Doctors` roles and responsibilities in child protection

The Medical Ethics Alliance is a coalition of 6 medical and nursing  Hippocratic and World Faith bodies.

It is happy to respond to the GMC consultation. The author of this response is a consultant community paediatrician and former member of the magistracy with 12 years experience of the Criminal and Family Proceedings Courts. He has also consulted legal opinion, a general practitioner and medical and nursing colleagues with experience of protection of the elderly and mentally infirm.

 There are a number of  ethical considerations concerning  child protection such as natural   justice, the common good,  and issues of good medical practice and confidentiality.

Consent and confidentiality

Question 1

“What problems do you see in relation to consent and confidentially when doctors work with children and their families where there are child protection concerns? If possible please provide examples of good practice, or areas where problems commonly arise”

Problems can arise on presentation where injuries may suggest child abuse but other explanations have been offered by parents for the injuries which maybe lesions of the  skin, oral cavity, genital region or skeleton.  Until these have been assessed by a senior doctor  trained in the recognition of child abuse it would not usually be necessary to raise the question of abuse with those who have parental responsibility, but once a diagnosis of non accidental injury has been made, this should be shared with the person with parental responsibility and the procedure to be followed explained before notification of the statutory authorities.

For a general practitioner, urgent referral to an A&E department or consultant clinic will normally be required. Children presenting in A&E  with suspicions  injuries should be referred at once. to the on call paediatric team who in turn should involve a fully trained or senior doctor.

 Emergency admission to a place of safety should take place and if necessary an emergency  protection order will be required via the Family Proceedings Court.

 When putting in place procedures to safeguard children and vulnerable adults it is vital that the requirements of confidentiality do not take precedence over the need to protect their welfare

Particular difficulties  may arise in the case of suspected fabricated or induced illness. Detailed investigations would be normative and the diagnosis may only emerge over time. An example of good practise would be for the doctor with ultimate responsibility to share the tentative diagnosis with consultant colleagues to see if there is agreement on the diagnosis. It would also be good practice to seek the advice of colleagues in a tertiary centre.

The doctor may be well advised also to seek independent legal advice from a defence organisation as well as the NHS legal team. This is a particularly contentious diagnosis and may well lead to a serious complaint against the doctor.

The confidentiality that is required by law in furnishing  reports for prosecutors and the giving of evidence in the civil courts is proscribed. Open evidence will be required in Crown Court and the doctor should not be afforded any anonymity and publicity cannot be avoided. If, however, the doctor has taken the steps outlined above this will afford some protection. Rarely  a doctor may choose to take independent legal steps to protect their interests.

With regard to confidentiality within the family, school or other organisation, doctors and nurses, including school nurses, must be open to disclosure from wherever it comes whilst respecting the confidence of the discloser such as another family member. That disclosure  must then be shared with the group who have a statutory need to know.

When putting in place procedures to safeguard children and vulnerable adults it is vital that the requirements of confidentiality do not take precedence over the need to protect their welfare

Relationships with parents, carers and the wider family

Doctors must ensure that a child`s safety and welfare is paramount and takes priority over other considerations. But they should also ensure that the child`s family members are treated with dignity and respect, take account of the rights of family members, for example to make decisions about their lives and lifestyles, and provide additional support or help they may need.

Question 2

Do you agree with this? If possible, provide examples of circumstances where a child`s and family`s needs and rights have been met and respected in context of child protection  proceedings, or occasions where they have been in conflict and how this conflict was managed by doctors.

Difficulties can arise when English is not understood or where because of a particular culture, the head of the family is the only person who will speak on behalf of parents and may fail to translate what is said by doctors. There can also be fears that translators may breach confidence in close knit ethnic groups. In Family Proceedings Courts and Criminal Courts accredited translators must be provided by law. In the clinical situation difficulties arise and an independent translator is advisable.

The doctor would be ill advised to accept a family representative, usually the senior male, as what is said may not be being accurately passed on. Indeed a parent may refuse to speak to a doctor except through a senior family member. Indeed, where the “honour” of the family is involved , this is likely to be the case.

 There are additional issues of confidentiality. Situations arise where a senior family member knows what is being said but selectively translates it, and later deals with the matter in accordance with his culture. Domestic violence or other injustice may follow the unwise revealing of sensitive information. Generally speaking,  child abuse is even more detested amongst most  ethnic minorities than it is in our own society. There are obvious dangers which can only be avoided by independent translators. These need to be accredited as in the courts and contemporaneous records kept.

Doctors working in partnership

Doctors are expected to work as part of a team alongside other health professional when they provide treatment and care to a child or young person. Doctors are expected to cooperate with other agencies, such as services for children and young people and the police, where abuse or neglect of a child or young person is suspected or known. Doctors may also be asked to work with colleagues when giving evidence to a court, for example on issues which they agree or disagree.

Question 3

What are your views or experiences about how well doctors work with other doctors, professionals and agencies, when there is the possibility of harm to a child.

Regrettably many doctors are loath to become involved in child protection as a result of adverse publicity, threats of legal action or complaints to the GMC. Direct threats also occur and many doctors feel that they or their own families are endangered. Ultimately, if many doctors refuse to become involved in the legal process child protection will fail. Fortunately most doctors feel that they are obliged in consience to do their utmost to protect children.

It has to be said that the GMC is seen as part of the problem and not part of the solution. That is because many aggrieved parents complain to the GMC. Doctors are looking to Lord Justice Thorpe’s expert group with members from the RCPCH to come to clear conclusions that would protect children and professionals alike. When the president of the Royal College of Paediatrics and Child Health is reported to be unwilling to become an expert witness and GMC decisions are overturned in the Court of Appeal, is it any wonder that paediatricians are unwilling to give evidence. It would be very helpful if a clear set of guidelines were to be published. If they were adhered to, then this should provide the doctor with a prime facie defence against complaint including complaint to the GMC. So far confidence has been damaged and children will bear the brunt.

It should also be recognised that all doctors coming into contact with children need training in the recognition of abuse and neglect and the legal framework. Paediatricians would certainly benefit from training in the writing of  legal reports and presenting evidence. As a member of the bench, I have seen witnesses` evidence undermined by hostile cross examination when a more experienced witness, such as a police  officer, would have been better able to assist the court. The police are trained in how to give evidence,  doctors are not.

With regard to expert evidence,  I believe there would be real benefit in a trained cadre of expert witnesses such as anticipated in Bearing Good Witness where a multidiscipline team including paediatricians are available. But in the pilots so far, there are insufficient paediatricians` involved. This may need to be addressed by inclusion of this task in  paediatricians job plans and sufficient time allowed  for this such time consuming work.  

Question 4

In your experience, what factors help or hinder clarity about who has what roles and responsibilities to protect children and young people? This might include, for example local working arrangemants, and apply to doctors working in different areas of practice, or the way doctors work with other professionals.

In the consultant  practice with which I am familiar, it was usual for examinations for possible sexual abuse to be carried out  in the ward in the presence of the mother, an experienced paediatric nurse and a  paediatrician and police surgeon examining the child jointly. This minimised the number of examinations and stress for the child. It must be remembered that for the young child in particular, the examination was almost a second assault. The police surgeon could bring to bear forensic skills, including photography which assisted the courts. It also reduced the likelyhood of conflicting evidence and was an important liaison. Police surgeons have their own skills and expertise from which paediatricians can benefit.The role of the nurse is also critical as it may result in additional evidence such as disclosure or an observation.

It has always to be remembered that, especially in cases of possible sexual abuse,  the medical evidence is often only a small part of the evidence upon which the court will rely. Paediatricians should not feel that their evidence is decisive, it is likely to be collaborative at best.

The method of obtaining reliable evidence from disclosure depends heavily upon the way in which it was obtained and the role of specialy trained police officers. In this field, paediatricians may only have a minor role to play and yet it is one with which  they are most reluctant to be involved. It would be helpful if they were reassured that it is all the evidence taken together that is decisive, and the most significant is likely to be disclosure. It is outside the scope of this submission to discuss how evidence is obtained by skilled professionals but doctors should be aware of the often limited nature of physical findings in sexual abuse.

The role of the local authority legal department is central in putting together any case that comes into court. Thus the multidiscipline case conference is of central importance. It is very important that all doctors, including general practicioners and paediatricians attend the conference and understand what the court will require of them. It has often been the case that doctors, and general practitioners in particular, do not attend or send represenatives.  This is not sufficient and certainly anyone giving evidence whether doctor or nurse, needs to be aware of the role they will be expected to play. We certainly hope that the working group under Lord Thorpe that is looking into child protection will have nurse representation. If it does not, it should. The evidence of say health visitors can be crutial and the role of nurses in general seems to be underplayed in child protection.  

Doctors` knowledge skill and experience

The GMC`s  guidance requires doctors to keep their knowledge and skills up to date, and work within the limits of their competence, and consult and take advise from colleagues where appropriate. These requirements apply to doctors` clinical knowledge and skills and to other professional activities, for example acting as a professional or expert witness in the family court. All doctors have some role in protecting children, but some have additional, specialised  knowledge and skills to undertake specific tasks in protecting children. 

Question 5

What training and other support do doctors need to undertake their particular roles in child protection, for example, in preparing and training to give evidence to the family court? If possible provide examples where doctors are (or are not) receiving appropriate training or other support.

Child protection should be included in the basic training for future doctors. Those who are likely to be front line doctors with children. Paediatricians, accident and emergency doctors and general practitioners in particular need to be trained by their respective colleges using such documents as the RCPCH compendium “ Child Protection  Companion”, 2006 which should be used in the annual appraisal of paediatricians.

Doctors should also be aware that other vulnerable groups besides children are in need of protection. It is a general requirement of all those close to vulnerable persons.

Local training should be made available on the presentation of evidence in family courts. The Magistrates Association and local Courts Committees may have a role.  

Regional teams of expert witnesses including psychiatrists, psychologists and paediatricians should be established and funded, with appropriate job plans to support local paediatricians and general practitioners.

Specific audit of the roles of doctors using sufficiently anonymised cases as a training and supportive tool.

A specific protocol on the preparation of medical reports should be available. Bearing Good Witness  and subsequent pilot studies and the work of a local family justice council may be helpful. 

Training on presenting evidence should be available.  Local prosecutors and the police may be able to advise on this. Many doctors have access to a local medico legal association which may take on this role such as the Worcestershire Medico Legal Association etc.

Clear guidance is required from the GMC which doctors would find helpful and supportive and in which they could be confident that their conscientious work and compliance would protect them from vexatious complaints.

Conclusion

Lord Justice Thorpe`s expert group is necessary if the lack of confidence of doctors in the legal process, which is endangering child protection and for which they are inadequately trained, is to be halted .

Dr Anthony Cole

JP FRCP FRCPCH

Chairman the Medical Ethics Alliance

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One Response to Doctors` roles and responsibilities in child protection

  1. AYODEJI says:

    I enjoyed and have learnt new things from the article above. But I need help regarding what to do when parents threaten to abandon a phocolic neonate and Health Management Organisation(HMO) also supporting such parents to cut cost and allow the baby to die?

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