1. Designated Nurse for Safeguarding Children Jackie Dyer

2. To enable participants to refresh and develop their knowledge of Child Protection in order to competently safeguard children within their role in General Practice.

3.  Identify and manage personal attitudes to and beliefs about child abuse  To understand your roles and responsibilities in Safeguarding  Recognise children who are suffering or at risk of suffering significant harm  To understand and improve joint working and assessments across agencies  Purpose Serious Case Reviews

4.  Legal Definition:Children Act 1989  ‘ actual or likely harm to the child, where harm includes ill-treatment such as emotional abuse, and the impairment of health or development, health meaning physical or mental health, and development meaning physical, intellectual, emotional, social or behavioural development’.

5.  A duty to protect children from maltreatment  A duty to prevent impairment

6. The Children Act 1989 introduced this concept as : The threshold that justifies compulsory intervention in family life in the best interests of children. It gives local authorities a duty to make enquiries to decide whether they should take action to safeguard or promote the welfare of a child who is suffering, or likely to suffer significant harm. There are no absolute criteria on which to rely when judging what constitutes significant harm. Often, it is a compilation of significant events, both acute and longstanding, which interrupt, change or damage the child’s physical and psychological development.

7. A child is in need if : He is unlikely to achieve or maintain, or have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority. His health or development is likely to be significantly impaired, or further impaired, without the provision for him of such services. He is disabled. He is a young carer. Source : Section 17, The Children Act, 1989

8. 1. Parents who are verbally aggressive to their children 2. Using physical punishment for unacceptable behaviour in a child 3. A fourteen year old dating a nineteen year old 4. A fifteen year old living with a family friend 5. Leaving a competent 10- year old to look after a 2 year old sibling for an hour 6. Parents who arrange and insist on their daughters marriage partner

9.  Hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer feigns the symptoms of, or deliberately causes ill health to a child whom they are looking after. Known as fabricated or induced illness, FII.

10. Is the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person, age or developmentally inappropriate expectations being imposed on children, causing children frequently to feel frightened, or the exploitation or corruption of children.

11.  The persistent failure to meet a child’s basic physical and /or psychological needs, likely to result in the serious impairment of the child’s health and development, such as failing to provide adequate food, shelter and clothing, failing to protect a child from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment.  It may also include neglect of or unresponsiveness to a child’s basic emotional needs.

12. Forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (e.g. rape or buggery) or non-penetrative acts. They may include non-contact activities, such as involving children in looking at pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways.

13. Sexual exploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive ‘something’ (eg. Food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of performing, and/or others performing on them sexual activities. Child sexual exploitation can occur through use of technology without the child’s immediate recognition, for example the persuasion to post sexual images on the internet/mobile phones with no immediate payment or gain. In all cases those exploiting the child/young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources... National Working Group for Sexually Exploited Children and Young People, 2010

14. Child Sexual Exploitation Gangs & groups Older ‘boyfriend’ Sexual Bullying FamilialOpportunisticOnlineTrafficked Trends in CSE Perpetrators are predominantly male, victims predominantly female Takes place between people who are known to each other Used as a means of boys and young men exerting power and control over girls and young women

15. Risk of harm from underage sexual activity Unable to make informed decisions Associated substance misuse Excessive secrecy Withdrawn, anxious Child Power imbalance Use of aggression, coercion or bribery History of sexual offences Partner Familial history of social difficulties – sexual offences, substance misuses Other

16. Risk harm from underage sexual activity Assess  Level of maturity and understanding  Child’s living circumstances and background  Age and role of partner

17. Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass but is not limited to the following types of abuse:  psychological  physical  sexual  financial  emotional  Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.  Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.”*  *This definition includes so called ‘honour’ based violence, female genital mutilation (FGM) and forced marriage, and is clear that victims are not confined to one gender or ethnic group.“ ( Home Office 2013 )

18.  New powers for the police and courts to tackle offenders while ensuring victims get the support and protection they need  Code of practice setting out services to be provided to victims  Commissioner for Victims and Witnesses at representing victims nationally.  Amends definition of cohabitants same sex couples, associated persons who have never lived together including first cousins.

19. 1in 4 women will experience abuse 12.9 million incidents recorded by British Crime Survey against women, 2.5 million against men 1 call a minute to police Children living DV represent 2/3 cases CP conference 2 women are killed UK each week DV is a feature of most CP cases worst outcomes. Feature in 56% of SCR’s in London Feature in 62% of child sexual abuse referrals included DV Hester and Pearson 1998 30% of DV starts or escalates during pregnancy, women are at greater risk after they have given birth

20. What is FGM?  partial or total removal, or injury to the external female genitalia  affects 100-140 million women worldwide  Increasing prevalence in UK due to migration from practising countries

21.  Type 1 Partial/total removal clitoris  Type 2 Partial/total removal clitoris& labia minora, with or without excision of labia majora  Type 3 Infibulation narrowing Vagina orifice with creation of a covering seal by cutting and appositioning labia minora/majora with or without excision of clitoris  Type All other harmful procedures to female genitalia for non medical purposes, picking piercing, incising scraping

22.  Breaches UN Convention on rights of child  Illegal  physical and psychological consequences  child protection  Lack of awareness amongst health professionals

23.  An estimated 66,000 women with FGM in UK  >20,000 girls under 15 yrs are potentially at risk of FGM (England and Wales) ref: “A Statistical Study to Estimate the Prevalence of Female Genital Mutilation in England and Wales: Summary Report”, FORWARD 2007

24. ◦ The implementation of prevention guidelines Intercollegiate Document ◦ Raise awareness in training ◦ Set up a process for sharing information ◦ Health (midwife/health visitor/school nurse/GP/paediatrician ◦ Referrals into tertiary local clinics, centralising expertise and services ◦ Involvement of Multi-professional Group ◦ Police /Social Care

25.  Advise FGM unlawful & harmful.  Encourage to speak to police as a crime may have been committed  Or they can speak in confidence to Crime stoppers on 0800 555111  and/or NSPCC FGM dedicated 24/7 helpline offers counselling & advice to public & professionals The helpline can be contacted on: 0800 028 3550 and emails sent to fgmhelp@nspcc.org.uk fgmhelp@nspcc.org.uk

26.  Staff in Local Child Safeguarding Board (LSCB) agencies MUST make a referral to social services if there are signs that a child under 18 yrs or an unborn baby: ◦ Is experiencing or may already have experienced abuse or neglect ◦ Is likely to suffer significant harm in the future  The timing of referrals should reflect level of perceived risk, but should usually be within 1 working day of recognition of the risk.

28.  Premature and low birth weight infant  Infant separated from mother for longer than 24 hours after delivery  Infant/child with a disability  Less than 18 months between birth of children  Born different to expectations, for example the wrong sex  Born unwanted and/or unplanned  History of being looked after  Not attending school

29.  Unhappy and abusive childhood experiences  Teenage parents  Lone, unsupported parent  Poor physical health or disability  Mental health problems, personality disorder  Learning difficulties  Intolerance, indifference or over anxiety towards the child  Little or no ante-natal and post-natal care

30.  Drug and alcohol misuse  Hostile family environment, unstable relationships  Previous history of family violence or abuse  Current family violence  Frequent moves, homelessness  Social isolation, weak supportive networks of family and friends  Socio-economic problems, such as poverty and unemployment  Diffuse social problems  Poor compliance with professionals

32. Protective factors - Children  Easy temperament  Good social skills  High intelligence and doing well at school  Mentor / teacher  Significant relative  Excels at a task e.g. sport

33. Protective factors – parents  Responding to child protection plan  Attending appointments for the child  Concerned re well being of child  Recognised negative influences such as violent or abusive relationship  Attending therapy/parenting class etc.  Attending support groups e.g. for anger

34. CHILD Safeguarding and promoting welfare PARENTING CAPACITY Basic care Ensuring safety Emotional warmth Stimulation Guidance and boundaries Stability CHILD’S DEVELOPMENTAL NEEDS Health Education Emotional and behavioural development Identity Family and social relationships Social presentation Self care skills FAMILY and ENVIRONMENTAL FACTORS Family history and functioning Wider family Housing Employment Income Family’s social integration Community resources

35. PRACTITIONER HAS CONCERNS ABOUT CHILD’S WELFARE Practitioner discusses with Manager and/or other senior colleagues as they think appropriate Still has concernsNo longer has concerns Practitioner refers to LA children’s social care, following up in writing within 48 hours No further child protection action, although may need to act to ensure services provided Source: What to do if you’re worried a child is being abused: Department for Education and Skills, 2006 Social worker and manager acknowledge receipt of referral and decide on next course of action within one working day Feedback to referrer on next course of action Initial assessment required Concerns about a child’s immediate safety No further LA children’s social care involvement at this stage, although other action may be necessary e.g onward referral

36. Information Sharing in Safeguarding Children  “Jigsaw” effect  Lots of small individual concerns  When added together make one big concern! Missed immunisations Poor attendance at CHP Visits A&E with bruises Frequent minor injuries Maltreatment

37.  MASH is a process which facilitates a safe quick multi-agency information sharing. The Information shared, informs decisions, ensure safeguarding activity & intervention are timely, proportionate & necessary. MASH Team are collocated & comprises of  SWs  Police Officers  Family Support Worker  MASH Liaison Health Visitor  Housing

38.  Raise concerns and refer to a statutory organisation  There is an initial assessment of the child’s situation  Urgent action - if necessary (in this case admitted to hospital)  Agencies have a strategy discussion/meeting  Assessment to gather information for the child protection conference  Child in need of protection - child protection plan/register with core group meetings  The review process Child Protection Process

39.  Professionals only  Establish the facts  Identify other agencies already involved  Assess the needs of the child  Consider other factors e.g. domestic abuse  Plan and agree any investigation process or further action Strategy meeting

40.  Where a local authority are informed that a child who lives, or is found, in their area— is the subject of  an emergency protection order; or  is in police protection; or  have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm,  the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.

41.  To ensure the child is safe and prevent him or her from suffering further harm  Promote the child’s health and development i.e. his or her welfare  Provided it is in the best interests of the child, to support the family and wider family members to safeguard and promote the welfare of the child The purpose of the Child Protection Plan

42.  Formal meeting convened by social care  Principle forum for key multi-agency professionals and family (sometimes child)  share information and concerns about a child at risk of continuing harm  Decides whether place child subject to protection plan  Formulates written plan  Initial and review (within 4m then every 6m)  GP plays key role through attendance or report writing

43.  Statutory multiagency body that coordinates what is done by individuals and other agencies in order to protect and safeguard the welfare of children in each area  Conduct serious case reviews when indicated Role of the LSCB local safeguarding children boards

44. Serious Case Review  Regulation 5 Local Safeguarding Boards Regulations 2006, sets outs their function in relation to SCRs A Serious Case Review is on where : “(a) abuse/neglect is known or suspected & ( b) either (i) the child has died or (ii) the child has been seriously harmed and there is cause for concern as to the way LA & Partners have worked together to safeguard the child.

45.  Conducted by LSCBs, Local Safeguarding Children Boards  Learn lessons as to how professionals and organisations work together  How lessons will be acted upon and what will change as a result  Improve interagency working Serious case reviews

46.  Family characteristics  < 20% known to social care  No account of child’s view  Poor interagency cooperation  Poor communication  Poor recording of information and decisions  Professional uncertainty  Hostile and non-cooperative families  Differing thresholds between agencies  Information not analysed critically Sidebotham 2012 Common themes in SCR

47. Is the child acutely sick, in pain, bleeding or has “medical” problems? YesNo Will the child be at immediate risk of abuse when he/she leaves the surgery? No Discuss with Mon- Fri 9-5 Child Protection Team Hotline Tel. 020 3317 2412 Refer for assessment to the Safeguarding Children Clinic Child Protection Team, Crowndale H.C 59 Crowndale Road, London NW1 1TU Fax 0203 317 2412 Not Sure Discuss with Mon-Fri 9-5 Child Protection Team Hotline Tel. 020 3317 2412 GP Child Protection Lead Claire Taylor 07736070327 clairetaylor5@nhs.net clairetaylor5@nhs.net Designated Nurse for Safeguarding Children Jackie Dyer Tel 07768886258 Designated Doctor for Safeguarding Children Deborah Hodes Deborah.hodes @nhs.net Duty Social Worker Team Out of Hours On call Paediatric Registrar at acute trust Yes Refer to Mon - Fri 9 -5 Duty Social Worker Team Contact either Tel. 020 7974 6600 (North Team) Tel 020 7974 4094 (South Team) Out of hours 020 7974 4444 Or dial 999 in emergency NB. All referrals to be followed in writing within 48hrs Contact the on-call Paediatric Registrar University College Hospital Tel. 08451 555 000 Whittington Hospital Tel. 020 7272 3070 Royal Free Hospital Tel. 020 7794 0500 You see a child and suspect abuse or neglect Child Protection Guidelines for General Practitioners in Camden

48. References  The Children Act (1989)  Framework for the assessment of Children in Need and their Families (2000)  What To Do If You Are Worried A Child is Being Abused (2003)  Sexual Offences Act (2003)  The Children Act (2004)  Domestic Violence, Crime and Victims Act (2004)  Working Together to Safeguard Children (2013)  The London Child Protection Procedures (2010)  When to Suspect Child Maltreatment NICE (2009)  www.core-infocardiff www.core-infocardiff  Child Protection Companion RCPCH 2006  Protecting children and young people: The responsibilities of all doctors, GMC 2012  Tackling FGM in the UK Intercollegiate recommendations RCOG, RCM, RCN 2013  Multi-Agency Practice Guidelines FGM, HM Government 2011