Child Safeguarding Update
Dr David W Jones
Named GP for Child Safeguarding
Newcastle CCGs
Note of Caution
• This subject may raise painful memories or
associations
• This is not a safe time to share personal
memories
• If required, seek advice from a professional
outside of this meeting, or contact the NSPCC
helpline 0808 800 5000
Subjects to be covered
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Child safeguarding – a brief bit of background
Female Genital Mutilation (FGM)
Child Sexual Exploitation (CSE)
Child Death Review
CQC inspection
RCGP Child Safeguarding Toolkit
and some ‘don’t forgets’!
What is child protection?
Child protection: the activity taken to protect children who
are suffering or at risk of suffering significant harm s47
Childrens Act
4 categories of abuse (from which children need protection):
• Physical
(8%)
• Sexual
(4%)
• Emotional (45%)
*Newcastle LSCB 2014
• Neglect
(41%)*
If it makes you feel uncomfortable or uncertain - SHARE THE CONCERN
What is safeguarding?
Child safeguarding: Arrangements to take all
reasonable measures to ensure that risks of harm
to children’s welfare are minimised. There are 2
main components;
• protecting children from maltreatment
• preventing impairment of children’s health or
development, including;
– ensuring that children are growing up in circumstances that are
consistent with the provision of safe and effective care
– undertaking that role so as to enable those children to have
optimum life chances and to enter adulthood successfully
Who needs safeguarding?
29,000 child subject to child
protection plans
235,000 children in need*
4 million vulnerable children
11 million children
We want to help children move out to the edge
*s17 Children’s Act 2004 :They are unlikely to achieve or maintain or to have the opportunity of achieving or maintaining, a reasonable standard of
health or development without the provision for him/her of services by a local authority.
The child health and safeguarding vortex
What makes a child vulnerable?
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Poverty
Stress within the family
Relationship problems
Mental Illness
Learning difficulties
Poor or absent parenting experience
Domestic Violence
Parental Substance Misuse
Housing issues
Physical illness
On average at least 1 child a week is killed by someone
known to them
The better we safeguard
the many,
The better we protect the few
Why GPs are well-placed to safeguard
children
• GPs are the first point of contact for most health needs in
children (and can examine)
• GPs might be one of only a couple of professionals seeing a
pre-school child
More generally,
• GPs know the family – ‘the family doctor’
• GPs have access to the complete medical record – (Baby P)
• GPs may have a ‘unique opportunity’* to safeguard the child
*counsel for the GMC in the Baby P case
Lord Laming said….
“Investigation and management of a case of possible
harm to a child must be approached in the same
systematic and rigorous manner as would be
appropriate to the investigation and management of
any other potentially fatal disease”
The Victoria Climbie Inquiry 2003: Lord Laming para. 11.53)
Case 1
• A 10 year old Somalian girl is brought in by her
mother (who speaks very little english) for
immunisations - she is about to go on an
extended holiday overseas
• You are aware that the family is not integrated
into UK society quite as much as other families
have
• An older sister who’s doing most of the talking
appears anxious, and reluctant to give any details
about the purpose of the trip.
FemaleWhat
Genital
Mutilation
is FGM?
All procedures which involve the partial or
total removal of the external genitalia or
injury to the female genital organs whether
for cultural or any other non-therapeutic
reasons
The World Health Organisation
Who is at risk?
• 2 million girls around the world every year are
subject to FGM
• Mainly African and Middle Eastern countries and
alarmingly now in the immigrant population of
Europe, America and Australia
• It is estimated that as many as 20,000 girls are at risk
of FGM within the UK every year
• Any girl is at risk – usually between 4-14
Communities at risk
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Djibouti – 98%
Somalia – 97%
Sierra Leone – 90%
Ethiopia - 79.9%
Sudan – 90%
Guinea – 98.6%
In Middle East – Egypt – 97%
Why FGM is carried out?
• Religion is NOT a basis for FGM
• Cultural identity – A tribal initiation into adulthood
• Gender Identity – Moving from girl to woman –
enhancing femininity
• Sexual control – believed to reduce the woman’s
desire for sex and therefore the possibility of sex
outside marriage
• Hygiene/cleanliness – unmutilated women are
regarded as unclean and not allowed to handle food
or water
How FGM is carried out
• Varies from community to community but generally
by an elder woman in the community using nonsterile, blunt instruments without anaesthetic
• UK girls are taken on “holiday” to become a woman,
it is seen as a celebration
• Communities in the UK are believed to have their
own practitioners here
• Some doctors will do this under anaesthetic
Female Genital Mutilation Act 2003
• Offence to commit FGM
• Offence to aid, abet, counsel or procure a girl to
commit FGM
• Offence for someone in the UK to aid, abet, counsel
or procure FGM outside of UK that is carried out by a
person who isn’t a UK national or resident
• Any act done outside UK by UK National or resident
Indications FGM is about to take place
• The family come from a community that is known to
practise FGM
• Parents state they will take the child out of the
country for a prolonged period
• A child may talk about a long holiday to a country
where the practice is prevalent
• A child may confide that she is to have a “special
procedure” or celebration
How should we respond?
• You should discuss any concerns with the
practice lead for safeguarding / Named GP
• You must consider making a referral to the
Local Authority Children’s Social Care or police
if urgent
• Follow local multi agency pathway/guidance
What can we do about it?
• Been trained
– http://www.fgmelearning.co.uk/
• Aware of FGM during examinations
• Awareness around requests for immunisation for
travel purposes in children
• Alert to adverse consequences of FGM (physical
and psychological)
• Information about FGM could be made part of
any ‘welcome pack’ given to a practice’s new
patients.
Case 2
• A 14 year old girl presents requesting
contraception. She appears to be Gillick
competent.
• She describes some symptoms suggestive of a
sexual transmitted infection and wants
treatment for that too.
• She has evidence of ‘cutting’ on her arm when
you check her blood pressure
Child Sexual Exploitation
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’ (e.g. food,
accommodation, drugs, alcohol, cigarettes, affection,
gifts, money) as a result of them performing, and/or
another or others performing on them, sexual
activities.
“For children over 10, sexual exploitation is the
most pressing and hidden child protection issue
in this country.” (Barnardo’s)
Rotherham Inquiry
• The Rotherham Inquiry into CSE in Rotherham
found that approximately 1400 children were
sexually exploited over the full Inquiry period,
from 1997 to 2013
• There is a current ongoing investigation in
Newcastle (Operation Sanctuary) into the
same issue of sexual abuse of children and
young people.
What did we learn from the
Rotherham Inquiry?
Of the children who were victims of CSE;
• 50% had misused alcohol or other substances (this was
typically part of the grooming process)
• 33% had mental health problems (again, often as a result of
abuse) and two thirds had emotional health difficulties
• parental addiction was present in 20% of cases and
parental mental health issues in over a third of cases
• there was a history of domestic violence in 46% of cases
• truancy and school refusal were recorded in 63% of cases
and 63% of children had been reported missing more than
once
• many were Looked After Children
Recommendations
1) All staff need to be aware of the problem of child sexual
exploitation - check LSCB online learning
2) All clinicians should be aware of the possibility of CSE
when discussing contraception with young people GMC
guidance 0-18 para 64-69:
3) All staff should be aware of the locally agreed flowchart
for managing cases of suspected CSE (included at the end of
this alert, from Northumbria Police) – see handout
4) Do not allow issues of race or culture to obscure
decision-making in the safeguarding of children
- consider equality and diversity training
GMC guidance 0-18
You should usually share information about abusive or seriously
harmful sexual activity involving any child or young person, including
that which involves:
(a) a young person too immature to understand or consent
(b) big differences in age, maturity or power between sexual
partners
(c) a young person’s sexual partner having a position of trust
(d) force or the threat of force, emotional or psychological
pressure, bribery or payment, either to engage in sexual
activity or to keep it secret
(e) drugs or alcohol used to influence a young person to
engage in sexual activity when they otherwise would not
(f) a person known to the police or child protection agencies as
having had abusive relationships with children or young
people”
Para 64-69
Case 3
• You receive a letter from the hospital about a 14
year old boy has DNAed several appointments in
the hospital asthma clinic.
• You invite him to attend for asthma reviews at the
surgery but he DNAs those too.
• He doesn’t come for his flu jab
• He comes home from school one day and asks
him mother where his inhaler is
• Within minutes he’s has had a respiratory arrest
and dies
Why Children Die
Every year it is estimated that 2,000 additional
children– around 5 a day – die in the UK
compared to Europe’s best performing country
for child mortality, Sweden.
All cause mortality in children aged 0-14 years
in European countries
Wolfe et al. Improving child health services in the UK: insights from Europe and their implications for the NHS reforms
BMJ2011;342:d1277
• Over half of deaths in childhood occur during
the first year of a child’s life, and are strongly
influenced by pre-term delivery and low birth
weight; with risk factors including maternal age,
smoking and disadvantaged circumstances.
• Suicide remains a leading cause of death in
young people in the UK, and the number of
deaths due to intentional injuries and self-harm
have not declined in 30 years.
• After the age of one, injury is the most frequent
cause of death; over three quarters of deaths
due to injury in the age bracket of 10-18 year olds
are related to traffic incidents.
Why Children Die
The report;
• highlights the importance of access to high quality
healthcare for children and young people
• calls for a reduction in preventable deaths through better
training of healthcare professionals to enable confident,
competent, early identification and treatment of illness
• recommends better use of tools such as epilepsy passports,
asthma plans and coordinated care between hospitals and
schools
• recommends all frontline health professionals involved in
the acute assessment of children and young people should
utilise resources such as the ‘Spotting the sick child’ web
resource
• action against the wider determinants of child health and
death
Child Death Review
1. A rapid response by a group of key professionals
(sometimes known as a rapid response team) who
come together for the purpose of enquiring into
and evaluating each unexpected death of a child;
2. An overview of all child deaths (under 18 years)
in the local safeguarding children board (LSCB) area
Lessons learnt are disseminated
Child Death Overview Panel Report
The North of Tyne CDOP identified modifiable
factors were identified in four out of ten recent
cases. The factors were:
– Co-sleeping
– Consanguinity
– Smoking and health issues in pregnancy
– Co-sleeping with maternal and postnatal smoking
by both parents incorporated with alcohol and
drug use.
What lessons might we learn in this
case?
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Proactive response to C+YP who DNA appts
Development of asthma management plans
More young people friendly services
Better links with school nursing teams
We need to address issues of poverty and
inequality
Care Quality Commission
CQC Inspection of Children’s Services
• CQC will inspect general practices as part of a
citywide inspection of children’s services
• They will announce a visit on a Thursday and
expect to be looking at notes early the
following week
CQC
As a bare minimum, all practices should;
1. have a child safeguarding lead
2. have a child safeguarding policy, that is up to date, and that all
staff can locate
3. ensure all staff members are suitably trained
4. appropriately code safeguarding concerns on your computer
system? In particular, can you identify the following vulnerable
children;
a child subject to a child protection plan
13Iv (XaOnx)
a Looked After Child
13IB (13IB)
a child considered a ‘cause for concern’
13If (XaMzr)
5. regularly meet with Health Visitors to discuss all children of
concern?
6. share (or explain) your concerns, and respond to requests for
information for child protection proceedings e.g. case
conferences?
Lead, policy, train; code, meet, explain!
RCGP Child Safeguarding Toolkit
RCGP Child Safeguarding Toolkit
What’s new?
• More detail on FGM, CSE, trafficking, DVA, forced
marriage, radicalisation as a form of abuse, etc
• Updated Child Safeguarding Policy
• Self-assessment tool
• Requirements of an ‘annual practice report’
• More emphasis on ‘whistle-blowing’
• Section of what happens after a CSC referral
• More focus on early intervention/CIN/CAFs
RCGP Child Safeguarding Toolkit
And don’t forget….
… some key facts!
• Those that don’t cruise rarely bruise
• Disclosure of DVA occurs after the 36th
incident (on average)
• Consider parental explanations of unusual
symptoms or signs of disease/injury with
‘respectful uncertainty’
• Consider safeguarding issues when assessing a
child whose behaviour is causing concern
• Actively engage in child protection procedures