Child Abuse Guideline

• Assessment
  • Physical Abuse
  • Sexual Abuse
• Management
  • Admission or Discharge?
  • Admitted patients
• Notes
• Resources

Assessment

The priorities in dealing with child abuse are:

1. to diagnose, treat and document the child's injuries,

2. to interpret a pattern of injury or behaviour leading to the suspicion of abuse,

3. to notify and involve the Victorian Forensic Paediatric Medical Service (VFPMS),

4. to provide, when consent is given, a verbal or written report to Child Protection and the Police.

The doctor must establish that consent has been given (by one of the parents or the child's legal guardian) to perform a clinical examination and to provide a report to Child Protection and the Police. Ideally this should be in writing. If the child is under a protection application then a nominee of Child Protection is the child's guardian. If consent is unobtainable the child should only be examined under a court order or if a medical emergency exists.

A proforma is available which, if completed fully, ensures that all salient points are covered. The last pages of this contain a suggested format for a medical report which should be completed in triplicate. If Child Protection require an urgent report then fill in this section and, after written consent has been obtained, release it to the requester. Non-urgent reports should be prepared in accordance with the administrative instructions concerning report writing. Review of these reports by VFPMS or a senior colleague is encouraged

Physical Abuse

Children who attend with an injury that might have been inflicted need a full physical assessment. This should be performed by a registrar or consultant. The examination must include height and weight as well as examination of the head, mouth, eyes, ears, chest, abdomen, back and limbs. The use of body diagrams and the available "physical abuse" proforma to record findings are strongly recommended.

Contact

and (at RCH) call ontact the Social Work Department ext.6111; or After Hours contact Social Worker On Call via RCH switchboard.

Investigation

A coagulation profile should be performed when there is a clinical suspicion of a clotting disorder. Abnormalities of clotting are rare so beware of attributing bruises to this cause.

Clinically suspected fracture sites should be X-rayed directly. A bone scan and skeletal survey are very useful for detecting clinically unsuspected recent and older fractures. They should both be used in children under the age of three who are likely to have sustained non-accidental injury.

Sexual Abuse

All instances of suspected sexual abuse should be referred in the first instance to the VFPMS, In general, genital examinations for the purpose of determining whether or not abuse has occurred will only be performed by appropriately trained and experienced consultants. Limited inspection for a specific purpose such as determination of the amount of bleeding or the extent of a rash or discharge may be performed with the cooperation of the child.

After an acute sexual assault (< 72 hours) rapid evaluation is required. Contact the the VFPMS,  and speak to the consultant on-call. You may be advised to assess and treat any urgent medical problems (eg. bleeding), being careful to collect any clothing that is removed in the process. Ensure the child is as comfortable as possible and has appropriate emotional support.

Ensure the child is as comfortable as possible and has appropriate emotional support. Await the on-call Consultant who will perform the examination and the Gatehouse Centre worker.

Management

Referrals from Child Protection

If Child Protection staff attend with a child requesting a medical examination it is appropriate to see the child to evaluate any medical condition which may need urgent investigation or treatment. In most instances the complete evaluation can occur the next morning.

Contact

Consultation

The evaluation of a child who has possibly been abused can be a time consuming and difficult process, and one in which help from a colleague can be invaluable. Consultant assistance is available from the on-call consultant for the Emergency Department or the on-call consultant for the Victorian Forensic Paediatric Medical Service

Documentation

The legal implications of a medical examination conducted for possible child abuse are significant. Accurate and complete documentation is essential. Clinical photographs are an excellent way of recording visible injuries. Mon-Fri 9am-5pm, call the Educational Resource Centre; after hours page on-call photographer.

Admission or Discharge?

Admission to hospital should be arranged when it is medically necessary (fractures, failure to thrive etc) or when it is necessary for the child's safety. A low threshold for admission is appropriate when dealing with an injured child whose only alternative is foster care.

Children should be admitted under the General Medical Unit of the day. If the child has specific injuries (eg. fractures) then a joint bedcard is appropriate.

Consider NAI in any infant who presents with an unexplained encephalopathy.

Any infant with a cerebral injury, from shaking or direct trauma, should be admitted to ICU for monitoring overnight. Delayed deterioration may occur.   (At RCH - ICU admission should only be declined following assessment by the ICU consultant).

The safe discharge of the child is the responsibility both of the hospital and Child Protection . This may be to the care of a relative, back home with the abusing adult removed or to a temporary foster family.

All Admitted patients:

A SCAN ("Suspected Child Abuse and Neglect") meeting must be held within 24 hours of admission.
This protocol is designed to help coordinate early discussions with Victorian Forensic Paediatric Medical Service, Child Protection and police.

See SCAN Meeting Resources

Notes

All medical staff working in the Emergency Department & Wards must be aware of the possibility of child abuse, and be able and prepared to act appropriately if it is suspected.

There is a legal obligation upon both medical and nursing staff to notify Child Protection if they have formed the opinion that a child is in need of protection. See  Children, Youth and Families Act 2005 - SECT 162

The Victorian Forensic Paediatric Medical Service is situated on the 5th floor of the south east building. As well as regular clinics they provide a 24 hour service for evaluation of possible causes of injury and advice regarding evaluation of suspected child abuse. They can also advise on good medical report writing and liaising with the external agencies.

Children suspected to have been abused or neglected require a full evaluation of their psychosocial situation.  Refer to social work for psychosocial assessment where there are concerns about risk of harm to a child.  Contact Social Work Department ext.6111 (physical abuse/ neglect) or Gatehouse Worker ext.6391 (sexual abuse).

Resources

• Victorian Forensic Paediatric Medical Service Web Site
• Proforma for suspected Child Abuse Consultation
• Diagrams for recording injuries
• Article on writing a good medical report
• WCPSRG - reviews of child protection literature 

SCAN Meeting Resources

(Suspected Child Abuse or Neglect)

• SCAN Meeting Procedures
• Medical Information summary for SCAN patients
• Agenda for SCAN meetings
• Minutes for SCAN meetings

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