Appendix 6 - Guide to Medical Assessments |
Contents
1.0 Purpose of Medical Assessment
The purpose of a medical assessment is to ascertain whether there is any medical evidence to support the existence or extent of abuse or other serious health needs and, if necessary, to treat the child. The need for the assessment, in the context of the enquiries, should be discussed so that the doctor is properly aware of its strategic significance when the request is made. The person taking the child for the assessment should also be fully aware of the child's circumstances and the purposes of the assessment.
2.0 Circumstances in which a Medical Assessment Usually will be Necessary
A medical assessment will be necessary when any of the following apply:
- There is a reasonable suspicion of Significant Harm to a younger or otherwise vulnerable child (usually below the age of ten or having a disability which impairs the ability to communicate about any abuse being suffered)
- There is a serious injury and assault is established or considered likely
- There are inconsistencies in the explanations given which require expert examination
- There have been previous injuries
- There are indications of detectable previous injuries, or neglect, or other suspicious physical presentations
- There is an allegation of Sexual Abuse
3.0 Circumstances in which a Medical Assessment will Usually Not be Necessary
A medical assessment will not usually be necessary if all of the following apply:
- The injury is of a clear and minor nature and doesn't need medical attention;
- The child is of an age (usually from about ten upwards) and understanding to give a confident account of any history of abuse;
- The child does not have a disability which would make it difficult to communicate that he/she was suffering abuse;
- The explanation given by the child and parent/carer is consistent both with each other and with the injury;
- There are no other indications of detectable previous injury or current neglect.
4.0 Consent
Provision of any medical treatment to a child may be a trespass to the person and constitute in law an assault, if consent to such treatment is not obtained.
A child who has attained the age of 16 years is capable of giving effective consent to his/her own treatment, whether it be surgical, medical or dental. This includes any procedure undertaken for the purposes of diagnosis.
It is clear that, even before a child attains the age of 16, he/she will have the right to consent or refuse to consent to treatment if he/she has sufficient understanding to be capable of making up his/her own mind on the matter requiring decision.
Children who are judged to be able to give consent cannot be medically examined or treated without their consent. This will normally be so, even if a Court Order has been obtained. The child's attention should be drawn to his/her right to give or refuse consent to examination or treatment if he/she is 16 or over, or if he/she is under 16 and the doctor considers him/her of sufficient understanding to understand the consequences of consent or refusal.
Subject to the above, the following applies:
- Any person with Parental Responsibility for a child may give consent to medical treatment for the child. Where more than one person has Parental Responsibility for a child each of them may act alone and without the other in meeting their responsibility
- A person with Parental Responsibility is not entitled to act in any way that would be incompatible with any Court Order
- The granting of an Emergency Protection Order vests Parental Responsibility for the child named in the order in the applicant. An Emergency Protection Order may contain a direction as to any medical or psychiatric treatment, or other assessment of the child
- The taking of the child into Police Protection does not vest Parental Responsibility in any individual
- The person caring for a child, but who does not have Parental Responsibility, would be entitled to consent to the child's medical treatment in the event of an accident or treatment which is not likely to be controversial, though not to major elective surgery;
Wherever practicable, the views of all persons with Parental Responsibility for a child should be sought, before any decision is made with regard to that child.
In the event of difficulty in interpreting any of the above legal advice should be sought.
5.0 Planning and Arranging the Medical Assessment
Where child abuse is alleged or suspected, a medical assessment should be considered as part of the Strategy Discussion. An expert opinion coupled with an accurate record of any explanation given as to how the injury or condition occurred, together with measurements, diagrams and photographs can be crucial in future care or criminal proceedings.
The police officer or social worker will be responsible for arranging the medical with the appropriate doctor, as agreed at the Strategy Discussion, although for emergency medical attention the child should be taken immediately to the hospital Accident and Emergency Department.
6.0 Who should Conduct the Medical Assessment?
In cases of Physical Abuse or Neglect the appropriate doctor will normally be a paediatrician. In some cases of suspected abuse of children it is desirable that a medical assessment is undertaken jointly by a police surgeon and a paediatrician.
In cases of Sexual Abuse, there are a number of police surgeons who have the training and expertise in the retrieval of forensic evidence and who are experienced in diagnosing Sexual Abuse. The police hold the rota for their availability and the police officer will be responsible for contacting the police surgeon.
Wherever possible, a child should have the choice of a male or female doctor and only one diagnostic medical assessment should take place.
A clear distinction is drawn between a forensic examination and a paediatric assessment, with the paediatrician typically less inclined to the more invasive examination. The police surgeon will lead a physical examination in relation to sexual abuse with the paediatrician adding their expertise in relation to the overall assessment of the child. If, during any assessment, a paediatrician suspects that the child has been sexually abused, then the matter should be referred to a police surgeon.
While the timing and venue of a joint examination/assessment may be subject to negotiation, the welfare of the child remains paramount and inconvenience and delays should be kept to a minimum.
7.0 The Medical Examination
The medical examination will normally consist of three elements:-
- Introductions
The paediatrician, social worker and/or the police will exchange relevant information concerning the referral, the child/ren and the family
- Medical Examination
The paediatrician, social worker and police will jointly decide who needs to be present for the medical examination. A parent will normally be present at the examination but it may also be appropriate for the social worker or police officer to be present. The views of the child will be taken into consideration in making this decision.
- Analysis of Findings
The social worker and/or police officer should discuss the paediatrician's findings and opinions, and seek clarification of anything which may be unclear.
If the initial findings of the medical examination are unclear the paediatrician will determine the need for further investigation e.g. skeletal survey, further examination/ opinion, monitoring of height and weight.
Should a radiologist's opinion be required the paediatrician will consult the radiologist within the hospital and the formal radiological opinion would be incorporated within the paediatric report. Should the paediatrician have any concerns and consider that a second radiological opinion is required, they would agree this with the hospital radiologist and seek a second opinion in the usual way. Where the immediate safety of the child or the progress of the police investigation does not depend upon the second opinion the paediatrician will make their own judgement about the urgency of the request for a second opinion.
The medical examination should provide the investigating agencies with as clear a medical view as possible as to whether any injuries were :-
- The potential causation of injury
- The result of an accident or natural causes
- Inflicted by another person and the possible characteristics of that person e.g. adult/child
- Impossible to determine
If there is conflicting medical opinion e.g. paediatrician/A&E consultant, the investigation will normally proceed on the basis of the paediatric opinion. Clarification should in the first instance be sought from the paediatrician and if this does not clarify the position contact should then be made with the named doctor or named nurse from the Trust or if not available the Clinical Director. Ultimately the designated doctor for the District should be involved if agreement/ resolution is not reached.
In some circumstances it may be appropriate for an expert opinion to be sought with respect to any findings. This may include circumstances where there is a difference in medical opinion. The social worker should accompany the parents and child to the hospital, and be present whilst the Consultant Paediatrician provides their opinion. The opinion should be discussed with the parents, where such discussion is not contrary to the child's best interests.
Following the medical examination, the paediatrician will write to the child/ren's General Practitioner in the normal way.
When a child has been examined by a doctor, and concerns about deliberate harm have been raised, no subsequent appraisal of these concerns should be considered complete until each of the concerns has been fully addressed, accounted for and documented. Victoria Climbie Report Recommendation 66
All doctors involved in the care of a child about whom there are concerns about possible deliberate harm must provide social services with a written statement of the nature and extent of their concerns. If misunderstandings of medical diagnosis occur, these must be corrected at the earliest opportunity in writing. It is the responsibility of the doctor to ensure that his or her concerns are properly understood. Victoria Climbie Recommendation 77End