Dr Matty Rubens and Dr Bianca Lee
Personally, I feel more confident managing a septic child than I do being confronted with a child protection case. Part of the problem is that I’m confused about the processes, forms and people involved in safeguarding on a wider scale. What are all the different ‘sections’ and why are we talking ‘strategy’? Why are all the police officers called Kate? And what’s the difference between a designated and named doctor?
I asked my colleagues at North Middlesex Hospital to send me a list of words and phrases they associated with the child protection process, including all the acronyms they don’t understand. Here’s what they came up with:
So by laying out the process start-to-finish, let’s try and clear things up!
All professionals working with children have a duty to safeguard their wellbeing. So if anybody identifies safeguarding concerns they should raise it with the Local Authority Children’s Social Care team.
Tips for trainees: With referrals, the devil is in the detail. Why, what, where, when and who? Remember that the referral needs to be factual, but should include an opinion about why you are concerned, or the perceived risk to the child.
To make that referral, the pathway differs slightly from region to region, but usually consists of either the single point of access (SPA, or sometimes single point of contact – SPOC), a team of social workers within Children’s services that receive, triage and action new referrals within 24 hours, or you refer directly to the Multi-Agency Safeguarding Hub (MASH), the social worker led multi-agency team which handles new safeguarding referrals.
The team receiving the referral will decide on one of 4 potential outcomes:
- No further action is required
- The case is suitable for Early Help (see Chapter 1 in ‘Working Together to Safeguard Children’)
- An assessment of the family is carried out leading to the child becoming a Child In Need (CIN) under Section 17 of the Children Act 1989
- The child has sustained or is at risk of significant harm and Child Protection proceedings must be started under Section 47 of the Children Act 1989
Tips for Trainees: Your responsibility doesn’t end once the referral is made – chase up the outcome and if you don’t agree, challenge it (and discuss with a senior).
Section 47 of Children Act 1989 – Requires the local authority to co-ordinate an investigation where a child has been subject to or is at risk of significant harm. The aim of this multi-agency enquiry is to decide whether any action is required to safeguard and promote the welfare of the child.
If the threshold has been met for a S.47 enquiry, a strategy discussion (AKA strategy meeting) will be arranged. Often referred to as the ‘strat’ meeting, this should be a conversation between social care, health and a branch of the police called CAIT – the ‘Child Abuse Investigation Team’. The purpose is to consider the immediate safety of the child and to plan the investigation into the allegations made. This may be a ‘strat’ discussion over the phone, for example when a child is referred to social care by a school teacher but is still in the community, or it might be a face-to-face ‘strat’ meeting on the paediatric ward, when a child has presented to hospital with injuries or other safeguarding concerns.
Tips for Trainees: The role of the doctor in the strategy meeting is to consider the need for and timing of a medical examination – remember, marks from physical abuse may fade, meaning the medical should be arranged asap. If the child has already been examined, our role is to present the findings and give an opinion on the child’s wellbeing in light of what we have seen. We also need to be able to comment on any health concerns in general and ideally give an overview of any past concerns – e.g. from the community health records
Section 47 Investigations – what’s involved?
The strategy discussion will help to decide whether the investigation should be ‘single agency’ or ‘joint agency’, meaning either social care alone or social care plus the police. This decision can, of course, be changed later. The social worker, plus or minus a police officer, will make a home/school/hospital visit straight away to speak to the child, the person who has made the referral and anyone else as appropriate.
The first consideration should be the child’s immediate safety (and don’t forget any siblings or other vulnerable children/adults who may be involved!). Should the child go home from school if the alleged perpetrator is a parent? If need be, they can be removed from a harmful environment using:
- Police powers of protection – often referred to as a police protection order (PPO), this is not in fact an order issued by the court. Police officers can remove a child from a harmful situation to protect them and temporarily house them in ‘a place of safety’ (ideally an emergency foster placement). The child can remain under police protection for 72 hours, but the parent retains parental responsibility.
- An emergency protection order (EPO) – Issued by the court, an EPO authorises the applicant (usually the local authority) to remove the child from their home or prevent their removal from hospital or another safe place. An EPO can last up to 8 days, but the parent retains parental responsibility.
Tips for Trainees: For a child under police protection or an EPO, parental responsibility remains with the parent. That means you must gain their consent before the child protection medical or performing investigations/interventions (unless delaying may cause further harm, of course!)
Next, the child needs a Child Protection Medical Assessment. This involves a thorough history and examination by a paediatrician. The purpose of this assessment is not only to identify and document any injuries sustained, but also to pick up on any unmet health needs and importantly, provide reassurance to the child where possible.
It is very important to discuss with the CAIT team whether they will be conducting an Achieving Best Evidence (ABE) interview. This is an interview conducted by specially trained officers, the contents of which can be presented as evidence in future court proceedings (preventing the child being called as a witness.
Tips for Trainees: If an ABE interview is scheduled for AFTER you conduct the child protection medical, you must be careful not to ask probing questions about the allegations in detail, as this could be considered as ‘contaminating’ the potential evidence. For example, you shouldn’t ask “did mummy hit you with a stick?”, but it would be ok to ask “what happened there?” if marks are found on examination. Document the child’s response word-for-word. This is a very tricky situation – always talk to the supervising consultant beforehand if possible!
The physical examination is a crucial part of the medical, particularly if signs are present suggestive of non-accidental injury. A ‘skin survey’ is a documented assessment of all markings on a child’s body, and all lesions should be drawn on a diagram, known as the ‘body map’. The findings of the assessment should be documented in a CP medical report, which should contain explanations given by the child/carer for all marks and scars seen, as well as your opinion about the general wellbeing of the child. (This recent paediatricFOAM article has more information on documentation during CP medicals).
Once the S47 investigation is completed (medical done, interviews conducted, family background checks completed, home environment inspected, etc), the children’s social care team must decide whether the child is at risk of significant harm and requires a child protection conference. If they do, a case conference (AKA initial child protection conference, ICPC) should be held within 15 working days, to decide whether a child protection plan is needed.
Who attends? A representative for all agencies involved, plus the parents (so social worker, police, health (doctor/health visitor/school nurse) school etc)
What happens? Each person discusses the perceived protective factors and causes for concern as they see them for the case.
Your Role: Provide a clear medical opinion and comment on any health issues raised
The decision: Those attending will be expected to give an opinion as to whether the threshold has been met for a child protection plan. This may be in the form of a vote, or by ranking the risk on a numeric scale.
Potential difficulties: The parents are present and you may feel like you are criticising their parenting. Just remember, first and foremost you are an advocate for the child’s safety – so stay calm and be honest.
The conference may decide that the threshold for a CP plan has not been met, but the child may still benefit from becoming a Child in Need (CIN) – this is a child that needs additional support from the local authority to meet their health and developmental needs. Think of CIN as a rung below CP on the safeguarding ladder.
The Child Protection Plan
This is a working document drawn up by the local authority after a case conference. The CP Plan should specify how to:
- Ensure the child is safe and prevent them from suffering further harm
- Promote the child’s health, welfare and development (this is where we can contribute most to the discussion!)
- Support the family to protect and promote the child’s welfare, provided this is in the child’s best interests.
The document should specify time-scales and allocate professionals to lead on each point of the plan. Crucially, a review conference should be held at regular intervals – first review is at 3 months then at 6 monthly intervals. If all the points of the CP Plan have been achieved, and the child is no longer considered to be at risk of harm, the CP plan can be discontinued. However if not, or if the child has been on a CP plan for approaching 2 years, a legal planning meeting is held to decide if care proceedings should be started. This may result in the child being taken into care, becoming ‘Looked After’.
….so that’s an abbreviated summary of the journey from a concern being identified to a child protection plan being initiated and reviewed. Being involved in child protection cases can feel overwhelming at times. Some key points to remember are:
- Always be clear when presenting your findings and your opinion.
- Remember to seek senior (and peer) support.
- Child protection cases can be complex – don’t lose focus on the child at the center of it all.
Below is a glossary of other terms (not exhaustive by ANY means) that you might see or hear used along the way that are not covered above:
|As described above, the multi-agency enquiry to assess whether a child is subject to or at risk of harm|
|The LA has a duty to safeguard and promote the welfare of a ‘child in need’|
|A voluntary order (requires parental agreement) for a child to be taken into foster care. The parent retains full parental responsibility|
Section 31 – care order
|Issued by court to remove the child from their home and share parental responsibility between the parents and the local authority. Lasts until the child is 18, until the child is put up for adoption, or until the court deems it no longer necessary.|
Section 38 – interim care order (ICO)
|Issued by the court to remove the child from their home environment, whilst a care order is sought. It initially lasts 8 weeks before review. Parental responsibility is shared between the parents and local authority|
|The court gives permission to place a child up for adoption|
|Parent retains parental responsibility but local authority can supervise and advise on how a child is parented. Usually lasts 1 year but can be extended/cut short|
Child arrangement order
|Where a child lives and who they have contact with (custody).|
|(In London) Referral form to CAIT team from social care|
|Standardised assessment tool for holistically assessing a child, so that the local authority holds information about them, including any concerns. Must have child’s/carer’s consent. Used for issues not meeting the threshold for safeguarding|
Looked after child (LAC)
|A child accommodated by the local authority, voluntarily by the parents (S.20) or not. They can be placed with foster carers (including relatives/friends), in children’s centres, in secure accommodation or with prospective adopters.|
|Within an organisation, the named doctor promotes good professional practice, provides advice and expertise to colleagues, and ensures safeguarding training is in place. Often referred to as the ‘safeguarding lead’.|
|Within a specified region, the designated doctor takes a professional and strategic lead on all aspects of the health service contribution to safeguarding children. They also advise and support the named doctors within their area.|
Local authority designated officer (LADO)
|Works within the local authority and is there for support and guidance when safeguarding concerns arise regarding any practitioner/professional who works with children; for example, a school teacher or children’s charity worker|
Duty social worker
|Out of hours social worker who receives and responds to all child safeguarding referrals.|
The core group
|The collection of professionals and family members responsible for the implementation and review of the child protection plan. Meet at regular intervals after the initiation of a plan.|
Dr Matty Rubens, Paediatric Registrar, and Dr Bianca Lee, Named Doctor for Haringey, Whittington Health, London