Alison MottConsultant Paediatrician

Named Doctor Cardiff and Vale UHBChair Child Protection Special Interest Group

Importance of safeguarding children◦ Background legislation/ guidance

Role of anaesthetist◦ Recognition◦ Response◦ Record

Training

‘Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Children may be abused in a family or in an institutional or community setting; by those known to them, or, more rarely, by a stranger.’

Safeguarding Children: Working Together Under the Children Act 2004

Protecting children from abuse and neglect Preventing impairment of their health or

development Ensuring they receive safe and effective

care..so as to enable them to have optimum life

chances

Children Act 1989/2004

U.N. Convention on the Rights of the Child 1991

Human Rights Act 1998

Sexual Offences Act 2003

Safeguarding Children: Working Together Under the Children Act 2004

Child Protection Procedures 2008 (Wales)

Child protection and the anaesthetist: safeguarding children in the operating theatre 2007 RCPCH, RCA, APA

All health professionals play an essential part in safeguarding and promoting children’s health and development◦ Recognition◦ Assessment◦ Ongoing support◦ Therapeutic intervention

Health professionals often first to recognise families experiencing difficulties

Involves all Service groups not just Child HealthSafeguarding Children: Working Together under the Children Act 2004

To act in the best interests of the child which are always paramount

To be aware of the child’s rights to be protected; To respect the rights of the child to confidentiality To contact a paediatrician with experience of child

protection for advice (On call paediatrician for CP, Named or Designated Doctor/Nurse)

To be aware of the local Chid Protection mechanisms

To be aware of the rights of those with parental responsibility

Child protection and the anaesthetist: safeguarding children in the operating theatre RCPCH, RCA, APA 2007

Known child protection concerns◦ Management of critically ill child e.g. NAHI◦ Anaesthetise for procedure e.g. genital bleeding

Anaesthetist identifies child protection concerns◦ Recognition of signs of abuse◦ Child’s disclosure◦ Resuscitation of critically ill child

Bruises in unusual places◦ You may notice in anaesthetic room

Resuscitation ?cause Inconsistent history

◦ Is the story from parent / child consistent with◦ A) what you were told by others?◦ B) what you can see?

Lack of crying Flinching or shying away Unusual parental contact / behaviour Inappropriate affection to staff

Listen and observe Seek an explanation Record If alerting feature prompts you to

◦ CONSIDER child maltreatment◦ SUSPECT child maltreatment◦ EXCLUDE child maltreatment

Record actions/ outcome

CONSIDER◦ Look for other alerting features now or historical

AND DO ONE OR MORE OF THE FOLLOWING Discuss concerns with colleague Gather more information Review child at appropriate time

SUSPECT◦ Refer to social services

EXCLUDE◦ Suitable explanation found◦ May be after discussion with experienced colleague

or after gathering more information

The J igsaw of Child AbuseHobbs and Wynne adapted

History f romparent Child’s History Any disclosure

PhysicalSymptoms

BehaviourBruises/ I njury

PhysicalExamination Sexually

TransmittedDiseases

Forensic

Police I nquirySocial Assessment

Siblings

Consider◦ Serious or unusual injury without explanation◦ Oral injury without explanation

Suspect ◦ Bruising in non mobile child◦ Human bite mark (not child)◦ Rib fractures◦ Visceral injury

Bruises Fractures Burns Torn frenum/ oral injuries Non accidental head injury Bite marks Visceral injuries

Spiral fracture of humerus Multiple fractures Ribs Femoral fracture in non mobile child Spinal fracture Metaphyseal fracture Skull fracture

There is no published evidence to date to confirm the diagnosis of abuse based on a torn labial frenum in isolation

Any unexplained torn labial frenum should be fully investigated to exclude the presence of other occult injuries

Consider◦ Pregnancy in 13-15 year girl◦ Gaping anus

Suspect ◦ Genital injury with absent explanation◦ Pregnancy in 12 year girl

Neglect◦ Faltering growth◦ Severe dental caries◦ Persistent symptoms eg persistently smelly and

dirty, ingrained dirt Emotional abuse

◦ Domestic violence: If children living in a household with domestic violence, make a child protection referral

Parent or carer – child interactions

Appropriate medical care Be suspicious but open minded Inform parents unless not in best interests

of child Discuss any concern with

◦ Supervisor or colleague◦ Paediatrician

Ensure child safety after discharge from your care◦ Your responsibility to refer if suspect child abuse

Document all discussions

Consent issues Practicalities Prolonging anaesthetic ‘visual inspection acceptable of eg skin

lesion but any additional or intimate/ invasive examination requires additional consent’

Child protection and the anaesthetist: safeguarding children in the operating theatre RCPCH, RCA, APA 2007

Consent for anaesthetic / surgical procedure only

Need to get consent from carer with parental responsibility for child protection examination

The six stages of the Child Protection process are:◦ Referral◦ Initial Assessment◦ Strategy Discussion◦ Strategy Meeting◦ Child Protection Section 47 Enquiries by Social

Services and/or Police◦ Child Protection Conference

Anaesthetic line manager Paediatric colleagues Named professionals Designated professionals Safeguarding children structure within

Trust/ Board with clear accountability Local Safeguarding Children Boards

Communication between healthcare professionals and partner agencies (police, social services)

Training and observation of child protection procedures

Staffing and recruitment

GOSH Whittington NMUH

Day care nurses

63% 83% 100%

Consultant anaesthetists

18% 88% No data

Consultant surgeons

35% 75% 13%

Emergency care nurses

NA 23% 100%

NHS trusts’ boards should urgently review their arrangements for safeguarding children – in particular the levels of up-to-date safeguarding training among their staff.

Their reviews should be completed within six months of this report’s publication

Pharmacists 35% Surgeons, anaesthetists and theatre nurses

who treat children 42% Dental staff 42% O&G 55% Emergency care 58% Child health 65% Clinical psychologists 75%Safeguarding children: A review of arrangements in the

NHS for safeguarding children July 2009

All anaesthetists should complete Level 1 and 2 training in Child protection

Paediatric anaesthetists will need Level 3 training

DH competence levels◦ Level 1: all staff working in a healthcare setting ◦ Level 2: clinical and non clinical staff who have

regular contact with parents, children and young people

◦ Level 3: all staff working predominantly with children, young people and parents

NPHS Wales levels College levels

Level 1 - Introduction to Safeguarding Children and Young People:A single session that covers the knowledge and competences required for Level 1 Safeguarding 

  Level 2 – Recognition, Response and Record:

Three sessions that cover the knowledge and competences required for Level 2 Safeguarding

These sessions are now available on e-Learning Anaesthesia (e-LA) to ALL anaesthetists.

Plan to develop enhanced Level 2 or modified Level 3 with Department of Health for non paediatricians who work predominantly with children

34% Level 1, 52% level 2, 14% Level 3 95% mandatory training 69% training ‘fit for purpose’ 83% local course Enhanced level 2 training to include

◦ Undertake local level 1 training for anaesthetic colleagues 60%

◦ Understand forensic procedures/ practice 31%◦ Report writing 9%

Anaesthetists have important role in safeguarding children

Understand the role of anaesthetist◦ Recognition◦ Referral process◦ Record

Training mandatory◦ Enhanced Level 2 or Level 3 for paediatric

anaesthetists Guidance for anaesthetist

Child protection and the anaesthetist: safeguarding children in the operating theatre 2007 RCPCH, RCA, APA

When to suspect child maltreatmentNICE clinical guideline 2009

CQC Review of arrangements within NHS Trusts for Safeguarding children 2009

Laming Progress against actions 2009 GMC guidance