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Running Sexual Assault Services for Children The Forensic Medical Examination Dr Rosalyn Proops Royal College of Paediatrics and Child Health Norfolk and Norwich Hospital 28th February 2008 Toby 18 months • Seen in the Children's Assessment Unit with mother • Bruising inside of thigh and pain passing urine. • Left with the babysitter ( male friend of the family ) • Initial findings of bruising on penile shaft and glans • Extended and immediate family known to Local Authority • Difficult to examine, unhappy and irritable • Examination under anaesthetic with paediatrician, paediatric surgeon and Forensic Medical Examiner • Full care order • No prosecution • Step brother of young girl who presents the following week with genital vesicles – chicken pox ! Rachel 15 years • Reports to teacher that father has been abusing her (penetrative intercourse) over 4 years • Last happened 2 days ago • Clear story. Supported by mother • Same day interviewed and • Examined by FME in dedicated centre • Forensic sampling photo documentation • Sexually transmitted diseases screen • Further support arranged • Father pleads guilty • Rachel supported and successfully completes schooling Amy 10 years • Admitted with severe oral injuries. Tripped over the dog and fell against the static washing line pole • Selective mute poor school attendance • Sister aged 15 years pregnant • Evidence of physical neglect, emotional harm • History of sexual abuse in mother’s family • Several multi disciplinary meetings later mother consented to EUA (whilst in Theatre having dental splints removed) • Paediatrician with forensic skills photographs taken • Under GA hymenal opening > 1cm smooth free margin • Diagnosis emotional harm neglect and probable CSA • Supervision order Good practice • Timely coordinated response • Child and young person focussed. • A specific response to the particular presenting problem. • The doctor and the team with the right complement of skills • Forensic skills ( injury, history, sampling, report writing ) • Paediatric skills in communication, examination and follow up Child Protection IS everyone's business • Awareness within the wider hospital team • Concurrent abuse: physical neglect, emotional harm and the family history • Planned examinations with specialists The Forensic Medical Examination • Clinical history • General examination • Examination relevant to the abuse • Detailed contemporaneous documentation (including line drawings) • Photo documentation • Forensic sampling • Arranging after care • Writing a report • Attending court Key service elements • Agreed ( national ) standards for forensic and medical examination in all relevant health care settings • Clinical governance and quality assurance • Training and qualifications • Follow through and on going care with ( mainstream ) health services mental and physical health • Provision to meet the needs of children experiencing chronic sexual abuse and meeting the needs of historical abuse on adults • Funding Forensic paediatrics Clinical pathways and networks • Needs • Prevention • Identification • Pathway • Assessment • Interventions • Outcomes • Long term support • Palliation • What needs to be done, based on best evidence • Who needs to do it based on competencies • Where it needs to be delivered based on safety convenience… • With which additional resource/ support • And common ground between commissioners, providers and regulators – clarity of purpose, underpinning values – leadership – commitment to innovation and learning What are the indications for a paediatric forensic medical examination? • Allegation (direct or indirect) of sexual abuse/ rape / assault • Sexually transmitted disease or pregnancy in a child • Problems such as recurrent vaginal discharge genital bleeding secondary enuresis AND relevant history of concern • Concerning genital injury • Behavioural disturbance e.g. self harm cruelty to children or animals AND relevant history of concern • Contact with sex offender • Sibling or close friend of index child Paediatric Forensic Examination When? • Whenever a child has made a disclosure of recent sexual abuse, sexual abuse has been witnessed or when a referring agency strongly suspects abuse has occurred • Suspicion of any form of abuse must be taken further to do nothing is not an option Timing depends on: • Medical care required • Likelihood of physical signs and / or positive DNA sampling • STD cultures ( repeat cultures in 2 weeks and samples for blood born infection after 3 and 6 months) • Legal requirement Sara 3 years • Advised to go to A&E by NHS Direct after visiting father and 2 uncles (aged 11 and 13 years ) • sore down below and using rude words • Examined in A&E by junior doctor: referred to paediatrics with bruise on vagina • Seen on the ward by on call paediatrician from St Elsewhere • Happy cooperative child. • Examined on the bed in the children's ward: nothing to find • Checks with Social Care negative • History of acrimonious parental separation • Follow up with Health visitor Inadequate practice? • Small rural DGH with no CSA service • Examined in A&E by junior doctor against local and national standards • Protocol written but is it followed? • Service delivery problems – does the child or the doctor travel? • Lack of appropriate kit and support • Lack of photo documentation • The wrong doctor ( not trained competent nor confident) • Delayed and poor quality reports • Inadequate commissioning • Is the employer aware of the potential risks? • Separated families and civil actions Kerry 13 yrs • Second pregnancy ( first terminated) • New boyfriend aged 20 yrs • Out of school for 2 years • Determined to keep the baby • Police concerned about mother’s collusion • Boy friend arrested • LA and Police requested joint examination- to what purpose? Where should the assessment take place? • Sexual abuse in young children is (usually) part of the bigger story of significant harm • What do the children want ? • Paediatric out patients with dedicated suite (SARC standards) – Hospital based - with all health support facilities – Community based - with LA / police • Sexual assault referral centres for all age providing services for children and young people ( paediatric standards) - Hospital based - Community based • Young people over 14 years • 16-18 years • Young people with (learning) disabilities Who ? Skills and competencies • Communication about sensitive issues awareness of child's developmental social and emotional needs • Consent and confidentiality • Competence to conduct a comprehensive general examination and genital examination • Understanding of normal and abnormal genital and anal anatomy ( based on current research evidence) • Specific examination including clinical technique, colposcopic examination (recording) and forensic samples • After care including post coital contraception sexual transmitted diseases management • and onward referral Who ? One or two doctors? • It depends… a single doctor examination may take place if he/ she has the full complement of knowledge skills and experience, or two doctors with complementary skills • Most general paediatricians will not have the forensic competencies • Most forensic physicians will not have the paediatric competencies • Children presenting with concerns about physical abuse neglect or emotional harm should also be fully examined as part of the assessment • May need other specialists Competencies • Staff groups: forensic physicians, paediatricians, forensic nurses • General – Safeguarding Children and Young People: roles and competencies of health care staff Intercollegiate document April 2006 – RCPCH competencies for basic and higher trainees – RCN CPHVA RCM and other • Specific – National Service Guidelines for Developing Sexual Assault Referral Centres Oct 2005 Training • Knowledge and understanding • Skills • Peer review of cases • Supervision of practice • Audit • Research David 12 years • On video interview tells of 1 year history of repeated anal abuse by 2 named men at least 25 times and over the last couple of days • Examined by male paediatrician with forensic skills with police officer • Normal physical examination. Forensic samples taken • Arrangements made for STD screen • Paediatrician suggested that D may have a previously unrecognised developmental disorder requiring further assessment • Police investigation. Alleged perpetrators arrested and questioned House very carefully examined. All negative • Alleged perpetrator dies from Myocardial Infarction 48 hours later • Developmental diagnosis of Asperger’s Syndrome • Educational support • Psychiatric support • No prosecution Jessica 14 years • Witnessed sexual act on a train with male who was arrested • J reported long standing ‘relationship’ • Collusion by J’s mother and by wife of perpetrator • Multiple long standing problems Physical: bowel bladder weight (100kg) asthma neglect Moderate learning difficulties (failing in mainstream school) • Clinical examination by paediatrician and gynaecologist with forensic training • Findings compatible with history of vaginal and anal abuse • Jessica taken into care • Four children of perpetrator examined: physical and emotional neglect and harm. • Criminal and civil cases pending The paediatric problem The child with a disability • Increase risk of children with disabilities to abuse • Children present with multiple co-morbidities • Children with a developmental disorder are vulnerable to: - abuse - returning to an abusive situation - understanding what is the truth and the consequences of a falsification • The importance of following all procedures • Immediate after care and long term paediatric follow up After care and follow up • Be clear about responsibilities within the team • Consider siblings • Follow up of medical, developmental and educational problems • Referral on for therapeutic support • Reports for Local Authority Children’s services, police, courts, GP, education Forensic samples • Sampling techniques and forensic requirements are specific and a competent practitioner needs both the theoretical and practical training • Evidential samples - Semen blood saliva or other body fluids containing cellular material - Loose hairs fibres debris particles - Blood urine hair for toxicological analysis - Unwashed clothing bedding items used in the assault • Control samples for comparison purposes • Persistence of cellular material can be up to 7days • Decide which samples are relevant to the particular case • Use recommended sampling materials and containers • Follow the precise storage instructions • Labelling of the sample and the evident bags with: - name of the person - description of the sample - ID number (using doctors initials) - date and time (urine and blood) • Labels must show: - the signature of the person who first handled the exhibit - signatures of all other persons (the chain of evidence) • Doctor must retain a list of samples and allocated identification numbers Forensic samples and their collection • For up to date information http://www.forensic.gov.uk • Guidelines for the Collection of Specimens http://www.fflm.ac.uk GMC 0-18 years: guidance for all doctors 2007 Assessing best interests Communication Making decisions Confidentiality Access to records by parents and children Child Protection except in an emergency, where the patient has the capacity to give consent you should obtain written consent in cases where providing clinical care is not the primary purpose of the examination or investigation and / or where there may be significant consequences for the patients ..social or personal life General Medical Council Seeking patients’ consent: the ethical considerations. 1998 Consent and assessing capacity to consent Can the young person understand the nature purpose and possible consequences of the investigation? – Understand – Retain – Use and weigh the information – Communicate their decision Must provide and discuss all relevant information before deciding if the young person has the capacity to consent • Competent young people must be consulted and may refuse and this cannot be overruled by the parent If a competent young person says no! Stop! • Capacity to consent depends more on ability to understand and weigh up options than on age – At 16 years can presume consent – Under 16 years may have the capacity depending upon their maturity and ability to understand what is involved and upon the complexity and importance of the decision Consent • We assume parental consent as a proxy for the best interests of the child • If the parents are not acting in the child’s best interests may need the intervention of the court • Parental Responsibility might be shared with the LA under an order (ICO or CO but not emergency orders) • Must obtain consent for examination, forensic sampling and photo documentation • Failure to obtain consent may constitute assault Very Useful Reading • GMC 0-18 years: guidance for doctors 2007 • Child Protection Companion RCPCH 2006 • The Physical Signs of Child Sexual Abuse: An evidence- based review and guidance for best practice March 2008 RCPCH in collaboration with RCP FFLM • Paediatric forensic examinations in relation to possible sexual abuse RCPCH and RCP FFLM 2007 • Recommendations of best practice in the management of intimate images that may become evidence on court RCPCH and RCP FFLM 2007 Joint RCPCH and FFLM Guidelines April 2007 • It is essential that high quality photo documentation be obtained, if not document the reasons • A single doctor can conduct a paediatric forensic exam provide he/ she has all the necessary skills ( complementary skills) • The examining doctor must ensure they are familiar with the evidence- based guidance regarding the interpretation of signs Competent and confident with: • Examination - general paediatric - developmental - specific examination • Forensic sampling • Photo documentation • Evidence base • Note keeping contemporaneous notes reports • Communication with other agencies, within and outside of health • Presenting evidence in court Do you have ? • Access to training • The right kit • Support at the time of the examinations • Supervision of practice • Peer review of cases • Supportive clinical team • Supportive management / employer team • Can you deliver a safe clinical service in your area? • Is it safe for the child • And safe for you ? Department of Children Families and Schools 2007 the Government's view is that where professionals are undertaking child protection work, their first duty is to the children concerned. As far as the children's parents are concerned, professionals must simply act in good faith, exercising reasonable skill and care.
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