Paediatric Assessment for Section 47 Enquiry (Child Protection Medical)

A Strategy Meeting must be convened when there is reasonable cause to suspect that a child is suffering or is likely to suffer significant harm and a Strategy Meeting is required to decide whether a Section 47 Enquiry under the Children Act 1989 is required or not. For more information, see Strategy Discussions/Meetings Procedure.

The on-call consultant Paediatrician for safeguarding should be included in the Strategy Meeting if it is likely that there will be a need for a medical examination. Strategy Meetings must consider, in consultation with the paediatrician (if not part of the discussion or meeting), the need for and timing of a paediatric assessment (child protection medical).

Where the child appears in urgent need of medical attention (e.g. suspected fractures, bleeding, loss of consciousness), they should be taken to the nearest accident and emergency department.

In other circumstances, the strategy meeting will determine, in consultation with the paediatrician, the need and timing for a paediatric assessment. Where a child is also to be interviewed by police and / or Children's Social Care, this interview should take place prior to a medical examination unless there are exceptional circumstances agreed with the police and social work service.

If the decision of the Strategy Meeting is to instigate Section 47 Enquiries, then the Paediatrician should arrange for appropriate medical tests, examinations or observations to be undertaken to determine how the child’s health or development may be being impaired. In planning Section 47 Enquiries and investigations, social workers and police officers must consider the need for a medical examination in all children for whom concerns exist, including whether there are any other children in the household or extended family who may also require a paediatric assessment.

For further information see Child Protection Enquiries - Section 47 Children Act 1989 Procedure and Appendix 1: Paediatric Assessment for Section 47 Enquiry – flowchart.

A paediatric assessment should demonstrate an holistic approach to the child and assess the child's well-being, including mental health, development and cognitive ability.

A paediatric assessment is necessary to:

• Secure forensic evidence;
• Obtain medical documentation;
• Provide reassurance for the child, parent and Children's Social Care;
• Inform treatment follow-up and review for the child (any injury, infection, new symptoms including psychological).

Only doctors may physically examine the whole child. All other staff should only note any visible marks or injuries on a body map and record, date and sign details in the child's file.

The following may give consent to a paediatric assessment:

• A child of sufficient age and understanding (Gillick competent/ Fraser Competent);
• Any person with Parental Responsibility, providing they have the capacity to do so;
• The local authority when the child is the subject of a Care Order (though the parent should be informed);
• The local authority when the child is accommodated under Section 20, and the parent/s have abandoned the child or are physically or mentally unable to give such authority;
• The High Court when the child is a ward of court;
• A family proceedings court as part of a direction attached to an Emergency Protection Order, an Interim Care Order or a Child Assessment Order.

When a child is looked after under Section 20 and a parent has given general consent authorising medical treatment for the child, legal advice must be taken about whether this provides consent for paediatric assessment for child protection purposes (the parent still has full parental responsibility for the child).

A child of any age who has sufficient understanding - generally to be assessed by the doctor with advice from others as required - (Gillick competent/ Fraser Competent) - to make a fully informed decision can provide lawful consent to all or part of a paediatric assessment or emergency treatment.

A young person aged 16 or 17 has an explicit right (s8 Family Law Reform Act 1969) to provide consent to surgical, medical or dental treatment and unless grounds exist for doubting their mental health, no further consent is required.

A child who is of sufficient age and understanding may refuse some or all of the paediatric assessment, though refusal can potentially be overridden by a court.

Wherever possible the permission of a parent should be sought for children under sixteen prior to any paediatric assessment and / or other medical treatment.

Where circumstances do not allow permission to be obtained and the child needs emergency medical treatment, the medical practitioner may:

• Regard the child to be of an age and level of understanding to give their own consent;
• Decide to proceed without consent.

In these circumstances, parents must be informed by the medical practitioner as soon as possible and a full record must be made at the time.

In non-emergency situations, when parental permission is not obtained, the social worker and manager must consider whether it is in the child's best interests to seek a court order.

In the course of Section 47 Enquiries, appropriately trained and experienced medical practitioners must undertake all paediatric assessments. Referrals for child protection paediatric assessments from a social worker or a member of the police are made as outlined in Section 5, Paediatric Assessment Clinics.

Single examinations should only be undertaken if the person has the requisite skills and equipment. For further guidance for paediatricians and forensic medical examiners (see the Guidelines on Paediatric Forensic Examinations in Relation to Possible Child Sexual Abuse (The Royal College of Paediatrics and Child Health - October 2012).

In cases of severe neglect, physical injury or penetrative sexual abuse, the assessment should be undertaken on the day of referral, where compatible with the welfare of the child.

The need for a specialist assessment by a child psychiatrist or psychologist should be considered.

In planning the examination, the Police Child Abuse Investigation Team (CAIT) officer and relevant doctor must consider whether it might be necessary to take photographic evidence for use in care or criminal proceedings. Where such arrangements are necessary, the child and parents must be informed and prepared and careful consideration given to the impact on the child.

In cases of suspected abuse, GPs must not perform a detailed examination unless this is agreed by the police and Children's Social Care. The assessment may be carried out jointly by a forensic medical examiner and a paediatrician. If a forensic medical examiner is not available, two paediatricians may carry out the assessment provided one has received forensic training. In these cases, a CAIT officer should directly brief the doctors and take possession of evidential items.

The Paediatric Assessment Clinics have been set up to ensure children in need of a paediatric assessment are seen in a timely manner, proportionate to their needs, and that the pressure of seeing such children is relieved from the on-call doctors, particularly out of hours.

The clinics follow the following format:

Clinic structure

• A child protection medical clinic will run every week day afternoon, Monday to Friday and have two daily appointments at 13.30hrs and 14.30hrs;
• Clinics on a Monday, Wednesday and Friday will be held in Children’s Outpatients (floor C Rotherham Hospital) and those on a Tuesday and Friday will be held on the Children’s Assessment Unit (floor A Rotherham Hospital).

Clinic Staffing

• The clinics will be conducted by a designated paediatric registrar, under the supervision of the ward based consultant;
• On a Tuesday and Friday, the clinic will be run by one of the community registrars, on a Monday, Wednesday and Thursday the clinic will be run by a ward based registrar;
• It is expected that all cases will be discussed between the paediatric registrar and the ward based consultant;
• If there are no appointments booked on a clinic day, the designated registrar needs to ensure they are available should any appointments are required at short notice.

Referral to clinic

• All children requiring a child protection medical will be referred via the on call Paediatric Registrar on bleep 346;
• At time of referral, the person referring will be required to provide the following information relating to the referral including:
  • Reason for referral;
  • Urgency of appointment – (see Section 7, Guidance Regarding Urgency of Appointments);
  • Child's full name;
  • Current address;
  • Date of birth;
  • Registered GP;
  • Name of parent/ carer/ legal guardian.
• The on call Paediatric Registrar will then arrange for the child to be booked in to an appropriate clinic;
• The nursing staff on clinic will request the notes and prepare the child protection pack, which will include medical photography form and growth chart;
• The on call Paediatric Registrar will contact the designated child protection clinic registrar to inform them that a child has been booked in for assessment;
• If a referral is deemed urgent (see Section 7, Guidance Regarding Urgency of Appointments) and no appointments are available, the child will need to be seen alongside the acute admissions on the children's assessment unit. The timings for attendance etc in this instance will be discussed and arranged with the on call Paediatric Registrar;
• Assessment of sibling groups, where there are more children than the number of appointments, may also be seen in the clinic at the discretion of the on call Registrar and Ward Based Consultant.

Clinic Information

• Children will be expected to arrive at least fifteen minutes prior to their clinic appointment, (i.e. 1315hr/1415hr) to allow time for details to be checked and height and weight to be measured;
• It will not be possible to see children who arrive late for their appointment, due to the time constraints of the clinic. In these cases an appointment will need re-booking or if urgent assessment is needed the child will need to be seen by the on call team on the Children's Assessment Unit, where the timing of the assessment cannot be guaranteed;
• Consent from someone with parental responsibility will be required before the medical begins. The referrer needs to ensure that this person is present or social worker confirm verbal consent from a person with parental responsibility;
• The referrer accompanying the child will be required to provide sufficient and relevant history relating to the case at the appointment as the person taking the referral will not be the same doctor as sees the child in clinic;
• The child may need to stay after their appointment for further investigations such as blood tests and medical photography. In some cases the decision may be made to admit the child to the ward;
• A chaperone will be required to be present throughout the appointment. It is appropriate for this to be the accompanying social worker dependent on age, gender and nature of examination. If this is not possible, the referrer must let clinic know as soon as possible so provision for an alternative chaperone can be made.

For more information, see Guidelines on Paediatric Forensic Examinations in Relation to Possible Child Sexual Abuse (The Royal College of Paediatrics and Child Health - October 2012).

The paediatrician should supply a report to the social worker, GP and, where appropriate, the police within 2 working days. The timing of a letter to parents should be determined in consultation with Children's Social Care and police.

The report should include:

• A verbatim record of the carer's and child's accounts of injuries and concerns noting any discrepancies or changes of story;
• Documentary findings in both words and diagrams;
• Site, size, shape and where possible age of any marks or injuries;
• Opinion of whether injury is consistent with explanation;
• Date, time and place of examination;
• Those present;
• Who gave consent and how (child / parent, written / verbal);
• Other findings relevant to the child (e.g. squint, learning or speech problems etc);
• Confirmation of the child's developmental progress (especially important in cases of neglect);
• The time the examination ended.

All reports and diagrams should be signed and dated by the doctor undertaking the examination.

Requirements specific for Rotherham reports

Paediatric Assessment Reports should be dictated, typed and sent out within 48hrs (2 working days). The registrar who has reviewed the child is responsible for ensuring dictation is completed in a timely manner. The reports will usually be typed by the secretary of the ward based consultant. They should be notified as soon as the dictation is completed, to allow timely typing.

All reports will be read and approved by the appropriate consultant prior to distribution.

In certain circumstances, the registrar who has seen the patient may not be available to approve the dictated letter, in these cases the task will fall to the appropriate consultant, with whom the case has been discussed, to ensure the 48hr turnaround is met. 

All paediatric assessments should be carried out within the timescales appropriate to the type of abuse and the requirement for collection of evidential samples.

For all paediatric assessments referrals, the doctor should make a decision about the timing of the examination, and where the examination should take place. It is good practice for the registrar to discuss this with the Ward Based Consultant Paediatrician.

It is essential to keep the best interest of the child central to the decision making.

Factors influencing the decision to include:

• Age of child;
• Time of last incident and how often it took place;
• Type of abuse;
• Severity of injury;
• Safety of the child and any siblings;
• Availability of appropriate doctor;
• Multi-agency Child Protection process.

Children with any physical injuries referred by Social Workers and Police Officers should be given an appointment within 24 hours to facilitate assessment of injuries according to the above factors.

Siblings associated with an acute Physical Injury - should be planned for the next working day following the medical on the index child. Children presenting with concerns about neglect and emotional abuse should be seen within 10 days of referral allowing clarification of the particular paediatric / developmental issues that the referrer needs addressing.

Other Examples:

• Court requested medical examinations;
• Abandonment where there is a need for early assessment e.g. for court advice;
• FGM where there are non-urgent child protection concerns;
• Self-harming behaviour with child protection concerns;
• Old physical injury.

All cases of Acute Sexual Assault and historic sexual abuse should be referred to Sheffield Sexual Abuse Referral Centre (SARC). A paediatrician may refer on to other professionals, particularly if there are suspicions of sexual abuse.

For more information about how to refer to SARC see Appendix 2: Referral Process to Sexual Assault Referral Centre (SARC) and Appendix 3: Referral Form for SARC.

Appendix 1: Paediatric Assessment for Section 47 Enquiry – flowchart.

Appendix 2: Referral Process to Sexual Assault Referral Centre (SARC).

Appendix 3: Referral Form for SARC.