Janet Riddell-Heaney, MA, RN, RHV, DipChild Protection, Cert Ed.
Designated Nurse for Child Protection, Harrow Primary Care Trust, Harrow
Professional Nurse 2003 Jan;18(5):280-4
The aim of this Study paper is to give the reader an overview of child protection.
The professional remit for all health professionals in the NHS, private sector and other agencies is enormous. The Nursing and Midwifery Council’s Code of Professional Conduct (2002) states: ‘Where there is an issue of child protection, you must act at all times in accordance with national and local policies’ (Section 5.4). It continues to emphasise that nurses have a responsibility to ‘identify and minimise the risk to patients and clients’. These statements, in conjunction with the Children Act (1989) demonstrate that the health professional’s role is broad and can be interpreted at several levels.
To enable readers to understand their own role in relation to child protection they need to be able to understand several key concepts. This Study paper will discuss these key concepts in detail. It will define the factors that can constitute child abuse and look at the concept of significant harm. The indicators that a child may be vulnerable are discussed and the key figures in a child’s life who may be in a position to assess a child’s situation are identified. The roles and responsibilities of individual professionals within the various health-care teams will be explored in detail.
Finally, this paper will look at the child-protection process in action and how the interactions between health professionals and those from other disciplines shape the final outcome for the child in question.
Definitions of child abuse are given in Box 1.
The concept of significant harm
Lyon (2002) states that harm is defined by Section 31 of the Children Act 1989 as meaning ‘ill treatment or the impairment of health or development’. Development is clarified as meaning ‘physical, intellectual, emotional, social or behavioural’. Health is defined as ‘physical or mental health’ (DHSS Northern Ireland, 1995; Section 93 Children (Scotland) Act 1995).
In order for significant harm to be recognised, any one form of harm may occur or be about to occur. The local authority has a duty to enquire where there is reasonable thought that a child is suffering or likely to suffer significant harm. They must decide whether a child is more at risk from significant harm if he is left in the current situation, and supported in that place, than if he or she is removed to a place of safety.
Working Together to Safeguard Children (DoH et al, 1999) recognises the difficulties in identifying ‘significant harm’. In order to understand it fully, several factors must be taken into consideration:
- The family context
- The child’s development within the family and wider social and cultural environment
- Any special needs such as a medical condition, communication difficulties or disabilities that may affect the child’s development and care within the family
- The nature of harm, in terms of ill treatment or failure to provide adequate care and severity of ill treatment
- The impact of the harm on the child’s development and health and the duration and frequency of suspected or real harm
- The adequacy of parental care, including extent of coercion, threat and premeditation of abuse.
Identifying vulnerable children
As well as being in privileged positions to assist families under stress in proactive and practical ways, health-care professionals can contribute to identifying children who are in need of support or safeguarding. The evidence for safeguarding vulnerable children is supported by research carried out over many years. We know that many of the families who seek help for their children, or children about whom others raise concerns about welfare, are multiply disadvantaged and may be socially excluded (National Commission of Inquiry, 1996a; 1996b). Many such families lack a wage earner. Poverty may mean that children live in crowded or unsuitable accommodation, have poor diets, health problems or disability, be vulnerable to accidents, and lack ready access to good educational and leisure opportunities (DoH, 1995).
Some parents and carers are substance abusers and funds that are needed to provide basic requirements for children may be diverted into obtaining or supporting a drug or alcohol habit (Barlow, 2000). Racism and racial harassment is an additional source of stress for some families and children. Add to this domestic violence, parental ill health, and relationship breakdown. Through the acute and com-munity services, nurses and doctors are constantly developing skills in finding and judging information that will identify who these children are.
Figure 1 describes key figures in the life of a child with a disability, while Figure 2 sets out those in the life of a child with no underlying medical needs.
Health service roles and responsibilities in child protection
Within the health services every member of staff has a responsibility for ensuring that children are protected as much as possible. It is important for staff to recognise the roles and responsibilities of colleagues in child protection, but this does not absolve them of responsibility or accountability in reporting or acting on reported concerns about a child who may be at risk. These responsibilities can be found in the following:
Primary care trusts (PCTs) - Since the development of PCTs in the NHS restructuring in April 2002, PCTs take the strategic lead for health service planning and provision, including health service involvement in the local area child protection committee groups. They ensure that adequate service planning and provision for children in need is commissioned. They co-ordinate the health component of case reviews and identify a senior paediatrician and a senior nurse with a health visitor qualification to take professional leads in this area. The professional leads also act as a resource point for other agencies and will promote and influence relevant training.
Hospitals and community trusts - Acute and community trusts are responsible for providing acute and community care in general. Staff will come into contact with children in the course of their normal work. It is therefore important that all staff are trained to be alert to potential indicators of abuse. All staff should be inducted with local policy and procedure in the event of suspecting child abuse. Each trust should have a medical and nursing professional lead appointed within the organisation. The professional leads will manage internal reviews except where they have had substantial contact with the child and family. All child visits to accident and emergency (A&E) departments should be recorded in their notes and health visitor/school nurses should be informed where applicable.
GPs and GP-attached nurses - Universal community services are ideally placed to recognise children and families in need of support or safeguarding. All members of staff should know how to refer a child to the local authority and how to contact colleagues who are experienced in child- protection matters, that is named or lead professionals. They are also well placed to recognise parents or carers who are in need of support and may pose a risk to a child. They require training to develop knowledge and skills in this area. They should be willing to share information with the local authority and other agencies involved as they have community-based contact with the child and family in a variety of ways. It is important that they are aware of child patients who are on the Child Protection Register.
Midwives, nurses and health visitors - Nurses, midwives and health visitors are well placed to recognise a child in need of support or safeguarding. All nursing, health visiting and midwifery staff can fulfil their roles adequately provided they are given appropriate training and regular updates on child-protection issues.
District and community nurses may observe events or incidents occurring to a child within a family where the child is not the patient. They need to be able to report it to the appropriate professionals and receive the support they may require to compose statements, attend conferences and in continuing to visit the family where the patient resides.
A health visitor’s relationship with a family is unique. Health visitors have special access to families during health and development checks that other professionals do not. Their unique position should allow them to be influential and key players in child- protection surveillance.
Midwives are involved with a family before a baby’s birth and may be instrumental in identifying young babies at risk due to parenting attitudes or lifestyles during the development of the unborn baby. They may be required to participate in a pre-birth child-protection conference.
School nurses’ skills and knowledge of child health and normal development processes mean that they have important roles in all stages of the child-protection process.
Mental health services - Irrespective of whether or not children are patients, all staff within this area should be aware of the welfare of children as it is well documented that children of parents with mental health problems are at increased risk of abuse or maltreatment. Mental health staff may be required to comment on parenting capacity and to attend child-protection conferences or reviews. Adult mental health services and forensic services play a role in assessing the risk posed by perpetrators of abuse and in the provision of treatment services. The expertise of substance abuse and learning disability services may also be required.
Child and adolescent mental health services - Professionals in this field have special access to children and will be able to identify or may suspect instances where a child has been abused. They have a special role due to the nature of their specific expertise with behavioural and emotional disturbance. Staff will be required to comment on therapeutic interventions to support a child who has been abused. Consultation, supervision and training resources should be available and accessible in each service.
Other health professionals - Other health professionals who have a role and responsibility in child protection include anyone who has had contact with a child and family unit:
- A&E staff
- Ambulance service staff
- Clinical psychologists
- Dental practitioners
- Staff in genito-urinary clinics
- Obstetric and gynaecological staff
- Occupational therapists
- Private health-care staff
- Sexual health-care and pregnancy advisory service staff
- Speech and language therapists
- All other professions allied to medicine.
Along with clinic and reception staff in outpatient departments, all these professionals should receive the training and supervision needed to recognise and act on child welfare concerns and to respond to children in need of support or safeguarding. All these roles can be found in the Working Together document, section 3.18 (DoH et al, 1999).
The child-protection process
Health professionals have no statutory responsibility for child protection. However, they are involved in the interagency consultations that occur when there is a referral to social services. Health professionals can by obliged by court to provide information unless proof can be given that it is incompatible with the normal duties (according to Section 27 of the Children Act).
Not all referrals result in formative action, but normally involve some degree of future involvement by social services or health services in order to provide the family/carers with the support they may require to be parents/carers to the child/children. With all referrals to social services, the Child Protection Register is checked to ensure that a child is not already on it. However, each authority holds individual localised registers: there is no national register. Although social services from different areas may share this information with other local authorities on request, there is no definitive way of clarifying a child’s status if they have recently moved from another area.
When a decision has been reached to hold a child-protection initial case conference, social services co-ordinate the meeting, inviting all the relevant agencies to attend. All health professionals will have varying degrees of responsibility, dependent on their contact with each child and family unit. At this point, the only power the child protection conference has is to decide whether or not to place the child’s name on the Child Protection Register. Registration can be categorised according to the definitions highlighted in Box 1. If it proceeds, a key worker is then allocated. Being placed on the register is not a protection in itself. It requires a child-protection plan to be produced in writing, which may require a further, fuller assessment of the child, family and home.
Occasionally when a child has been significantly harmed, or if significant harm is thought likely to continue, there is no time for a child-protection conference to be arranged. Social services may gather information from the key professionals involved with the child, in order to speed up the process of ensuring the child’s safety. It would be unjustifiable if a child continued to be at risk because a child-protection conference had not occurred.
In this situation, social services may apply to the court for an emergency protection order (EPO) under Section 44 of the Children Act (a Child Protection Order in Scotland). The police also have powers under Section 46 of the Children Act 1989 to remove children and take them into police protection. The police can also apply for an EPO either with or without local authority consent.
Once the child is safe, reasonable measures can be taken to plan for the child’s future. Once a decision has been reached at the initial child-protection conference about what measures should be taken, it is in the child’s best interests to work together to plan effectively for the management of what is a difficult time for the family. Regular ‘statutory’ reviews are required to be held. Working Together calls these subsequent discussions ‘child-protection reviews’ (DoH et al, 1999). See Figure 3.
The impact of legislation
The NHS Plan (DoH, 2000) recognises that we now live in a diverse, multicultural society and that ethnicity can be a key factor in health inequalities and gives commitments to tackling health inequalities for minority ethnic users: ‘The NHS has to be redesigned around the needs of the patient.’ This is a real opportunity to ensure that the needs of all patients are addressed in redesigning services, ensuring that specific minority needs and requirements are taken into account.
With specific regard to child protection, one of the problems highlighted in Protecting Children from Racism and Racial Abuse (NSPCC, 1999) was the clear lack of evidence available from black, Asian and ethnic minority people. From research undertaken, it is clear that inequalities exist and may contribute to further distress for a child and family. It is important that all these principles of care within The NHS Plan are actioned so quality of services can improve for all children.
- The second study paper in this series will look at issues of racism for health staff in relation to safeguarding children from abuse. The third paper will deal with culture and the fourth will focus on listening to children.
It is considered that training in safeguarding children should be made compulsory for health-care staff. Reflect on what would be the training needs for both individuals and your department as a whole.
As a nurse you are likely to come in contact with children under the age of 18 in a variety of ways - as hospital visitors, clients/patients, siblings or a household member. Consider your responsibility to keep them safe.
Research informs us that children who are disabled are more vulnerable to being abused. Why would this be so? Consider the nature of disabilities and why they cause children to be more susceptible to abuse.
Identify the responsibilities of the area child protection committee. Reflect what impact these responsibilities have on your practice and service delivery.
The core philosophy of the Children Act 1989 is that children and their safety are paramount. This requires health staff to pass on information that comes to their notice that would indicate a child has been abused. Reflect on your responsibilities to protect children and yet maintain confidentiality.
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