Doctors responsibilities in child protection cases

Guidance from the Ethics Department

Part one: introduction
Summary Where doctors have concerns about a child who may be at risk of abuse or neglect, it is essential that these concerns are acted upon, in accordance with the guidance in this note, or other local and national protocols. The best interests of the child or children involved must guide decision-making at all times. Where suspicions of abuse or neglect have been raised, doctors must ensure that their concerns, and the actions they have either taken, or intend to take, including any discussion with colleagues or professionals in other agencies are clearly recorded in the child or childrens medical record. Where doctors have raised concerns about a child with colleagues or with other agencies and no action is regarded as necessary, doctors must ensure that all individual concerns have been properly recognised and responded to. When working with children who may be at risk of neglect or abuse, doctors should judge each case on its merits, taking into consideration the likely degree of risk to the child or children involved. Disclosure of information between professionals from different agencies should always take place within an established system and be subject to a recognised protocol. This guidance applies equally to both information about children who may be subject to abuse, a well as to information about third parties, such as adults who may pose a threat to a child. General principles In child protection cases, a doctors chief responsibility is to the well being of the child or children concerned, therefore where a child is at risk of serious harm, the interests of the child override those of parents or carers. All doctors working with children, parents and other adults in contact with children should be able to recognise, and know how to act upon, signs that a child may be at risk of any form of abuse or neglect, not only in a home environment, but also in residential and other institutions. Efforts should be made to include children and young people in decisions which closely effect them. The views and wishes of children should be therefore be listened to and respected according to their competence and the level of their understanding. In some cases translation services suitable for young people may be needed. Wherever possible, the involvement and support of those who have parental responsibility for, or regular care of, a child should be encouraged, in so far as this is in keeping with promoting the best interests of the child or children concerned. Older children and young people may have their own views about parental involvement. When concerns about deliberate harm to children or young people have been raised, doctors must keep clear, accurate, comprehensive and contemporaneous notes. All doctors working with children, parents and other adults in contact with children must be aware of, and have access at their place of work to, their local Area Child Protection Committees Child Protection Procedure manual. Contents Page
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Part one: introduction Summary General principles General Medical Councils guidance BMA guidance Terminology Child abuse definitions Physical abuse Emotional abuse Sexual abuse Neglect Childrens rights Scope of medical involvement in child protection cases Part two: initial concerns Where a doctor has concerns about a child Local procedures Confidentiality and suspected abuse Sharing information The General Practitioner and the primary health care team Hospital-based doctors Continuity of care Differences of medical opinion Should children be detained in hospital? Weekend admission Medical note keeping Communicating with children Involving parents and carers Part three: statutory child care proceedings Children Act 1989 The concept of significant harm Emergency protection proceedings Referral to social services departments Section 47 enquiries Criminal proceedings Part four: child protection cases conferences and follow-on Child protection case conferences Child protection case conferences and confidentiality Action following the initial child protection conference Who should take the lead in child protection cases? Collaborative working Part five: serious case reviews Confidentiality and serious cases reviews Part six: examination or assessment for child protection purposes The need for consent Requirements for valid consent to a child protection assessment The need to avoid unnecessary assessments The role of the court under the Children Act Refusal of examination Recommendations concerning a childs refusal The role of the expert witness Information to be provided to experts Duties of experts Further advice Conclusion Further reading References

Guidance from the BMAs Ethics Department

The General Medical Councils guidance The GMC also emphasises the importance of listening to the patient but gives specific advice about young patients who lack the ability to give valid and unpressured consent to disclosure. If you believe a patient to be a victim of neglect or physical, sexual or emotional abuse and that the patient cannot give or withhold consent to disclosure, you should give information promptly to an appropriate responsible person or statutory agency, where you believe that the disclosure is in the patient's best interests. You should usually inform the patient that you intend to disclose the information before doing so. Such circumstances may arise in relation to children, where concerns about possible abuse need to be shared with other agencies such as social services. Where appropriate you should inform those with parental responsibility about the disclosure. If, for any reason, you believe that disclosure of information is not in the best interests of an abused or neglected patient, you 1 must still be prepared to justify your decision. BMA guidance In January 2003, Lord Laming published his report of the inquiry into the circumstances surrounding the death of 2 Victoria Climbi. Among much else, the report drew attention to a number of serious failings in the provision of child health services for this extremely vulnerable girl. As a result of the inquiry, the government published revised guidance for all professionals directly involved in child protection, What to do if youre worried a child is being abused.3 This replaced the existing guidance for 4 doctors, Child protection: medical responsibilities. The BMA has developed this subsequent guidance note in order to highlight the particular ethical responsibilities that doctors have when working with children who may be at risk of harm or neglect. It aims to augment and expand upon the governments guidance, and is based in part on enquiries to the BMAs Ethics Department from doctors. Doctors and health care workers who require more detailed clinical information about assessing the needs of vulnerable children should refer at the outset to the governments publication Framework for the assessment of children in need and their families.5 Working with children and families where there are concerns about neglect or abuse is difficult and demanding. No two cases are identical, and the needs of children and families vary from case to case. Decisions about how best to respond when there are concerns about harm to a child necessarily involve a degree of risk at the extreme, of leaving a child for too long in a dangerous situation, or of removing a child unnecessarily from its family. In each case, these risks need to be weighed and advice may need to be taken from other professionals and local agencies such as the Area Child Protection Committee (ACPC). To protect patient confidentiality in cases where the evidence for suspicion may be uncertain, doctors can discuss their concerns with colleagues on a no-name basis. Nevertheless, a guidance note cannot provide a substitute for the development of sensitive professional judgement based on a sound assessment of the childs needs, the parents capacity to respond to those needs, and the wider developmental context. This note aims rather to provide some general ethical pointers to assist
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doctors in their practice in this area. It draws heavily on the governments wide-ranging 1999 guidance Working 6 together to safeguard children. The guidance in this document applies equally to those doctors directly involved in providing care to children, and to those doctors working with adults whose illness or condition may have an impact on the health or well being of a child. Terminology For the sake of ease of use, child also includes young people up to the age of 18. As is stressed throughout however, due recognition must be given to the capacity of the child or young person to make decisions on his or her own behalf. Doctor includes both GP and hospital doctor, and although this guidance note is principally directed toward doctors, much of the information is applicable to other health care workers. Unless expressly indicated otherwise, parent or carer refers to those individuals with parental responsibility for the child or young person. (The BMA has produced a separate guidance note on the meaning of parental 7 responsibility. ) Although the terms abuse and neglect are sometimes used interchangeably, different responses are frequently called for if the child is suffering actual abuse, or is being neglected due to family stresses or other parental problems. As is emphasised throughout this guidance, the appropriate response for each child will have to be based on an assessment of the facts of the individual case. The Children Act 1989 introduced the concept of significant harm as the threshold for intervention under the Act. As is discussed in part 3 of this guidance, there are no absolute criteria by which significant harm can be judged. Decisions in this area will however involve weighing up the effect of any ill-treatment on the childs overall physical and psychological well being. Child abuse definitions Child abuse and neglect is a generic term that includes all ill treatment of children including serious physical and sexual assaults as well as cases where the standard of care does not adequately support the childs health or development. Children can suffer abuse or neglect through the direct infliction of harm, or through the failure to prevent harm occurring. Abuse can occur in a family or institutional setting and the perpetrator may or may not be known to the child. In its guidance note Working together to safeguard children, the government defines four broad categories of abuse, and these are given below.8 Physical abuse Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer feigns the symptoms of, or deliberately causes ill health to a child whom they are looking after. This situation is commonly described using terms such as factitious illness by proxy or Munchausen syndrome by proxy.

Guidance from the BMAs Ethics Department

Emotional abuse Emotional abuse is the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the childs emotional development. It may involve conveying to children that they are worthless or unloved, inadequate or valued only in so far as they meet the needs of another person. It may feature age or developmentally inappropriate expectations being imposed on children. It may involve causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of ill-treatment of a child, though it may occur alone. 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 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. Neglect Neglect is the persistent failure to meet a childs basic physical or psychological needs, likely to result in the serious impairment of the childs health or development. It may involve a parent or carer failing to provide adequate food, shelter and clothing, failing to protect a child from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a childs basic emotional needs. Childrens rights The United Kingdom ratified the United Nations Convention on the Rights of the Child in 1991. The Convention places a duty on the state and its actors to promote the well-being of all children in its jurisdiction. The Convention sets out standards that should be reflected in health care. Article 3 of the Convention states that any decision or action affecting children, either as individuals or as a group, should be focussed on their best interests. In addition to these Convention rights, doctors should bear in mind that the rights of children and parents under the Human Rights Act 1998 will be engaged by child protection proceedings. Where these rights are in tension, they may need to be traded against each other. Of particular importance here are Article 2, the right to life, Article 3, the prohibition of torture, inhuman or degrading treatment of punishment, Article 6, right to a 9 fair trial, and Article 8, respect for private and family life. Discussion of childrens rights in relation to health care can be complex. It can introduce an adversarial or confrontational element into an area that has traditionally focussed on consensual care. Societal attitudes are also generally more complex here than in relation to adults rights, as society tends to have a vested interest in ensuring that childrens health is not avoidably put at risk, even though a young person may want to refuse medical treatment. In cases of abuse, for example, it may be necessary to override the wishes of a competent young person and refer concerns about
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significant harm to an appropriate body. The following are generally regarded as childrens basic health rights: Children have rights: to child-centred health care to be looked after appropriately, without discrimination of any kind to be encouraged in every possible way to develop their full potential to take opportunities to be involved, from the beginning, and to choose not to be involved in decision-making to receive clear information about matters closely affecting themselves and about the right to decline detailed information at a particular time to have opportunities to express opinions without pressure or criticism to ask someone else to decide a particular issue to receive an explanation of the reasons when their preference cannot be met to confidentiality subject to certain constraints; and to redress where appropriate through a fast, accessible complaints procedure.10 Scope of medical involvement in child protection cases All health professionals, both in the NHS, the private sector, and those working for other agencies have a role to play in ensuring that children and families receive the care, support and services they need in order to promote childrens health and development. Because of the universal nature of health provision it is likely that health professionals will be among the first to have contact with children or families in difficulty. In addition to the direct provision of clinical services to children, both in primary care and in hospitals, medical participation in child protection encompasses a range of activities. These can include: Recognising children in need of support or protection, and parents who may need extra help in bringing up their children Contributing to enquiries about a child or family Assessing the needs of children and the capacity of parents to meet their childrens needs Planning and providing support to vulnerable children and families Participating in child protection conferences Planning support for children at risk of significant harm Providing therapeutic help to abused or neglected children and parents under stress Contributing to case reviews

Part two: initial concerns

Where a doctor has concerns about a child As outlined in the basic principles above, where a doctor has a reasonable belief that a child is at serious risk of immediate harm, he or she should act immediately to protect the interests of the child, and this will almost always involve contacting one of the three statutory bodies with responsibilities in this area: the police, the social services or the NSPCC, and making a full report of concerns. The precise action taken should be governed by the procedures set out by the local Area Child Protection Committee. In some cases, however, signs of abuse or neglect are not straightforward or

Guidance from the BMAs Ethics Department

clear-cut. Patterns of behaviour or of symptoms develop over time, neglect can shade into abuse, and children and adults can become adept at masking difficulties and misleading professionals. Doctors are therefore often forced to make difficult decisions on the basis of fragmentary and ambiguous evidence. Where doctors believe, however, that there may be genuine grounds for concern, it is important that they do not ignore any early warning signs, even where they may consider the evidence too uncertain to warrant the immediate commencement of child care proceedings. In these circumstances, doctors should initially consider discussing the matter with other colleagues and health care professionals and should also seek the advice of trained professionals with experience in child protection. Where uncertainty exists, it can be extremely helpful for doctors to test out hypotheses in this way, without necessarily disclosing identifying data about the patient. It is also important that the option of talking to the carers or family at an early stage is not ruled out. Obviously this needs to be sensitively done and is not feasible in all cases, but it may indicate opportunities to work constructively with parents to improve parenting skills. It is difficult to over-emphasise the importance of documented professional discussion and support in this area. Local procedures All doctors who are likely to come in contact with children in a professional capacity should familiarise themselves with local procedures for promoting and safeguarding the interests of children. Every area is obliged to identify a senior paediatrician, and a senior nurse with a health visiting qualification (designated senior professionals) to take a lead on all relevant aspects of child protection. These professionals are a key source of advice on child protection matters. Ordinarily therefore, a doctor with suspicions of potential child abuse or neglect should consult with a designated senior professional within the area. Confidentiality and suspected abuse A frequent area of difficulty for doctors involves the extent to which they should respect the wishes of children who they suspect may be being abused but who do not want the information disclosed further. Children may also try and elicit a promise of confidentiality from adults to whom they disclose abuse. At the time of writing, the government was considering introducing statutory duties on professionals working with children to report certain kinds of information.11 Until clear legal guidelines exist, doctors will need to make judgements based on the facts of the individual case, bearing in mind that their primary duty is the protection of the child. As with all other patients, children at risk of neglect and abuse are entitled to have their confidentiality respected. Where there is a risk of significant harm, however, either to the patient, siblings or to others, doctors have a duty to take action, including, where necessary, the disclosure of relevant confidential information (significant harm is the threshold that triggers assessment under the Children Act 1989). Doctors should not therefore promise to keep information about child abuse confidential, but should explain to the child or young person their general rights in this area, and also point out that such rights are not absolute.
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Where doctors believe that, in the interests of the child or others, it is important that action is taken, they need to discuss disclosure with the child, and, if possible, the child should be given sufficient time to come to a considered decision. If the child cannot be persuaded to agree to voluntary disclosure, and there is an immediate need to disclose information to an outside agency, he or she should be told what action is to be taken, unless to do so would expose the child or others to increased risk of serious harm. It can also be helpful in certain circumstances if professionals arrange a safe way to contact the child.12 Sharing information Although both the rights of children to have their confidentiality respected, and the existence of limits to this right are clear, a frequent grey area for doctors is the extent to which this respect for confidentiality needs to be balanced against the requirement to share information with other professionals in the interests of the child. Doctors are also unsure sometimes as to whether they can be breach the confidentiality of other patients, such as a childs relatives, on the basis of an unconfirmed suspicion or hearsay reports. Clearly each case must be considered on the available evidence, but the Climbi report made it clear that keeping children safe from harm requires professionals and others to share information. Often it is only when information is pieced together from a number of sources that it becomes clear that a child is at risk or is suffering harm. The difficulty for doctors here is that they may have some initial concerns about a child but are uncertain whether the appropriate threshold of severity has been reached to justify a disclosure of information without consent. As already mentioned, at the time of writing, the government had indicated that it may change the law in relation to the release of information in child protection cases. Until such time as the law is changed, doctors should recognise that personal information that is held about children and families is confidential and should not normally be released without the consent of the subject. However, both the law and the GMC permit the disclosure of information where it is necessary to protect a child against a risk of harm. In these cases, the public interest in protecting children overrides the public interest in maintaining confidentiality. It is sometimes the case that both the abused or neglected child, and the person suspected of responsibility for the abuse or neglect, are registered with the same doctor. Doctors in these circumstances have sometimes reported feeling a sense of divided loyalty, as they have professional responsibilities to both parties. In these circumstances, the doctors primary responsibility is to the child, as the more vulnerable party, and where the interests of the child and the suspected abuser conflict, the latters interests should always give way to the childs. Doctors should, however, treat all parties sensitively and professionally, and try and respect both partys wishes, in so far as this is conducive to promoting the best interests of the child or children concerned. The general practitioner and the primary health care team Although these guidelines are intended to apply to all doctors who have professional contact with children, or

Guidance from the BMAs Ethics Department

with adults whose circumstances may have an impact on the well being of children, there are inevitably going to be differences of emphasis between, for example, GPs and doctors working in hospitals. General practitioners and the wider primary health care team are likely to be among the first professionals to come in contact with children who are either at risk, or who are in need of additional support. Consultations, home visits as well as information from health visitors, midwives and practice nurses can all help to build up a picture of a child in difficulty. GPs and all members of the local primary health care team should know how to act on concerns they may have about a child, and, in particular, what steps to take when a child is considered to be at risk of significant harm. All members of the primary health care team should therefore be familiar with both local procedures, and the names and contact details of colleagues with experience in child protection procedures, such as the designated professionals within their trust. GPs are also well placed to recognise when a parent or other adult carer has problems which may affect their ability to look after a child. While GPs have responsibilities to all their patients, the welfare of children at risk must be their primary concern. Health visitors play a particularly important role in the protection of vulnerable children. Their knowledge of individual children and families, combined with their expertise in monitoring and assessing child health and development means that they have an important role to play in all stages of family support and child protection. Midwives, as a result of their involvement with the mother throughout pregnancy and with the mother and child during the months after birth, are also well placed to identify any problems during pregnancy, birth and the childs early care. It is important that doctors collaborate closely with all members of the primary care team to secure the safety and well being of children. Hospital-based doctors Partly as a result of the extremity of Victoria Climbis injuries, problems arising in her hospital care were at the centre of the health care recommendations of the Climbi report, and these recommendations are reflected in the guidance below. It is frequently the case that SHOs in Accident & Emergency Departments or Paediatrics are the first point of contact in a hospital and many non-accidental injuries or cases of neglect are presented to these junior doctors first. It is crucial that these doctors receive training in how to identify injuries which need further investigation, how to spot warning signs, and how to raise concerns with appropriate colleagues and professionals in other agencies. Continuity of care Summary of points: Wherever a doctor sees a child who may be at risk, he or she must ensure that systems are in place to ensure follow-up care As full a picture as possible of the circumstances of a child at risk must be drawn up Where a child presents at hospital, inquiries must be made about any previous admissions

Child protection
Where a child is admitted to hospital, a named consultant must be given overall responsibility for the child protection aspects of the case Any child admitted to hospital about whom there are concerns about deliberate harm must receive a thorough examination within 24 hours unless it would compromise the childs care or well being Where a child at risk is to be discharged from hospital, a documented plan for the future care of the child must be drawn up A child at risk must not be discharged from hospital without being registered at an identified GP All professionals must be clear about their own responsibilities, and which professional has overall responsibility for the child-protection aspects of a childs care

The Climbi report highlighted a series of concerns relating to the lack of continuity of support for vulnerable and at risk children. Health and social care was found to be provided piecemeal, and communication both between health workers and between health and other professionals was sporadic and unreliable. The report therefore called for the development of procedures to ensure that whenever a child who may be at risk is seen by a health professional, that professional must be satisfied that systems are in place to provide follow-on care. It is essential that children about whom suspicions of neglect or abuse are raised are not simply abandoned without mechanisms for continued support being triggered. Where a health professional has contact with a child about whom there are child protection concerns, it is important that as full a picture of the childs situation as possible is developed. Where a child presents at hospital, this must include inquiring about any previous hospital admissions, and efforts must be made to gain access to all relevant notes and records. Where children are admitted to hospital, a named consultant must be given overall responsibility for the child protection aspects of the childs case. The identity of this consultant must be clearly marked in the notes. Any child admitted to hospital about whom there are concerns about deliberate harms must receive a thorough, carefully documented examination within 24 hours of their admission, except when doing so would, in the opinion of the examining doctor, compromise the childs care or the childs physical and emotional well being. Doctors should not discharge children about whom child protection concerns have been raised until a discussion has taken place with the local social services department, and appropriate medical and social follow up has been arranged. Although it may prove difficult in some cases, such children must not be discharged without their being registered at an identified GP. Decisions relating to discharge should ordinarily be made by the consultant in charge of the childs care, or by another senior trained paediatrician. Where social care and other agencies are also involved in continuing care, it is important that individual areas of responsibility are clearly demarcated, and all professionals involved are clear about both their own responsibilities, and about which professional has overall responsibility for the child-protection aspects of the childs care.

Guidance from the BMAs Ethics Department

Health staff, particularly those working in A&E departments should also be alert to carers who seek medical care from a number of sources in order to conceal the repeated nature of a childs injuries. A childs GP or primary health care team should be informed of any visit to an A&E department, and appropriate records kept. Differences of medical opinion Where there are disagreements between health professionals in relation to a diagnosis of possible deliberate harm to a child, it is important that a full discussion takes place between those with differing views, and the substance of the discussion is recorded in the childs medical record. Where deliberate harm has been raised as a possible diagnosis, it must not be rejected without proper consideration and, if necessary, the securing of a second opinion. Should children be retained in hospital? The BMA has received inquiries from doctors in the past about whether they should ever keep children in hospital when concerns about child abuse or neglect have been raised. Where children are competent to make the decision, their own wishes will normally be determinative. Where children are not competent, those with parental responsibility will need to consent on their behalf. Where doctors are concerned that parents are either responsible for neglect or abuse, or are unable to protect their children from abuse, then an assessment must be made of the risks to the children concerned. Where doctors reasonably believe that there is a risk to the life of a child, or a risk of serious immediate harm, the police or social services should be contacted immediately and emergency protection procedures should be initiated. Police have powers, for example, to remove children to a place of safety for up to 72 hours. Where there is no immediate risk of serious harm or death and parents wish them to be discharged, but health professionals do not believe it to be in their best interests, legal advice should be sought as a matter of urgency. Doctors should discuss the matter with parents and explain why they believe that further clinical supervision would be advisable. Where children are competent, but seem to be making decisions that are significantly at odds with their best interests, legal advice should again be sought. It needs to be recognised that hospitals are not ideal environments for children unless they have serious health problems which require hospital admission. Weekend admission Difficulties with inter-agency working, general communication and timely referral can be exacerbated when children are admitted over the weekend. It is often much more difficult for doctors to gain immediate access to necessary information, to liaise with other agencies, and to arrange examinations by an appropriate specialist. There is no straightforward solution to these administrative difficulties. Nevertheless, the fact that a child about whom child protection concerns have been raised is admitted over the weekend should not be allowed to interfere with an assessment of his or her needs, and of any risks of harm. It may be the case, for example, that where admitting doctors have concerns that a child is at risk but cannot secure an immediate assessment from a specialist, the child should be encouraged, with discussion with those with parental
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responsibility where appropriate, to remain in hospital for supervision. Clearly, where there is a risk of serious harm to the child, emergency protection proceedings should be commenced immediately. All local authorities have a social services officer permanently on call with access to the child protection register. He or she can also take referrals if concerns are raised about a child who is not on the register. Doctors with concerns about child protection can contact this officer even out of hours. Where children are admitted over the weekend, it is clearly important to ensure that full notes of relevant findings are made, with clear indications of any future referral and follow-up that are required. Responsibility for any actions that are to be taken should be clearly marked. It is important that children who at risk of serious harm should not be allowed to slip through the net as a result of weekend admission. Medical note keeping The Climbi report identified a number of problems in the keeping of medical records, and its subsequent recommendations reinforced established best practice. When doctors are concerned about a child or children being exposed to abuse or neglect, they must ensure, in keeping with GMC guidance, that accurate, comprehensive and contemporaneous notes are made. Where the child is unknown to the doctor, detailed factual information about the child should be recorded at the point of contact, including information about those with parental responsibility and any primary carers, if these are different. This information should be verified at appropriate intervals. When making notes, it is important that doctors record all their relevant concerns, without venturing into speculation that cannot be justified, and that a record is kept of any discussions about the child, including telephone conversations, any decisions that are made, and the reasons behind the decisions. Where doctors are working in situations in which case notes are not available, any relevant information should be entered into the notes as soon as is practicable. Notes should clearly show the difference between information given by the child or carers, the health care workers own direct observations, and any subsequent interpretation or assessment of the situation. Notes should also record any action that has been taken or will be taken, as well as any action by, or intended by, other relevant parties. It is good practice for GPs and hospital doctors to have a clear means of identifying in records those children (together with their parents and siblings) about whom child protection concerns have been raised, although due consideration will have to be given to ensuring that the means of identification remains confidential. The tagging of medical records should only be considered where other systems that involve less likelihood of inadvertent disclosure cannot be used. Ordinarily, tagging should only be used with the consent of the individual concerned. Where young childrens records are tagged, permission will usually come from the parent until the child is able to decide for him or herself. Communicating with children It is imperative that doctors listen to children and take their views into account as far as possible, even where

Guidance from the BMAs Ethics Department

the doctor believes that the child or young person concerned does not have the capacity to fully engage in any decision-making process. Children can have a very clear idea of what needs to be done to ensure their safety and well-being. Communicating sensitively with children, and establishing sufficient trust to enable them to be open about distressing information and experiences takes considerable skill, and doctors who are likely to be involved in child protection work require special training in this area. Doctors need to ensure that children understand the extent and nature of their own involvement in decisionmaking. They should be helped to understand how child protection processes work, how they can be involved, and that they can contribute to decisions about their future to the extent that their age and understanding allows. Doctors should make it clear, however, that children, particularly young children, will not necessarily have the final say in decisions concerning their welfare, and that decisions may have to be taken based upon information contributed by a number of professionals and carers. It is vital that doctors attempt, as far as possible, to develop a relationship of trust with children they believe to be at risk, and it would be difficult to exaggerate the importance of good communication in this process. Although in practice this may be difficult, as their trust in adults may have been abused in the past, doctors should work towards establishing as far as possible, a positive professional relationship with children. At whatever stage in their development, children should be encouraged to talk openly to health professionals about their experiences, and be assured that confidential information will only be revealed if it is absolutely necessary and in their best interests. Doctors should use methods of communication that are appropriate to the age, understanding and needs of the child, particularly where the children are young, disabled or with a limited understanding of English. As mentioned previously, translators from outside the family may be needed in some cases. Wherever possible, medical professionals with expertise in caring for children should be involved, either directly or through consultation. When children are first involved in discussions about potential abuse or neglect, the extent of any possible harm, or whether criminal acts have been committed may not be obvious. It is important that even initial discussions with children are conducted in a way that minimises any distress caused to them, and increases the likelihood that they will provide accurate and complete information. It is important, wherever possible, to have separate communication with a child. Children may need time, and more than one opportunity for discussion, in order to develop sufficient trust before they can begin to discuss their experiences, particularly if they have communication difficulties, are very young or have learning or mental health problems. (For further information on potential criminal proceedings, see part 3 below.) Doctors and other health care workers should be honest and open with children and families about professional roles and responsibilities. They should be clear about what professionals can offer in the way of services, and on the limits of their powers. Doctors should take care that children are clear about any legal and professional
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restrictions they operate under, such as in relation to confidentiality. Involving parents and carers Doctors sometimes express considerable uncertainty about the extent to which parents or carers should be involved in decisions relating to children who may be victims of intentional harm. Decision-making in this area can be difficult, particularly where children are not competent to make decisions on their own behalf. Generally speaking, where children are competent to make decisions, their views are very influential although, exceptionally, decisions that are clearly contrary to their best interests can be challenged.13 Ordinarily, where children cannot make decisions for themselves, those with parental responsibility have a legal right to make decisions on their behalf. Such rights, however, are not absolute, and when children are at risk of avoidable harm, professionals involved in caring for them have a clear duty to take appropriate action. Where children lack the competence to make decisions, those with parental responsibility should therefore be involved, provided it is in the best interests of the child or young person concerned. Parents or carers should not be involved where there is a reasonably found belief that it would put a child at further risk of harm. Reasons for such a decision might include situations where there is a possibility that a child would be threatened or otherwise coerced into silence; where there is a strong likelihood that important evidence would be destroyed; or that the child in question does not wish the parent to be involved at that stage and is competent to make that decision. When harm or neglect is identified as a possible diagnosis by a doctor, he or she should consider whether taking a history directly from the child is in that childs best interests. Where it is, the history should be taken even when the consent of the carer has not been obtained, with the reasons for dispensing with consent recorded in the medical record. A decision to exclude an individual with parental responsibility is obviously a serious one, and, if time allows, it should be made in consultation with colleagues with expertise in this area. Doctors should bear in mind that almost all children about whom child protection concerns are raised either remain with, or are returned to their families. Involving the family in child protection processes, to the extent that it promotes the interests of children, is therefore likely to be productive. Doctors need to bear in mind that family structures are increasingly complex. In addition to those adults who have daily care of a child, a variety of other adults such as estranged parents, grandparents or other family members may play a significant part in the childs life. Some children may also have been supported by adults outside the family during periods of difficulty, depending on their age and maturity. Children may themselves be able to identify adults who provide a supportive influence in their lives.

Part 3: statutory child care proceedings

Children Act 1989 The Children Act 1989 places specific duties on agencies to co-operate in the interests of vulnerable children. Of particular relevance to doctors are Section

Guidance from the BMAs Ethics Department

17, which places a general duty on every local authority to safeguard and promote the welfare of children within their area who are in need, and Section 27, which provides that a local authority may request help from any health authority, Special Health Authority or National Health Service Trust in pursuance of its duty to provide support and services for children in need. Section 47 places a similar duty on the same bodies to respond to a request to help a local authority in its enquiries in cases where there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. Doctors should respond to a request for assistance in making enquiries unless doing so would be unreasonable in all the circumstances of the case.14 It is important that doctors who may come in contact with children in need are familiar with the relevant parts of the statutory proceedings for the care and protection of children. These can be quite complex, and the key areas that doctors are likely encounter are given below. Doctors should bear in mind however that local procedures may vary. The concept of significant harm The Children Act 1989 introduced the concept of significant harm as the threshold for compulsory intervention in child protection cases. As discussed above, where local authorities have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm they are under a duty to investigate the claim. Furthermore, courts can only make a care or supervision order if they are satisfied that: The child is suffering, or is likely to suffer, significant harm; and That the harm or likelihood of harm is attributable to a lack of adequate parental care or control. There are no absolute criteria by which significant harm can be judged, but decisions in this area will involve a consideration of the effect of any ill-treatment on the childs overall physical and psychological health and development. Any doctor working with children who may have to refer children onward for treatment or investigation should also ensure that they are familiar with appropriate professionals among the local providers of specialist health services, such as paediatricians. Emergency protection proceedings Where there is a risk to the life of a child or a likelihood of serious immediate harm, an agency with statutory child protection powers either the local authority, the police or the NSPCC can act quickly to secure the immediate safety of the child. Doctors do not have powers to intervene directly, and their role here is usually limited to the initial process of referral or to the subsequent provision of information where required. Where doctors believe that a child is immediately at risk of serious harm, they should inform the police or social services without delay, usually by telephone, and confirm the telephone referral in writing. When considering emergency action the agency needs to take account of whether action is also required to safeguard other children in the same household or residential institution. Responsibility for taking emergency action rests with the local authority in whose
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Child protection
area the child is found although this sometimes involve advice or action by other service providers, such as the police or the education department. Referral to social services departments Social services have a duty, under the Children Act 1989, to provide assistance to all children whose health or development may be impaired without the provision of support or services. Where a doctor or other health professional has reason to believe that a child or young person is suffering, or may be at risk of suffering significant harm, then those concerns should be referred promptly and in detail to the social services. Ordinarily it is quicker to make the initial report by telephone, but any such contact should be followed up immediately in writing. Any contact should be fully noted in the medical record, and copies of any letters sent or received should also be kept in the record. Where the child is competent, referral should ordinarily proceed with the consent of the child, although in certain circumstances, where, for example, the child or third party is at risk of serious harm, it may be necessary to act without the childs express consent. If time permits, children should be given the opportunity to consider the possibility of consensual referral. If a decision is made to go ahead without consent, the reasons for this should be discussed with the child. Where the child lacks competence, any decision to refer should ordinarily be done with the agreement of parents or carers, provided this would not put the child at increased risk of harm. At the end of the discussion about a child, both the health care professional, and the social services department should be clear about who will be taking what action, or that no further action is to be taken. These decisions, and the reasons for them should be clearly documented in the childs medical record. The social services department normally makes a decision about the next course of action within 24 hours of receiving the original referral. It decides whether there are grounds for concern about the childs health or welfare, and whether there is any potential or actual harm. Referrals may lead to no further action, to the direct provision of services, including emergency intervention, or to a fuller assessment of the childs needs. Any decision that social services make, including a decision to take no further action, should be relayed back, along with its justification, to the referring health care worker. This information should be clearly held in the childs medical record, bearing in mind that children and carers have rights of access to the medical record. (For further information about rights of access to medical records, see the BMAs guidance note, Access 15 to health records by patients. ) Section 47 enquiries As discussed above, Section 47 of the Children Act 1989 places a duty on Trusts to respond to a request to help a local authority in its enquiries in cases where there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm. Where doctors are asked to respond to Section 47 enquiries, the consent of the child, where he or she has capacity, should be sought. If the child lacks capacity, the consent of the parent or career should be sought. Information can be released without consent, however, where

Guidance from the BMAs Ethics Department

seeking consent is likely to increase the risk to the child or children concerned, or to a third party. Criminal proceedings Significant harm to children gives rise to both child welfare and law enforcement concerns. The police have a duty to carry out thorough and professional investigations into allegations of crime, and the obtaining of good evidence is often in the best interests of a child, as it may make it less likely that a child victim will have to give evidence in court. It also contributes to the development of a sound empirical base upon which to develop future support and help for the child and family. On the other hand, children should not be exposed to multiple intimate examinations simply in an attempt to provide evidence for court proceedings. Doctors and other health care workers therefore need to keep in mind that child protection work can lead to criminal proceedings. Leading or suggestive communication with children or other members of the family should always be avoided. Advice should be sought either from the police or the Trust legal team where a doctor believes that criminal offences may have been committed. Initially, such discussions should respect the confidentiality of the individuals concerned, unless or until evidence of harm is established when it may be necessary to proceed without the consent of parents, carers, or, exceptionally, the children concerned.

Child protection
Membership of the initial child protection conference will usually include: those with parental responsibility the child social/key worker and first line manager police officer health services involved with child or children education services standing members, if applicable, such as child protection officers Doctors have a key role to play in child protection case conferences and the BMA considers it important that, as far as possible, doctors should attend them in person, rather than sending in a written report. The BMA recognises, however, the difficulties for GPs if such case conferences are called at short notice. Wherever possible, Area Child Protection Committees should give GPs adequate advance notice. Where doctors are unable to attend in person, they should pay due attention to the confidentiality of any written report they submit, taking into account the guidelines in the following section. Child protection case conferences and confidentiality The BMA receives many inquiries about the extent of doctors obligations to release confidential information at child protection conferences. The evidence and opinion that doctors provide at these conferences can be fundamental to an understanding of the childs circumstances, but doctors often express concerns about the extent to which other participants are under a similar professional duty of confidentiality. Doctors attending case conferences should only release information that is both relevant to the purposes of the case conference and in the best interests of the child or children concerned. Occasionally, doctors may need to request that sensitive information is released in a limited fashion, either to selected individuals or to the chairman of the conference. Once a child protection conference has been convened, parents or carers should have been informed of the proceedings, and their co-operation should be sought when disclosing information. When doctors are attending case conferences, it is important that, as far as possible, they present clinical information in a way that can be understood by all those attending the conference. It can be difficult for nondoctors to assess the significance of some clinical data and it is important that the conference reaches a decision based on sound and clearly understood evidence. Action following the initial child protection conference When a child is placed on the child protection register, one of the child care agencies with statutory powers, either the NSPCC or the social services, takes responsibility for the childs case and designates a member of its staff as a key worker. Where doctors and other health care workers are professionally involved with children who have been placed on the register, they should identify the name and contact details of the key worker. This information should be placed in the childs medical record. The key worker is responsible for acting as lead worker for the inter-agency work with the child and family. She or he should co-ordinate the contribution
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Part 4: child protection case conferences and follow-on

Child protection case conferences The child protection conference is a key feature of the child protection process. A conference is usually called after the social services and police have investigated some initial concerns about the welfare of a child (s.47 enquiries under the Children Act 1989) and decided they require further investigation. The case conference usually brings together a variety of professionals who have involvement with the child concerned. The main role of the child protection conference is to assess the childs well being, to consider whether they are suffering or are likely to suffer significant harm, and to decide what future action, if any, needs to be taken to support the child. A decision will also be made as to whether or not the child or children should be put on the Child Protection Register. The conference usually makes recommendations about whether it is necessary to take any legal action to protect the child, and whether the police should take any action if a crime has been committed. If the child is put on the register, the conference must also put together a child protection plan that sets out how the childs needs are to be met in the future. This plan should make it clear what is expected of each agency involved in the childs care and protection. The details of the care plan are usually decided at a core group meeting held after the conference, which is composed of those agencies who are most closely involved with supporting the child in the future. Once a child has been put on the Child Protection Register, an initial follow-up conference is usually held after three months, and then, if the child remains on the register, at six monthly intervals thereafter.

Guidance from the BMAs Ethics Department

of health workers and other agencies in order to put in place the child protection plan. At the initial child protection conference, a decision may be made that the child should not be put on the child protection register. This does not necessarily mean that the child or the family does not require additional support or protection. If they do require further support, it is important that a care plan is drawn up and that all professionals involved are clear about their responsibilities in implementing the plan. Who should take the lead in child protection cases? Doctors have no legal powers to intervene in the lives of children whom they suspect may be subject to abuse or neglect, and doctors and other health care workers do not therefore assume lead responsibility. Ordinarily, this responsibility rests with nominated individuals in one of the statutory bodies: the social services, the NSPCC or the police. Where doctors are involved in child protection cases, it is important that they identify the lead professional as soon as possible and ensure that lines of communication remain open. Nevertheless doctors often have a good relationship with the family and can be influential in encouraging good parenting and assisting the family in remaining together. It is frequently the case that doctors, having passed on concerns about a child to the police or social services, will continue to see the child in a professional capacity. If the doctor considers that there is new evidence of abuse, or that initial concerns have not been listened to, then it is important to take action, even where another professional may have overall responsibility. Action could include further discussion with the lead professional or the Trusts nominated child care professional. If the concerns are sufficiently serious, doctors may consider requesting that social services convene, or reconvene, a child care conference. Where a doctor has raised concerns about deliberate harm, it is important that he or she ensures that, in any future appraisal, each of the concerns has been fully 16 addressed, accounted for and documented. Where doctors or other health care workers have been involved with caring for the child or family, or have taken part in enquiries, they have the right to request that social services convene a child protection conference if they have serious concerns that a child may not otherwise be adequately protected. Collaborative working Effective support and protection for vulnerable children can only be provided by an inter-disciplinary team of health and social care professionals, and the effectiveness of this team, in turn, depends upon good liaison and communication between separate agencies and professionals. All doctors who may have contact with vulnerable or at risk children must ensure that they are aware of whom to contact in the local hospital, health authority, social services and police should they need to raise any concerns. Another of the recommendations of the Climbi report was the need to develop a common language to be used across different agencies in order to ensure that an evidencebased consensus could be reached by all those involved in decision-making. Health professionals have a responsibility to ensure that any communication they
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Child protection
have with external agencies is expressed in language that is, as far as possible, clear to non-health professionals.

Part 5: serious case reviews

Where a child dies, and abuse or neglect is known or suspected to be a factor in the death, local agencies, including the health services should consider immediately whether there are other children at risk of harm who need safeguarding, such as siblings or other children in an institution where abuse is alleged, and take appropriate action. Subsequently, the Area Child Protection Committee (ACPC) has a responsibility to convene a case review panel (commonly known as Part 8 reviews). Case review panels are also convened where a child commits suicide. ACPCs also have the discretion to convene a case review in cases of serious injury to a child where abuse or neglect is considered to be a factor, and the case gives rise to concerns about the way in which local professionals and services work together to safeguard children. The purpose of these reviews is to: establish if there are lessons to be learned about the way in which local professionals and agencies work together to safeguard children identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result, and therefore to improve inter-agency working and to better safeguard children A serious case review is not, and forms no part of, a criminal investigation, nor is its goal to identify how a child died or who was culpable. This is a matter for the Coroners and Criminal Courts. The findings may, however, be used as a basis for further professional investigations. Confidentiality and serious case reviews It is important that doctors and health professionals contribute to serious case reviews where they have had responsibilities for the care or treatment of the child. Questions arise, however, about the extent of doctors duties to release confidential information to Part 8 reviews without consent. This can be further complicated, in some instances, by ongoing criminal proceedings, and concerns about prejudicial disclosure. Where criminal proceedings have been commenced, it is important that those responsible for co-ordinating the review discuss with the relevant criminal justice agencies how it should best take account of the proceedings. This would include matters such as the timing and structure of the review, which individuals should contribute at what stage, and whether some information should be withheld until criminal proceedings have finished. Where doctors have concerns about releasing information in these contexts, they should ensure they discuss the matter with the professionals co-ordinating the review. The Trusts designated professional can also be a useful source of advice. In terms of confidential patient information, it is important to recognise that as the goal of the review is to analyse the way in which local professional agencies work together, much useful work can be done without releasing confidential information. Having said this,

Guidance from the BMAs Ethics Department

those conducting the review frequently ask for copies of the records of any children, parents or carers who may have been involved with the child, as well as the records of the deceased or injured child concerned. In these circumstances, doctors should initially ask for the consent of the person involved. Where the records relate to a child who does not have the capacity to make the decision, then ordinarily someone with parental responsibility should give consent. Where consent is not forthcoming, doctors will need to carefully balance the need to maintain confidentiality to the child, family members and others with the responsibility to provide relevant information in the public interest to those with a legitimate need to know. As the purpose of the review is to look at inter-agency working, it is unlikely that the information will need to be released without consent for the immediate protection of a child. Nevertheless, there is a genuine public interest in ensuring that relevant information is exchanged in order to ensure the proper protection of children, and this will need to be weighed in the balance. Decisions will need to be made on a caseby-case basis, but doctors need to recognise that without consent, confidential information should not be released without either a legal obligation, such as a court order or statutory obligation, or where there is a strong public interest justifying disclosure. A decision to disclose on the grounds of public interest is likely to be based at least in part on a balancing of several moral imperatives, including the risk and likelihood of harm if no disclosure is made, and the need to maintain the trust of the patient. Doctors should bear in mind that advice can always be sought from the Trusts nominated professional, or from professional and indemnifying bodies. For further information on disclosure of confidential information, see the BMAs guidance note, Confidentiality and disclosure of health information.

Child protection
try as far as possible to work with the child, explaining in ways meaningful and sensitive to the child, the nature of the examination and the reasons that lie behind it. As in other contexts, any person with parental responsibility may provide consent. The opposition of one person with parental responsibility does not prevent valid consent being given by another. Therefore, if there are concerns about the possibility of abuse by a young childs father, for example, it may be possible to obtain consent for an assessment from the childs mother. If an assessment is necessary, and no valid consent can be obtained, legal advice must be sought and it may be necessary to apply to the courts for authorisation of an assessment. Requirements for valid consent to a child protection assessment To obtain legally valid consent, it is necessary for the person giving consent to be informed of the nature and purpose of the proposed assessment. The person giving consent should not be deceived or misled about the purpose of an assessment. Being open about the purpose is clearly necessary when an assessment is requested by a statutory agency responsible for child protection (for example, social services or the police). The need to avoid unnecessary assessments The courts have emphasised that it is harmful for children to be exposed to an unnecessarily large number of assessments. For example, in the case of Re CS, the High Court heard that a child had been subjected to 12 intimate physical examinations by the 19 same doctor. Mrs Justice Bracewell said: By reason of the failure of the court to control the examination of [the child], she was, in my judgment, subjected to abusive intimate examinations on more 20 occasions than could possibly be justified. Once legal proceedings have begun, the court is responsible for deciding whether an assessment is required for the purposes of the proceedings, having regard to the childs welfare. Nevertheless, there is a danger that children may be repeatedly assessed before court proceedings have been initiated. For example, one parent may be convinced that the other parent is abusive, and be determined to seek evidence to confirm this. In other cases, a parent may agree to a series of assessments at the request of a local authority, because of a fear that the local authority will initiate care proceedings if consent is not granted. In such situations, professionals must exercise independent judgment in deciding whether a further assessment is necessary and in the childs interests. Where there are concerns that inappropriate and unnecessary assessments are being carried out, it has been suggested that an order could be sought from the court, prohibiting a parent from granting consent for further assessments.21 The role of the court under the Children Act Once legal proceedings under the Children Act (or its 22 equivalent in other UK jurisdictions ) have been initiated, the court is responsible for making decisions about the conduct of the proceedings, including whether

Part 6: examination or assessment for child protection purposes

This section describes the doctors role in obtaining consent for an examination or assessment of a child for child protection purposes. It also outlines the permission which is required if proceedings under the Children Act 1989 (or its equivalents in other UK jurisdictions) have been started, what to do if the child refuses examination or assessment, and the role of the expert witness. Further advice is available jointly from the Royal College of Paediatrics and Child Health and the Association of Police Surgeons.17 The need for consent Except in an emergency, any examination or assessment which involves physical contact with the child requires consent (from a competent child, a parent or another person with parental responsibility), or authorisation from a court. Even if assessment does not involve physical contact, (for example an interview as part of a psychological or psychiatric assessment), consent is required.18 In exceptional circumstances, particularly with young children, it may be in the best interests of the child to undergo an examination without explicit consent. These circumstances are likely to be infrequent, and would require clear justification based upon an informed judgement of the best interests of the child. In these circumstances doctors should make a clear record of the decision to go ahead, and its justification in the childs medical notes. Doctors should
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Guidance from the BMAs Ethics Department

any assessments should be carried out. The Family Proceedings Rules 1991 state: No person may, without the leave of the court, cause the child to be medically or psychiatrically examined, or otherwise assessed, for the purpose of the preparation of expert evidence for use in the 23 proceedings. Therefore, before undertaking an assessment for the purpose of legal proceedings, medical professionals should confirm that the court has granted permission (known as leave) for the assessment. Obviously this requirement does not prevent any assessment which is necessary for the childs health, since this is not undertaken for the purpose of the preparation of expert evidence. In addition, when the court makes certain orders, it can positively direct that an assessment should take place, or direct that there is to be no examination of the child. For example the Children Act states: (6) Where the court makes an interim care order, or interim supervision order, it may give such directions (if any) as it considers appropriate with regard to the medical or psychiatric examination or other assessment of the child; but if the child is of sufficient understanding to make an informed decision he may refuse to submit to the examination or other assessment. (7) A direction under subsection (6) may be to the effect that there is to be -(a) no such examination or assessment; or (b) no such examination or assessment unless the court directs otherwise.24 Similar provisions apply to emergency protection orders and child assessment orders.25 Refusal of examination It is significant that the sections of the Children Act which allow the court to direct that an assessment should take place also state that a child who is of sufficient understanding to make an informed decision may refuse to submit to the examination or assessment.26 Therefore, even where an assessment has been specifically authorised by a court, it is still necessary to assess the level of the childs understanding, and to seek the childs agreement, before proceeding with the assessment. Recommendations concerning a child's refusal Where a child refuses to co-operate with an assessment, there are several possibilities. It may be decided that assessment is impossible without the childs co-operation, or that it would be inappropriate to proceed in the face of the childs objections. In these circumstances, legal advice should be sought. It may be decided that the child lacks sufficient understanding to make an informed decision. An authorised assessment can lawfully proceed despite the childs objections, although health professionals may well be unwilling to proceed in such circumstances. If it is likely to be necessary to use force or sedatives to overcome the childs resistance, legal advice should be sought. It may be decided that the child is considered to have sufficient understanding to make an informed
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Child protection
decision. In these circumstances, the court has no power under the Children Act to override the childs refusal. However, in the case of South Glamorgan County Council v W and B,27 it was decided that the High Court exercising its inherent jurisdiction may authorise an assessment against the wishes of a competent child if the child would otherwise be likely to suffer significant harm. This power is not available in magistrates courts or county courts, and this precedent is unlikely to be followed in Scotland. Carrying out assessments of children against their wishes is very controversial. Such assessments are unlikely to be appropriate unless: there is a high probability that useful evidence can be obtained; the evidence cannot be obtained in any other way; and the benefit to the child from obtaining the evidence outweighs the burdens involved in imposing the assessment on the child. The role of the expert witness Specific guidance on providing expert evidence for courts is provided in the professional literature.28 There are now also a large number of judicial decisions, where the courts have given guidance on the appointment of 29 experts. The important points are summarised below. Information to be provided to experts Experts should seek further information and documentation when required. Doctors who have prior clinical experience of a child should have all clinical materials in advance of the hearing for inspection by the court and other experts. This might include medical notes, hospital records, x-rays, photographs and correspondence. Experts who are to give evidence must be kept up to date with developments in the case relevant to their opinions and it is the duty of the solicitor instructing the expert to provide such information.

Duties of experts Expert evidence presented to the court should be, and should be seen to be, the independent product of the expert, uninfluenced by others. Experts should provide independent assistance to the court by objective unbiased opinion, in relation to matters within their expertise. Experts should state the facts or assumptions on which their opinions are based, and should not omit to consider material facts which detract from their conclusions. Experts should make it clear when a particular aspect is outside their expertise. If an expert opinion is not properly researched by reason of insufficient data, then this must be stated with an indication that the opinion is provisional. If at any time an expert changes his or her opinion on a material matter, this information must be communicated to the other parties, and when appropriate, to the court. If an opinion is based, wholly or in part, on research conducted by others, this must be clearly set out in the report, the research relied on must be identified,

Guidance from the BMAs Ethics Department

and the expert must be prepared to justify the opinions expressed. Further advice Further advice on these issues may be sought from professional, regulatory or indemnifying bodies. Conclusion Doctors are, and are likely to remain, central to the provision of good care and support for vulnerable children and their families. The Climbi report drew attention both to the tragedy of child abuse, and to the complex, multi-agency response that is required to combat it. Where several different agencies or professionals share joint responsibility, however, it is clearly possible for vulnerable children to be overlooked. Where doctors have concerns about a child who may be at risk of abuse or neglect, it is essential that these concerns are acted upon, in accordance with the guidance in this note, or other local and national protocols. Where suspicions of abuse or neglect have been raised, doctors must ensure that their concerns, and the actions they have either taken, or intend to take, including any discussion with colleagues or professionals in other agencies are clearly recorded in the child or childrens medical record. Where doctors have raised concerns about a child with colleagues or with other agencies and no action is regarded as necessary, doctors must ensure that all individual concerns have been properly recognised and responded to. When working with children who may be at risk of neglect or abuse, doctors should judge each case on its merits, taking into consideration the likely degree of risk to the child or children involved. Disclosure of information between professionals from different agencies should always take place within an established system and be subject to a recognised protocol. This guidance applies equally to both information about children who may be subject to abuse, a well as to information about third parties, such as adults who may pose a threat to a child. There is, finally, a need for both further evidence based research and medical education and training in this field. Professionals working in this area should therefore try actively to encourage and promote these activities. Further reading British Medical Association. Medical ethics today: the BMAs handbook of ethics and law. London: BMA, 2004. British Medical Association. Consent, rights and choices in health care for children and young people. London: BMJ Books, 2001. British Medical Association. Confidentiality and disclosure of health information. London: BMA, 1999. British Medical Association, General Medical Services Committee, Health Education Authority, et al. Confidentiality and people under 16. London: BMA, no date. Department of Health. Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. Norwich: TSO, 1999.
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Department of Health and Home Department. The Victoria Climbi inquiry. Norwich: TSO, 2003 Department of Health. What to do if youre worried a child is being abused. London: DoH, 2003. Department of Health and Home Department. The Victoria Climbi inquiry. Norwich: TSO, 2003.

June 2004 BMA 2004

Medical Ethics Department British Medical Association BMA House, Tavistock Square, London WC1H 9JP Tel 020 7383 6286 Fax 020 7383 6233 E-mail ethics@bma.org.uk Web www.bma.org.uk References
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General Medical Council. Confidentiality: protecting and providing information. London: GMC, 2000. para 39. Department of Health and Home Department. The Victoria Climbi inquiry. Norwich: TSO, 2003 Department of Health. What to do if youre worried a child is being abused. London: DoH, 2003. Department of Health, British Medical Association, Conference of Medical Royal Colleges. Child protection: medical responsibilities. Department of Health, Department for Education and Employment and the Home Office. Framework for the assessment of children. London: TSO, 2000. http://www.doh.gov.uk/qualityprotects/work_pro/project_3.ht m. Department of Health, Department for Education and Employment and the Home Office. Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. London: TSO, 1999. http://www.doh.gov.uk/pub/docs/doh/safeguard.pdf. British Medical Association. Parental responsibility guidance from the ethics department. London: BMA, 2004. Department of Health. Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children. Norwich: TSO, 1999: 5-6. For further information on the impact of the Human Rights Act 1998 on decision-making in health care see, British Medical Association. The impact of the Human Rights Act 1998 on medical decision making. London: BMA, 2000. British Medical Association. Consent, rights and choices in health care for children and young people. London: BMJ Books, 2001. 14. See, Every child matters. Norwich: TSO, 2003. For further information on confidentiality and children see: British Medical Association, Royal College of General Practitioners, Brook Advisory Centres et al. Confidentiality and people under 16. London; BMA et al. Undated. For a more detailed discussion, see: British Medical Association. Consent, rights and choices in health care for children and young people. London: BMJ Books, 2001. Children Act 1989, s47 (10). British Medical Association. Access to health records by patients. London: BMA, 2000. Department of Health and Home Department. The Victoria Climbi inquiry. Norwich: TSO, 2003. Royal College of Paediatrics and Child Health, The Association of Police Surgeons. Guidance on paediatric forensic examinations in relation to possible child sexual abuse. London: RCPCG, APS, 2002. http://www.rcpch.ac.uk/publications/recent_publications/Chil d_sex_abuse.pdf. The courts have stated that a decision whether a child should be interviewed is an aspect of parental responsibility and that therefore consent is needed. Re F (Minors)

Guidance from the BMAs Ethics Department

(Specific Issue: Child Interview), sub nom Re F (Minors) (Solicitors Interviews) [1995] 1 FLR 819, [1995] 2 FCR 200 , CA. Re M (Minors: Interview), sub nom Re M (Minors) (Solicitors Interviews); Re M (Care: Leave to Interview Child) [1995] 1 FLR 825, [1995] 2 FCR 643, [1995] Fam Law 404. Re CS (Expert Witnesses) [1996] 2 FLR 115. Re CS (Expert Witnesses) [1996] 2 FLR 115 at 119. D v D (County Court Jurisdiction: Injunctions) [1993] 2 FLR 802, [1994] Fam Law 8. Children (Northern Ireland) Order 1995. Children (Scotland) Act 1995. Family Proceedings Rules (SI 1991/1247). Family Proceedings Rules (SI 1991/1247). Children Act 1989 s43 and 44. The Children (Northern Ireland) Order 1995 art 62 and 63. 11 Children Act 1989 s38(6). The Children (Northern Ireland) Order 1995 art 57(6). Children (Scotland) Act 1995 s90. 11 Children Act 1989 s38(6). The Children (Northern Ireland) Order 1995 art 57(6). Children (Scotland) Act 1995 s90. Royal College of Physicians. Physical signs of sexual abuse in children. London: RCP, 1997. See also Black, D, Harris-Hendricks J, Wolkind S. Child psychiatry and the rd law, 3 edition. London: Gaskell, 1998: chapters 3 and 4. British Medical Association. Medical ethics today: the BMAs handbook of ethics and law. London: BMA, 2004. 576. Children Act Advisory Committee. 1994/5 Report of the Children Act Advisory Committee. London: Lord Chancellors Department, 1996. 25-26

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