The GP's role in child protection

Protecting children against abuse is vital. Dr Sudip Bhaduri details the common signs of child abuse

The welfare and safety of children has recently become a bigger public issue in light of some tragic cases.

Locally, here in North East Lincolnshire, there was a major inquiry by independent social services inspectors regarding the case of Phillip Martin who died in 1999.

More significantly (without disrespecting the Martin report) was the plight of Victoria Climbie who suffered at the hands of a relative and her boyfriend who are now serving a life term after the abuse and eventual death of Victoria.

The report by Lord Laming brought forth issues and recommendations for all agencies involved in safeguarding children. Time after time, there have been serious failings in arrangements to protect children.

As a GP with a special interest in safeguarding children on behalf of the local PCT, I have been involved in several serious case reviews as well as liasing with agencies who are more engaged in the overall picture.

In the wake of the Climbie inquiry, I undertake annual training and attend quarterly local safeguarding children board (LSCB) meetings.

What is child abuse?

Child abuse broadly describes the different ways in which a child’s development as well as physical, emotional, intellectual and spiritual health is damaged by the action of another (usually an adult, mainly carers including relatives). These can be classified in several categories.

It is also important to be aware of Munchausen’s syndrome by proxy, which is becoming alarmingly common, where a carer (usually the mother) fabricates the symptoms and signs of a child’s illness. Extensive investigations and observations may never find any physical problem.

It is a known fact that a child with a non-accidental injury is most likely to present at A&E, however, GPs should always be alert to the possibility of seeing the occasional case.

Child protection issues

All personnel involved in the everyday running of a surgery should be familiar with child protection issues.

There should be a well worded history as well as a detailed examination for medico-legal reasons, when it comes to face to face consultations.

It is vital to receive input from health visitors, school nurses and social workers when a specific case causes possible concern.

The GP may decide that a second examination should be carried out by a consultant paediatrician. There may be tell tale signs such as bite marks, cigarette burns, scalding, finger marks made by gripping and elements of face slapping.

The GP must be aware of Mongolian blue spots which may mimic bruises.

If the GP suspects violent shaking, then retinal haemorrhages and tense fontanelles should be excluded. I always feel that in cases where sexual abuse is suspected, that a referral should be made as soon as possible to the trust, especially to a named paediatrician with expertise in these matters.

LSCBs provide the hub for action in cases of abuse and neglect. There are serious case review groups who meet regularly when the time arises. Members of all primary care teams should have guidelines devised in-house or with help from the LSCB via training courses, relating to ‘What to do if you suspect child abuse’.

We need to ensure that nurse specialists in this field have access to GPs and their staff to undergo basic training as often as possible.

If a GP suspects abuse, he or she should refer urgently for paediatric assessment. It is the responsibility of the trust to determine the next course of action. If the child is thought to be in immediate danger, then it should be admitted to a place of safety.

It is vital to maintain a good relationship with the family of the child, because health and social services will inevitably be involved.

A conference may be convened to decide a strategy.

GPs and health visitors may be asked to attend but a full written report in their absence would suffice. Agencies involved include the NSPCC, the police, education and legal representatives.

Dr Bhaduri is a GP at Cleethorpes and North East Lincolnshire PCT and a GP member of the Safeguarding Children Board

The RCGP is developing a training programme on safeguarding children and young people

Responding to child abuse

  • Consequences of missing child abuse may be severe.
  • Taking a good history may discover suspect non-accidental injury.
  • Good multi-agency communication and liaison is a vital pivot.
  • Refer suspected cases of non accidental injury to a consultant.
  • Examination of sexual abuse should be carried out by experts.
  • Refer to social services if not admitted to hospital.

References

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