Consideration should always be given to the need for a medical examination of each child, about whom there are concerns.
the social worker co-ordinating the enquiry should discuss the need for a medical examination with a suitably qualified and experienced paediatrician or forensic medical examiner/physician and agree the timing and location of the examination taking account of the best interests of the child;
there should also be consideration of the need for other children in the household or in contact with the alleged perpetrator to be medically examined;
although a medical examination is not a requirement in every s47 enquiry, it needs to be considered regardless of whether the child has any apparent or visible injuries or appears neglected. The medical examination should be dispensed with only if those managing the enquiry are satisfied that they can achieve the purposes of the enquiry without it. This must involve discussion with the appropriate paediatrician. Those reasons will need to be clearly recorded by all professionals involved.
Practitioners need to be aware that the purpose of a medical examination or assessment is to:
ensure the child’s condition is medically assessed and treatment given as appropriate;
obtain assessment about possible indications of abuse;
ensure that any injuries or signs of neglect or abuse are noted for evidential purposes;
secure forensic evidence.
The child’s welfare is the paramount concern and the gathering of evidence must not become an additional source of abuse of the child. The need for forensic evidence should always be considered as secondary to the need for medical treatment for a child.
there should be liaison with police and social services to avoid the need for repeated medical examinations;
the police or social worker will fully brief the examining doctor if he or she has been unable to attend the strategy discussion/meeting;
the social worker will ensure that the person with parental responsibility is available to give consent for the examination (see below on refusal to consent).
The doctor, to whom the request for an examination is made, must judge the timing of the examination. The following should be taken into consideration:
physical abuse and/or neglect. if the report concerns physical injury or severe neglect a medical examination should be arranged, wherever possible, on the same day. not to see the child on the day of the report would be exceptional;
sexual abuse, in cases of any alleged sexual abuse, a medical examination should be considered, and if required, be available, including out of hours. This will be to protect the health of the child and to secure and preserve evidence such as forensic samples photo-documentation.
The assessment of the child should be carried out by a paediatrician with Level 3 competences as per Safeguarding Children and Young People: Roles and Competences for Health Care Staff.
Where a trainee carries out the assessment, they should be supervised by a consultant or senior paediatrician (RCPCH) guidance from Royal College of Paediatrics and Child Health.
for physical abuse and/or neglect a paediatrician should undertake the examination;
for alleged sexual abuse, a suitably qualified paediatrician should only undertake the examination. where forensic information is sought, as in acute sexual assault, if the paediatrician does not have the necessary forensic skills, he/she may request from the police that a forensic medical physician (fmp), be in attendance for the collection of forensic specimens. See: Guidelines on Paediatric Forensic Examinations in Relation to Possible Child Sexual Abuse The Royal College of Paediatrics and Child Health. October 2012).
Doctors undertaking the examinations must be aware of latest guidance from Royal College of Paediatrics and Child Health.
Examining doctors must be aware of the principles of informed consent and of the guidance contained in the RCPCH Child Protection Companion 2006.
Social workers and police officers undertaking s47 enquiries and criminal investigations also need to be aware of the issues of consent for the medical examination.
N.B. Examination without consent may be held in law to be an assault. It is the responsibility of the examining doctor to obtain the informed consent preferably in writing.
A child of 16 years and over can give their own consent. If they are unable to consent, for example because of a learning disability, consent may be sought from a person with parental responsibility.
Children under the age of 16 years, who are able to fully understand what is proposed and its full implications, are competent to consent (Gillick v Wisbech 1986)
However, the more serious the medical procedures proposed a correspondingly better grasp of the implications is required. Therefore, the examining doctor needs to ensure that the child fully understands the nature of the medical examination and how the information obtained might be shared with others.
If a child is not deemed to be Fraser/Gillick competent, consent from a person with parental responsibility is required. However, the child may still refuse to be examined.
For a child under 16, consent for a child protection medical examination will require the informed consent of a person with parental responsibility and of the child, preferably in writing.
Where the child is already the subject of proceedings in a court, the consent of the same Court is required. If the child is subject to a Care Order, see local arrangements as to who in the local authority can provide consent.
For the consent to be informed the doctor needs to speak directly to the person with parental responsibility and explain:
the purpose and process of the medical examination;
clearly specify all of the elements of the examination i.e. history, examination, forensic specimens, use of video/still photo-documentation;
explain information will be shared for discussion with colleagues;
findings and reports will be shared with social services, police, crown prosecution service and Courts;
That information gained by the examination may also be read out in Court.
Consent should always be sought on a face-to-face basis – that is with the parent in attendance with the child. However, if the parent cannot or does not want to be present the doctor will need to decide on the action needed to obtain a valid consent.
Only in the case of a medical emergency where the child needs urgent medical attention, is consent not required.
An application for a Child Assessment Order, can be made if parents continue to refuse access to a child for the purpose of establishing basic facts about the child’s condition but concerns about the child’s safety are not so urgent as to require an Emergency Protection Order.
The Order enables the Court to direct the parents to co-operate with an assessment, the details of which will be specific, but does not allow for the removal of the child from home.
The Order does not take away the child’s own right to refuse an assessment. The parents should be informed of the legal steps that could be used.
This should include:
a verbatim record of the carer’s and child’s accounts of injuries and concerns nothing any discrepancies or changes of story;
documentary findings in both words and diagrams;
site, size, shape and where possible age of any marks or injuries;
opinion of whether injury is consistent with explanation;
date, time and place of examination;
who gave consent and how (child / parent, written / verbal);
other findings relevant to the child (e.g. squint, learning or speech problems etc);
confirmation of the child’s developmental progress (this is especially important in cases of neglect);
the time the examination ended.
date of the report
any other examinations that were undertaken
The report and any diagrams should be signed and dated by the doctor undertaking the examination.