Children and the Law: for OSCEs David Hankin GP ST2 BSc Healthcare Ethics and Law

OSCE: General approach Knowledge professional guidance, law, ethics Application to scenario Communication

Learning objectives (1) What is a child protection issue? What should you do about it? CASE SCENARIOS ROLE PLAY

Learning objectives (2) Consent and minors: when can children/minors consent for themselves? what is Gillick competence/the Fraser guidelines? how should you assess best interests? can minors refuse treatment? Communicating with children (briefly!)

Learning objectives (3) Feel CONFIDENT for ethics OSCE station!

Children/young people/minors! Law Mental Capacity Act 2005 Children’s Act 1989 Fraser guidelines/Gillick case Professional guidance GMC: Good medical practice GMC: 0-18 years GMC: Consent

Child Protection (1) You must inform an appropriate person or authority promptly of any reasonable concern that children or young people are at risk of abuse or neglect, when that is in a child's best interests or necessary to protect other children or young people

Discuss with your senior Social services - child protection duty social worker Designated doctor for child protection A+E ? Involve police? What/who is an appropriate person/authority?

Child abuse Physical Emotional Sexual Neglect

Child protection You must not delay sharing relevant information with an appropriate person or authority if delay would increase the risk to the child or young person or to other children or young people

Case Scenario (1) A mother presents to A+E with 8 month old boy. She is concerned about a swelling on his head and is unsure of how it happened. O/E - boggy swelling right parietal area.

Case scenario (2) Anxious parents present with 18m girl who is refusing to weight bear. Her parents report a witness fall whilst playing with 3 yr old brother. X ray - spiral fracture of femur

Case scenario (3) 29 yr old single mother attends her GP. She is feeling low and anxious. You notice a recent A+E attendance on her record for ‘leg wound’. She reports slipping whilst cutting vegetables. On examination you notice a deep 4cm laceration to her thigh. Referred to practice counsellor: depressed, history of domestic abuse, separated from husband.

Case scenario (4) Mother with 6 year old son. He has missed multiple asthma appointments with paediatrician and poor school attendance.

When to refer... Unexplained injury Inconsistent history/injury Disclosure of abuse by child Evidence of neglect Also consider delayed presentation of injury, interaction between child/parents etc

Role play 1 DOCTOR: You are a house office in paediatric ED. You see a 8 month old boy with their mother/father. He/she is concerned about a swelling on his head. O/E - boggy swelling right parietal area. CT confirms an underlying fracture.

Roleplay 1 PARENT: You are a mother/father who presents to A+E with your 8 month old son. You are concerned about a swelling on his head and is unsure of how it happened. He was left alone with his father/mother who occasionally visits. You separated 2 months ago.

Role play 2 DOCTOR You are a house officer in paediatric ED. You see an 18 month old with a spiral fracture of the right femur. There is no history of injury from his mother who has brought her today

Role play 2 PARENT You bring your 18 month old daughter, Kylie into PED. She has been refusing to weight bear today. You are defensive and react angrily to any suggestion that you or your boyfriend might have caused the injury.

Role play 3 DOCTOR Ben, aged 6 has had multiple exacerbations with asthma. You are concerned about poor compliance with treatment and there have been repeated ‘DNAs’ to outpatients. When speaking to the school nurse about his inhalers at school you discover that his attendance at school is poor.

Role play 3 PARENT You are separated from your ex husband and have 4 children at home. One of your children has autism and has particularly challenging behaviour. You have some help from your mother in looking after them but she has been having increasing difficulty with hip pain. You feel strongly about looking after your children and react negatively to any involvement with social services. (You are more responsive if involvement from social services is discussed in terms of providing you with extra help to assist you and your family).

Law & Consent

Mental Capacity Act 2005 Gillick competence (Gillick v West Norfolk and Wisbeck HA) Fraser guidelines - Lord Fraser

Gillick and Fraser: What’s the difference? Gillick competence – applies to under 16s and their ability to consent to treatment Fraser guidelines – criteria for prescribing contraception and giving sexual health advice without parental knowledge

Consent & Minors You can provide medical treatment to a child or young person with their consent if they are competent, or with the consent of a parent or the court. You can provide emergency treatment without consent to save the life of, or prevent serious deterioration in the health of, a child or young person At 16 a young person can be presumed to have the capacity to consent

Consent & Minors You should encourage young people to involve their parents in making important decisions, but you should usually abide by any decision they have the capacity to make themselves Parents cannot override the competent consent of a young person to treatment that you consider is in their best interests.

Consent & Minors If a child lacks the capacity to consent, you should ask for their parent's consent. It is usually sufficient to have consent from one parent. If parents cannot agree and disputes cannot be resolved informally, you should seek legal advice about whether you should apply to the court

In Summary... Child competent - child consents Child not competent - parent/parents consent Parents disagree - may need court decision In emergency - no consent required (as per adults)

Parental responsibility Married - both parents. Unmarried - mother plus... Father if name is on birth certificate (post Adoption and Children Act 2003) Father with parental responsibility agreement or court order

Treatment refusal (1) A person with parental responsibility can consent for a child refusing treatment, if in the child’s best interest’s

Treatment refusal (2) You must carefully weigh up the harm to the rights of children and young people of overriding their refusal against the benefits of treatment, so that decisions can be taken in their best interests. In these circumstances, you should consider involving other members of the multi-disciplinary team, an independent advocate, or a named or designated doctor for child protection. Legal advice may be helpful in deciding whether you should apply to the court to resolve disputes about best interests that cannot be resolved informally. i.e. weigh up best interest and seek advice!

Assessing best interests You should consider: a) Views of child b) Views of parents/others close to child c) Cultural, religious or other beliefs of child/parents d) Views of other healthcare professional involved in child’s care/have interest in their welfare e) The choice that will be least restrictive to the child’s future options f) Any other relevant information!

Fraser guidelines the young person understands the health professional’s advice; the health professional cannot persuade the young person to inform his or her parents or allow the doctor to inform the parents that he or she is seeking contraceptive advice; the young person is very likely to begin or continue having intercourse with or without contraceptive treatment; unless he or she receives contraceptive advice or treatment, the young person’s physical or mental health or both are likely to suffer; the young person’s best interests require the health professional to give contraceptive advice, treatment or both without parental consent

Role play.... Doctors look away

Role play 4 PATIENT You are Jamie a 15 yr old girl. You have been in a relationship with Tom for 9 months. You had sex for the first time last week. He used condoms appropriately but you are worried you might get pregnant so want the ‘pill’ like some of your mates. You definitely don’t want your parents to know as they would go mad and you know it all coz you’ve been to sex ed classes at school

Role play 4 Assessment of capacity Child protection issues Understanding re: sex/contraception Persuasion to tell parents Will she continue having sex? Best interests

Role play 5 Doctors look away now....

Role play 5 You are Tara a 15 yr old girl requesting the ‘morning after pill’. You have been with Johnny for 2 years and you had sex for the first time last night. You didn’t use condoms and are terrified at the thought of getting pregnant. You are even more scared about your mum finding out.

Communication (briefly!) involve children and young people in discussions about their care a. be honest and open with them and their parents, while respecting confidentiality b. listen to and respect their views about their health, and respond to their concerns and preferences c. explain things using language or other forms of communication they can understand d. consider how you and they use non-verbal communication, and the surroundings in which you meet them e. give them opportunities to ask questions, and answer these honestly and to the best of your ability f. do all you can to make open and truthful discussion possible, taking into account that this can be helped or hindered by the involvement of parents or other people g. give them the same time and respect that you would give to adult patients

Summary: consent A competent child can consent to treatment, cannot be overridden by parents Parents can consent for incompetent child in their best interests Minors have no absolute right to refuse treatment even when competent - consider best interests and seek advice! Be open and honest with children and respect their right to confidentiality

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