7. Other Related Policies and Procedures

1.0	PiP Child Protection Standing Group and Child Sexual Abuse Services Project Group
2.0	Process map to guide Primary Health Care professionals where there is concern about the possibility of child Sexual Abuse
3.0	List of Standards

1.0 PiP Child Protection Standing Group and Child Sexual Abuse Services Project Group

Introduction

1.	Partners in Paediatrics' Child Protection Group met in 2004 to 2006 to discuss shared issues - clinical and organisational - concerning: Child Sexual Abuse; and Strategic roles in child protection (designated professionals in particular).
2.	A service benchmarking process helped to establish the need for a thoroughgoing examination of the pathways into and through services for children and families where sexual abuse is alleged or suspected. There is evidence of significant variation in how cases are handled from area to area and there is concern among child protection professionals about variation in the process of care from case to case
3.	The document 'What to do if you're worried a child is being abused' provides guidance about safeguarding processes, but does not give detailed guidance on the specialist assessments that may be required in cases of suspected or alleged child sexual abuse.
4.	This 'care pathway' for CSA has been drawn up, in part, to inform work by the Child Sexual Abuse Services Project Group to secure arrangements for the effective provision of services for CSA, including appropriate arrangements for medical examination.
5.	The pathway and the standards of service it specifies are intended to ensure that, following a Strategy Meeting, where sexual abuse is alleged or suspected, all children and young people (normally up to the age of 16 years): See an appropriately experienced doctor for the joint paediatric assessment and forensic examination; and Receive care that meets certain minimum quality standards, with an overriding emphasis on the interests and wellbeing of the child throughout. Note the pathway includes children up to the age of 16, the usual remit of paediatric services. The Children Act 1989, however, defines a child as up to their 18th birthday. There may be a role for paediatricians, in particular where a child over 16 years has known disabilities. For those aged 16-18, medical examinations will depend on locally agreed arrangements.
6.	The care pathway and standards recognise the realities/practicalities of service provision and service resourcing, but they do reassert the importance, also expressed by Laming and others, of exceptional inter-agency collaboration and a highly skilled workforce.
7.	The care pathway currently comprises A process map, intended to capture the key sequence of events that form the pathway. This has been presented in terms that should be recognisable to all professionals involved in the care of children; A document that elaborates on the events identified within the process map, indicating standards of service that should guide resourcing and operation of the service.
8.	Standards appear in a number of documents that have authority at national level 3,4,5,6,5. This pathway brings the relevant materials together from these.
9.	It is intended that associated guidance and 'standard' documents or templates be adopted or developed for use by specialist practitioners across the PiP area and these may, in due course, become an integral part of the pathway.
10.	The pathway is intended to be a dynamic document, to be reviewed and revised regularly. It is also intended to provide a basis for 'audit' so that the quality of service provided can be measured and assured.

3 Working Together to Safeguard Children, A guide to inter-agency working to safeguard and promote the welfare of children. HM Government. (2006, updated 2010)
4 Guidance on Paediatric Forensic Examinations in relation to Possible Child Sexual Abuse RCPCH/AFP. (September 2004, updated 2007)
5 The Victoria Climbie inquiry TSO 2003 (chaired by Lord Laming)
6 Guidance on investigating child abuse and safeguarding children (ACPO 2005)
5 What to do if you're worried a child is being abused (DOH 2003, updated 2006, now archived)

Care Pathway: Child Sexual Abuse

"Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (e.g. rape, buggery or oral sex) or non-penetrative acts. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways." (Working Together para 1.32).

This care pathway applies when there is a referral or an allegation of sexual abuse of a child or young person following a strategy meeting. (DOH 2003)

The purpose of the care pathway is to ensure that all children, where Sexual Abuse is alleged or suspected, receive care that meets specified minimum quality standards, with an overriding emphasis on the interests and wellbeing of the child throughout.

The pathway requires active and effective management of inter-agency relations to ensure that the interests and wellbeing of children and young people who enter this care pathway are served.

The pathway assumes the general principle set out in the Fraser rules: the right to involvement of the child or young person in all decisions, as appropriate to age and understanding.

The pathway covers the processes leading to medical examination, the examination itself, and subsequent health care processes. The medical examination is only a small part of the process, but it plays a crucial role in ensuring the health care of the child. RCPCH guidelines on paediatric forensic examinations in relation to possible child sexual abuse make clear that the purpose of the examination is two-fold: it concerns BOTH health assessment and forensic examination.

The pathway is in two parts:

A process map, which identifies the sequence of events that should follow from the first point of contact a child makes with services;
A list of standards to apply in the design, resourcing and operation of the service.

2.0 Process map to guide Primary Health Care professionals where there is concern about the possibility of child Sexual Abuse

Click here to view Flowchart

3.0 List of Standards

A. Presentation

Child/young person presents, leading to disclosure/suspicion of CSA

B. Referral

All staff should refer to Section 2 of this Manual: Procedures for the Management of Individual Cases Where There Are Concerns About a Child's Safety and Welfare.

"A referral is a communication between agencies which alerts the agency to a concern for a child. This includes communication from the police to social services, NSPCC, school or health care professional and a communication from one of these agencies to the police." (ACPO 2005:6.4.1:p75 and also see 7.2)

"Where it is decided that it is in the best interests of the child to proceed with a full criminal investigation, the investigation is the responsibility of the police. There will however be less serious cases where, after discussion, it is decided that the best interests of the child are served by social services-led assessment rather than a full investigation ...Where any doubt exists as to the seriousness of the case, the police should take responsibility from the outset..." (ACPO 2005: 7.2.1)

1.	Police have clear protocol to involve a paediatrician, agreed with health agencies
2.	There should be a paediatrician on the on call rota, who can give advice on and co-ordinate a medical assessment in suspected child Sexual Abuse. Local arrangements may vary but details need to be shared with the investigating agencies. (See also ACPO 2005 guidance on the role of the examining doctor: 4.6.3 p52 and Strategy discussions at 7.3, p85)

C. Multi-agency strategy discussion

The Strategy Discussion is the primary mechanism through which professionals can discuss and determine the best course of action for a child, the time and place at which a medical examination, if required, should be conducted and to seek any specialist advice needed e.g. from the Forensic Science service.

"Whenever there is reasonable cause to suspect that a child is suffering, or is likely to suffer Significant Harm, there should be a Strategy Discussion... convened by LA children's social care and those participating should be sufficiently senior and able, therefore, to contribute to the discussion of available information and to make decisions on behalf of their agencies. If the child is a hospital patient (in- or out-patient) or receiving services from a child development team, the medical consultant responsible for the child's health care should be involved, as should the senior nurse if the child is an in patient. Where a medical examination may be necessary or has taken place a senior doctor from those providing services should also be involved." (WT 5.54 p89)

4.	To assist the examination, the investigating Police Officers should provide the forensic physician/paediatrician with the account that the victim has provided to the police. (ACPO 2005 advises that "A strategy discussion between the police, social services and other agencies, when relevant....)
5.	"Any information shared, all decisions reached, and the basis for those decisions, should be clearly recorded by the chair of the Strategy Discussion and circulated within one working day to all parties to the discussion." (WT 5.57, p91)

"Cases of abuse in which the victim does not require urgent medical attention allow for a medical examination to be carefully planned. The purpose of any forensic examination in such a case is to assess the medical needs of the child and record any evidence relevant to the case" (ACPO 2005: 4.6.2 p52)

D. Interview of Child and/or Witnesses

6.	The video interview should (usually) happen first i.e. before the examination, subject to agreements reached at the strategy meeting

"The investigating officer should discuss with the forensic physician or paediatrician whether it might be more appropriate to conduct a victim interview prior to the forensic medical examination. The advantage of such a procedure is that it may suggest additional opportunities for evidence collection and prevent the possibility of a further examination to check on any disclosures made during the interview. Carrying out the interview first should prevent the child from having to repeat the disclosure to the examining doctor..." (ACPO 2005: 4.6.2 p52)

If an interview takes place prior to the medical examination, relevant history is available to paediatrician in advance of medical examination.(ACPO 2005 4.6.4)

The welfare of the child may dictate the need for medical treatment without delay. "...... When it is decided that the examination should take place before the interview, the examining physician or paediatrician will need to speak to the child so that the required samples can be collected and the scope of the examination determined...The conversation should be recorded by the examining physician or paediatrician and included in their witness statement" (ACPO 2005: 4.6.2 p52)

E. Joint Medical Examination

i. Purpose and Timing

Timing of the medical: the needs and routines of the child/young person to be sensitively considered along with the need for forensic examination (See ACPO 2005 4.6.2 p51 on the timing of the forensic examination)

10.

Procedures may be required to gather and preserve evidence. Timing may also be affected by the deterioration of potential evidence such as bodily fluids or by healing processes. It should be noted that it is possible for body fluids such as semen to be recovered up to seven days after an assault and this may also prompt the need for an early examination if the abuse is disclosed near to this time limit (ACPO 2005).

If there is uncertainty, advice can be sought from the Forensic Science Service.

11.	Even where forensic evidence may not be secured, where there is other evidence that Significant Harm from sexual abuse may have been suffered, a health/Medical Examination should still be considered and offered to the child and carers as part of a therapeutic process

The purpose of the examination is two-fold: it concerns BOTH health assessment and forensic examination. The health assessment is a basis for action to protect the health of the child/young person. The process map thus indicates other health care processes that should be accessible, about which information should be available, and to which the child/young person should be referred, as appropriate, following the examination. (RCPCH/AFP guidance)

ii. Examination: Examiner(s)

12.	Experienced paediatrician(s) should be identified accessible, if not 24 hours seven days per week, then at least between 9am and 5pm 365 days/year. Commissioners/ PCTs must consider how the service can be provided out of hours. ACPO 2005:4.6.2 p51 acknowledged that the ideal conditions for the examination are likely to be during normal working hours
13.	"Any doctor (e.g. paediatrician or forensic physician) who undertakes a forensic assessment of a child who may have been subjected to abuse must have particular core skills" (RCPCH/AFP p2) 1.

Specification of Core Skills:

The ability to communicate comfortably with children and their carers about these sensitive issues;
To understand, and be sensitive to, the child's developmental, social and emotional needs and intellectual level;
An understanding of consent and confidentiality as they relate to children;
The competence to conduct a comprehensive general and genital examination of a child and skill in the different techniques used to facilitate the genital examination (e.g. labial traction);
An understanding of the normal genital and anal anatomy, and its variants, for the age and gender of the child to be examined;
An understanding of the diagnosis and differential diagnosis of physical signs;
Competence in the use of a colposcope and obtaining photo-documentation ensuring that the latter properly reflects the clinical findings and documenting if it does not;
An understanding of what forensic samples may be appropriate to the investigation and how these samples should be obtained and packaged according to the current Association of Chief Police Officers, Forensic Science Service and Association of Forensic Physicians guidance;
The ability to comprehensively and precisely document the clinical findings in their contemporaneous notes;
The competence to produce a detailed statement/ report describing and interpreting the clinical findings;
A willingness to communicate and co-operate with other agencies and professionals involved in the care of the child; this may include attending a case conference, referral to other health professionals, e.g. paediatricians, psychiatrists, genitourinary physicians;
The aptitude to present the evidence, and be cross-examined, in subsequent civil and criminal proceedings;
An ability to discuss the presentation and findings in the context of the child's level of development and the relevant medical literature.

Case dependent skills: Any or all of the following components may be pertinent to the examination of a given child.

An understanding of the different types of post-coital contraception available, the indications and contraindications of the various methods, and the capacity to prescribe the hormonal types of contraception where appropriate;
Training in prophylaxis (including Hepatitis B, HIV), screening and diagnosis of sexually transmitted infection.

14.	A joint examination (two paediatricians or one paediatrician and an FME/FP) should be arranged if a single doctor does not have all the necessary knowledge, skills and experience for the examination (RPCH/AFP p3)
15.	If one doctor performs the examination, a permanent record in the form of photo-documentation should be made (RCPCH/ AFP p3)
16.	Any doctor undertaking CSA examinations should have access to peer support and review. An example of this is the West Midlands Child Protection Special Interest Group
17.	All doctors undertaking CSA examinations should undertake appropriate CPD, to be reviewed at their appraisal
iii. Facilities, Location and Environment
18.	It is 'every examiner's responsibility to ensure there is a therapeutic and supportive environment for the child and carer(s) during the medical examination.' (RCPCH/AFP) - 'culturally sensitive' - to age, gender, ethnicity, religion of child.
19.	'Support for child and carers throughout' RCPCH/AFP p4) Care should be available outside the examination from a professional who is not part of the examination process - nurse or care worker (soc services/police). Access to play materials appropriate to age
20.	PiP group recommends the medical examination is undertaken EITHER in a purpose built examination facility OR in a healthcare facility, with access to basic clinical investigations for health needs - swabs, urine samples

PCTs jointly commission services of Sexual Assault Referral Centres (SARCs) with the police and voluntary sector organisation for victims of rape and sexual assault, including Children & Young People's Service. SARCs provide forensic, medical and counselling services involving specialist sexual health input (WT 2.51, p22)

21.	"Permanent record (still photos or video) to be obtained (usually via colposcope)" (RCPCH/AFP p3)
	21.1	with specific informed consent(s)
	21.2	forming part of medical record
	21.3	stored securely

iv. Consent, History Taking, Examination

"Children should be informed, consulted and involved in any matter affecting them, according to their age and understanding." (ACPO 2005: 4.8.1 p58)

22.	ACPO guidance states that "A forensic medical examination may only be carried out with the consent of the child, if they have the capacity to consent, or with the consent of the parent, carer or person with Parental Responsibility. If there is no one with parental responsibility available, or they refuse consent, then the local authority may apply for an Emergency Protection Order or a child assessment order" and "It is the forensic physician or medical care professional who should be satisfied that consent has been obtained" (ACPO 2005:4.6.1, p54)
23.	Consent must be clarified (RCPCH/AFP; MDU, BMA guidelines, ACPO 2005 4.6.2 p51) Agree a standard form of documentation for use across the PiP area
24.	The issue of obtaining informed consent should be an explicit objective of a strategy discussion
25.	NB Children subject to legal orders, such as an interim care order, also require leave of the court to be presented for medical examination
26.	Paediatrican conduct: It is important that even initial discussions with children are conducted in a way that minimises any distress caused to them, and maximises the likelihood that they will provide accurate and complete information. It is important, wherever possible, to have separate communication with a child. Leading or suggestive communication should always be avoided. (WT 5.64 p92)
27.	During the examination, the examining physician/paediatrician may need to speak to the child, especially if a video interview has not taken place. The conversation should be recorded by the examining physician or paediatrician in their witness statement (ACPO 2005 p 52)
28.	If forensic (or other) sampling is to be undertaken, the rationale for taking and processing should be discussed. It may be necessary for the investigating police officer to remain present or near to the place where it is being undertaken to ensure the chain of evidence.
29.	Necessary, written and informed consents are sought, obtained and recorded for:
	29.1	The exam itself
	29.2	The photorecord (consent and storage need to be considered carefully if undertaken by the clinician, according to local policy. It is appropriate for a child/carer to understand the purpose/use of this recording). RCPCH 2004 contains helpful information on this matter
	29.3	Use of data for teaching/peer review.

v. Contemporaneous Notes

'Comprehensive, contemporaneous notes, including line drawings...' (RCPCH/AFP p4)

30.	"A comprehensive assessment considering the physical development and emotional well being of the child or young person against the background of any relevant medical, family or social history must be undertaken. This enables a full evaluation of the degree of Significant Harm suffered, or likely to be suffered..." (RCPCH/AFP 2004)
31.	Effective history taking and recording of examination findings lead to a better informed assessment and diagnosis. There should be use of agreed standard reporting format to assure greater consistency in depth and quality of information
32.	A secure storage facility should be available
33.	The paediatrician and forensic physician should try to give an immediate verbal opinion and provide a written statement after any forensic examination, which outlines the findings of the examination and expresses their opinion (ACPO 2005: 4.6.4 pp53)
34.	ACPO guidance places a responsibility on police officers investigating child abuse to be prepared to question the views of other professionals (ACPO 2005: 4.10 p63)

F. Health Care Consequent on the Examination Findings

"appropriate arrangements for any ongoing medical assessments and necessary intervention, ensuring that psychological support is made available" (RCPCH/AFP p4)

35.	Immediate follow-up should be available in relation to:
	35.1	Pregnancy test
	35.2	Post-coital contraception
	35.3	STD screening including blood borne viruses (e.g. Hep b, HIV These may depend on local arrangements with Departments of GU Medicine
36.	Follow-up information and advice for parents should be readily available
37.	Psycho-social follow-up should be available and offered as appropriate:
	37.1	If specific symptoms, refer to Child and Adolescent Mental Health Service or (via social services) other specialist service provider, NSPCC counsellors. This may depend on local arrangements/services
38.	All referrals for counselling, therapy etc must be guided by national and local pre-trial therapy guidelines. Families should be given appropriate leaflets and the police MUST be informed
39.	General support to child/family to help with distress -on the ground contact should be provided
	39.1	social workers
	39.2	Victim Support network
	39.3	specialist voluntary organisations

G. ONGOING CARE

40.

Following the examination there should be discussion with police/social services as to the need of ongoing care for these children and whose responsibility it is to follow this through

41.

It is the responsibility of the examining doctor to ensure that arrangements are in place for follow up health provision. This may include liaison with community nursing (health visitors/school nurses) and contact with any local service providers, especially if the child is assessed outside of their local area. The use of networks of Named and Designated health professionals can facilitate this process.

End