Safeguarding children: everyone's responsibility Call to do more for children at risk of harm

All children and young people have the right to be protected from abuse and exploitation and to have their health and welfare safeguarded, and practice nurses have as great a responsibility to play their part in safeguarding as any other healthcare professional

We have had a slew of legislation and policies about safeguarding over the past two years. All children deserve protection against violence, neglect and exploitation and deserve the optimum nurturing to ensure their well-being and this is the essence of safeguarding. Children’s safeguarding is an area which is heavily reinforced under legislation. The main legislation is the Children Act of 1989 which was introduced to bring together all of the historic separate pieces of legislation covering the topic. It was revised in 1984 following the death of Victoria Climbie in Haringey London.

The Children Act balances the parents’ rights and responsibilities as a caregiver with the rights of the child. The parents’ responsibilities set out in the Act can be important in situations where children are brought in for treatment as not every caregiver has the right to consent to treatment for the child.

Where children are deemed to be in need, as defined under what is called section 17 of the Act there is help available from local authorities. If a child has to live away from home for their own safety this can be provided under section 20. Care orders can also be made where the child has received poor or harmful parenting under section 31 of the Act. Care orders can be temporary or until the child is deemed mature enough to live alone.

This article will not dwell on legislation but will look at some sound principles of practice that can be applied within the general practice arena. Safeguarding can be fearsome for practitioners as the law and practice emanating from it can be complicated and where practitioners are unsure they put themselves at risk of not acting safely.

Situations linked to safeguarding, are more common than you may think. It affects all groups in society no matter their culture, education levels and spiritual beliefs.

A major principle to help you to work within the Act is to ensure that you know something about the family. This often boils down to good record keeping practices. When you complete an episode of care you should know who has parental responsibility, who lives with the child and how the physical or mental health of the caregivers may impact on the child. The safety of children should always be prioritised within a family. You need to be sensitive to situations where an older child wishes to access care on their own.

You need to have a professional curiosity both towards parents but also to other members of staff. This can mean that you need to ensure that staff have been properly recruited but can also apply to workers within practices that have power to make their own rules. A major case from 2015 involving Cambridge University Hospitals shows that not taking note of chaperoning practices can leave children vulnerable during care. A consultant paediatrician manipulated the appointments systems in order to allow him to see patients out of hours. Whilst the rest of the staff assumed that he was doing his job conscientiously it gave him the opportunity to perform intimate examinations on children. The hospital had a rule that a chaperone should be present for these examinations but it was often ignored.

One of the types of child abuse which general practice commonly comes into contact with is fabricated illness. The main characteristics of this are illness in a child which is instigated by the parents. These include attempts to suffocate, direct injury, or poisoning and the child may consequently have many unnecessary invasive medical procedures. The symptoms stop when the child is separated from the parent. These signs are often acted upon when medical histories do not match with reports from the parents or there are poor responses to treatment regimens or when the child is separated from the caregiver the symptoms stop.

Practice staff need to be aware of domestic abuse. It can present in a variety of different ways. The law was recently extended in order to cover any incident or pattern of incidents of controlling coercive or threatening behaviour violence or abuse between those aged over 16 years in an intimate relationship. Bruises can be an indicator and can alert a practitioner to ask more questions, as can overbearing behaviour. These are useful starting points, but they can’t definitively ascertain if someone is a victim or not. It is up to practice staff to make it clear that service users can disclose their situation. In a family where children witness abuse it changes the way that they relate to others and normalises it in the child’s eyes. Children are also more likely to be subject to violence if it is a norm in the home. Where you have these types of concerns a referral to children’s social care should definitely be made.

INFORMATION SHARING AND REFERRALS

Practice nurses have a responsibility for raising concerns, sharing information and working with others to contribute to decisions on early help child protection and children in need processes. The Department of Health ‘Information Sharing’ (2015) provides advice on sharing information. Practitioners should be aware that they should ask for consent to share information unless there is a compelling reason for not doing so. It is important to remember that information can be shared without consent if it is justified in the public interest or required by law. As a general rule in safeguarding children, consent is not required for referrals where a child is considered at risk or is thought to have suffered significant harm. If you receive requests for information from other practitioners you naturally need to ascertain that these are genuine but there would need to be very good reasons not to share relevant information. Some children have come to harm due to a lack of information sharing, but none has been harmed because information has been shared.

All local authorities will have different referral forms but it is worth thinking about what information you need to include.

• Do not inform the parents if you have any reason to believe this would put the child at further risk of harm.
• If possible, it is important that the child understands why the referral is being made. Children may have strong opinions about their needs and ways in which they can be met. Professionals should take into account the child’s age, developmental level, language, disability, gender, culture and age when communicating with children. Include issues such as cognitive development, interaction with other children/adults and attendance at school, observations about the child/children’s behaviour and social presentation.
• Provide a picture of the child/ren’s current and future development needs. Include information from other relevant assessments where appropriate e.g. Statement of Special Educational Needs
• Provide a brief account of the child/children’s health issues to include immunisations where appropriate and developmental checks, dental and optical care, any illnesses, disabilities or episodes of hospitalisation.
• Information that may be relevant includes factors such as missed appointments, gaps in education or going missing from home.
• You will need to give evidence of your knowledge of the parent/carer’s ability and capacity to provide a nurturing environment. This will include basic shelter, clean and appropriate clothing and adequate personal hygiene, protection from significant harm or danger, emotional warmth towards the child, encouragement and praise, a sufficiently stable environment with a secure attachment to the primary carer(s). in this section you should indicate any parental difficulties that you know about such as, drug or alcohol misuse, mental health issues, domestic abuse and how they impact upon their care of the child. You should also mention your awareness of any housing, income or employment issues that are having an impact on the child. If you have knowledge to share about community issues in the local area or whether the family is isolated within the community these should be shared. It is important that you also highlight what the strengths are, and what is working well for the child and family.
• Provide information to the best of your knowledge about any members of the child’s wider family who has a significant relationship with the child, any significant changes within the family like a separation between parents and what the sibling relationships are like.

This is by no means the definitive guide to children’s safeguarding but it can help to foster an attitude of mind that makes practitioners update themselves, keep vigilant and organise their practice so that it is safe.

Practitioners need to ensure that their policies and practices within their workplaces reference the following legislation and guidance (Box 1) and that they keep in contact with the local safeguarding board to learn any new information that arises from case reviews.

The Care Quality Commission (CQC) has issued a call to healthcare staff and leaders to do more to identify and listen to children at risk of harm, in a new report.

Not seen, not heard looks at how effective health services are in providing early help to children in need, the health and wellbeing of looked-after children and how these services identify and protect children at risk of harm.

All children and young people have the right to be protected from abuse and exploitation and to have their health and welfare safeguarded, the review reminds us.

Although local authorities have overarching responsibility for safeguarding, every organisation and person who comes into contact with a child has a role to play and healthcare professionals are in strong position to address children’s health and welfare needs and safeguarding concerns.

The report concludes that health professionals have improved the way they assess risk and recognise safeguarding concerns, but that services are not consistently protecting and promoting the health and welfare of children. It urges everyone working with children to do more to listen to and involve children in need in their care.

More must be done by health providers, including staff in hospitals, health visitors practice nurses and GPs, as well as commissioners, to ensure that services are improving outcomes for children, strengthening the quality of information sharing and joint working, the report says.

This first national review of how well health services safeguard children considers 50 inspections carried out over the last two years, as well as focus groups with inspectors and children and young people themselves.

The inspections focused on the local area’s effectiveness to identify children at risk of harm in healthcare settings as well as the healthcare for children in care.

The review contains many best practice examples and CQC is appealing to health staff and leaders to use it as a learning tool.

Society has changed dramatically over the past 50 years, with leaps in technology and increased global mobility presenting new challenges, the report says. Children are groomed for sexual exploitation and radicalisation on social media and young people can be at risk of trafficking and female genital mutilation (FGM).

CQC’s chief inspector of general practice, Professor Steve Field said: ‘The number of children identified as having been abused or exploited is just the tip of the iceberg – many more are suffering in silence. As new risks emerge and more children are identified as being in need, it is more crucial than ever that staff across health and social care, education, the police and the justice system all work together.

‘We know that with the right questions and support, services can discover the risks and harms that threaten many children, including those from parental-ill health, sexual exploitation and female genital mutilation.

‘We owe it to the children. We must provide the support they deserve and the help they need to move forward with their lives.’

Not seen, not heard says the extent of problems such as exploitation, and parental ill-health and sexual exploitation is still largely unknown and how well children are being protected from them, even less so. Most areas are not yet effectively identifying and protecting children at risk of hidden harms.

Themes in the report include:

IDENTIFICATION

The risks to children are not always obvious and require a continuous professional curiosity about the child and their circumstances. The emphasis should be on preventative work with those in need of early help (such as children with parents with substance misuse issues) well as those at risk of hidden harms. Staff working in adult health services, including mental health, should be routinely assessing any risks to children who may be at home. Staff across services should be better supported to identify, protect and support children at risk of other harms such as sexual exploitation and FGM.

REFERRALS

While health professionals have improved how they assess risk and recognise safeguarding concerns, CQC has identified problems with the way these risks are shared with other services (for example a GP, nurse or doctor to a social worker). Practitioners frequently did not articulate the risks to the child to set out what they expected from the referral, leaving the receiving team unclear of the concerns (a referral is made by health professionals to child protection/social workers when they are concerned a child is at risk of harm or abuse).

INFORMATION SHARING

Children experience more coordinated, joined-up and efficient care where there are arrangements for how to share information, make referrals and provide support. CQC has identified the features of safe joint working and information sharing and also endorsed the national implementation of the Health and Social Care Information Centre’s Child Protection Information Sharing Project. This is designed to improve the level of protection given to children who present unscheduled in NHS settings such as GPs, hospitals, and minor injury units. All NHS organisations are required to implement this system by 2018.