Practice dilemma: Bruises on a teenage girl

A young patient refuses to discuss suspicious bruising. What should you do?

The dilemma

It is a busy emergency surgery. A 16-year-old schoolgirl attends with symptoms of a chest infection. As you are examining her, you notice she has multiple bruises on her torso. She refuses to talk about the cause of the bruises and is reluctant to discuss the situation any further despite gentle questioning.
She is adamant that she does not wish you to discuss your findings with her parents, the school or any external agency.

How would you proceed with the consultation?

A GP’s view

Dr Louise Newson is a GP in the West Midlands

This is potentially a very difficult situation and needs to be managed carefully. Although you do not want to jump to the wrong conclusions about this bruising, you also do not want to miss this opportunity to help her if they are caused by non-accidental injury.

You need to clearly explain your duties of confidentiality as the girl’s doctor and try to gain her trust.

You could explain that there are many different causes of bruises, including some medical conditions, so it is important that you know if they are spontaneous bruises because this will help you to determine whether you need to undertake more investigations, for example, blood tests. 

You need to ask her directly why she does not want the bruises discussed with any other adult. If she does not give a plausible reason for the bruising, you really need to express your concerns with other healthcare professionals.  In the first instance, it may help to talk to your partners, to find out if any of them know this girl or her family better than you. 

You could speak to the school nurse, to see if she has any concerns.  It would be worthwhile making an appointment for this patient for a week’s time, to review her chest infection, and this will give you an opportunity to talk to her again and try to obtain more information.

It is always important to act on your instincts. If she does not attend the review appointment a week later, you need to take further action.

A medico-legal response

Dr Zaid Al-Najjar is a medico-legal adviser at the Medical Protection Society

This is a difficult scenario, particularly given that it has presented in a busy surgery.

With a 16-year-old, ordinarily there would be a presumption of capacity and a duty of confidentiality. You will need to consider if there is sufficient concern and imminent risk to the girl to warrant immediate action.

If so, you would be expected to discuss your concerns with the patient and explain your obligation to involve others, such as social services, with or without her consent. If she withholds consent or remains evasive about the cause of the injury, you should consider breaching her confidence, as outlined in the
GMC guidance, Protecting Children and Young People:

‘You must tell an appropriate agency, such as your local authority children’s services, the NSPCC or the police, promptly if you are concerned that a child or young person is at risk of, or is suffering, abuse or neglect unless it is not in their best interests to do so. You do not need to be certain that the child or young person is at risk of, or is suffering, abuse or neglect, the possible consequences of not sharing relevant information will, in the overwhelming majority of cases, outweigh any harm that sharing your concerns with an appropriate agency might cause.’

If you do not believe there is an immediate risk, you may wish to ask the patient to return for a longer appointment in the next day or two, to explore the matter further and build her trust. Alternatively, you could seek help from a colleague to cover the next appointments on the emergency list.

This may just be innocent bruising associated with an accidental injury; however, the girl’s reluctance to discuss it is cause for concern. If you remain unsure what is best to do, you should discuss the case, anonymously in the first instance, with the designated child protection lead for the area.

A patient’s opinion

Antony Chuter is an expert patient

Busy surgery or not, this patient needs some attention and care. The GP should show the patient kindness and understanding, treat the symptoms and her chest infection, then ask her to return in a few days for review.

Keeping in contact is a must; perhaps you could book the next appointment for her.

Trust takes time to be built and can be destroyed very easily. The girl may need a professional on her side, who will be patient with her and let her tell her story in her own time.

Perhaps the next appointment, or the one after, will be the time when she opens up. Giving her time to explain her feelings would appear to be a very human response to this young woman. She has come to the right place in visiting a GP and if not pressured, she will tell her story and be given help if appropriate.

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