Forensic paeds by fjwuxn


									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
• 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
• Who needs to do it based on competencies
• Where it needs to be delivered based on safety
• 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 /
• Sexually transmitted disease or pregnancy in a child
• Problems such as recurrent vaginal discharge genital
  bleeding secondary enuresis AND relevant history of
• 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
•   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

• 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
• 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
• Happy cooperative child.
• Examined on the bed in the children's ward: nothing to

• 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
• 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
   - 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
• 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

• Most forensic physicians will not have the paediatric

•   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
• 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
• 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
• 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

• 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

• Guidelines for the Collection of Specimens
0-18 years: guidance for all doctors 2007

                      Assessing best interests


                      Making decisions


                      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 or personal life

General Medical Council
Seeking patients’ consent: the ethical considerations.
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
• 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
• 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

• 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

• 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
• It is essential that high quality photo
  documentation be obtained, if not document the

• 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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