Child abuse
Assessment
The priorities in dealing with child abuse are:
to diagnose, treat and document the child’s injuries,
to interpret a pattern of injury or behaviour leading to the suspicion of abuse,
to notify and involve the Victorian Forensic Paediatric Medical Service (VFPMS),
to provide, when consent is given, a verbal or written report to Child Protection and the Police.
The doctor must establish that consent has been given (by one of the parents or the child’s legal guardian) to perform a clinical examination and to provide a report to Child Protection and the Police. Ideally this should be in writing. If consent is unobtainable the child should only be examined if a medical emergency exists. Seek senior advice if other conditions apply.
A proforma is available which, if completed fully, ensures that all salient points are covered. Medical reports should follow a standardised format ( example) and must be reviewed by a senior doctor and VFPMS or the Medicolegal office.
Physical abuse
Children who attend with an injury that might have been inflicted need a full physical assessment. This should be performed by a registrar or consultant. The examination must include height and weight as well as examination of the head, mouth, eyes, ears, chest, abdomen, back and limbs. The use of body diagrams and the available “physical abuse” proforma to record findings are strongly recommended.
Contact
Victorian Forensic Paediatric Medical Service
(24 hours 7 days a week)
1300 66 11 42
and (at RCH) call the Social Work Department ext. 56111; or After Hours contact the Social Worker On Call via RCH switchboard.
Investigation
A coagulation profile should be performed when there is a clinical suspicion of a clotting disorder. Abnormalities of clotting are rare so beware of attributing bruises to this cause.
Clinically suspected fracture sites should be X-rayed directly. A bone scan and skeletal survey are very useful for detecting clinically unsuspected recent and older fractures. They should both be used in children under the age of three who are likely to have sustained non-accidental injury.
Sexual Abuse
All instances of suspected sexual abuse should be referred in the first instance to the VFPMS, In general, genital examinations for the purpose of determining whether or not abuse has occurred will only be performed by appropriately trained and experienced consultants. Limited inspection for a specific purpose such as determination of the amount of bleeding or the extent of a rash or discharge may be performed with the cooperation of the child.
After an recent sexual assault ( < 72 hours) rapid evaluation is required. Contact the the VFPMS, as soon as possible and speak to the consultant on-call. You may be advised to assess and treat any urgent medical problems (eg. bleeding). Ensure the child is as comfortable as possible and has appropriate emotional support. If possible do not offer food and drink and avoid visits to the toilet until VFPMS advise the best site, time and person to collect forensic samples.
Referrals from child protection
If Child Protection staff attend the RCH Emergency Department with a child requesting a medical examination it is appropriate to see the child to evaluate any medical condition which may need urgent investigation or treatment. In most instances the complete forensic paediatric evaluation can occur the next morning.
Contact
Victorian Forensic Paediatric Medical Service
(24 hours 7 days a week)
1300 66 11 42
Consultation
The evaluation of a child who has possibly been abused can be a time consuming and difficult process, and one in which help from a colleague can be invaluable. Consultant assistance is available from the on-call consultant for the Emergency Department or the on-call consultant for the Victorian Forensic Paediatric Medical Service. See RCH procedural guideline for RCH patients http://ww2.rch.org.au/policy_rch/index.cfm?doc_id=12296.
Documentation
The legal implications of a medical examination conducted for possible child abuse are significant. Accurate and complete documentation is essential. Clinical photographs are an excellent way of recording visible injuries. Call x57087 for Photography (business hours) and pager 5477 for after hours (see Creative Studio after hours page on-call photographer for more information). Photographic documentation is an adjunct to standard recording methods. It is still important to describe injuries and to use appropriate diagrams when helpful.
Admission or discharge?
Admission to hospital should be arranged when it is medically necessary (fractures, failure to thrive etc) or when it is necessary for the child’s safety.
Children should be admitted under the General Medical Unit of the day. If the child has specific injuries (eg. fractures) then they may be admitted under a surgical unit but the General Medical Unit of the day should be involved by consultation.
Consider NAI in any infant who presents with an unexplained encephalopathy.
Any infant with a cerebral injury, from shaking or direct trauma, should be admitted to ICU for monitoring overnight. Delayed deterioration may occur.
(At RCH - ICU admission should only be declined following assessment by the ICU consultant).
The safe discharge of the child is the responsibility both of the hospital and Child Protection.
All admitted patients:
A SCAN (“Suspected Child Abuse and Neglect”) meeting must be held within 24 hours of admission.
This protocol is designed to help coordinate early discussions with Victorian Forensic Paediatric Medical Service, Child Protection and police.
See SCAN Meeting Resources
Notes
All medical staff working in the Emergency Department & Wards must be aware of the possibility of child abuse, and be able and prepared to act appropriately if it is suspected.
There is a legal obligation upon both medical and nursing staff to notify Child Protection if they have formed the opinion that a child is in need of protection. See Children, Youth and Families Act 2005 - SECT 162
The Victorian Forensic Paediatric Medical Service is situated on the 1st floor of the East Building - Clinic Reception C. As well as regular clinics they provide a 24 hour service for evaluation of possible causes of injury and advice regarding evaluation of suspected child abuse. They can also advise on good medical report writing and liaising with the external agencies.
Victorian Forensic Paediatric Medical Service
(24 hours 7 days a week)
1300 66 11 42
Children suspected to have been abused or neglected require a full evaluation of their psychosocial situation. Refer to social work for psychosocial assessment where there are concerns about risk of harm to a child. Contact Social Work Department ext. 56111 (physical abuse/ neglect) or Gatehouse Worker ext.6391 (sexual abuse).
Resources
Victorian ForensicPaediatric Medical Service Web Site
Proformafor suspected Child Abuse Consultation
Diagrams for recording injuries
Outline template for medical report
WC PSRG - reviews of child protection literature
SCAN meeting resources
(Suspected Child Abuse or Neglect)
SCAN Meeting Procedures
Medical Information summary for SCAN patients
Agenda for SCAN meetings
Minutes for SCAN meetings