1. Child Protection Health Staff (Level 3)

2. HOUSEKEEPING

3. Aim  To give participants the opportunity to identify and act upon areas of concern which may impact on the welfare and safety of children  To give participants an increased understanding of the Child Protection process and their role within that process

4. Learning Objectives 1  Recognise what constitutes a concern and what your responsibilities are  Identify adult behaviour which may have a negative effect on the welfare of children  Maintain a child focus  Have an awareness of holistic assessment and good documentation  Identify those professionals to be consulted for support and advice

5. Learning Objectives 2  Identify the roles and responsibilities of other agencies  Recognise the role of health staff in multi- agency information sharing and decision making at all stages in the child protection process  Have a clear understanding of the child protection conference system

6. Quiz  How many children suffer harm?

7. The Children Act 1989/2004

8. The Main Principles of the Act The welfare of the child is paramount. Wherever possible, children should be brought up and cared for within their own families. Children should be kept informed about what happens to them, and should participate when decisions are made about their future. Children should maintain contact with those who are important to them.

9. Parents continue to have parental responsibility for their children, even when their children are no longer living with them. Every effort should be made to work in partnership with parents. Individuals are regarded as children up until the age of 18 years.

10. The Children Act 1989 places two specific duties on agencies to co-operate in the interests of vulnerable children:

11. Section 17 Section 17 places a duty on local authorities to provide support and services for Children in Need.

12. A Child in Need He is unlikely to achieve or maintain, or to have the opportunity to achieve or maintain, a reasonable standard of health or development without the provision made 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.

13. Section 47 Section 47 places a duty on local authorities to make enquiries in cases where there is reasonable cause to suspect that a child is suffering, or is likely to suffer, significant harm.

14. Significant Harm Criteria The Children Act (1989) defines 'Harm' as ill-treatment or the impairment of health and development. ‘Significant’ is not defined in the Act other than a reference to it, depending on a comparison with what could reasonably be expected of a similar child.

15. Level 4: Children and families in crisis needing urgent intervention Level 3: Children and families needing intensive assistance Level 1: Available for all children and families Level 2: Children and families needing extra support

17. Potential pre- disposing factors of Child Abuse or Neglect

18. Exercise Factors influencing parenting Factors that increase the vulnerability of a child Factors that contribute to an insecure environment

19. What impact does parental behaviour have on the child? Mental Ill-Health Substance Misuse Alcohol Use Fighting Child

21. Resistant Families  “ Gathering information for assessment is not enough it needs to be organised and analysed, and information from a number of sources and about individuals other than mothers must be included in the analysis.”  “Children and families who did not have a detailed assessment were four times more likely than their counterparts to experience recurrence.”  “a history of prior abuse of a child is one of the most consistent and strongest predictors of recurrence.”  C4EO Safeguarding Directors Summary 6: March 2010

22. Disguised Compliance  Parent/carer gives the appearance of co- operating with agencies  Professionals should practice “respectful uncertainty” and maintain an open mind  Child Protection Supervision facilitates reflective practice  NSPCC fact sheet Disguised compliance March 2010

23. Substance Misuse - including Drugs and Alcohol

24. Assessing Risk - 1 Parental substance use: Is there a drug free parent, supportive partner or relative? Accommodation and the home environment: Are the family living in a drug using community? Provision of basic needs: Are the children attending school regularly?

25. Assessing Risk - 2 Procurement of drugs: Is this causing financial difficulties? Health risks: Safety and storage. Family social network and support systems: Will parents accept help/support from family/professionals? Parents perception of the situation: Do the parents place their own needs before the needs of the children?

26. Substance Misuse in Pregnancy Increases risk of having a premature baby, low birth weight baby, death of a baby before or shortly after birth and increased risk of SIDS

27. Domestic Abuse

28. How may Children be affected?  It can pose a threat to an unborn child – domestic abuse often begins or intensifies during pregnancy.  Children may get hurt in the crossfire  Children’s carer is injured  Domestic Abuse is emotionally damaging for children. Domestic Abuse: Handbook for Health Professionals (DOH 2006)

29. Assessment  All situations where domestic abuse occurs in families where children are present will need careful assessment  Multi-agency assessment may take place under MARAC arrangements (Multi-Agency Risk Assessment Conference) – no single model across North Yorks

30. Parental Mental Illness

31. Assessing Risk 1 When did you last see the children: Are levels of child care different during periods of illness? Child/adult relationships: What does the adult say about their relationship with the child? Social networks: Are there extended family support networks?

32. Assessing Risk 2 Provision of basic needs: Is there adequate food, clothing and warmth for the children? Safety within the home: Is all medication kept securely? Roles in family: are children taking on inappropriate parenting role? Other: Does the family remain in one area, or move frequently? If the latter, why?

33. Parental Mental Illness  Referrals must be made to social care if service users express delusions/bizarre/aggressive thoughts or behaviours that incorporate child, or might harm their child as part of a suicide plan.  A consultant psychiatrist should be directly involved in all clinical decision making for services users who may pose a risk to children www.npsa.nhs.uk/patientsafety/alerts-and-directives (May 2009)

34. Abuse of Children with Disabilities

35. Abuse of Disabled Children Abusers think it is safer to victimise a disabled child. Abusers are attracted to immature behaviour Disabled children may have compromised communication. Disabled children may be socially isolated. Disabled children receive less information about abuse. May be less able to understand that behaviour is inappropriate. More dependent – need extra care.

36. What is Abuse?

37. Exercise In small groups discuss whether the scenarios are abusive/acceptable

38. Categories of Abuse Physical Emotional Sexual Neglect

39. Physical Abuse Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child, including by fabricating the symptoms of, or deliberately causing, ill health to a child.

40. Non-accidental injury?  History?  Repetitive injuries?  Different types of injury?  Delay in presentation?  Other concerns re child’s presentation?  Injury consistent with developmental stage/ disability?  Inappropriate interaction between child and carers?

41. Burn Accidental distribution

42. Burn Non-accidental distribution

43. Accidental fracture patterns in children

44. Fabricated/ Induced Illness (FII) ‘ Significant harm which is caused to a child by the actions of a parent or other carer who deliberately fabricate symptoms in a child which would not otherwise be present’. Safeguarding Children in whom Illness may be fabricated or Induced (DOH 2008)

45. Spectrum of behaviour  Fabrication – signs and symptoms past medical history  Falsification – hospital charts and records; specimens of body fluids; letters and documentation  Induction – by a variety of means

46. Assessment of FII  At the point of “dawning” practitioners should consult a Named Nurse/Doctor without delay for advice  The child must be made safe whilst the investigation is ongoing  Suspicions should not be discussed widely  The parent/family must not be informed  Where in discussion with the Named Person it is thought that there is some foundation to suspect the abuse, a referral must be made to Children’s Social Care

47. Emotional Abuse ‘ Emotional abuse is the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development’  Conveying to children that they are worthless or unloved.  Inappropriate expectations.  Overprotection and limitation of exploration and learning.  Seeing/hearing ill treatment of another.  Serious bullying.  Exploitation or corruption.

48. Sexual Abuse “Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening”  Physical contact, including penetrative (e.g. rape or buggery) or non-penetrative acts.  Involving children in looking at, or in the production of, pornographic material.  Watching sexual activities.  Encouraging children to behave in sexually inappropriate ways.

49. Neglect Neglect is 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 or development. Neglect may occur during pregnancy as a result of maternal substance misuse.  Failing to provide adequate food, shelter and clothing.  Failure to protect a child from physical or emotional danger.  Failure to ensure access to appropriate medical care or treatment.  Failure to ensure adequate supervision.

50. Indicators of Neglect  Dirty clothes/skin/nails/odour  Chronic infestation  Hair matted or thin  Chronic nappy rash  Infected sores (especially in skin folds)  A long history of illness, accidents, ingestions and repeated hospital admission

51. Dealing with a Child’s disclosure Listen carefully and take it seriously Reassure children they are right to tell Negotiate getting help and obtain help quickly Do not jump to conclusions Ask open questions Do not make promises you cannot keep – in particular, never promise confidentiality Do not make the child repeat what he or she has said to another member of staff

52. Adults who disclose abuse in childhood In addition to previous slides – Try to ascertain if the perpetrator may still pose a risk to children. If so, you have a responsibility to protect those children  Encourage and support the adult in disclosing as much information as they are willing and refer the child to Social Care Services  Provide information about services  Ask adult to consider a formal disclosure to the Police

53. Reasons why people do not act to protect children Not wanting to interfere Not wanting to be involved Fear of appearing racist or prejudiced. Think someone else is dealing with the problem. Fear of repercussions – intimidation Fear of spoiling relationship with the parents/family Fear of breaching confidentiality

54. Break for Lunch

55. Consent and Confidentiality

56. Legislative Framework  Common Law Duty of Confidentiality  Data Protection Act (1998)  Human Rights Act (1998)  Crime and Disorder Act (1998)  Children Acts (1989 & 2004)  “Working Together to Safeguard Children” (2010) - statutory guidance

57. In summary...  We all have a right to expect our personal information to be obtained and processed fairly, to be accurate, to be held securely and to remain confidential.  However, this right is not absolute and may be breached in certain circumstances:  - upon the order of a court  - for the prevention of a crime  - in the wider public interest

58. The Seven Golden Rules  Remember that the Data Protection Act is not a barrier to sharing information  Be open and honest  Seek advice  Share with consent where appropriate  Consider safety and well being  Necessary, proportionate, relevant, accurate, timely and secure  Keep a record  Information Sharing: Pocket Guide (DCSF 2008)

59. Do you know what the 5 steps recommended by NICE in response to a child protection concern are ?

60. Professional Response in Child Protection  NICE guidance (2009) suggests 5 key steps  Listen and observe  Seek an explanation  Record what is observed and heard and why this is a concern  Either consider, suspect or exclude child maltreatment  Record actions taken and the outcome  (And then get advice and support, follow CP procedures, and refer to social care)

61. NICE Guidelines – Key Points  Stress the need for good communication between health professionals and the child/young person as well as their families and carers is essential  Confidentiality – when can we share information without consent?  Emphasis on the difference between when we should consider child maltreatment and when we should suspect it

62. So what does NICE mean by Consider?

63. When NICE uses the term Consider it means that child maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.

64. What does NICE recommend we should do if we Consider child maltreatment  Discuss your concerns with a more experienced colleague, a community paediatrician, child and adolescent mental health service colleague, or a named or designated professional for safeguarding children.  Gather collateral information from other agencies and health disciplines, having used professional judgement about whether to explain the need to gather this information for an overall assessment of the child.  Ensure review of the child or young person at a date appropriate to the concern, looking out for repeated presentations of this or any other alerting features.  However in the practice situation what would you do?

65. What does NICE mean by Suspect?

66. Suspect means a that that alerting feature should lead us to have a serious level of concern about maltreatment but is not proof.

67. What does NICE recommend we should do if we Suspect child maltreatment.  Should refer the child or young person to children’s social care, following Local Safeguarding Children Board procedures.  This may trigger a child protection investigation, supportive services may be offered to the family following an assessment or alternative explanations may be identified.

68. Teenager who is suspended from school: case study  This young person (aged 13) is registered with the practice. The GP saw her when visiting her grandmother who suffered with terminal cancer and has now died.  The GP hears from her mother that she has taken grandmother’s death badly. She stays out at night, her school attendance has suffered and she is extremely moody. She has been suspended from school for unusual rudeness to teachers. The deputy head teacher is calling a CAF meeting (Common assessment Framework). The mother asks the GP to go.

69. Lets look at the 5 steps  Listen and observe  Seek an explanation  Record what is observed and heard and why this is a concern  Either consider, suspect or exclude child maltreatment  Record actions taken and the outcome

70. Teenager who is suspended from school: discussion questions  What is an appropriate GP action in this case?  What are the roles of other practice staff and other professionals in this case?  Is this a safeguarding issue? Is it an abuse issue?  Is this child in need of services? Is she in need of protection?

71. Teenager who is suspended from school continued  Need for the GP to see her and hear her own concerns. She refuses Social Care involvement;  Alleged risk-taking behaviour such as drugs, sexual risk, alcohol;  Grief and other diagnoses;  Need for her consent;  GPs attending CAF meetings;  Recording concerns in the notes;  Referral options.

72. Baby who is slow to progress: case study One of the GP trainees is concerned about a baby aged 11 months with a cough. Her respiration is 40/min with mild recession, temperature 37, pulse 120/min. She seems small. Mum reports that she weighs about 14lb (4lb 8oz born) and that she is not sitting alone yet. They missed the last paediatric follow-up. Her mother is aged 24 and has three other children aged 3, 5 and 8. She also confides that she thinks she may be pregnant again. The GP knows that she was abused herself as a child.

73. What are our 5 steps?

74. When would Faltering Growth lead us to suspect child maltreatment?

75. Consider Neglect  Consider neglect if a child displays faltering growth (failure to thrive) because lack of provision of an adequate or appropriate diet.

76. Suspect Neglect  Suspect neglect if parents or carers fail to seek medical advice for their child to the extent that the child’s health and wellbeing is compromised

77. Baby who is slow to progress: discussion questions  What is an appropriate GP action in this case?  What are the roles of other practice staff and other professionals in this case?  Is this a safeguarding issue? Is it an abuse issue?  Is this child in need of services? Is she in need of protection?

78. Baby who is slow to progress: issues raised and further notes  Use of NICE guidelines in observation recording proved helpful when assessing the case;  Threshold for seeking more support for such a family through the Child in Need process is lower where there are risk factors;  Information-sharing through this process, with the health visitor, midwife or school nurse may give added reasons for further assessment or support;  There may be other confidential issues with the mother such as an alcohol problem, partner having moved on, or postnatal depression;  Referral following local procedures as required.

79. Child who fell off the sofa: case study  Tom, aged 18 months was brought by his mother to the GP with bruising on one of his cheeks. She said he had fallen off the sofa. The GP noticed that the child was previously subject to a Child Protection Plan as it was coded as an ‘active problem’ in the notes. The GP knew that his mother had a regular methadone prescription and had been a victim of domestic violence. The boy’s father was not allowed access.

80. Lets look at the 5 steps  Listen and observe  Seek an explanation  Record what is observed and heard and why this is a concern  Either consider, suspect or exclude child maltreatment  Record actions taken and the outcome

81. Which bruises would make you Suspect child maltreatment?

82. Suspect Bruising  Suspect child maltreatment if a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement.

83. Suspect Bruising  Suspect child maltreatment if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable.  Unsuitable means implausible, inadequate or inconsistent.

84. Suspect Bruising - examples  bruising in a child who is not independently mobile  multiple bruises or bruises in clusters  bruises of a similar shape and size  bruises on any non-bony part of the body or face including the eyes, ears and buttocks  bruises on the neck that look like attempted strangulation  bruises on the ankles and wrists that look like ligature marks [1] Unsuitable means implausible, inadequate or inconsistent. See section 1.

85. Child reported to have fallen off a sofa : discussion questions  What is an appropriate GP action in this case?  What are the roles of other practice staff and other professionals in this case?  Is this a safeguarding issue? Is it an abuse issue?  Is this child in need of services? Is he in need of protection?

86. Child who fell off the sofa: issues raised and further notes  Appointments for children with falls;  Importance of making risk factors available to GPs who don’t know the family so well;  Read Code 131v for child subject to CP plan helps highlight those whose injury should be reported;  Recording of all injuries: time, context, examination findings;  Scepticism about the history of the injury;  Information sharing with Health Visitor;  Referral using local guidelines.

87. Child with bruises on arm: issues raised and further notes  Recording of all injuries – even those found incidentally: time, context, examination findings;  Scepticism about the history of the injury;  Information sharing with primary care;  Check central data base/register.  Referral using local guidelines.

88. Outcome of Referral  Invitation to attend strategy meeting  Would be likely to go on to Initial Child Protection Conference (ICPC)  GP would be invited, needs to write a report and attend if possible  Mother admits that the child was at the park with his father when he had the injury

89. Plenary  Concerns and suspicions are different: NICE Child Maltreatment 2009;  Patchwork information from different sources comes together, sometimes collated over time; so ensure you record and share all your concerns with Primary Care  GPs are used to sorting and managing risk.

90. Summary  Child-centeredness - children have rights - adults have responsibilities  Safeguarding is everyone’s responsibility

91. The Practicalities.  What to do next!

92. Professional Response 1. Record keeping Immediately write down what you have seen/heard and retain this recording. Use the child’s words – what he or she actually said (including swear words) rather than what you thought they meant. Describe how the child presented or appeared. Do not use generalisations such as angry, depressed, anxious. Be specific, e.g. “the child was holding her head down and crying”. All notes must be signed and show date and time of event and date and time of recording.

93. Professional Response 2. Sharing our concerns By discussing concerns with your manager, named or designated health professional. By discussing your concerns (without necessarily identifying the child) with your colleagues or senior colleagues in other agencies. By making a formal referral to Social Services or the Police in accordance with child protection procedures.

94. Professional Response 3. Making a referral If you need to make a formal referral, you should work openly with parents and tell them you are making a referral unless: You suspect sexual abuse or Factitious or Induced illness, Or This may put the child or yourself in danger, Or This may hinder future investigations.

95. Making a Referral  Check the North Yorkshire Database/City of York CP register  Consider using the SAFER referral guidelines  Make referral by telephone to Customer Services Centre (N. Yorks) or referrals and assessment team in City of York  Follow up with written referral form within 48 hours  Copy of referral filed with child’s record and copy sent to local Safeguarding Children Team  Document clearly the concerns, interactions, actions taken  Follow up outcomes of referral within 7 days

96. What happens with the Referral Referral to Social Care. Social worker and manager decide on course of action within one working day. Depending on circumstances, a strategy meeting/discussion takes place with staff from at least two agencies. Initial assessment to be undertaken and Child Protection Conference organised if significant concerns identified. Initial Child Protection Conference – decision made re whether child (and siblings) need a Child Protection Plan, a Child in Need Plan or no plan at all. Core Group convened to deliver Child Protection Plan and monitor progress. Review Child Protection Conferences held until such time as criteria for registration no longer applies. In a few cases, court proceedings will be undertaken.

97.  If you disagree with a decision made by staff from health or other agencies:  Ask why decision has been made  Record conversation in records  Seek advice from child protection staff  Don’t be put off by role or status of other person Challenging Decisions

98. Child Protection Strategy Meeting  Always attended by Police and CSC  Other professionals (including the referrer) may also be invited to take part  Should take place within 24 hours of it coming to notice that child may be at risk of significant harm  Minutes will be taken, signed by all members, and copies distributed

99. Purpose of Strategy Meeting  Share information and establish facts  Decide whether Section 47 enquiries should be initiated  Decide if there is a need for medical examination or video interview  Identify sources and levels of risk  Decide what immediate action is required to safeguard child/children

100. Initial Child Protection Conference (ICPC)  An ICPC will take place when:  The outcome of S47 enquiries is that concerns are substantiated and it is judged that the child will suffer/continue to suffer significant harm  A child who is subject to a Child Protection Plan in another local authority moves into North Yorkshire

101. Preparing for ICPC  All invited professionals should provide a written report which should be based upon the Framework for Assessment of Need.

102. QUIZ!!!!

103. The Conference - 1  Introductions/ground rules/ confidentiality/reasons for conference  Professionals read reports  Family go through the reports with the Chair in a separate room  Conference re-convenes and professionals invited to share any additional/new information

104. The Conference - 2  Clarification of any inaccuracies/queries in reports  Views of parents/carers highlighted  Views of child represented  Summary and analysis of issues by conference Chair

105. Analysing Information  What are the protective factors?  Is the child at continuing risk of significant harm?  What are the risks to the health and welfare of the child?  What is the potential for change in the short term?  Does the child need a Child Protection Plan, a Child in Need Plan or no plan at all?

106. Decisions of conference  Does child need a Child Protection Plan?  Does child need a Child in Need Plan?  Identify key worker and core group membership  Agree dates for first core group meeting/review conference/child in need planning meeting

107. Child Protection Plan  Completed during the conference and further developed by Core Group  Is outcome focused  Should clearly indicate what changes need to be made  Each action accompanied by timescale and named worker

108. Child in Need Plan  If a Child in Need Plan is required, the Social Work Manager will take over the Chair and formulate the plan together with the family and conference members.  Child in Need Plan should also be outcome focused, have nominated workers and a date for review.

109. Core Group Meetings  Aim of core group is to review and progress the Child Protection Plan  Chair of first core group meeting will be a Social Care Manager  Subsequent meetings to be held at a minimum of every six weeks  Written record should be taken by a member of the group who is not acting as chair  Key worker must visit the child at least once every two weeks

110. Review Child Protection Conferences (RCPC)  At core group immediately preceding RCPC, the conference report content and recommendations should be agreed.  Key worker completes the Review Report Form and sends to Chair at least 5 working days prior to conference.  Report should include views of parents/carers/ children.

112. www.saferchildrenyork.org.uk

113. Local Child Protection Services  City of York:  Designated Doctor - Robin Ball 01904- 631313  Named Nurse - Stephanie Rees 01904 724906  Designated Nurse - Sue Roughton 07946 337290  CP Advisor - Lorraine Fox 01904 724797  Emergency Duty Team - 0845 0349417  Children’s Social Services - 01904 - 551900  Child Protection Register - 01904 555640  www.saferchildrenyork.org.uk

114. Local Child Protection Services Named Doctor – Jon James 01609 779911 Designated Doctor – Kate Ward 01535 292422 Named Nurse – Elaine Wyllie 01609 751411 Child Protection Advisor- Brigid Gough 01609 751411 Designated Nurse – Sue Roughton 07946 337290 Customer Relations – 0845 034 9410 Social Care H&R – 0845 034 9410 Emergency Duty Team – 0845 034 9417 Central Database – 01609 774298

115. Local Child Protection Services Named Doctor – Dr Venkatesh 01723 368111 Designated Doctor – Kate Ward 01535 292422 Named Nurse – Angie Kershaw 01723 380514 Designated Nurse – Sue Roughton 07946 337290 CP Advisors Jackie Adams, Sue Ward, Alison Wood, Sue Clarke – 01723 380534 or ext. 80534 Customer Relations – 01609 536993 Emergency Duty Team – 08450 349417 Central Database – 01609 774298

116. Local Child Protection Services  Designated Doctor – Kate Ward 01535 292422  Named Doctor – Doug Munro 01423 885959  Named Nurse – Emma Curran 01423 558106  Designated Nurse – Sue Roughton 07946 337290  CP Advisor – Liz Killeen/Helen Scoullar 01423 558106  Emergency Duty Team – 0845 0349417  Children’s Social Care: 01609 536993  Central Database – 01609 774298

117. Any questions?