Advanced Trainees
and FellowsP
inAEDIATRIC
Forensic PaediatricM
Medicine
– 2014 SERVICE
VICTORIAN
FORENSIC
EDICAL
Forensic Paediatric
Medicine
Trainees’
Advice and Information
Medical Director, Anne Smith
2014
Contents
No table of contents entries found.
R C H VFPMS
AND
Anne Smith, Director
MONASH CHILDREN’S VFPMS CLINICS
Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
Forensic Paediatric Medicine Trainees Manual 2014
Table of contents
PRINCIPLES GUIDING PRACTICE ................................................................................................................ 3
AIMS and COMPETENCIES ......................................................................................................................... 3
WHAT DO DOCTORS OF THE VFPMS DO? ................................................................................................. 6
WHAT DO THE VFPMS NURSE MANAGERS DO? ....................................................................................... 6
WHAT DO SOCIAL WORKERS, GATEHOUSE & SECASA COUNSELLORS DO? ............................................. 6
ROLE OF THE TRAINEE / FELLOW IN FORENSIC PAEDIATRIC MEDICINE ................................................... 7
VFPMS GUIDELINES FOR TRAINEES’ CLINICAL PRACTICE .......................................................................... 8
REPORT WRITING – FORENSIC OPINION SECTION .................................................................................. 14
REFERRALS AND INVESTIGATIONS .......................................................................................................... 16
CASE CONFERENCES ................................................................................................................................ 17
CONSENT ................................................................................................................................................. 17
CONFIDENTIALITY .................................................................................................................................... 18
COURT APPEARANCES ............................................................................................................................. 18
TELEPHONE ADVICE................................................................................................................................. 19
MEDICAL DEFENCE .................................................................................................................................. 19
POLICE CHECKS AND WORKING WITH CHILDREN ................................................................................... 19
MEETINGS................................................................................................................................................ 19
SYSTEMS ACCESS ..................................................................................................................................... 20
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
Training in Child Abuse Paediatrics:
Tips for clinical practice and advice for administrative matters
PRINCIPLES GUIDING PRACTICE
Many of the children seen by VFPMS are living in deprived circumstances with adults who are finding it
very difficult to adequately provide for their children’s health, development and emotional needs.
Contact between VFPMS and each child provides a “one-stop-shop” comprehensive assessment of
his/her needs.
The philosophies underpinning the operation of the Victorian Forensic Paediatric Medical Service
are clearly outlined on the website. In summary, the care we provide for children and their carers is:
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holistic (paediatric, forensic, psychosocial and beyond)
based on an awareness of the ecology of child abuse
integrated with all other services for children (don’t duplicate health services)
specialist (using FPM specialist knowledge and skills)
effective (monitor outcomes)
efficient
accountable
evidence based (and evidence informed)
continuously improving
AIMS and COMPETENCIES
The training program in forensic paediatric medicine and child abuse has been designed to meet the
training needs set out in the framework of the RACP Division of Paediatrics and Child Health Advanced
Training Curriculum in Community Child Health and General Medicine (Paediatrics) in Child Protection.
The CCH curriculum is more detailed and intensive than the Curriculum in General Medicine. The CCH
performance assessment tools aim to measure the skill and knowledge doctors use when working with
abused and vulnerable children.
I encourage you to keep a log of cases seen for your own records, to monitor your progress and
inform you about the scope of work experienced. Your ‘log book’ will not be assessed by VFPMS but the
possibility exists that someone from an SAC, or one of your supervisors, might want to view it at some
time in the future.
The VFPMS fellows’ training manual aims to provide you with information about how best you
might acquire knowledge, skills and experience to increase your expertise in this field of medicine. Note
that VFPMS awards a Certificate of Competency to successful trainees who have completed the training
program and demonstrated the requisite knowledge, skills, attitudes and behaviours. The VFPMS
evaluation of competencies is modelled on the Royal College of Paediatrics and Child Health 1 categories
of desired competencies for forensic physicians and paediatricians.
1
Guidance on Paediatric Forensic Examinations in Relation to Possible Child Sexual Abuse Produced by The Royal
College of Paediatrics and Child Health and The Association of Forensic Physicians September 2004
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
WHAT DO DOCTORS OF THE VFPMS DO?
The key work of VFPMS is to provide assessments of children when child abuse is suspected and to make
recommendations for intervention, aiming to improve the quality of children’s lives. Many doctors
consider the “one child at a time” approach to be deeply rewarding. This approach does not preclude a
co-existing public health approach to working with populations of abused and vulnerable children and
most if not all of you will work in both these fields of medicine during your professional lives.
The format of the assessment of the individual child follows the usual “history / examination /
investigations / opinion / medical report” sequential process, although there are a few additional tasks
that might be required for specific presenting problems such as child sexual abuse.
VFPMS doctors also provide consultation and advice, in person and via electronic media and
telephone. We also provide case file reviews, opinions in relation to children’s injuries and advice about
appearing in court.
VFPMS provides education and training about child abuse, forensic paediatric medicine and
information about appropriate responses to suspected child abuse.
You will be invited to sit in with a consultant for at least one sexual abuse assessment and to
have a consultant sit in with you for your first sexual abuse assessment. For subsequent assessments you
should conduct the assessment on your own (with advice as needed) and discuss each assessment with
your supervisor. As the demand for medical services varies and we have no control over the types of
presenting problems that greet us each day, we cannot guarantee when this will occur. We assume you
will be able to conduct an assessment of a physically injured child (with supervision) from your first day.
All medical reports are subject to quality assurance. You will be expected to conduct an
appropriate review of the literature about each case to ensure that your information and knowledgebase is current.
WHAT DO THE VFPMS NURSE MANAGERS DO?
The nurse managers at RCH and MMC perform a key role in being the point of first contact for VFPMS.
The nurses triage incoming requests for VFPMS services, liaise with referring agencies and counselling
services and coordinate service delivery within VFPMS.
Appointment booking, data analysis and reporting are all completed primarily by the VFPMS
nurse managers. They provide education and training, advice and assistance for clinical practice and have
a key role in policy development, improvements in clinical practice and in quality assurance.
WHAT DO SOCIAL WORKERS, GATEHOUSE & SECASA COUNSELLORS DO?
Social workers working within hospitals in Victoria are familiar with the needs of patients interacting
with the health system. The field of “medical social work” is becoming highly specialised. Social workers
are trained to recognise children’s vulnerability to a range of harms and to intervene to better protect
and support vulnerable children and their carers.
Some of their work involves collaboratively assessing injured children with medical staff. This is
more likely to occur for children who have recently sustained injuries or who present after hours. If the
doctor wishes, he/she may conduct a joint assessment with the social worker or counsellor.
Anne Smith, Director VFPMS
Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
Alternatively, some doctors prefer to provide medical consultations first and encourage counsellors to
perform their assessments subsequent to this. This decision is at the discretion of the doctor.
The counselling teams comprise professionals who trained as social workers or psychologists.
Some have family therapy training. Some have additional training in different counselling techniques and
styles. All are supervised according to guidelines established by their disciplines. All of these professional
groups provide teaching and liaison work.
Much of the counsellors’ work involves therapeutic services for abused children and their
families. The counsellors provide individual therapy, group therapy, family therapy or a combination of
these.
The Sexually Abusive Behaviours Treatment program (SABT) was designed for children aged 10
to 14 years who display sexually abusive behaviours. Centres against Sexual Assault are the service
providers for this program (Gatehouse and SECASA demonstrate leadership in this field).
SECASA does not usually provide individual services to children younger than 5 years. You are
encouraged to consider referral for younger traumatised and emotionally distressed children to CAMHS
or other local mental health services. Use your clinical experience and the advice of senior VFPMS staff /
colleagues in order to refer children to the most suitable service for the child’s needs.
You can refer children to local mental health services, including CAMHS and RCHMHS and
OryGen. Your clinical judgement about the child’s symptoms and their family situation should guide you
to make a referral to the service best suited to meet the child’s particular needs.
ROLE OF THE TRAINEE / FELLOW IN FORENSIC PAEDIATRIC MEDICINE
Almost all trainees and fellows in FPM are doctors completing advanced training in paediatric medicine.
Clinical work is supervised by VFPMS consultants. Fellows also have access to a mentor in
addition to their RACP supervisor. I recommend both a clinical supervisor (for RACP supervision of
training) and a VFPMS mentor (for more personal advice when / if the ‘going gets tough’). One hour of
clinical supervision should be provided each week.
The fellows’ role is twofold: firstly to perform medical evaluations of children in whom child
abuse is suspected (a clinical service component) and secondly to increase the doctors’ personal
knowledge and skills in relation to child abuse (and thus, their own clinical competencies).
What does this mean for me?
Clinical work will occupy a significant percentage of your time with VFPMS. Time must be set aside (and
protected) for clinical supervision. Time for personal study is likely to fit around demand for your clinical
services.
How do I ‘fit in’?
The trainee / fellow in FPM functions as part of a multidisciplinary team, liaising with the counselling
team, police, protective services workers and the courts. The trainee conducts child abuse assessments
of children referred because of suspected child abuse or neglect. At all times, the trainee is expected to
consult with his / her supervisor about any cases or issues of concern. The VFPMS Medical Director
reviews all medical reports before reports are sent to police or Child Protection workers.
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
As a general rule, trainees should initially sit in with consultants and observe medical evaluations
for suspected physical and sexual child abuse. The trainee should then conduct his / her own assessment
while the consultant observes the process. The trainee should then be able to conduct the assessments
using the consultant for advice and technical assistance for the first few genital assessments using the
DVD-colposcope.
The trainees have been rostered for times when consultants are available in the department. (I
accept that we don't always live in an ideal world and there are times when consultants are NOT on site
with you). Use the consultant often and please do not hesitate to ask for advice or assistance! Call me if
there are ANY problems and let me know early if you are NOT getting the help you need from my usually
wonderful team of consultants.
VFPMS GUIDELINES FOR TRAINEES’ CLINICAL PRACTICE
See sections on the VFPMS website regarding How to refer and VFPMS CPG (members area)
On call – recall
Attitude from the outset
The aim of the VFPMS 24/7 telephone advice service is to promptly solve problems, minimise angst and
increase diagnostic accuracy. We aim to be helpful. We go the extra mile. We work hard. We collaborate.
We demonstrate integrity. As good team players we are mindful of everybody’s roles and responsibilities
and we always work as respectful partners with other professionals. We advocate for the safety,
wellbeing and health of children and adolescents that we treat and we will not be bullied into
compromising the quality of their medical care.
During rostered on call shifts, the fellow will receive incoming telephone calls to VFPMS (24/7
telephone number 1300 66 11 42) as the “first on call”. The senior on call for VFPMS will act as backup
and “second on call” for advice and consultation to the fellow and, where necessary, may respond to the
original caller. Early in 2014, the Victorian Institute of Forensic Medicine (VIFM) will provide the afterhours call service, taking over this role from the Magistrates Court.
Telephone advice is provided to:
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Victoria Police
health professionals
Child Protection practitioners
All incoming calls must be discussed with the senior on call as soon as possible after the
telephone call. If any doubt exists about case management, the fellow will plan management in
consultation with the senior on call prior to advice being offered to the caller. In some instances the
senior on call may “take over” the case and deal directly with the caller.
The after-hours telephone call service : Melbourne Magistrates Court / VIFM
The after-hours Melbourne Magistrates Court currently provides the after-hours call service. The VFPMS
1300 66 11 42 number is answered by the Melbourne Magistrates Court after 5.00pm and prior to 9am
on week days and for 24 hours on weekends and public holidays. The registrar will call the on call VFPMS
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
doctor who must maintain contact and availability for advice while on call (telephone charged, on and
doctor able to respond).
Calls received after-hours are usually received in relation to requests for an urgent consultation
(after-hours face-to-face) but may also relate to information about more general in-hours VFPMS
services, advice regarding injury interpretation, procedural guidelines or appointments for in-hours
services.
The Medical Director, Anne Smith or a senior VFPMS consultant provide 24/7 on call advice for
occasions when there are service difficulties and / or complaints.
Sexual abuse
VFPMS has sole responsibility for provision of forensic medical services to under-18 year olds who might
have been sexually abused. This means that VFPMS is the service that collects forensic samples using the
FMEK according to recognised (VIFM) standards. All medico-legal reports regarding sexual abuse of
under-18-year-olds should be written using the VFPMS report format, even when children are examined
in regional Victorian locations.
VFPMS provides MEDICAL TRIAGE regarding concerns about sexual abuse of under 18 year olds.
This means that VFPMS collects sufficient information from the caller about the caller’s concerns
regarding the nature and timing of possible sexual abuse in order to make decisions about:
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whether a face-to-face consultation with VFPMS might be required, and if so
o the best location
o the best time
o the best health professional to conduct the assessment
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if no VFPMS face-to-face consultation is required then decisions are made and (when required)
planning occurs for counselling, mental health care, medical care and engagement with Child
Protection and police
When children have symptoms and signs that might be associated with sexual assault, medical
triage by VFPMS (for the purposes listed above) should occur prior to engagement with sexual assault
counsellors in order for optimal health care to be arranged at the best location, best time and with
appropriately skilled medical professionals.
When children are seen face-to-face by VFPMS for urgent evaluations of sexual assault, these
evaluations should occur as joint responses with counsellors.
Category 1. Allegation of sexual assault
When children allege recent sexual assault joint responses by VFPMS and counsellors should always
occur. This means that sexual assault counsellors must be promptly informed by telephone about under18-year-olds who might require urgent counselling (possibly because of recent “disclosures”), even when
VFPMS deems that individual case details indicate that an urgent VFPMS evaluation is not required (and
VFPMS plans an in-hours evaluation).
When children require urgent face-to-face evaluations for suspected sexual assault, both VFPMS and
counsellors should attend.
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
The presence of individuals other than the doctor and patient in the consultation room is at the
discretion of the doctor and patient.
A chaperone should be present whenever a genital examination occurs.
Only essential persons enter DNA-cleaned rooms. A log must be maintained of all persons entering
DNA-cleaned rooms.
VFPMS provides holistic health responses inclusive of a forensic component (which is forensic
sample collection and provision of evidence for the legal system). VFPMS services are offered regardless
of children’s or their guardians’ willingness to involve police (although the decision about police
involvement might affect the time and location of the VFPMS service delivery. Sometimes, when forensic
samples do not need to be collected after hours, VFPMS face-to-face evaluations can be delivered during
working hours on the next business day). This means that VFPMS offers a medical service to EVERY
under-18-year-old who is considered to be a possible victim of sexual assault. The collection of forensic
samples is part of the service we provide but only a component; the other components of the service are
documentation of history and examination findings with reports written for future legal action, general
health care including preventive health care (e.g. prescription of Azithromycin to prevent STI), discussion
of sexual health, contraception, mental health and other concerns, discussion of safety issues and
consideration as to whether contact should be made with Child Protection. All of these components of
VFPMS service should be offered to victims of sexual abuse / assault regardless of decisions to report to
police or not.
Category 2. No allegation of sexual assault
When no allegation of sexual assault has been made but children have symptoms and signs that might
be associated with sexual abuse but alternatively might be caused by conditions other than sexual abuse
(that is, there exists a differential diagnosis that includes but is not limited to sexual abuse), then careful
medical evaluation is required. Accurate diagnosis is extremely important. An open mind regarding all
possible diagnoses must be maintained during the evaluation process.
In these situations it is not appropriate for a sexual assault counsellor to be engaged until there
exists a “reasonable belief” or at the very least, a strong suspicion, that the child might have suffered
sexual abuse. It is not appropriate to refer children to sexual abuse counsellors when, in the absence of
other concerns, the children have conditions such as accidental fall astride injuries, urinary tract
infections, dermatitis in the genital area, vulvovaginitis, labial adhesions, normal behaviour and medical
conditions confused with abuse.
Consider urgent referral to Child Protection if further comprehensive protective evaluation is
required because of the child’s psychosocial situation. This should be considered regardless of the child’s
reason for referral, just as you would for a child seen in any other professional / medical consultation.
Suicide risk
When children are deemed to be at risk of serious self-inflicted harm (i.e. children express suicidal
ideation and suicidal behaviours, excluding isolated non-suicidal self-injury) then the hospital-based
mental health service should be asked to assess the children or a CAT assessment might be urgently
required. Do not discharge a child from VFPMS when you hold serious concerns about the child’s current
risk of suicide or self harm. Refer immediately to the crisis mental health team, documenting your
concerns and the referral process.
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
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Urgent mental health assessments may occur while the child is in the Emergency Department.
This may require the child to be “transferred” from VFPMS to the Emergency Department in
order for this to occur.
Referral to outpatient CAMHS or alternative should be arranged prior children leaving the
hospital premises. The planned time, date, location and (if known) name of service provider
should be recorded in the UR file-notes.
If children are deemed to require an inpatient admission because of serious mental illness
associated with significant risks to health and safety then the responsibility for arranging
admission rests with the mental health clinicians and Emergency Department staff.
When an urgent after-hours mental health assessment is required for a child’s parent or caregiver, arrangements for this should be made in collaboration with Child Protection.
Presentations to Emergency Departments
Children present to hospital Emergency Departments because of a broad range of conditions, concerns,
injuries, symptoms and signs. Among this group of children there exists a very broad range of situations
and conditions that raise concerns about possible sexual assault / abuse. Situations and conditions that
generate thoughts about possible sexual abuse range from clear statements (allegations) of sexual
assault to vague and non-specific thoughts about sexual abuse that might be ill-founded, based on
misinformation or unreasonable suspicions. Children attending triage desks in Emergency Departments
thus have “pretest probabilities” of a diagnosis of sexual abuse that range from a high likelihood (>95%
probability) to an extremely low probability that sexual abuse has occurred.
There is no algorithm or formula that reliably predicts the probability of a diagnosis of sexual
abuse based on presenting symptoms and signs. An unbiased, objective, impartial evaluation is required
in all circumstances, including when allegations of sexual assault have been made.
When sexual abuse is considered in the context of a number of differential diagnoses (that is,
sexual abuse might or might not be the reason for the child’s symptoms or signs), then VFPMS will
consult with ED staff about possible examination and investigation. Attendance by VFPMS for urgent
face-to-face assessment is possible, but not the only management option. Sometimes VFPMS
consultants might have sufficient expertise to exclude the diagnosis of sexual abuse with a reasonable
degree of certainty and under such circumstances will recommend medical management in the absence
of VFPMS face-to-face consultation and / or follow up.
When clear statements about alleged sexual assault exist, both VFPMS and counsellors should
respond to a request from ED staff. VFPMS should perform medical triage to determine the requirement
for an urgent face-to-face forensic evaluation or an in-hours consultation. Counsellors should be
promptly informed in order to respond as they deem appropriate, regardless of the timing and location
of the forensic medical service. On some occasions, for example because of psychological distress caused
by a recent disclosure, urgent counselling may be provided when a medical consultation has been
deferred.
Emergency Department staff will attend to the child’s medical needs PRIOR to attendance of
VFPMS.
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
This Emergency Department assessment and treatment might include:
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resuscitation
examination / treatment of serious physical injury (assault or accident)
examination for signs of head injury, monitoring and treatment
examination and monitoring for signs of airways compromise if strangulation is suspected
treatment of effects of drugs / alcohol, including hypoglycaemia
prevention of complications of injury
stabilisation and treatment of pre-existing medical conditions (e.g. diabetes)
monitoring of vital signs while effects of drugs and alcohol wear off
NOTE: It is absolutely contraindicated for children who allege recent sexual assault AND who
have not yet had an assessment of their medical needs to wait in an out-of-the-way area of an
Emergency Department unsupervised by ED staff or supervised by individuals who lack medical training
(this includes social workers such as CASA staff). If after initial assessment by ED staff, counsellors
assume sole responsibility for monitoring the physical wellbeing of children who allege recent sexual
assault then this decision should be made in conjunction with senior ED staff who are aware of the risks
posed.
Consent
Consent for forensic medical examination must be obtained:
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by doctor / nurse conducting the examination / forensic procedure
from the right person
after ensuring that this person has the capacity to consent
for each specific aspect of the procedure
after informing about all aspects of the procedure including risks of adverse outcomes that might
eventuate if the patient proceeds and risks / consequences if the patient does not proceed
and it must be freely given (and able to be retracted at any time during the procedure)
Note that consent for forensic medical procedures may be provided by mature minors in some
circumstances and it is the duty of the doctor who discusses matters of consent with the minor to
determine the minor’s capacity to consent or withhold consent. Factors used by the doctor to determine
a minor’s capacity to consent (or lack of capacity to consent) should be documented in the VFPMS file
notes. (See the RCH Handbook Version 9 for information about doctor’s assessments of mature minors’
capacity to consent. Use the VFPMS mature minor consent form.)
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Chaperones should be present during genital examinations.
Support persons of the children’s choice should also be present if the children wish.
Assessments for sexual abuse of children in regional Victoria
VFPMS-style consultations in regional Victoria are to be planned in consultation with the VFPMS NUMs
or consultants. Services in regional Victoria are in a constant state of flux and the NUMS and consultants
are likely to know of the current situation in each region on a month-by-month basis. Currently children
from the Geelong / Barwon and Traralgon (West Gippsland) regions who have recently been sexually
assaulted and who urgently need samples collected must travel to Melbourne for VFPMS consultations.
Other areas of Victoria are better serviced. The VFPMS website – regional service information under
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
“How to refer” titled “VFPMS contacts in your Region” – includes links to contact details of service
providers in each Region. www.rch.org.au/vfpms/refer
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Barwon South West
Gippsland
Grampians
Hume
Loddon Mallee
Peninsula
Goals for forensic paediatric medical service delivery in regional Victoria
In general, aim to have the child seen in the closest site where a high standard of forensic medical care
can be provided.
Do not accept an inadequate medical service, or a dangerous or risky option merely because it
suits other professionals.
Regional services (large publically funded health services that employ paediatricians and child
health professionals) are responsible for the medical care provided to children when child abuse and
neglect is suspected. These health services employ the paediatricians and other doctors and nurses who
provide health care. VFPMS provides these doctors and nurses with advice, tools to use when evaluating
children in relation to suspected abuse, professional support and assistance for report writing and court
appearances.
VFPMS is responsible for the advice offered to callers regarding the adequacy of a forensic
service in regional Victoria and in recommending the use of local / available expertise. If in doubt, a child
should travel to Melbourne in order to obtain forensic paediatric medical expertise.
When doctor or nurse who is on call for a regional Victorian health service refuses to provide a
child with a forensic medical service, local options (e.g. doctors in neighbouring regions) may be
considered or the child may need to travel to Melbourne.
Physical abuse
Most doctors and many nurses possess the knowledge and skills to assess injuries and wounds in order
to determine appropriate treatment. Some of these professionals have also been trained to assess
wounds and injuries in order to determine CAUSE. It is these medically-trained professionals who work in
the broader health system who have the capacity to provide (at least a component of) forensic
evaluations of children’s injuries and reports / testimony in court. These professionals might include
doctors working in Emergency Departments, some General Practitioners, most paediatricians, most
forensic physicians, some specialists and some forensically trained nurses.
VFPMS works in an integrated way with other medically trained professionals to provide a
forensic medical service to physically assaulted / abused children. This is a shared skill and duty.
After hours VFPMS provides a 24/7 telephone advice service in relation to suspected physical
assault / abuse.
Most children seen in Emergency Departments will be adequately managed by ED staff in
relation to the evaluation of their injuries. This includes medical investigations and photography. A
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
follow up appointment (for an in-hours VFPMS clinic) maybe be arranged for some children who require
a comprehensive holistic VFPMS-style assessment after their attendance at ED.
Photographs
Photographs of injuries should be taken when there is a forensic component to the medical evaluation
and treatment. This means that photographs should be taken whenever assault / abuse might have
caused injury AND ALSO when injury might have been caused by parental / care-giver neglect.
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At RCH there is a photographer on call 24/7.
At MMC there is a photographer on call during business hours and a camera (Canon SLR) in the
VFPMS clinic.
Photographic equipment (cameras) and doctors’ willingness to take photographs varies from site
to site. Encourage doctors to take photographs if facilities exist.
Inpatients referred to VFPMS
Children admitted to hospital should be seen face-to-face by VFPMS within 24 hours of admission,
preferably as soon as possible. A child who is medically unstable and / or who has a serious head injury
should be seen promptly. Note that children requiring intensive care might deteriorate extremely rapidly
particularly when hypoxic ischaemic brain injury has occurred. Attendances by VFPMS should be
provided in collaboration (often as joint responses) with social workers.
In hours it is usually sensible for the NUM to participate in the consultation on the ward and for
her to remain actively involved in the child’s case during admission. She should maintain daily contact
with Gen Med (or alternative) medical staff to ensure a daily two-way exchange of information.
VFPMS consultants must oversee all VFPMS fellows work in relation to inpatients.
Reports for inpatients should be completed promptly. A template exists for INTERIM reports
when Child Protection need a written interim opinion from VFPMS for court.
REPORT WRITING – FORENSIC OPINION SECTION
The key question to address is, “Has this child been assaulted / abused?”. The opinion section should
enable the reader to clearly understand your thoughts about this, even if your answer is “maybe”, “the
cause is undetermined” or “I don’t know”. Comments about probability are appropriate.
Comments about someone’s guilt or lack of guilt are entirely inappropriate.
Anne’s notes regarding formulation of forensic opinion and presentation of evidence should be
read. You will each be given a copy at the start of your VFPMS term.
The opinion section should answer the following questions:
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what is the story?
is the child injured?
what are the injuries?
what else (physical damage) might be injured? Harmed?
how did it happen? (mechanism)
what forces were / might have been involved?
when did it happen? (timing of all injuries)
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
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what consequences might result?
how do the findings and the story “match up”?
what are ALL the possible differential diagnoses, and how are they weighted?
overall probability of assault versus accident versus other cause for findings (if you can)
Proformas are available for use. The VFPMS proformas are available on the website. Use them.
Diagrams – there are diagrams for three sizes of children: infants, children and adolescents. Print
off relevant pages to document the injuries using body diagrams. www.rch.org.au/vfpms/tools/
Detail your description of injuries according to:
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site (reference body landmarks, anatomical position of the body, centimetres from a joint)
size (use one measurement – either centimetres or millimetres and remain constant)
shape
surrounds
surface
edge (margins)
colour
contour
contents
pattern
swelling
blanch / stretch / movement
tenderness / pain on movement
discharge / fluid / debris
Additional proformas are available within VFPMS for your use with children you are assessing for
Neglect.
Write, type or dictate a report for every child you assess. (Yes, every single one!)
Take dictation to administration staff for typing. Alternatively you may type reports yourself if
you wish or use Dragon Dictate (I am happy to show you how if you have not used voice transcription
software before).
All reports are checked by the Medical Director (or nominee).
Changes (edits to your reports) will be suggested but you MUST ensure that you do not alter the
facts or veer away from the truth.
All editing of reports can only address matters of grammar, syntax, congruity between stated
history and examination findings, etc. I like to see photographs and the DVD genital exam findings
particularly for complex cases and I also like to see the radiology findings and RetCam photos. However,
YOU will have a MUCH stronger impression about the case than someone merely reading your report
and you must ensure than your report remains accurate. After all, it is YOUR report with your signature
at the bottom. You must be happy with it. Accuracy is paramount! At the end of the day it will be up to
YOU to defend all the statements in it.
Do one report only (even if asked for different things by different professionals) as an initial
approach. Occasionally an interim report is required prior to a final (comprehensive) report and then a
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
third medical report might be required for the criminal justice system (this court report would have
“hearsay” and sensitive psychosocial information removed). If in doubt talk to me.
Seek advice, seek advice, seek advice…
Highly recommended
There are folders of confidential medical reports available for you to view in order to see examples of
other doctors’ work in this field. One folder is a compilation of various doctor’s reports.
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One folder relates to inpatients
One is for head injured children
On the VFPMS website is a selection of recent reports based on real cases (somewhat deidentified)
Note that all these reports are from actual children’s files and the cases might still be active in
the courts (and are therefore highly confidential!!!) Please do not discuss the contents with others
working outside VFPMS for privacy and legal reasons.
SHOCK, HORROR AND TAKE NOTICE!!!!
You are strongly discouraged from using the following words unless you are quoting someone, in which
case the words should be included in parentheses.
Banned words and phrases:
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rape
assault – always say “alleged assault”
disclosure – use “allegation” or an alternative phrase
intercourse – refer to the actual penetration or attempted penetration, for example, “attempted
penile-vaginal penetration” or “penetrated her vagina with his penis” (the second is simpler – it
is good to say what went where)
sex / had sex – refer to actual penetration instead – this phrase means different things to
different people e.g. many adolescents do not regard oral-genital contact as “real sex”
oral sex – specify precisely what went where, for example, penile-oral penetration or you could
use the technical terms (fellatio, cunnilingus) if you wish
belted (unless a belt WAS used), gave someone a beating – use other words whenever possible,
or in your conclusion, refer to inflicted blunt force trauma
note the need to use correct terminology for injuries (bruise, petechiae, abrasion, laceration,
incised wound, puncture wound, etc)
REFERRALS AND INVESTIGATIONS
Feel free to investigate and refer children you see in this centre as though you were functioning as a
paediatrician in a general medical clinic or in the community. Use the paediatricians and other
consultants for advice if you wish to “run things by someone” first.
VFPMS provides an holistic service. You might hear others imply (or state) that VFPMS is merely
a service for initial evaluation of suspected child abuse. This is NOT the case. The medical evaluation of
children with whom we have contact should be thorough and comprehensive and, of course, there
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
should be a therapeutic component. I (and others) get a bit miffed when children’s problems are
identified but doctors do nothing to intervene!
Please consider investigations and referrals to best evaluate, monitor, intervene and safeguard
children’s health, growth, developmental, emotional and psychological wellbeing. The quality of
relationships and each child’s self concept are also very important considerations.
Doctors are encouraged to review children to ensure that the children’s medical care is being
managed appropriately and that measures are in place to ensure the children’s ongoing medical followup, safety and psychological treatment.
Please consider the child’s ongoing health needs and have a low threshold for referral to a
General Practitioner or Paediatrician in the community. It is NOT enough to merely say that a referral is
required. It is up to you to actually arrange the referral and ensure that the process is commenced to
ensure that the child attends required appointments and has recommended investigations. Child
Protection workers need your help to make this happen! Be explicit and arrange everything you can.
Insert the time, date and location into the recommendations section in your medical reports or at a bare
minimum refer to timeframes such as “within the next three months” or “before the end of this year”.
CASE CONFERENCES
You are encouraged to attend case conferences in relation to children that you have assessed for VFPMS.
We keep data about VFPMS attendances at case conferences (including SCAN meetings) so
please ensure the NUMs are aware so it can be included in your stats.
VFPMS will pay for your time if you need to attend case conferences in non-rostered time.
CONSENT
Aim for VALID written (informed and freely given) consent.
Use the consent forms to detail precisely what consent has been provided / withheld.
At times Child Protection workers and police might arrive with a signed ‘consent form’ that is not
a VFPMS form. This is not a valid VFPMS consent form. Arguably, this is often not valid consent and even
if it is, how can you be sure?
You are encouraged to discuss with a consultant each situation when you are asked to examine a
child but you do not have valid consent from a guardian. These cases are complex and accurate
documentation of the circumstances of the examination is essential. For mature minors, competency to
consent may be obtained from the young person according to the Gillick principle.
Verbal consent is OK if you are not able to obtain written consent and you explicitly go through
each step of the consent form with the appropriate person. I strongly discourage you from using
“implied” consent (i.e. they are here – therefore they must be consenting to everything!)
In an emergency, the wellbeing of the child must take priority over all other considerations but
note that an examination of a child without adequate informed consent leaves the doctor open to an
allegation that the doctor “did the wrong thing”.
Reference the Child Abuse chapter in the RCH Handbook Version 9.
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
Other useful documents / references
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Note VFPMS information and RACP guidelines related to genital examinations in girls and young
women.
Note VFPMS information related to photo-documentation.
Note the VFPMS Memorandum of Understanding with the Office of Public Prosecutions.
CONFIDENTIALITY
In the child abuse field it may not be possible (or safe) to guarantee confidentiality, especially when it
might jeopardise a child’s safety.
As a general principle during most consultations between doctors and patients it is acceptable to
offer confidentiality to children and adolescents (and their parents / guardians) provided that there are
no concerns about the child’s safety or the safety of another child. In this line of work there are usually
concerns about safety and it is NOT possible to offer confidentiality because the Mandatory Reporting
requirements in the Children Youth and Families Act 2005.
Be cautious and sensible about sharing information in medico-legal reports. Sometimes people
ask that personal information be NOT documented or NOT included in a report. If information is included
in your notes but not in the final report then your notes should indicate this situation and the reasons for
it. Your notes are legally discoverable, which means that whatever you write in your notes can be
discovered in court.
COURT APPEARANCES
Please discuss any and all concerns about court cases with your supervisor or a consultant.
Always discuss a subpoena with a VFPMS consultant. Always prepare for a court hearing by
discussing case details with a consultant.
At times your comprehensive report will provide the information that Child Protection seek and
you might not be required in court. On other occasions you will need to appear – either in person or via
video link.
The legal system operates under very different rules to the medical system but the legal system
is usually respectful of doctors and attempts are made to minimise disruptions to doctors’ day-to-day
work and responsibilities.
We might be able to have someone come to court with you for moral support but it is unlikely.
Please use any opportunity you can to accompany a consultant who is going to court to give
evidence.
Please discuss with the consultant how you might be remunerated for your time in court.
(Payment from the courts is appallingly meagre – don’t get your hopes up). VFPMS will pay you for your
time in court at the usual hourly rate of each half day (3.5 hours) and it may also be possible to claim
time in lieu.
Anne Smith, Director VFPMS
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
TELEPHONE ADVICE
Do not give out advice about medical reports or comment on medical management by other
practitioners. NOT EVER!!!!
Note that VFPMS has a policy on providing advice on medical reports to police, protective
services and the legal profession. We insist that this is performed as a professional service when (and
only when) all available information has been offered, the conditions under which the report will be
reviewed are detailed in writing and the informed consent of all parties has been obtained.
An ‘expert opinion’ should be offered only by those with the required knowledge and skills and
with all the required ‘safeguards’ in place.
In general, opinion about another doctor’s clinical practice should be offered when all the facts
are openly able to be assessed. We prefer that the other doctor is aware that an expert opinion has been
sought and that they are aware of the evidence upon which this opinion will be based.
See clinical practice guidelines regarding provision of expert opinions based on case file reviews.
MEDICAL DEFENCE
Fellows must maintain their medical indemnity insurance. This is a condition of employment.
POLICE CHECKS AND WORKING WITH CHILDREN
It is a condition of employment that police checks are conducted on employees prior to commencement
of employment. All VFPMS employees must have a current Working with Children Card.
MEETINGS
You are expected to attend VFPMS Peer Review meetings. These are held on the first Thursday of each
month from 9.30am – 11am. In 2014, they will be held in CLS – 1.047-HELP-1st Floor West.
These meetings are part of the peer review program and it is expected that ALL abnormal videocolposcopy / DVD-colposcopy findings and other interesting cases will be reviewed by the group. If you
are unable to attend a meeting please provide clinical material to the case presentation coordinator
(currently Tim Davis) to present for discussion by the group.
Minutes of the peer review meetings are emailed to the group.
Strongly encouraged
At least once during your term you might like to attend the VIFM Thursday morning meeting at 8.30am.
This is a clinico-pathology meeting.
Additional social ‘meetings’ occur from time to time and all fellows and other team members are
encouraged to attend.
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Advanced Trainees and Fellows in Forensic Paediatric Medicine – 2014
SYSTEMS ACCESS
There are several systems that you will need access to at RCH in order to carry out your clinical work.
These are:
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Medical Photography System (MPS)
Synapse
CLARA
Electronic Scanned Medical Records (ESMR)
it may also sometimes be useful for you to have access to the VFPMS shared network drive
HR will arrange your access to Synapse, CLARA and ESMR. You will be provided with login details
for these three systems at your general RCH orientation (held 02/02/14). The VFPMS administrative
officer will arrange access to the MPS and VFPMS shared drive for you within your first week. You will
need to provide her with your RCH Windows logon and your RCH email address (provided at your
general RCH orientation) to facilitate this.
Trainees 2014 tips prepared by Anne Smith
Anne Smith, Director VFPMS
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