CHAPTER 20 HOSPITALS / CLINICS (HOSPITAL AUTHORITY) 20.1 Medical Officers (MOs), nurses and para-medical staff of hospital / clinic of the Hospital Authority should familiarize themselves with the procedures of handling suspected child abuse. They should be alert to the signs of child abuse by making reference to the Indicator of Possible Child Abuse & Guide to Risk Assessment in Chapter 2. If a child has symptoms or signs which indicate that sexual abuse may have taken place, the MOs, nurses and para-medical staff should follow the Guide to People Working with Children Who Disclose Sexual Abuse at Appendix IV and Guidance for Paediatric Wards, A&E and Staff involved with Child Abuse at Appendix XVI. GOVERNING PRINCIPLES 20.2 The primary objectives in managing victim of suspected child abuse or neglect are : (a) to protect the child; (b) to plan and provide a healthier environment for the child; and (c) to facilitate criminal investigation and subsequent prosecution. 20.3 Principles : (a) The child must not be further traumatized by the investigative process. (b) The best interest of the child must be accorded top priority. The emotional well-being of the child must be protected and all those involved must be sensitive to the social and psychological needs of the child and the family. The clinical interview should be conducted in private to minimize further distress to the child. (c) History is the keystone in establishing a diagnosis of child abuse. A detailed medical history from the child, as far as possible, and from the carer should follow the format of a thorough paediatric health assessment with special attention to the injuries and to factors that may determine any continuing risk. However, the clinical interview can be very distressing for the child and should be carefully planned. At the initial contact, it is probably the best to keep the number of interview to a minimum. (d) The number of investigative / assessment interview on the suspected abuse incident(s) should be kept to a minimum, say one interview. The 1 interviewer may be the responsible caseworker, the professional to whom the child has established trust for disclosure, the representative from the Police, or jointly by these professionals. For video-recorded interview to be used in court proceedings, the interview should be conducted by police officer, social worker or clinical psychologist employed by the Government. The information collected with regard to the suspected abuse incident(s) shall be shared with relevant parties concerned as soon as possible. (e) Advanced training and experience are needed for the proper recognition and examination of child sexual abuse cases. The initial assessment should be limited to a general examination with visual inspection of the genital area depending on the history, and the age and level of distress of the child. A careful and comprehensive record should be made. Normal physical findings do not exclude the diagnosis of child sexual abuse. (f) For child sexual abuse cases in need of full medical / forensic examination, the child should be examined by medical professionals with expertise in child abuse examination. Should the child indicates the preference for a female medical officer, this should be entertained if a female expertise is available. (g) The number of examination must be kept to a minimum. ROLE OF MEDICAL CO-ORDINATOR ON CHILD ABUSE (MCCA) 20.4 Medical Co-ordinators on Child Abuse (MCCA) are designated in the Paediatric Departments within the Hospital Authority Hospitals (List of MCCA at Appendix XI) for handling child abuse cases. Working closely with medical social workers (MSW), nurses, clinical psychologists, psychiatrists and other related personnel through their expertise in child protection, the MCCA provide support to the suspected child victims by making their physical, emotional and developmental needs understood. 20.5 The duties of a MCCA include : (a) acting as a source of referral and providing medical service to child abuse cases; (b) assisting to arrange direct admission for the child to Paediatric Ward upon receiving a referral as appropriate; (c) providing expert medical advice to colleagues and other professionals; (d) co-ordinating and facilitating intra-agency and inter-agency communication, investigation and planning for further handling of the case, through the assistance of MSW. INTAKE PROCEDURES 20.6 For child sexual abuse cases, the handling procedures for medical officer are outlined at Appendix XVII. Such cases will be managed according to the index of suspicion at Appendix XVIII and the need for urgent medical treatment. When handling these cases, all medical officers are advised to read the following procedures together with Appendix XVII & XVIII. Referral received by Accident & Emergency Department (AED) and Specialist Outpatient Clinic (SOPC) 20.7 (a) If child sexual abuse or serious physical abuse is suspected, the doctor should : (i) inform the Consultant / Senior Medical Officer (SMO) in charge of the case who may in turn consult the MCCA of the hospital or nearby hospital or the Social Work Officer of Family and Child Protective Services Unit (SWO/FCPSU) at Appendix VII or seeking advice from Child Abuse Investigation Unit (Police/CAIU) on crime-related issues at Appendix VIII; or (ii) admit or refer the child to a paediatric in-patient unit. (b) If other form(s) of child abuse is/are suspected, the doctor should inform: (i) the Consultant / SMO in charge of the case who may in turn consult the MCCA of the hospital or nearby hospital; and (ii) the MSW who would initiate the child protection mechanism including checking with Child Protection Registry (CPR) via his/her supervisor (reference on CPR at Appendix VI), contacting the respective SWD / NGO staff if the case is known to the SWD / NGO unit, or consult / refer the case to FCPSU as appropriate if the case is not known to other SWD / NGO unit. (c) For cases in need of urgent intervention / investigation, the doctor should inform the Police (the nearest Hospital Police Post or Police Station) or social worker (SWD hotline / FCPSU or Hospital MSW) as appropriate, and keep the Consultant / SMO in charge of the case and MSW informed of the case for assistance as soon as possible. (d) For cases where child abuse is suspected and the child concerned is not going to be warded in hospital before the child leaves the AED or SOPC, the doctor or MSW concerned who has first-hand information on the suspected abuse incident(s) should make a report to the Hospital Police Post if police investigation and management is considered helpful. The concerned police unit will then contact the doctor or MSW concerned for further enquiries as soon as possible. The MSW should make sure that the case is reported to the Police as soon as possible. For known cases of SWD / NGO unit, the MSW will keep the SWD / NGO staff informed of the case for follow-up. For new cases, the MSW will refer the case to FCPSU for follow-up actions. (e) For suspected child abuse cases where hospitalization for observation or treatment is necessary, the child can be admitted to the Department of Paediatrics or other appropriate Department of the Hospital or nearby Hospital. (i). The MCCA and other relevant staff will as far as possible ensure that appropriate assessment to the child be completed. These will include both physical and mental aspects. (ii) If parent(s) / guardian(s) resist hospital admission, the doctor-in-charge should try to persuade the parent(s) / guardian(s) to stay whilst contact is made with the responsible social worker of known case or SWO/FCPSU or IFSC / SWD for assistance or consideration who is relevant for invoking powers under Section 34F(2) / Section 35(1)(a) of the Protection of Children and Juveniles Ordinance, Cap 213. The MSW in hospital should assist whenever situation warrants in office hours. Assistance could also be obtained through the SWD hotline (Tel. no.: 2343 2255). (iii) If the child’s life and safety is endangered and/or the parent is in breach of peace, police officers may intervene. Once an order for removal and detention under Section 34F(2) / Section 35(1)(a) is made by the relevant public officers, the Police will, as far as possible, assist to ensure enforcement of the order. (f) For doubtful cases where in-patient treatment is not required and the level of suspicion of child abuse is not high, Consultant / SMO in charge of the case or MCCA or FCPSU can be consulted. The child should be referred to the MCCA or relevant welfare organisation for follow-up, or be followed up by the MO in-charge of the AED for review as soon as possible. (g) For cases where in-patient treatment is not required and there is not enough evidence to substantiate the suspicion of child abuse but the child or the family has other welfare needs, the doctor of AED / SOPC is advised to ensure that the case is referred to the relevant welfare organisation for follow up e.g. MSW / IFSC / ISC. Referral received by Paediatric Ward 20.8 (a) If child abuse is suspected, the doctor should inform : (i) the Consultant / SMO in charge of the case who may in turn consult the MCCA of the hospital or nearby hospital or SWO/FCPSU or seeking advice from Police / CAIU on crime-related issues; or (ii) the MSW who would initiate the child protection mechanism including checking with Child Protection Registry (CPR) via his/her supervisor (reference on CPR at Appendix VI), contacting the respective SWD / NGO staff if the case is known to the SWD / NGO unit, or consult / refer the case to the FCPSU as appropriate if the case is not known to SWD / NGO unit. Referral received by Orthopaedic / Gynaecological / Medical / Surgical Ward, etc. 20.9 (a) If child abuse is suspected, the doctor should : (i) inform the Consultant / SMO in charge of the case who may in turn consult the MCCA of the hospital or nearby hospital or SWO/FCPSU or seeking advice from Police / CAIU on crime-related issues; or (ii) refer the child to a paediatric in-patient unit. MEDICAL AND FORENSIC EXAMINATION 20.10 Reference can be made to Chapter 9 for the procedures for medical / forensic examination. MULTI-DISCIPLINARY CASE CONFERENCE ON CHILD ABUSE 20.11 The MO attending the case would be invited to attend the Multi-disciplinary Case Conference to formulate the welfare planning of the child. A written report on the child’s condition should be prepared for reference of the Conference (paragraph K of Annex I to Chapter 11). COLLABORATION WITH OTHER PARTIES 20.12 All parties concerned should maintain communication about the case progress as appropriate for the protection of the child and provision of welfare service to the family.
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