Clinical dilemma - When social services are necessary

A health visitor concerned about the welfare of two young children asks for advice on whether to alert social services.

A health visitor concerned about the welfare of two young children asks for advice on whether to alert social services

The dilemma My health visitor came to see me recently and he was very upset. He described a difficult case he was currently involved with where a family's home situation clearly put two young children at risk. However, he did not want to refer the case to social services because he felt he first needed to build more of a relationship with the family. Moreover, the father had threatened violence if he took that step. What advice or help can I give him?

A GP’s view
Dr Louise Warburton, a GP in Ironbridge, Shropshire
The guidance in such situations is clear; the welfare of the children is paramount and the family should be referred to social services if there is any worry about the welfare of the children.

If there is the threat of violence then perhaps the police need to be involved. I would talk the situation through with the health visitor and make an assessment of the risk myself. It may be that I would be sufficiently concerned to report the family to social services myself, removing any ‘blame’ from the health visitor. I do not think it is safe for a lone worker to ‘build up more of a relationship with the family’. It is not safe for the worker or for the children concerned. They need the immediate protection of social services.

Social services can also be informed anonymously if nec­essary and I would inform the health visitor of this and my feeling that he should pass on responsibility for the family immediately.

A medico-legal opinion
Dr Sarah Cornock, medico-legal adviser, Medical Protection Society
It is the overriding responsibility of all healthcare professionals to act in the best interests of the children. Any individual may report their concerns about the welfare of children to social ser­vices. However, there is an explicit duty to report placed on healthcare professionals.

There is clear guidance from the DoH in their document ‘What to do if you’re worried a child is being abused’ (2007). It states that the health visitor should discuss the situation with their manager, and others if necessary, and, if they believe that the children are at risk, this should be reported to soc­ial services.

Your health visitor needs support and encouragement to address this duty. It is more
appropriate for him to make the referral, as he has first-hand information regarding the facts of the case. If there is a risk of violence, he may also wish to involve the police.

However, if you cannot persuade him to alert the appro­priate authorities, and you have reason to believe that the children are or may be at risk, you will need to take action yourself. The welfare of the children is paramount.

A patient’s view
Ailsa Donnelly, member of the RCGP Patient Partnership Group
The priority here is very clear, and it is the safety of the children. The health visitor may want to build a relationship with the family, but there is no guarantee that this will ame­liorate the situation and meanwhile the children remain at unnecessary risk.

The GP should advise the health visitor that he must report the situation as soon as possible; in fact the GP should also tell the health visitor that if he is unwilling to report it then the GP has a moral duty to do so. The health visitor is undoubtedly in a difficult position, but I suspect his own emotional turmoil is hindering his profess­ional judgment.

The best support the GP can give him is the confidence that in reporting the situation he is acting professionally, res­ponsibly and appropriately. If he is worried enough to seek advice, then he clearly feels there is a risk, and that in itself gives the answer. He may worry that reporting the situation might precipitate violence, but this may equally occur if he does not report the situation, and the GP should ask him how he would feel if his inaction resulted in violence and harm. Social services may be able to offer guarantees of confidentiality and anonymity.
The health visitor needs to feel he has full support from the GP.

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