Safeguarding children

See also the separate Safeguarding Children - How to Recognise Abuse or a Child at Risk article.

General principles of safeguarding children

• The child's welfare is paramount. The child's best interests override other considerations such as confidentiality, consent and the carer's interests.

• Where there is an immediate risk of serious harm to a child, act immediately (see 'Initial actions if you think a child may be at risk', below).

• Share information with other agencies on a 'need to know' basis.

• Where possible, and if compatible with the child's best interests:
  

  • Respect the child's views.

  • Obtain consent.

  • Involve the carers (if the child is competent, this must be with the child's agreement). Do not involve carers if this would compromise the child's safety or evidence.

• Keep full and contemporaneous records.

• Remember other children in the household - are they at risk?

• All doctors have a duty to safeguard children and to ensure follow-on care for the child:
  

  • The non-specialist's role is not to make a definite diagnosis of child abuse but to recognise the possibility and enlist appropriate help.

  • The doctor concerned about a child must ensure follow-on care.

• As of 31st October 2015, health professionals have a mandatory duty to report female genital mutilation (FGM) in girls under the age of 18¹ .

If a child discloses abuse to you

• Stay calm; find a quiet place to talk.

• Believe in what you are being told. Listen but do not press for information.

• Say that you are glad that the child told you.

• Explain that the abuse was not the child's fault.

• Explain that you will do your best to help the child. Do not promise confidentiality. (See 'Confidentiality and sharing information', below.)

• Involve them in the discussion and plan of action and ask what would be a good outcome in their eyes.

Confidentiality and sharing information²

• Doctors have a statutory obligation to tell an appropriate agency (eg, local children's social services, the National Society for the Prevention of Cruelty to Children (NSPCC) or the police) promptly if they suspect that a child or young person is at risk of, or is suffering, abuse or neglect, unless it is not in their best interests to do so.

• Delaying the decision to share information with an appropriate agency where a child or young person is at risk of, or is suffering, abuse or neglect must be taken with extreme care. Such a situation might arise where the increased risk to the safety or welfare of the child or young person clearly outweighs the benefits of sharing information. The decision must be justifiable and documented, and any advice sought from a third party should be recorded.

• If there is a possibility of abuse or neglect but the child or young person is not necessarily at immediate risk of significant harm, seek advice. This would normally be from the designated lead child protection GP in the locality in the first instance.

• The importance and benefits of sharing this information with appropriate people/agencies should be explained to the child and their consent obtained if possible. If this presents a delay, the need to share the information in the case of significant risk to the child or other children should over-ride any concern about consent. Confidentiality remains important and sharing of information should be proportionate to the risk of harm. If in doubt, advice can be sought from the designated lead GP for child protection, your defence organisation or a professional body such as the GMC or the British Medical Association (BMA).

• The child should be given an explanation of what information has been shared, with whom and why, unless doing this would put the child, young person or anyone else at increased risk.

• If the child does not have the understanding or capacity to consent, the parents should in most circumstances be approached for their consent. The principles of the best interests of the child however remain paramount if consent is denied.

• Information can be shared without consent if it is justified in the public interest or required by law, or if it is judged to be in the best interests of the child and they do not have the maturity to reach this decision.

• When sharing concerns about possible abuse or neglect, the doctor who shares information does not have the final decision about how best to protect a child or young person. That is the role of the local authority children's services and the courts.

• All discussions and decisions about information sharing should be recorded and justified.

National Institute for Health and Care Excellence (NICE) recommendations³

CONSIDER child maltreatment

CONSIDER means maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.

If an alerting feature prompts you to consider child maltreatment: look for other alerting features of maltreatment in the child or young person's history, and presentation or parent-child (or carer-child) interactions now or in the past and do one or more of the following:

• Discuss your concerns with a named or designated professional for safeguarding children, a more experienced colleague, a community paediatrician, child and adolescent mental health service colleague.

• Gather collateral information from other agencies and health disciplines.

• Ensure review of the child or young person at a date appropriate to the concern, looking out for repeated presentations of this or any other alerting features.

At any stage during the process of considering maltreatment, the level of concern may change and lead to excluding or suspecting maltreatment.

SUSPECT child maltreatment

SUSPECT means serious level of concern about the possibility of child maltreatment but not proof of it.

If an alerting feature or considering child maltreatment prompts you to suspect child maltreatment then refer the child or young person to children's social care, following Local Safeguarding Children Partnership procedures.

EXCLUDE child maltreatment

EXCLUDE child maltreatment if a suitable explanation is found for the alerting feature. This may be the decision after discussion of the case with a more experienced colleague or gathering collateral information as part of considering child maltreatment.

Keeping records⁴

• Keep clear, accurate and legible records.

• Make records at the time the events happen, or as soon as possible afterwards.

• Record your concerns, including any minor concerns, and the details of any action you have taken, information you have shared and decisions you have made relating to those concerns.

• Make sure information that may be relevant to keeping a child or young person safe is available to other clinicians providing care to them.

Looked-after children and young people⁵

NICE has produced guidance on looked-after children and young people, which includes a section on safeguarding. In summary this recommends:

• A multidisciplinary approach facilitated by local authorities.

• Safeguarding meetings that bring together practitioners from multiple agencies, eg, social care; fostering, residential and connected care; education, healthcare; voluntary agencies, housing services, emergency services, policing and immigration.

• Specialist support to address safeguarding risks outside the home, exploitation and children missing from care.

• Data sharing across agencies at individual, group and community level.

• Training and review meetings.

• Positive relationships (including broader relationships such as those with carers, siblings and practitioners) as the main way to prevent exploitation and children going missing from care.

• Tailored support for the looked-after child or young person to prevent exploitation, by addressing issues specific to young girls and boys, trafficking children and unaccompanied asylum-seeking children.

• A review of the case files to help the safeguarding partnership learn and develop future safeguarding responses (or to inform best practice).

Initial actions if you suspect a child may be at risk⁶

In primary care

If you suspect child maltreatment, you should refer immediately as appropriate to one of three agencies:

• The local child social services.

• The police.

• The NSPCC.

All three agencies have statutory child protection powers to act immediately to secure the safety of a child. Where there is no immediate danger, the local child social services would normally be the referral route. This team is responsible for responding to families and children in need of extra help, investigating suspicions of child maltreatment, convening meetings and child protection conferences and co-ordinating child protection plans. They may take cases to court where needed to protect children and they are responsible for children in care of the council or children in placement outside their family home. The Director of Children's Services of the local authority has ultimate responsibility for the safeguarding of children. (Government guidance, however, stresses that child protection is everyone's responsibility and to be effective, all services must play their part .)

Where there is immediate danger to a child, the police have the authority (under the Children's Act) to enter a house and remove a child for their safety. The police can enter premises and remove a child to a place of safety for 72 hours. Examples of emergencies are:

• Recent sexual assault (<72 hours ago) - see 'Suspected sexual abuse', below.

• The child is unprotected and at risk of serious harm.

• Any baby with signs of non-accidental injury.

The NSPCC is a voluntary organisation with 'authorised person status' and can apply to the courts for a care order, or a child assessment order. It offers advice to children and to anyone who may be concerned about the welfare of a child.

Other points:

• Within 48 hours, confirm in writing any telephone referral you have made. Social services should acknowledge your written referral within two days of receipt. If not received within three working days, contact social services again.

• If in any doubt about level of risk, or uncertainty about suspicions, discuss your concerns with colleagues and seek advice:
  

  • Within the team (lead GP in the practice for child protection, or a more experienced colleague).

  • Outside the team (with the designated child protection health professional or, if unavailable, with social services).

• 
  Document all your concerns, discussions and decisions.
  

• Consider the safety of other children within the family.

• If the child requires referral/admission to hospital, ensure the paediatrician is aware of your concerns. Check that the child has arrived and been seen. Consider liaising with the hospital so that your referral letter is sent directly to the appropriate person by the most expedient route (eg, confidential e-mail).

• If sexual abuse is suspected, see 'Suspected sexual abuse', below.

• As of 31st October 2015, cases of FGM in girls under the age of 18 should be reported to the police¹ .

Hospital or accident and emergency

• All hospitals will have their own protocols and designated lead professional.

• When a child presents at hospital, enquire about previous admissions.

• If you suspect a child is at risk, consult with colleagues - eg, a named professional for child protection or a consultant paediatrician.

• If there is a risk of immediate serious harm, refer to the police (as above), who can arrange emergency protection for the child.

• If the child is admitted:
  

  • A named consultant must be responsible for the child protection aspects of care.

  • The child must be thoroughly examined within 24 hours (unless too unwell).

• If there are concerns, do not discharge the child from A&E or a ward unless:
  

  • There is an arranged plan in place for future care.

  • The child is registered with a GP.

• Notify the GP of hospital/A&E attendances.

• In a non-emergency situation, where it is thought best for the child to stay in hospital but the parents (or a competent child) request discharge, obtain urgent legal advice. Explain to the family why clinical supervision is advised.

• A concern about suspected abuse must not be dismissed without proper consideration, including a second opinion if necessary.

• Roles: consultant paediatricians are central to the investigation and treatment of abused children but have no legal authority to conduct a child protection inquiry. Therefore, social services (and the police, in urgent cases) should be involved.

• As per the section 'In primary care', above, all professionals who identify cases of FGM in girls under the age of 18 during their professional work have a duty to report this to the police.

Safeguarding children across the UK

Principles and policies are similar across the UK, although there may be some slight differences between naming of agencies and referral procedures. Information in government policy specific to the four nations is available as follows:

England: "Working Together to Safeguard Children " - GOV.UK.

Wales: the GOV.UK document above and also the "A Guide for Safeguarding Children and Adults at Risk in General Practice" from NHS Wales.

Scotland: "National Guidance for Child Protection in Scotland" and "Getting it right for every child" from the Scottish Government^{7 8} .

Northern Ireland: "Understanding the needs of children in Northern Ireland" from the Department of Health, Social Services, and Public Safety⁹ .

Suspected sexual abuse^{6 10}

• Do not undertake an intimate examination unless there is an urgent health need to do so.

• Use open questions, and record all questions and replies verbatim.

• Do not perform a forensic intimate examination unless you have the training and facilities to do so. (You may, if appropriate, perform a routine general examination to check general health or other injuries.) Refer urgently to a specialist in the forensic assessment of sexual assaults for the purposes of conducting a forensic examination and to consider the need for contraception and potential for sexually transmitted infection (STI).

• The police or a Sexual Assault Referral Centre (SARC) will be able to arrange a specialist assessment.

• To obtain evidence of sexual abuse, a forensic examination should preferably be done within 24 hours of the event; up to 72 hours is acceptable. Therefore, where suspected sexual abuse has occurred <72 hours previously, there should be an immediate discussion between the child/young person, health professionals, social workers and the police regarding the need for a medical examination. Depending on the type of assault, DNA can be gathered from 12 hours to 7 days after the event.

• Specialist follow-up for STIs and psychological sequelae and support will be required.

Further action¹¹

Following referral (other than in an emergency situation), a named social worker will gather information and make an assessment. They will then determine the course of action - for example, that none is required or that an Early Assessment Framework (EAF) be initiated (in England). If a child is considered to be in need, ways to address these needs will be planned. If the child is deemed to be in need of protection, a strategy discussion will be convened, which may lead (via a Section 47 enquiry) to a child protection conference. If the child is considered to be in immediate danger of significant harm then more urgent protective action would be taken.

GPs will usually be asked to provide reports on the whole family. It is good practice to obtain consent and involve the child and family and allow them access to the reports, although this may be difficult within the short statutory timescale allowed for completing the process. Guidance from the Royal College of General Practitioners (RCGP) and the GMC advises that GPs be involved in child protection conferences but accepts it may be logistically difficult to attend. Should this be the case, GPs should produce a comprehensive report in advance and discuss it by phone with the social worker or conference chair.

All members of the Primary Healthcare Team must be aware of local referral pathways and the role of joint working in child protection. It is also essential to develop and maintain the necessary knowledge and skills to help support families and to protect children and young people.

• Regular training (appropriate to level of involvement) in safeguarding children is mandatory.

• Ensure that the child and family have follow-on care.

• Medical records: ensure that child protection concerns are clearly identified (eg, coded in computer records).

• Child maltreatment raises strong feelings; those dealing with it may need support.

Sources of help in child protection