Safeguarding Children

1. Safeguarding Children GP Trainees June 2012

2. Safeguarding ChildrenIntroduction

3. Learning Objectives • Understand your role within NHS Calderdale/Kirklees and what actions to take if you have concerns about a child • Know who to contact if you have concerns about a child • Recognise the signs and symptoms of abuse • Have a basic understanding of the risk factors associated with child abuse • Have an understanding of the legal context of your responsibility for safeguarding children • Know how to make a referral to Social Care

4. Outline of session Group exercise – what’s acceptable? Legal Framework Facts & Figures Group exercise – types of abuse Joint working and information-sharing Referrals to social care Coffee Break Group exercise – scenarios Close

5. How old is a child? AND Lets not forget vulnerable adults !

6. What’s acceptable? Group Exercise Score 1-5 (1 being most acceptable, 5 least acceptable) Personal vs society vs professional view

7. The Legal Framework Children’s Act 2004 – Duty to safeguard and promote the welfare of children The welfare of the child is the paramount consideration Parents never lose parental responsibility for their child (unless their child is adopted) The child’s wishes should be taken into consideration (Gillick principle-Fraser competency) Every Child Matter Agenda states that all children deserve the opportunity to achieve their potential Staying safe is the primary focus of safeguarding children

8. What does Safeguarding mean? The statutory inquiry into the death of Victoria Climbie (2003) highlighted a lack of priority status given to safeguarding. Safeguarding is about: • Protecting children from maltreatment; • Preventing impairment of children’s health or development; and • Ensuring that children grow up in an environment which provides safe and effective care to give them the best chance of entering adulthood successfully (Working Together 2010)

9. Our duties in Safeguarding • To ensure that the risks of harm to children’s welfare are minimised • When there is a concern it is acted upon • Following of local policies and procedures • Partnership working with other agencies

10. Facts and Figures • IN 2007/2008, 55 CHILDREN WERE KILLED BY SOMEONE KNOWN TO THEM – (NSPCC) report that every 10 days in England and Wales a child is killed at the hands of a parent. • 750,000 CHILDREN LIVE IN HOUSEHOLDS WHERE THERE IS KNOWN DOMESTIC ABUSE • 450,000 PARENTS ARE ESTIMATED TO HAVE MENTAL HEALTH PROBLEMS • 250,000-350,000 CHILDREN HAVE PARENTS WHO HAVE PROBLEMATIC DRUG ABUSE • 1.3 MILLION CHILDREN LIVE WITH PARENTS THOUGHT TO MISUSE ALCOHOL. (LAMING – 2009/DOH 2009)

11. Facts & Figures • In a class of 30… • 4 will have suffered physical abuse • 3 will have suffered sexual abuse • 3 will have been seriously neglected • 2 will have been subjected to • prolonged verbal abuse • 1 will grow up as a young carer

12. Safeguarding ChildrenSigns and Symptoms of Abuse

13. Group Exercise 1 4 Groups • Each group to look at a category of abuse. • Come up with a definition of sexual; emotional; physical abuse and neglect. • List the signs of each category of abuse.

14. Definition of Physical Abuse Physical abuse is caused by an action, which results in physical harm being done to a child. Factitious Illness (Munchausen’s Syndrome By Proxy) also comes under the category of physical abuse (Working together 2010)

15. Signs of Physical Abuse • Unexplained bruises, marks or injuries on any part of the body • Multiple bruises in clusters, often on the upper arm, outside of the thigh (non bony prominences) • Cigarette burns • Human bite marks if not a small child • Fractures especially in non mobile children/ multiple fractures • Scalds • Multiple burns with demarcated edges

16. Signs of Physical Abuse • Implement marks • Fear of a particular person • Aggressive behaviour/ severe temper outbursts • Flinching • Reluctance to get changed/ excessive clothing • Withdrawn behaviour • Running away from home • Delay in seeking medical attention • History given does not support injuries sustained • Changing story • Abnormal parental anxiety/ over suspicion

17. Definition of Neglect “Neglect is the persistent failure to meet a child’s basic physical and / or psychological needs, which is likely to result in the serious impairment of the child's health or development.” (Working together 2010)

18. Signs of Neglect • Constant Hunger • Constantly dirty/ smelly • Sudden weight loss • Obesity • Inappropriate clothing for weather • Poor school attendance • Lack of appropriate medical attention • Failure to attend necessary follow up appointments

19. Signs of Neglect • Isolation • Lack of appropriate supervision • Being left alone • Reluctance to get changed/ excessive clothing • Withdrawn behaviour • Running away from home • Failure to protect from physical harm

20. Definition of Emotional Abuse Emotional abuse is the persistent emotional Ill treatment of a child so as to cause severe and persistent adverse effects on the child’s emotional development. This may involve conveying to the child that they are worthless, inadequate and unloved. (Working together 2010)

21. Signs of Emotional Abuse • Fear of making mistakes • Compulsive hair twisting/ rocking • Poor interaction with peers • Self harming • Fear of a particular person • Emotional developmental delay • Poor self esteem • Insecurity • Needy children • Striving for perfection • Frozen watchfulness

22. Definition of Sexual Abuse Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. (Working Together 2010) May include physical and non physical acts.

23. Signs of Sexual Abuse • Bruised; bleeding genitalia • Sexually transmitted diseases • Vaginal discharge/ infection • Abdominal pains • Genital discomfort • Pregnancy • Sudden change in behaviour e.g. Aggression

24. Signs of Sexual Abuse • Fear of a particular person • Nightmares • Advanced sexual knowledge • Regression e.g. Bedwetting • Self harming • Eating disorders • Hints about secrets

25. Risk Factors • History of domestic violence • Parental mental illness • Alcohol misuse/ dependence Substance misuse • Lack of support systems • Parental history of deprivation/ violence in childhood • Unrealistic expectations of a child • Poor parenting skills/ poor role models • Social problems (poverty, unemployment, housing) • Lack of parental/ child attachment • Private fostering arrangement

26. Joint Working • Safeguarding Children is a shared responsibility between agencies • Agencies must understand and respect each others roles and responsibilities to facilitate effective co-ordinated working

27. Information Sharing • If you are worried about sharing information about a child or young person seek advice from a named/ designated professional • If your concerns are based on information given by a child explain that you maybe unable to maintain confidentiality. Explore their concerns about information sharing and reassure them that they will be kept informed about what actions are being undertaken (NICE – 2009 http://www.nice.org.uk/cg89) • Confidentiality of children and families should be maintained by professionals involved with them. When there is a clear risk of significant harm to the child information must be shared with relevant people on a need to know basis. • The Children Act (2004) reinforces the duty of the professional to safeguard and promote the welfare of children

28. Communication • Wherever possible professionals should inform the child/ family when they are planning to make a referral to social care. • Family members or friends should not be used as interpreters, since the majority of domestic and child abuse is perpetrated by family members or adults known to the child. Children should not be used as interpreters.

29. Race, ethnicity, culture • Children from all cultures are subject to abuse and neglect. All children have a right to grow up safe from harm. In order to make sensitive and informed professional judgements about a child’s needs and a parents’ capacity to respond to their child’s needs. It is important that professionals are sensitive to differing child-rearing patterns specific to minority racial, ethnic and cultural groups. • Professionals must be clear that child abuse cannot be condoned for religious or cultural reasons.

30. Victoria Climbie 02.11.1991- 25.02.2000 Victoria was born on the Ivory Coast and was brought to England by her great Aunt in 1999 for a better life

31. For Victoria there was: • no lead professional • no common process • no continuum of need • Not one agency had a holistic overview of Victoria’s need’s • More than 12 missed opportunities where relevant agencies could have intervened to save her life • The basic discipline of medical evaluation covering history taking, examination, arriving at a differential diagnosis and arriving at the outcome was not put into practice in Victoria’s case • Should events have been looked at in a different way???

32. Peter Connelly 01.03.2006 – 03.08.2007 • Peter’s mother met her partner in a pub in June 2006 • In October Peter presented at the GP’s with bruising to his face. • By Nov/ Dec 2006 it is believed her new partner had moved into the family home. • In December Peter was taken to A&E with a head injury and bruising. A referral was made to social care. Peter was discharged into the care of a family friend and his mother and grandmother were charged with neglect and assault. • However in January 2007 Peter was returned to his mother whilst she was still on bail for assault. No one appeared to know that the partner was living in the house. • On the 1stAugust 2007 Peter was examined at a child development centre, bruises were noted on Peter, however a full examination was not carried out because he was miserable and cranky..

33. The post mortem for Peter showed that he had severe cuts on his head caused by a human bite. He had blackened finger nails and some of his finger tips were missing. He had 8 broken ribs, a broken back and skin was missing from the top of his tongue and lips caused by a blow. The skin between his upper gum was torn and his tooth had been knocked out. Peter and his family were known to and visited by a number of different agencies and the serious case review concluded that professionals were too accepting of the explanations by his mother about any injuries he had received. One image of Peter released was that where his face had been smeared in chocolate to cover bruising. Peter had been subject to a Child Protection Plan since December 2006.

34. Barriers to effective safeguarding in General Practice • Not seeing the child • Not looking • Looking for the wrong thing • Underestimating the problem • Condoning the problem • Not knowing what to do next • Jigsaw nature of safeguarding • Concerns about doctor-patient relationship

36. Common Assessment Framework • The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for an holistic assessment of children’s needs and strengths; taking account of the roles of parents, carers and environmental factors on their development. Professionals are then better placed to agree with children and families about appropriate modes of support. The CAF also aims to improve integrated working by promoting coordinated service provisions.

37. CAF Consider: If a child is identified as having more than one unmet need in respect of the ECM 5 outcomes Talk to the parent and gain their consent Never do a CAF if the concern is Child Protection If little progress is made or maintained, gather your evidence together and use as the basis for a referral to Social Care for a Child in Need Assessment Do a CAF; devise a plan and review progress regularly

38. Referrals to Social Care What do you think ?

39. Gather information:- Demographic details • Details of child: Full name, DOB, Address, GP, School attended or Health visitor. Identified other Professionals. Who has parental responsibility. Who the child is living with. Who accompanies the child • Details of Parents: Full name , DOB, Address, telephone contact details • Details of Partners and other significant adults involved with the child (as above) ALL THESE DETAILS MUST BE DOCUMENTED IN THE CHILDS RECORDS

40. Gathering information :- Other. • Contact other professionals involved • Review historical and existing information on the child and family • Identify your concerns in the medical records; think about overall risk to that child and the steps already taken (if any) • Enquire with Children’s Social Care if child is known or has been known – daytime and out of hours tel numbers • Discuss with senior colleague, practice lead for safeguarding, Named professional • What has changed to escalate this case to a referral? • Formulate plan of actions All contacts / discussions with other Professionals must be documented in the child's records

41. Safeguarding Principles “Any person who has knowledge or suspects that a child is being harmed must refer him or her to one or both of the agencies with statutory duties or powers to investigate or intervene” (Social Services or Police)

42. Reluctance to report concerns • Fear of being wrong • Concerns about the effects on the child and family • Fear of retaliation from the abuser • Not believing the child when disclosure is made • Poor previous experiences of reporting • Concerns over having to provide statements/ attend court proceedings • Lack of understanding of the safeguarding procedures • Not wanting to spoil relationships with the child/ family

43. Referral Process • Telephone referral to social care • Written referral faxed to social care within 48 hours (a copy must be kept in the medical record) • Social care to review information and following initial assessment. • 3 possible outcomes – case closed, section 17 or section 47 investigation • It is the responsibility of the referrer to follow up the outcome of the referral if no communication from social care is received

44. Section 17 – Child in Need • Section 47 – Child at Risk of Significant harm (Duty to Investigate) • If the referrer is dissatisfied with the outcome of the referral they must follow the escalation guidance within local guidelines

45. Social Care Investigations • GPs may be asked to contribute information to social care enquiries – should be done promptly and in writing • May be invited to attend case conference • Remember you may be the one person who ties all the information together

46. Significant Harm • Significant Harm is any Physical, Sexual or Emotional Abuse, Neglect, accident or injury and is sufficiently serious to adversely affect progress and enjoyment of life. Harm is defined as the ill treatment or impairment of health and development. • There are no absolute criteria on which to rely when judging what constitutes significant harm. Sometimes a single violent episode may constitute significant harm but more often it is an accumulation of significant events, both acute and longstanding, which interrupt, damage or change the child’s development. (CSCB procedures)

47. Child Protection Plan Children at risk of significant harm are now subject to a child protection plan (CPR no longer exists) The decision for a child protection plan will be made at an initial case conference Children who are subject to a child protection plan are reviewed in line with statutory requirements and the plan will cease once the continuing risk of significant harm has ceased The purpose of the plan is to assist in the protection of children. Those children with a plan are only a small number of the children at risk.

48. Local perspective

49. LSCB Children’s Act (2004) required each Local Authority to establish LSCB’s • Calderdale Safeguarding Children Board – www.calderdale-scb.org.uk • Kirklees Safeguarding Children Board – www.Kirklees.gov.uk/safeguarding children

50. LSCB - Responsibilities Development of policies and procedures Participation in the planning of services for children within the local area Monitoring the effectiveness of safeguarding children Provision of safeguarding training Undertaking serious case reviews Co-ordinating responses to unexpected child deaths Collecting and analysing information about child deaths