Health professionals are well placed to identify families who need early help. They have an overview of issues affecting individual family members that may impact on a child's welfare. They are also in a position to co-ordinate the work of different agencies supporting children and families.
Reasons case reviews were commissioned
This briefing is based on case reviews published between 2013 and 2015 that have highlighted lessons for health professionals to improve safeguarding practice.
In these case reviews, children died or suffered serious harm in a number of different ways:
- non-accidental injuries
- physical neglect
- emotional neglect
- child sexual exploitation.
Key issues for the health sector in case reviews
Seeing the bigger picture
Case reviews warn professionals against focusing exclusively on a child's physical health needs. The impact of emotional stress on some medical conditions should be considered. When professionals work with a large number of families with similarly complex needs, there is a risk that issues such as drug and alcohol misuse become "normal". This can mean professionals are less alert to the dangers posed to children and can become desensitised to safeguarding risks.
GPs are best placed to get an overview of the issues facing a family and how these might impact on parents' ability to care for their children. Case reviews found that some GPs were not recognising the "social aspects" of a case and did not have a sense of problems accumulating within a family.
The case reviews uncovered a number of reasons for these difficulties in GPs:
- a system of accountability which focuses too much on measurable disease outcomes rather than on holistic health and wellbeing outcomes
- complex family structures: family members with different surnames and addresses, and adults who change partners
- a move towards larger practices with a number of full- and part-time GPs that has affected continuity of care.
Challenging parents and hearing the child's voice
Although it is very rare, parents can sometimes be deceptive or manipulative when reporting children's health problems. In some case reviews, professionals were relying too much on parents' reports and not examining the child or observing their behaviour.
Repeat prescriptions were also issued by administrative staff over a long period without the doctor seeing the child. It is important to gather the views of children and other family members, particularly if one parent is dominant or assertive.
Case reviews also highlighted professionals' reluctance to challenge parents' views or probe for further information for fear of provoking a confrontation. When practitioners have to deal with parents who are hostile and aggressive, they focus too much on the parents and not enough on the impact this behaviour will be having on their children.
Following up missed appointments
Children rely on their parents and carers to take them to medical appointments, so missed appointments are always a cause for further action. Failure to attend appointments is recognised as a child protection issue within statutory definitions of neglect.
Reviews have noted a tendency to record missed appointments, but no collation of information or questioning its significance. Reviews criticised the system of flagging non-attendance at medical appointments as DNA (Did Not Attend) which in some cases led to a withdrawal of services.
Dealing with incidents in isolation is especially common in hospital emergency departments where there is a high turnover of patients. Considering previous hospital admissions can help professionals distinguish non-accidental injuries from other medical conditions.
Identifying and responding to child abuse
Case reviews stress being aware of the significance of bruising on non-mobile babies and the importance of referring cases to children's social care with accurate information.
A lack of key medical diagnostic services can lead to failure to quickly identify and respond to injuries suffered by the child.
Some case reviews found that GP postnatal checks were a tick-box exercise with not enough analysis of potential indicators of child neglect such as slow weight gain.
Some reviews flagged the issue of not considering child protection and safeguarding issues when treating teenagers under the age of 18, particularly in A&E.
Some case reviews criticised the system of assigning health visitors to a geographical area rather than a specific GP. This can result in little or no information being exchanged between health visitors and GPs. Information sharing is also compromised when the full range of health professionals working with a family fail to attend child protection conferences and core groups.
Working with professionals in social care and other agencies
Reviews highlighted that health professionals were uncertain about what level of concern should prompt a referral and how to escalate concerns when a referral has not been dealt with.
There was reluctance on the part of health professionals to challenge social workers on the presumption that they knew best. There was also a tendency to not persist in flagging "niggling concerns" because of the complications of multi-agency work.
Learning for improved practice
Having a family focus
- Find out each patient's family details and their links to children. Record these and tell other agencies when this information is relevant to an assessment of need.
- When working with mothers, make regular enquiries about male partners.
- Make routine enquiries about parents' drug and alcohol use, and domestic abuse.
- Always ask patients with mental health difficulties, learning difficulties or drug and alcohol misuse whether they have significant child care responsibilities. Consider their capacity to care for children safely and record information.
- GPs who work with different members of the same family need to share information with each other on a regular basis.
- Explore how continuity of care can be improved by individual patients and members of the same family seeing fewer GPs and healthcare professionals.
- Develop documentation which prompts an assessment of the social history and background of the child and their family.
- When treating a child who may have sustained non-accidental injuries, it is important to make enquiries about any other children who may be at risk.
- Implement a system to alert hospital staff to children on child protection plans.
Listening to and seeing the child
- Do not automatically accept a parent's or carer's report without talking to the child and, if possible, other family members and close friends.
- When referring children, highlight anything that has only been reported by adults or has not been observed by professionals.
- Be alert to patterns in parents' and children's behaviour over time that may indicate the child is at risk of abuse or neglect.
- Do not give repeat prescriptions to children without a GP regularly examining the child.
- Be prepared to challenge parents and carers to gather information about a child's wellbeing.
- Provide training for staff that models how to challenge parents and carers effectively and gives staff the confidence to inquire into potential abuse.
Responding to missed appointments
- Always follow up a child's missed appointments. Consider changing the non-attendance code from DNA (Did Not Attend) to WNB (Was Not Brought) which should prompt more positive intervention.
- Liaise with health, police and social care about arrangements for hospital discharge and the after-care of vulnerable children.
Recognising child abuse
- Always be aware of the significance of bruising on non-mobile babies. Refer these cases to children's social care with full and accurate information which includes a medical and social history, and the explanation given by the parent.
- Look for signs of trauma in seriously ill babies when there is no clear cause of illness.
- Take clinical photos as near to the time of injury as possible to record the greatest detail and include the photos in all formal child protection reports.
- During post-natal checks, remove a baby's nappy before weighing. Plot the baby's weight on the growth centile chart.
- Professionals should document they have read and understood the nature of safeguarding concerns about the child they are treating.
- Record discussions that take place during a medical supervision meeting where safeguarding concerns are identified.
Effective information sharing
- GPs should automatically share their records with health visitors and vice versa.
- If a GP cannot attend a child protection conference, they should ensure that another member of the primary health care team attends to represent their views.
- Health commissioners should ensure primary health care teams have access to prison health records and court reports to identify adults who may pose a risk.
Working with other professionals
- Ensure there are policies and procedures for challenging professionals in other agencies who are not responding to concerns about a child.
- When referring to children's services and other agencies, make sure that referrals are clear and concerns are spelt out.
- GPs have the best overview of all services involved with a child and their family.
- Be prepared to communicate with out-of-hours GPs to provide them with the information they need to weigh up risks to a child.
- Follow up any recommendations made by an out-of-hours GP about a child quickly and inform them of outcomes.
Supervision and workloads
- Newly qualified health professionals need to discuss all their complex safeguarding cases during supervision.
- Experienced practitioners should bring a handful of complex cases to supervision for in-depth discussion and analysis.
- Supervisors should encourage their staff to reflect on the emotional impact of managing complex cases.
Physical Signs of Child Sexual Abuse, Review and Guidance for Best Practice, Royal College of Paediatrics and Child Health, 2015
Safeguarding Children and Young People: Roles and Competences for Health Care Staff, Intercollegiate document, third edition, March 2014
Child Protection Companion. Covers the child protection processes across the whole range of medical and social interactions. Royal College of Paediatrics and Child Health, 2013