4.7 Medical Examination of a Child |
Contents
- When a Medical Examination is necessary
- Purpose of a Medical Examination
- Consent for Medical Examination / Medical Treatment
- Arranging the Medical Examination
1.
When a Medical Examination is necessary
Strategy Discussions must consider, in consultation with the paediatrician (if not part of the discussion or meeting), the need for and timing of a medical examination. Consideration must also be given as to whether there are any other children in the household who may also require a medical examination.
Medical examinations should always be considered necessary where there has been a disclosure or there is a suspicion of any form of abuse to a child.
Additional considerations are the need to:
- Secure forensic evidence
- Obtain medical documentation and treatment if required
In cases of severe neglect, physical injury or acute (recent) penetrative sexual abuse, the examination should be undertaken on the day of the referral, where compatible with the welfare of the child.
Only suitably qualified health specialists may physically examine the child for the purposes of a medical examination. Other staff should note any visible marks or injuries on a body map and document details in their recording.
2. Purpose of a Medical Examination
The purpose of a medical examination is:
- To diagnose any injury or harm to the child and to initiate treatment as required
- To document the findings
- To provide a medical report on the findings, including an opinion as to the probable cause of any injury or other harm reported
- To assess the overall health and development of the child
- To provide reassurance for the child and parent
- To arrange for follow up and review of the child as required, noting new symptoms including psychological effects
3. Consent for Medical Examination / Medical Treatment
The following may give consent to a medical examination:
- A young person of 16 and over
- A child of under 16 where a doctor considers he or she is of sufficient age and understanding to give informed consent and is Fraser Competent
- Any person with Parental Responsibility
- The local authority when the child is the subject of a Interim Care Order (although the parent/carer should be informed)
- The local authority when the child is Accommodated and the parent/carers 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 Court as part of a direction attached to an Emergency Protection Order, an Interim Care Order or a Child Assessment Order
Where the child is the subject of ongoing Court proceedings, legal advice should be obtained about obtaining the Court's permission to the medical examination.
It is generally good practice to seek wherever possible the permission of a parent for children under 16 prior to any medical examination and/or other medical treatment even if the child is judged to be of sufficient understanding to give consent in their own right. If this is not considered possible or appropriate, then the reasons should be clearly recorded.
When a child is Looked After and a parent/carer has given general consent authorising medical treatment for the child, legal advice must be taken about whether this provides consent for a medical examination for child protection purposes (the parent/carer still has full parental responsibility for the child). Where the local authority shares Parental Responsibility for the child, the local authority must also consent to the medical examination.
A child who is of sufficient understanding may refuse some or all of the medical examination, although refusal can potentially be overridden by a court.
In emergency situations where the child needs urgent medical treatment and there is insufficient time to obtain parental consent:
- The medical practitioner may decide to proceed without consent; and/or
- The medical practitioner may regard the child to be of an age and level of understanding to give her/his own consent and be Fraser Competent
In these circumstances, parents must be informed 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 seek legal advice - see above.
For additional guidance to doctors, see the GMC Guidance for Doctors Working with 0 to 18 Year Olds.
4. Arranging the Medical Examination
Medical examinations must take into account the need for both specialist medical expertise and forensic requirements in relation to the gathering of evidence.
Only approved Consultant Paediatricians, Police Surgeons or other suitably qualified specialists may undertake medical examinations carried out as part of a Section 47 Enquiry. There should be only one medical examination of the child.
Where child sexual abuse is suspected, usually two doctors with complimentary skills will conduct a joint medical examination. A single doctor may carry out the examination where he or she has the necessary knowledge, skills and experience for the particular case. For further guidance, see Guidance on Paediatric Forensic Examinations in relation to possible child sexual abuse, September 2004, issued by the Royal College of Paediatrics and Child Health and the Association of Forensic Physicians (which can be found at the Royal College of Paediatrics and Child Health Website).
Consideration should be given to the gender of the examining doctor in consultation with the child and the parents.
In planning the medical examination, the social worker, the manager responsible, the Police CPPU and relevant doctor(s) must consider whether it might be necessary to take photographic evidence, for example, for use in care or criminal proceedings or where a second opinion may be necessary. Where such arrangements are necessary, the child and parents must be informed and prepared and careful consideration given to the impact on the child.
If the child refuses to be examined or becomes distressed during the examination, consideration must be given to arranging a further examination.
In circumstances where medical examination of a child is required, the child should be examined by a paediatrician at the Rainbow Centre, Alder Hey Hospital, rather than the child's G.P. A social worker or police officer can request a medical examination by contacting the Rainbow Centre and should be clear about the purpose of the examination, making this clear to the doctor undertaking the examination.
After 5.00pm or at weekends, a medical examination of a child should be arranged by contacting the Alder Hey Hospital switchboard, who will arrange for medical examination by the appropriate doctor or medical registrar.
Any police officer or social worker requesting medical examination of a child should ensure that someone with Parental Responsibility:
- accompanies the child to the hospital and is prepared to sign the Rainbow Centre consent form; or
- has signed the Rainbow Centre consent form and agrees to the child attending the hospital without a parent
Without such consent the social worker or police officer will need to consider legal advice with a view to making application for an Order which will enable consent to be dispensed with.
5.
Recording of the Medical Examination
At the conclusion of the medical examination, the doctor must give a verbal report explaining his or her findings to the social worker/Police officer attending, followed by a written report as soon as practicable.
Disclosure of the information contained in the report to the parent(s) of the child and/or the child should be agreed in consultation with the Children's Social Care Service and the Police.
The report should include:
- Date, time and place of examination
- Those present
- Who gave consent and how (child/parent, written, phone or in person)
- 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
- Other findings relevant to the child e.g. squint, learning problems, speech problems etc.
- Confirmation of the child's developmental progress (especially important in cases of neglect)
- Time examination ended
- Medical opinion of the likely cause of injury or harm
All reports and diagrams should be signed and dated by the doctor undertaking the examination.
If criminal or family proceedings are instituted, the doctor's written report may be filed and served as well as the doctor's statement of evidence. The doctor's attendance at subsequent Court hearings may also be required.
Where there has been a joint medical examination, the doctors involved should agree which of them will provide the report. If they disagree in their clinical findings and interpretations, they should both provide full reports and usually a further independent medical opinion should be obtained. For further guidance, see Guidance on Paediatric Forensic Examinations in relation to possible child sexual abuse, September 2004, issued by the Royal College of Paediatrics and Child Health and the Association of Forensic Physicians.
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