses are made only after a period of inter-disciplinary, inter-agency assessment and review;
• The examining doctor should attend any strategy meeting/Case Conference about the child/young person to which they are invited. If unable to attend, a written report should be sent to the Chairperson ideally at least 2 days prior to the meeting.