Health assessment and medical examination

In all cases brought to IRD the need for medical examination must be discussed, agreed and documented. Although a medical examination is not a requirement in every investigation, it needs to be considered by the IRD regardless of whether the child has any apparent or visible injuries or appears neglected. A discussion with the consultant paediatrician is required to plan the type and timing of any medical assessment or examination.

The medical examination of a child for whom there are child protection concerns aims to:

• Establish what immediate treatment the child may need
• Provide a specialist medical opinion on whether or not child abuse or neglect may be a likely or unlikely cause of the child’s presentation
• Support multi-agency planning and decision making
• establish if there are unmet health needs, and to secure any on-going; health care (including mental health), investigations, monitoring and treatment that the child may require
• Listen to and to reassure the child
• Listen to and reassure the family as far as possible in relation to longer-term health needs

The decision to carry out a medical examination and the decision about the type of medical examination is made by a paediatrician informed by a multi-agency discussion with police, social work and other relevant health staff.

Through careful planning, the number of examinations must be kept to a minimum. The decision to conduct a medical examination may:

• Follow from an IRD and inter-agency agreement about the timing, type and purpose of the examination
• Follow when a child or young person presents directly to health services e g an emergency department
• This includes the possibility of self-referral for victims of rape and sexual assault who are over 16 years old as described below

All medical examinations/assessments are holistic, comprehensive assessments of the child/ young person’s health and developmental needs. There may be variations in who undertakes medical examination, and the purpose of the examination must be clear prior to the examination (usually discussed at IRD or at time of referral for the examination) to allow for a clinician with the appropriate skill set to undertake the assessment.

Concerns about physical abuse and injuries

When there are concerns about injuries and potential physical abuse a specialist paediatric examination with a forensic approach will be undertaken by a Child Protection consultant paediatrician.

Children under one year of age are at an increased risk of physical abuse When concerns have been identified for a child under the age of one, they will be admitted to hospital for further examination (link to under one policy from health services).

In most cases where there is visible evidence of injuries (e g burns or bruises) photographing the child’s injuries timeously will be required and this may form part of the evidence for the Procurator Fiscal.

Child Sexual abuse

In cases of any disclosed sexual abuse, which is reported to have occurred within the previous 7 days, a medical examination should be considered, as a matter of urgency. This will be to protect the health of the child and to secure and preserve evidence. Where a medical examination is required but not immediately, this will be arranged to suit the child, family and relevant professionals.

Children under 13 years old will usually be examined by the Child Protection service at the Royal Hospital for Children Glasgow, whereas children over the age of 13 years will be examined by a medical examiner at Archway Glasgow (Archway Glasgow—telephone 0141 211 8175).

For children who may have experienced non recent sexual abuse, an IRD should be convened to consider a Joint Investigative Interview (JII) and consideration for any subsequent medical examination that may be required.

Informed consent of the non-abusing person with parental responsibility and, where appropriate, that of the child must always be obtained.

A paediatric medical examination may be required where there has been parental or a professional concerns regarding child sexual abuse but no clear disclosure has been made. They would only be held following appropriate gathering of information, an IRD and consultation with the appropriate paediatrician. Consideration will also be given to examining children where Female Genital Mutilation is a concern.

Neglect

The health needs of all children experiencing neglect should always been considered at IRD or when child protection concerns have been raised Health professionals already involved with the child or young person should be included in discussions about update assessments. There may be extreme or urgent cases of neglect that will require a discussion with Child Protection consultant paediatrician to agree nature and timing of examination.

Where victims of rape or sexual assault are aged 16 and over, they are able to self-refer for a forensic medical examination without first making a report to Police Professional judgement is required as to whether following self-referral, a forensic medical examination is in the person’s best interests. This includes clinical and non-clinical considerations. Even when a Forensic Medical Examination is not provided, the need for healthcare support and treatment must be considered.

Significant new information may arise from a medical examination that requires the reconvening of an IRD.

Wherever possible, the wishes of children who may have experienced sexual abuse, should be considered and supported in respect of choice of sex of examiner:

• Following a referral being received in relation to concerns about physical abuse a medical will be planned within an IRD, unless the child requires an urgent response
• When a child has been victim of acute sexual assault within the last 7 days the aim would be for a discussion as to the need for medical examination to take place as soon as possible and only in urgent circumstances planned outwith the IRD. In non-recent sexual assault cases then a medical would be planned at the IRD.

As far as can be achieved in the circumstances, the examining doctor should have:

• All relevant information about the cause for concern
• Information on previous concerns about abuse or neglect
• The inter-agency plan to meet the child’s needs at this stage
• Relevant known background of the family or other relevant adults
• Information from joint investigative interview if available
• Preparatory discussion with the relevant Social Work and Police Officer
• A preparatory meeting with parent or carer and child

It should be recorded what information is handed over/conveyed verbally to the examining doctor and by whom.

Social Work, the Police and the examining doctor should ensure that the child and parent(s) (and/or any other trusted adult accompanying the child) have the opportunity to hear about what is happening, why and where so that they have an opportunity to ask questions and gain reassurance.

Consent must be obtained in one of the following ways:

• From a parent or carer with parental rights
• From a young person assessed to have capacity
• Through a court order

Consent will be sought for CP medical examinations and as part of these it may also be sought in relation to investigations such as blood tests, x-rays or scans, the taking of photographs or video recording.

The consultant paediatrician would always seek informed consent from the person(s) with parental responsibilities and/ or a child with sufficient age and understanding Consent needs to be directly obtained from the person(s) with parental rights and responsibility and not via a third party and where possible in written form.

When the alleged perpetrator is also the person with parental rights and responsibilities then they still need to be asked for consent for the child’s medical. Consideration must be given to how to obtain consent safely and without impacting on the child or investigation.

The Age of Legal Capacity (Scotland) Act 1991 allows a child under the age of 16 to consent to any medical procedure or practice if in the opinion of the qualified medical practitioner the child is capable of understanding the nature and possible consequences of the proposed examination or procedure. Children who are assessed as having capacity to consent can withhold their consent to any part of the medical examination, for example, the taking of blood, or a video recording. Consent must be documented within medical notes and must reflect which parts of the process have been consented to and by whom. This includes consent to forensic medical examination.

In order to ensure that children and their families give properly informed consent to medical examinations, it is the role of the examining doctor, assisted if necessary by the Social Worker or Police Officer, to provide information about all aspects of the procedure and how the results may be used and to ensure informed consent has been obtained. Where a medical examination is thought necessary for the purposes of obtaining evidence in criminal proceedings, but the parents/carers refuse their consent, the Procurator Fiscal may, in exceptional circumstances, consider obtaining a warrant for this purpose. However, where a child who has legal capacity to consent declines to do so, the Procurator Fiscal will not seek a warrant.

If the local authority believes that a medical examination is required to find out whether concerns about a child’s safety or welfare are justified, and parents refuse consent, the local authority may apply to a sheriff for a child assessment order, or a child protection order with a condition of medical examination This is still subject to child’s consent under section 186 of the Children’s Hearings (Scotland) Act 2011 Act.

Timing of the medical examination is agreed jointly by the consultant paediatrician and the other agencies involved.

Child protection medicals should be carried out, in the child’s interests, during the day, unless there is a forensic need or other clinical indication of urgency.

In some cases, when there is not a forensic urgency, it may be a priority that the child has had time to rest and prepare. This may also allow for more information to become available. The majority of cases arise in working hours, and a comprehensive medical assessment will be carried out locally and timeously.

In cases of suspected or reported non-recent sexual abuse, examinations should be planned during normal working hours.

Local arrangements must be in place for medical examinations out of hours, where these differ from daytime/weekday arrangements to ensure the opportunity to collect forensic trace evidence is not lost.

The Clinical Pathway for Children and Young People who have disclosed sexual abuse is relevant for children under 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs) (Scottish Government 2022).