Child Safeguarding Essentials

Child Safeguarding Update Dr David W Jones Named GP for Child Safeguarding Newcastle CCGs

Note of Caution This subject may raise painful memories or associations This is not a safe time to share personal memories If required, seek advice from a professional outside of this meeting, or contact the NSPCC helpline 0808 800 5000

Subjects to be covered Child safeguarding a brief bit of background Female Genital Mutilation (FGM) Child Sexual Exploitation (CSE) Child Death Review CQC inspection RCGP Child Safeguarding Toolkit and some don t forgets !

What is child protection? Child protection: the activity taken to protect children who are suffering or at risk of suffering significant harm s47 Childrens Act 4 categories of abuse (from which children need protection): Physical (8%) Sexual (4%) Emotional (45%) Neglect (41%)* *Newcastle LSCB 2014 If it makes you feel uncomfortable or uncertain - SHARE THE CONCERN

What is safeguarding? Child safeguarding: Arrangements to take all reasonable measures to ensure that risks of harm to children s welfare are minimised. There are 2 main components; protecting children from maltreatment preventing impairmentof children s health or development, including; ensuring that children are growing up in circumstances that are consistent with the provision of safe and effective care undertaking that role so as to enable those children to have optimum life chances and to enter adulthood successfully

Who needs safeguarding? 29,000 child subject to child protection plans 235,000 children in need* 4 million vulnerable children 11 million children We want to help children move out to the edge *s17 Children s Act 2004 :They are unlikely to achieve or maintain or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him/her of services by a local authority.

The child health and safeguarding vortex

What makes a child vulnerable? Poverty Stress within the family Relationship problems Mental Illness Learning difficulties Poor or absent parenting experience Domestic Violence Parental Substance Misuse Housing issues Physical illness On average at least 1 child a week is killed by someone known to them

The better we safeguard the many, The better we protect the few

Why GPs are well-placed to safeguard children GPs are the first point of contact for most health needs in children (and can examine) GPs might be one of only a couple of professionals seeing a pre-school child More generally, GPs know the family the family doctor GPs have access to the complete medical record (Baby P) GPs may have a unique opportunity * to safeguard the child *counsel for the GMC in the Baby P case

Lord Laming said. Investigation and management of a case of possible harm to a child must be approached in the same systematic and rigorous manner as would be appropriate to the investigation and management of any other potentially fatal disease The Victoria Climbie Inquiry 2003: Lord Laming para. 11.53)

Case 1 A 10 year old Somalian girl is brought in by her mother (who speaks very little english) for immunisations - she is about to go on an extended holiday overseas You are aware that the family is not integrated into UK society quite as much as other families have An older sister who s doing most of the talking appears anxious, and reluctant to give any details about the purpose of the trip.

What is FGM? Female Genital Mutilation All procedures which involve the partial or total removal of the external genitalia or injury to the female genital organs whether for cultural or any other non-therapeutic reasons The World Health Organisation

Who is at risk? 2 million girls around the world every year are subject to FGM Mainly African and Middle Eastern countries and alarmingly now in the immigrant population of Europe, America and Australia It is estimated that as many as 20,000 girls are at risk of FGM within the UK every year Any girl is at risk usually between 4-14

Communities at risk Djibouti 98% Somalia 97% Sierra Leone 90% Ethiopia - 79.9% Sudan 90% Guinea 98.6% In Middle East Egypt 97%

Why FGM is carried out? Religion is NOT a basis for FGM Cultural identity A tribal initiation into adulthood Gender Identity Moving from girl to woman enhancing femininity Sexual control believed to reduce the woman s desire for sex and therefore the possibility of sex outside marriage Hygiene/cleanliness unmutilated women are regarded as unclean and not allowed to handle food or water

How FGM is carried out Varies from community to community but generally by an elder woman in the community using non- sterile, blunt instruments without anaesthetic UK girls are taken on holiday to become a woman, it is seen as a celebration Communities in the UK are believed to have their own practitioners here Some doctors will do this under anaesthetic

Female Genital Mutilation Act 2003 Offence to commit FGM Offence to aid, abet, counsel or procure a girl to commit FGM Offence for someone in the UK to aid, abet, counsel or procure FGM outside of UK that is carried out by a person who isn t a UK national or resident Any act done outside UK by UK National or resident

Indications FGM is about to take place The family come from a community that is known to practise FGM Parents state they will take the child out of the country for a prolonged period A child may talk about a long holiday to a country where the practice is prevalent A child may confide that she is to have a special procedure or celebration

How should we respond? You should discuss any concerns with the practice lead for safeguarding / Named GP You must consider making a referral to the Local Authority Children s Social Care or police if urgent Follow local multi agency pathway/guidance

What can we do about it? Been trained http://www.fgmelearning.co.uk/ Aware of FGM during examinations Awareness around requests for immunisation for travel purposes in children Alert to adverse consequences of FGM (physical and psychological) Information about FGM could be made part of any welcome pack given to a practice s new patients.

Case 2 A 14 year old girl presents requesting contraception. She appears to be Gillick competent. She describes some symptoms suggestive of a sexual transmitted infection and wants treatment for that too. She has evidence of cutting on her arm when you check her blood pressure

Child Sexual Exploitation Sexualexploitation of children and young people under 18 involves exploitative situations, contexts and relationships where young people (or a third person or persons) receive something (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing, and/or another or others performing on them, sexual activities. For children over 10, sexual exploitation is the most pressing and hidden child protection issue in this country. (Barnardo s)

Rotherham Inquiry The Rotherham Inquiry into CSE in Rotherham found that approximately 1400 children were sexually exploited over the full Inquiry period, from 1997 to 2013 There is a current ongoing investigation in Newcastle (Operation Sanctuary) into the same issue of sexual abuse of children and young people.

What did we learn from the Rotherham Inquiry? Of the children who were victims of CSE; 50% had misused alcohol or other substances (this was typically part of the grooming process) 33% had mental health problems (again, often as a result of abuse) and two thirds had emotional health difficulties parental addiction was present in 20% of cases and parental mental health issues in over a third of cases there was a history of domestic violence in 46% of cases truancy and school refusal were recorded in 63% of cases and 63% of children had been reported missing more than once many were Looked After Children

Recommendations 1) All staff need to be aware of the problem of child sexual exploitation - check LSCB online learning 2) All clinicians should be aware of the possibility of CSE when discussing contraception with young people GMC guidance 0-18 para 64-69: 3) All staff should be aware of the locally agreed flowchart for managing cases of suspected CSE (included at the end of this alert, from Northumbria Police) see handout 4) Do not allow issues of race or culture to obscure decision-making in the safeguarding of children - consider equality and diversity training

GMC guidance 0-18 You should usually share information about abusive or seriously harmful sexual activity involving any child or young person, including that which involves: (a) a young person too immature to understand or consent (b) big differences in age, maturity or power between sexual partners (c) a young person s sexual partner having a position of trust (d) force or the threat of force, emotional or psychological pressure, bribery or payment, either to engage in sexual activity or to keep it secret (e) drugs or alcohol used to influence a young person to engage in sexual activity when they otherwise would not (f) a person known to the police or child protection agencies as having had abusive relationships with children or young people Para 64-69

Case 3 You receive a letter from the hospital about a 14 year old boy has DNAed several appointments in the hospital asthma clinic. You invite him to attend for asthma reviews at the surgery but he DNAs those too. He doesn t come for his flu jab He comes home from school one day and asks him mother where his inhaler is Within minutes he s has had a respiratory arrest and dies

Why Children Die Every year it is estimated that 2,000 additional children around 5 a day die in the UK compared to Europe s best performing country for child mortality, Sweden.

All cause mortality in children aged 0-14 years in European countries Wolfe et al. Improving child health services in the UK: insights from Europe and their implications for the NHS reforms BMJ2011;342:d1277

Over half of deaths in childhood occur during the first year of a child s life, and are strongly influenced by pre-term delivery and low birth weight; with risk factors including maternal age, smoking and disadvantaged circumstances. Suicide remains a leading cause of death in young people in the UK, and the number of deaths due to intentional injuries and self-harm have not declined in 30 years. After the age of one, injury is the most frequent cause of death; over three quarters of deaths due to injury in the age bracket of 10-18 year olds are related to traffic incidents.

Why Children Die The report; highlights the importance of access to high quality healthcare for children and young people calls for a reduction in preventable deaths through better training of healthcare professionals to enable confident, competent, early identification and treatment of illness recommends better use of tools such as epilepsy passports, asthma plans and coordinated care between hospitals and schools recommends all frontline health professionals involved in the acute assessment of children and young people should utilise resources such as the Spotting the sick child web resource action against the wider determinants of child health and death

Child Death Review 1. A rapid response by a group of key professionals (sometimes known as a rapid response team) who come together for the purpose of enquiring into and evaluating each unexpected death of a child; 2. An overview of all child deaths (under 18 years) in the local safeguarding children board (LSCB) area Lessons learnt are disseminated

Child Death Overview Panel Report The North of Tyne CDOP identified modifiable factors were identified in four out of ten recent cases. The factors were: Co-sleeping Consanguinity Smoking and health issues in pregnancy Co-sleeping with maternal and postnatal smoking by both parents incorporated with alcohol and drug use.

What lessons might we learn in this case? Proactive response to C+YP who DNA appts Development of asthma management plans More young people friendly services Better links with school nursing teams We need to address issues of poverty and inequality

Care Quality Commission

CQC Inspection of Childrens Services CQC will inspect general practices as part of a citywide inspection of children s services They will announce a visit on a Thursday and expect to be looking at notes early the following week

CQC As a bare minimum, all practices should; 1. have a child safeguarding lead 2. have a child safeguarding policy, that is up to date, and that all staff can locate 3. ensure all staff members are suitably trained 4. appropriately code safeguarding concerns on your computer system? In particular, can you identify the following vulnerable children; a child subject to a child protection plan a Looked After Child a child considered a cause for concern 5. regularly meet with Health Visitors to discuss all children of concern? 6. share (or explain) your concerns, and respondto requests for information for child protection proceedings e.g. case conferences? Lead, policy, train; code, meet, explain! 13Iv (XaOnx) 13IB (13IB) 13If (XaMzr)

RCGP Child Safeguarding Toolkit

RCGP Child Safeguarding Toolkit What s new? More detail on FGM, CSE, trafficking, DVA, forced marriage, radicalisation as a form of abuse, etc Updated Child Safeguarding Policy Self-assessment tool Requirements of an annual practice report More emphasis on whistle-blowing Section of what happens after a CSC referral More focus on early intervention/CIN/CAFs

RCGP Child Safeguarding Toolkit

And dont forget.

some key facts! Those that don t cruise rarely bruise Disclosure of DVA occurs after the 36th incident (on average) Consider parental explanations of unusual symptoms or signs of disease/injury with respectful uncertainty Consider safeguarding issues when assessing a child whose behaviour is causing concern Actively engage in child protection procedures