Safeguarding Children UHL Policy - EM3

Safeguarding Children Policies and Procedures

Approved By:

Policy and Guideline Committee

Date Approved:

27 January 2012

Trust Reference:

B1/2012

Version:

V3

Supersedes:

V2: B1/2012

Author / Originator(s):

Katharine Bouch Named Nurse for Safeguarding Children, UHL

Name of Responsible Named Nurse for Safeguarding Children, UHL Committee/Individual: Latest Review Date

17 June 2016 – PGC

Next Review Date:

April 2019

CONTENTS

Section

Page

1

Introduction

4

2

Policy Aims

4

3

Policy Scope

4

4

Definitions

5

5

Roles and Responsibilities

5

6

Policy Statements, Standards, Procedures, Processes and Associated Documents

8

7

Education and Training

11

8

Process for Monitoring Compliance

11

9

Equality Impact Assessment

11

10

Legal Liability

12

11

Supporting References, Evidence Base and Related Policies

12

12

Process for Version Control, Document Archiving and Review

12

Appendices

Page

1

A Guide to Who Has Parental Responsibility

14

2

Guide to Involving Parents and Carers in Safeguarding Children Cases

17

3

Guideline to Obtaining Consent in Safeguarding Children Cases

19

4

Completion of Medical Reports in Safeguarding Children Cases

21

5

Guideline for Dealing With Disclosures and Avoiding Leading or Probing Questions in Safeguarding Children Cases

22

6

Procedure for Supervision of Patients in Safeguarding Children Cases

24

7

Guideline for the Management of Allegations of Sexual Abuse in Children and Young People

25

8

Guideline for the Management of Mental Health Issues and Deliberate Self Harm in Children and Young People

30

9

Procedure for a Child Presenting with a Fracture and Responding to Safeguarding Children Concerns

35

10

Guideline for Providing Written and Verbal Statements to the Police in Safeguarding Children Cases

36

11

Procedure for Requesting a Second Opinion in Safeguarding Children Cases for Independent Review if Concerns Remain

38

12

Guideline for the Emergency Department-Children Accompanying Adult Patients Who Require A Hospital Admission

39

13

Procedure for Children Who Do Not Attend (DNA) Hospital Appointments

41

14

Guideline for the Provision of Data to External Agencies in Safeguarding Children Cases

45

15

Guideline for holding Safeguarding Information Sharing Meetings (“SISMs”)

50

16

Guidelines for obtaining Photographic Evidence in child protection cases

51

17

Guideline for Managing Safeguarding Children issues in cases of adults attending

54

Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012

2 of 90 Next Review: April 2019

NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents

suffering from Mental Health issues

18

Guideline for Managing Safeguarding Children concerns where an adult reports Domestic Abuse

56

19

Guideline for Managing Paediatric Patients who Leave Hospital prior to medical discharge

59

20

The 4 R’s UHL Safeguarding Children Team Case Management Process

61

21

The UHL Safeguarding Children Team Traffic Light System

62

22

The UHL Safeguarding Children Referral Form A

69

23

Guideline for Completion of Child Protection Medical Examinations

71

24

Guideline for Staff Requesting Covert Video Surveillance (CVS) in Children’s Safeguarding Cases

75

25

Guideline to be followed in the Event of an Unexpected Death of a Child (SUDIC) on Intensive Care, Inpatient wards and All Other Areas in UHL, Excepting ED

76

REVIEW DATES AND DETAILS OF CHANGES MADE DURING THE REVIEW 2015: This review has been a significant re-write of the original Safeguarding Children Policies and Procedures. KEY WORDS Child Protection, Safeguarding Children, welfare, Social Care, Social Services, consent, involving parents and carers, medical reports, dealing with disclosures, supervision, allegations of sexual abuse, deliberate self -harm, Police statements, requesting a second opinion, missing persons, children accompanying adult patients, DNA appointments, provision of data, Form A, Four R’s, Safeguarding Referral Form, Traffic Lights, child protection medical, Section 47, Child Death Overview Processes, Community Liaison, CONI, Care of Next Infant, Child Death, parental responsibility, leading questions, teenager, mental health, CAMHS, Did Not Attend, data protection, data requests, information request, Safeguarding Children Team, Safeguarding Information Sharing Meeting, discharge meeting, medical illustration, photographs, photographic evidence, adult mental health, domestic abuse, domestic violence, child welfare, absconding. SUMMARY This policy provides core details of the role of Safeguarding Children within University Hospitals of Leicester NHS Trust. Guidance is supplied on the role of individuals to safeguard children, and the processes in place within the trust to support staff in taking action to identify and respond to a safeguarding concern. In addition, the wider role of safeguarding is outlined, to include the Child Death Overview functions and the Liaison and Care of the Next Infant Services.




1

INTRODUCTION This Trust wide policy sets out how the Trust should work together to safeguard and promote the welfare of children, in line with Working Together to Safeguard Children (2015). The policy reflects the expectations of the Leicester and the Leicestershire & Rutland Safeguarding Children Boards. The purpose of the policy is to clearly outline the process of safeguarding and protecting individual children coming into contact with Trust services, who are identified as either suffering, or at risk of suffering, significant harm as a result of abuse or neglect, ensuring those with additional support needs are identified and referred on to appropriate services, and that there is a consistent supportive approach following the death of a child.

2

POLICY AIMS

2.1

The policy outlines the responsibilities of the Trust and the process for managing the risks associated with safeguarding children.

2.2

To provide a service for safeguarding children within the University Hospitals of Leicester NHS Trust which operates within the legal framework of The Children Act of 1989 and The Children Act of 2004, Working Together to Safeguard Children (2015), and the Leicester and Leicestershire & Rutland Local Safeguarding Children Boards Thresholds for Access to Services for Children and Families in Leicester, Leicestershire and Rutland (April 2015).

2.3

To clearly define how the Trust works in partnership with other agencies to safeguard and promote the welfare of children.

2.4

To enable staff to manage an individual case effectively in accordance with the national and local frameworks.

2.5

To provide guidance associated with the safeguarding children’s training needs, supervision and support throughout the Trust.

2.6

To provide a system of control and monitoring of safeguarding children procedures.

3

POLICY SCOPE

3.1

This policy applies to all staff who work within University Hospitals of Leicester NHS Trust (“UHL”).

3.2

This includes all staff that work in a bank/locum capacity or have honorary contracts.

3.3

This also includes “satellite” units which work as part of UHL, including the Loughborough Sports Injury Clinic and The Alliance.

3.4

This policy must be read in conjunction with local joint Local Safeguarding Children Board (“LSCB”) policies and procedures. Electronic policies should be consulted as these will provide the most up to date guidance. Available via http://llrscb.proceduresonline.com/index.htm.




4

DEFINITIONS

4.1

In this document, a child is defined as anyone who has not yet reached their 18th birthday. ‘Children’ therefore means ‘children and young people’ throughout. (Working Together to Safeguard Children, 2015)

4.2

Safeguarding and promoting the welfare of children is defined for the purposes of this document as:

5

•

Protecting children from maltreatment;

•

Preventing impairment of children’s health or development;

•

Ensuring that children grow up in circumstances consistent with the provision of safe and effective care; and

•

Taking action to enable all children to have the best outcomes. (Working Together to Safeguard Children, 2015)

ROLES AND RESPONSIBILITIES

An overview of the individual, departmental and committee roles and responsibilities, including levels of responsibility and any education and training requirements 5.1 Responsibilities within the Organisation 5.1.1

The Chief Executive and Board of Directors have overall responsibility for Trust compliance with policies and procedures to effectively safeguard children.

5.1.2

The Deputy Chief Nurse is the director with lead responsibility for Safeguarding Children. The Deputy Chief Nurse represents the Trust on the Leicester City and Leicestershire & Rutland LSCB’s and provides feedback at appropriate UHL forums. Where necessary the Deputy Chief Nurse takes responsibility for communicating relevant information to Government Departments and/or professional bodies of those considered unsuitable to work with children. The Deputy Chief Nurse provides support on Safeguarding Children concerns and provides supervision to the Head of Safeguarding, ensuring the role is fulfilled. The Deputy Chief Nurse chairs the UHL Safeguarding Assurance Committee.

5.1.3 The Head of Safeguarding is the strategic lead for Safeguarding Children. The Head of Safeguarding represents the Trust on the Executive Groups and appropriate subgroups of both the Leicester City and Leicestershire & Rutland LSCB’s. The Head of Safeguarding provides line management and support to the Named Nurse for Safeguarding Children, ensuring this post is fulfilled.

5.1.4 The Named Doctor for Safeguarding Children is the medical lead for UHL, providing peer support to medical staff within the Trust. The Named Doctor is recruited by the Children’s Hospital.

5.1.5 The Named Nurse for Safeguarding Children is the operational lead for safeguarding children. The Named Nurse represents the Trust on appropriate subgroups of the Leicester City and the Leicestershire & Rutland LSCB’s. The Named Nurse also provides supervision to the Senior Specialist Nurses of the Safeguarding Children’s Team. The Named Nurse supports the Deputy Chief Nurse and the Head of Safeguarding by providing advice and support on safeguarding children concerns. The Named Nurse chairs the UHL Safeguarding Children Operational Group.

5.1.6 The Safeguarding Children Team (non-maternity) oversee and provide support to clinical staff on all safeguarding children cases raised to them. This will include managing cases, ensuring actions are appropriately taken, supporting staff to meet their duties, liaising with Police, Social Care and community health practitioners. The Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



Safeguarding Children Team mentor the Safeguarding Children Clinical Links. The team includes the Safeguarding Children Child Death Overview Lead and the Safeguarding Children Community Liaison Lead.

5.1.7 The Safeguarding Assurance Committee (“SAC”) has a strategic function to oversee, scrutinise and endorse safeguarding processes. Members are responsible for sharing information from the SAC, raising awareness of safeguarding processes, escalating concerns, and supporting the implementation and monitoring of compliance with the policy and procedures across their CMG staff groups. SAC members complete safeguarding reporting tools to the SAC to enable the monitoring of compliance within each CMG.

5.1.8 The Safeguarding Children Operational Group (“SCOG”) has an operational focus to ensure safeguarding processes are embedded within the operational functioning of the trust. Members are responsible for identifying and reporting operational issues relating to safeguarding to the Group, which are then addressed and where necessary, raised to the SAC.

5.1.9 Safeguarding Clinical Links (“SCL’s”) are identified by their clinical area managers and are responsible for working closely with the Safeguarding Children Team to ensure safeguarding work is embedded within their clinical area. The work of SCL’s is reported into the SCOG. Each SCL is supported by a Safeguarding Children Team member.

5.1.10 All staff are responsible for raising any concerns about abuse/neglect of a child to an appropriate person, agency or manager in a timely manner. All staff are responsible for identifying which policies are applicable to their area of work and for following Trust policy documents. All staff must adhere to safeguarding children processes and carry out their duty to report actual or suspected abuse. All staff must attend safeguarding children’s training as appropriate for individual roles.

5.2 Responsibilities of and communication with stakeholders 5.2.1 Safeguarding and promoting the welfare of children and young people is everyone's business. Therefore all workers who come into contact with children and young people must accept a shared responsibility to work jointly across agencies to achieve the best outcomes for children and young people.

5.2.2 This shared responsibility extends to being prepared to challenge colleagues in one’s own and in other agencies if it is believed that they are failing to recognise child maltreatment and/or their response leaves children at risk of significant harm

5.2.3 Integrated working Agencies and professionals working together to provide a holistic service to children and young people is fundamental to the successful implementation of these policy and procedures. All workers need to be confident about other people's roles and responsibilities, and about sharing information across disciplines. Measures to safeguard children should be viewed as part of the wider range of support available to meet the needs of children, young people and their families. . 5.2.4 Safe working practices All agencies and staff working with children, young people and their families have a duty to ensure that the services they deliver keep the children and young people they are working with safe. This includes robust recruitment practices, promoting safe staff conduct and ways of dealing with staff who pose a risk to children. 5.2.5

The legislation and guidance relevant to safeguarding and promoting the welfare of children includes the following: • Children Act 1989 and 2004




• Working Together to Safeguard Children (2015) – statutory guidance • Promoting the Health and Well-being of Looked After Children – statutory guidance • Safeguarding children and young people: roles and competences for health care staff, intercollegiate document (updated 2014). 5.2.6

A full exposition of statutory provisions relating to children’s safeguarding can be found in appendix B of the statutory guidance document Working Together to Safeguard Children.

5.2.7

While many key statutory provisions apply directly to a broad range of public bodies, including the NHS and the Police, some key provisions of legislation impose duties directly on local authorities only. The duties are not placed directly on any other agencies. However the NHS, as well as other agencies, is covered by these duties indirectly, because it has statutory duties to co-operate with local authorities over safeguarding.

5.2.8

There are some broad, fundamental safeguarding duties, namely: • There is a duty on local authorities to “safeguard and promote the welfare of children within their area who are in need” Section 17(1) Children Act 1989. The concept of “need” is defined very broadly, covering any child whose health or development will be impaired without support, or who has a disability. (Section 17(10) Children Act 1989) • Local authorities also have a further duty to “take reasonable steps…to prevent children within their area suffering ill-treatment or neglect” (Paragraph 4, Schedule 2, Children Act 1989). • All public sector agencies providing services to children, including local authorities and all NHS bodies, “must make arrangements for ensuring that their functions are discharged having regard to the need to safeguard and promote the welfare of children”. (Section 11 Children Act 2004) • A child-centred approach is required. As far as reasonably possible, local authorities must ascertain the child’s wishes and feelings, and devise their support in consideration of those wishes and feelings. Local authorities do not have to provide the support themselves. (Section 53 Children Act 2004) • A local authority must enquire whether it needs to take safeguarding action if it has reasonable cause to suspect a child in its area is suffering, or is at risk of, significant harm. This duty also covers any child in Police Protection, or under an Emergency Protection Order. (Section 47 Children Act 1989).

5.2.9

It is essential practice that all agencies recognise that safeguarding is everyone’s business. No individual agency can assume that safeguarding issues will be picked up by others. To confirm and illustrate this, there are the following duties on interagency co-operation: • If, in discharging its safeguarding duties, a local authority asks certain specified agencies for help, those agencies must help as long as it is compatible with their own duties, and does not hamper the discharge of their own functions. These agencies include NHS England, CCGs, and all NHS trusts. (Section 27 Children Act 1989) • Local authorities are under a duty to make arrangements to promote co-operation with other agencies, including NHS England and all CCGs, in order to promote the well-




being of children in general, and to protect them from harm and neglect in particular. Those other agencies are under an express reciprocal duty to co-operate with the local authority. (Section 10 Children Act 2004). 5.3.0 The task of monitoring inter-agency co-operation falls to the Local Safeguarding Children Board (LSCB). Local authorities must establish an LSCB for their area. NHS England, CCGs, designated professionals and local providers should ensure appropriate representation on the LSCB. The local authority and the other board members owe to each other reciprocal duties of co-operation specifically in relation to the establishment and operation of the LSCB. (Section 13 Children Act 2004). 5.3.1

The objectives of an LSCB are to co-ordinate activities of board members to safeguard and promote the welfare of children, and to ensure the effectiveness of those activities. LSCBs also commission Serious Case Reviews where abuse or neglect of a child is known or suspected, the child has either died or been seriously harmed, and there is concern over how agencies and service providers have worked together. (Section 14 Children Act 2004 and paragraph 5 of the Local Safeguarding Children Boards Regulations 2006)

6

POLICY STATEMENTS, STANDARDS*, PROCESSES*, PROCEDURES* AND ASSOCIATED DOCUMENTS

6.1

Managing Individual Cases

6.1.1

University Hospitals of Leicester NHS Trust Safeguarding Strategy works to the “4 R’s”: RECOGNISE, RESPOND, REFER and RESPONSIBILITY. This is summarised in Appendix 20.

6.1.2

Recognition: 6.1.2a Those who work with children: All professionals working with children should be alert to indicators that a child may be being maltreated and aware of the appropriate response. 6.1.2b Those who work with adults who may be parents or caregivers: Agencies and individual practitioners working with and/or providing services to adults who may need help in promoting and safeguarding their children's welfare should always consider the implications for children of the adult’s behaviour. For example: Adults presenting to hospital with mental health issues, drug/alcohol issues, assault, domestic abuse or learning difficulties. When dealing with cases of domestic abuse, the Police and other involved agencies should consider the implications of the situation for any children in the family. Note that the 1989 Children Act definition of “significant harm” has been extended to include “seeing or hearing the abuse of another”.

6.1.3

Respond: 6.1.3a It is recognised that each individual child has varying needs and that each case within the Trust will be different. 6.1.3b As such, a Traffic Light approach has been designed to support staff in identifying the process to follow to address the needs of the child. The Traffic Light System can be viewed in detail in Appendix 21.

6.1.4

Refer: 6.1.4a All safeguarding cases (red, amber or green) should be referred to the University Hospitals of Leicester NHS Trust Safeguarding Children Team using the UHL Safeguarding Form A, which can be found on the Safeguarding Children Team pages on




INsite. This should be completed in full by the person with the concern at the time of the event. 6.1.4b Children may attend the Trust from Local Authorities outside of Leicester, Leicestershire or Rutland. In such circumstances, safeguarding concerns about the child or family must be referred to the relevant area in which they normally reside. The UHL Safeguarding Children team can assist in identifying the correct area if there is any uncertainty about where a referral should be made to. 6.1.5

Responsibility: Every member of staff employed by UHL has a responsibility for safeguarding the interests of children and adults they come into contact with during their work. To fulfil these duties, post holders are required to attend training and development to recognise the signs and symptoms of abuse or individuals at risk, to follow local and national policy relating to safeguarding practice and to report and act on concerns they may have.

6.1.6

In addition to the Child Protection/ Safeguarding Children policy there is also further Trust Guidance:

Guideline/Procedure

Appen dix

A Guide to Who Has Parental Responsibility

1

Guide to Involving Parents and Carers in Safeguarding Children Cases

2

Guideline to Obtaining Consent in Safeguarding Children Cases

3

Completion of Medical Reports in Safeguarding Children Cases

4

Guideline to Dealing With Disclosures and Avoiding Leading or Probing Questions in 5 Safeguarding Children Cases Procedure for Supervision of Patients in Safeguarding Children Cases

6

Guideline for the Management of Allegations of Sexual Abuse in Children and Young 7 People Guideline for the Management of Mental Health Issues and Deliberate Self Harm in 8 Children and Young People Procedure for a Child Presenting with a Fracture and Responding to Safeguarding 9 Children Concerns Guideline for Providing Written and Verbal Statements to the Police in Safeguarding 10 Children Cases Procedure for Requesting a Second Opinion in Safeguarding Children Cases for 11 Independent Review if Concerns Remain Guideline for the Emergency Department-Children Accompanying Adult Patients Who 12 Require A Hospital Admission Procedure for Children Who Do Not Attend (DNA) Hospital Appointments

13

Guideline for the Provision of Data to External Agencies in Safeguarding Children 14 Cases Guideline for holding Safeguarding Information Sharing Meetings (“SISMs”)

15

Guidelines for obtaining photographic evidence in Safeguarding Children cases

16

Guideline for managing safeguarding children issues in cases of adult attending 17 suffering from Mental Health issues Guideline for managing safeguarding children concerns where an adult reports 18 domestic abuse Guideline for Managing Paediatric Patients Who Leave Hospital prior to medical 19 discharge The 4 R’s UHL Safeguarding Children Team Case Management Process Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012

20



The UHL Safeguarding Children Team Traffic Light System

21

The UHL Safeguarding Children Referral Form A

22


23

Guideline for Staff Requesting Covert Video Surveillance (CVS) in Children’s 24 Safeguarding Cases Guideline to be followed in the Event of an unexpected Death of a Child (SUDIC) on 25 Intensive Care, Inpatient wards and All Other Areas in UHL, Excepting ED 6.1.7

Multi-agency supplementary guidance is also available at the Leicester, Leicestershire and Rutland Local Safeguarding Children Board websites, and is listed below:

• • • • • • • • • • • • • • • • • •

Safeguarding Children procedures Achieving best evidence in criminal proceedings Bullying Child protection and HIV Children’s participation in child protection conferences and core groups Culturally appropriate practice Family group conferences/ meetings Intimate care good practice guidelines Neglect Uncooperative and hostile families Historical abuse allegations2.1 Safeguarding Disabled Children Children using Abusive Behaviour Abuse Linked to Spiritual and Religious Beliefs Allegations of Harm Arising from Under Age Sexual Activity E-safety Safeguarding Children and Young People from Child Sexual Exploitation Children and Families who go Missing Children from Abroad (including Migrant Children and Unaccompanied Asylum Seeking Children) Children Living Away from Home (including Children and Families living in Temporary Accommodation and Private Fostering) Children Missing from Education or with Poor School Attendance Children Moving Across Boundaries Domestic Abuse/Violence Complex (Organised or Multiple) Abuse Fabricated or Induced Illness Forced Marriage Harm to Animals and Possible Implications for Children Race and Racism Safeguarding Trafficked Children Pre-Trial Therapy Female Genital Mutilation Managing Individuals who Pose a Risk to Children Children's Visits to Special Hospitals/Psychiatric Units Cross-Border Child Protection Cases Under the 1996 Hague Convention Children and Young People who Run away or go Missing from Home or Care Safeguarding Children and Young People who Self-Harm Safeguarding Children and Young People with Suicidal Behaviour Safeguarding Children Vulnerable to Violent Extremism (PREVENT)

• • • • • • • • • • • • • • • • • • •




7

EDUCATION AND TRAINING REQUIREMENTS

7.1

Safeguarding Children Training is mandatory for all UHL employees with all Trust staff required to complete Safeguarding Children Training once every three years. It should be noted however that for Level 3 training the needs of the service ensure that in key areas shorter sessions are carried out annually to meet the needs of the 3-yearly requirement.

7.2

Level 1 Training is for non-clinical staff with no or minimal contact with children. This provides a basic level of understanding regarding the signs and indicators of abuse and who to contact if you have a concern. Current Level 1 training is available via eUHL.

7.3

Level 2 Training: This training is for clinical staff but who have limited contact with children. The Training provides staff with a more in depth knowledge of safeguarding and their role as a professional member of staff. Staff in this group need to complete Level 1 Training before Level 2. Both levels are available via eUHL.

7.4

Level 3 Training: This training is for clinical staff who work with children/or who have limited but intense periods of clinical contact with children. This training is currently carried out face to face and sessions are available to book on eUHL.

7.5

All training content will refer to these policies and procedures.

7.6

The Trust recognises the need for clinical supervision for Named and core Safeguarding staff, and all levels of staff who may be involved in child protection/ safeguarding children cases.

7.7

Clinical supervision for Named Nurses/ Midwives/ Doctors is provided by the Designated Safeguarding professionals.

7.8

All involved in any child protection/ safeguarding cases will have the availability of supervision/ support from the Safeguarding Children Team.

7.9

The Safeguarding Supervision policy can be found on INsite, providing the detail of supervision arrangements within University Hospitals of Leicester NHS Trust for Safeguarding cases.

8

PROCESS FOR MONITORING COMPLIANCE

8.1

This policy supports compliance with Outcome 7, Safeguarding people who use services from abuse, of the Care Quality Commissions Essential Standards of Quality and Safety (CQC, 2010). Practice is audited against this standard through quality assurance and monitoring. A quarterly assurance is presented to the Trust Board with details of compliance to CQC Outcome 7. Compliance is also reviewed on an ongoing basis with CCG commissioners through quality monitoring.

8.2

See policy monitoring table on Page 15.

9

EQUALITY IMPACT ASSESSMENT

9.1

The Trust recognises the diversity of the local community it serves. Our aim therefore is to provide a safe environment free from discrimination and treat all individuals fairly with dignity and appropriately according to their needs.

9.2

As part of its development, this policy and its impact on equality have been reviewed and no detriment was identified.




10

LEGAL LIABILITY

The Trust will generally assume vicarious liability for the acts of its staff, including those on honorary contract. However, it is incumbent on staff to ensure that they: • • • •

Have undergone any suitable training identified as necessary under the terms of this policy or otherwise. Have been fully authorised by their line manager and their Directorate to undertake the activity. Fully comply with the terms of any relevant Trust policies and/or procedures at all times. Only depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible clinician it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes.

It is recommended that staff have Professional Indemnity Insurance cover in place for their own protection in respect of those circumstances where the Trust does not automatically assume vicarious liability and where Trust support is not generally available. Such circumstances will include Samaritan acts and criminal investigations against the staff member concerned. Suitable Professional Indemnity Insurance Cover is generally available from the various Royal Colleges and Professional Institutions and Bodies. For further advice please contact Assistant Director (Head of Legal Services) on 0116 258 8960.

11

SUPPORTING REFERENCES, EVIDENCE BASE AND RELATED POLICIES

HM Government, Working Together to Safeguard Children - a guide to interagency working to safeguard and promote the welfare of children (2015) Leicester, Leicestershire and Rutland Safeguarding Child Boards Joint Procedures, Protocols and Practice Guidance The Children Act 1989 The Children Act 2004 Thresholds for Access to Services for Children and Families in Leicester, Leicestershire and Rutland, Leicester, Leicestershire and Rutland Local Safeguarding Children Boards.

12

PROCESS FOR VERSION CONTROL, DOCUMENT ARCHIVING AND REVIEW

This document will be uploaded onto SharePoint and available for access by staff through INsite. It will be stored and archived through this system. The policy will be referred to in all Trust safeguarding training sessions/programmes. This policy and procedures contained within it will be reviewed after 3 years by the Policy Author. The review will include the following: • Audit of procedures. • Analysis of information from any complaints or incidents that have been reported.




POLICY MONITORING TABLE

Element to be monitored

Lead

Tool

Frequency

Reporting arrangements

Lead(s) for acting on recommendations

Change in practice and lessons to be shared

Appropriateness of safeguarding children referrals made by UHL Staff

Named Nurse Safeguarding Children

Observation and review of safeguarding children referral forms

Annually

Safeguarding Children Operational Group

Named Nurse for Safeguarding Children

Safeguarding Children Operational Group

Head of Safeguarding

Feedback via Serious Case Reviews/ Serious Incident Learning Processes

Quarterly

Safeguarding Assurance Committee QAC SCR Subgroups of City, County and Rutland Local Safeguarding Children Boards


Safeguarding Assurance Committee QAC SCR Subgroups of City, County and Rutland Local Safeguarding Children Boards Safeguarding Children Operational Group


eUHL records


QAC Safeguarding Assurance Committee Safeguarding Children Operational Group

Mandatory staff training at all levels


Annually

Safeguarding annual report



APPENDIX 1

A Guide to who has Parental Responsibility

Safeguarding Children Team September 2015

1. Introduction This guide is intended to outline the legal basis of determining who can hold parental responsibility for a child. 2. Scope This guidance is designed to support all disciplines of staff within UHL. 3. Guideline statements The law sets out who has parental responsibility, also referred to as ‘PR’. 3.1 Automatic Parental Responsibility You have parental responsibility automatically if you are: •

The biological mother of the child

•

The biological father of the child and were married to the mother at the time of the birth

•

The father is listed on the birth certificate

•

You are the adoptive parents once an adoption order has been made

Even if the marriage breaks down, both father and mother will continue to have parental responsibility. 3.2 Unmarried Fathers Unmarried fathers did not have the same rights and responsibilities as married fathers until the Adoption and Children Act 2002 came into force on the 1st December 2003. This is not retrospective however, therefore: If the child was born before 1st December If the child was born after 1st December 2003 the father can gain parental 2003, the father can gain parental responsibility by: responsibility by: Registering with responsibility

a

court

for

parental Being jointly registered with the mother on the child’s birth certificate

Marrying the mother of the child

Marrying the mother of the child Registering with responsibility

a

court

for

parental

3.3 Children subject to care orders Various care orders can be used to safeguard a child, with varying transfer of parental responsibility. An outline of various care orders can be found on the Safeguarding Children Team web pages on INsite.




3.4 Additional Circumstances: Additional information can be found on the Trust Policy for Consent to Examination or Treatment (V9) accessed 2nd December 2015. If you are unsure about who has parental responsibility for a child, please contact the Safeguarding Children Team for advice on x5770 4. Education and Training Training on this guidance is provided on the Safeguarding Children mandatory training modules within UHL. 5. Monitoring and Audit Criteria Please refer to section 8 of the Safeguarding Children Policies and Procedures document.




Checklist for UHL Staff to check who has parental responsibility for a child Child born before 1st December 2003 and …

a) The male is married to the biological mother b) The male has registered with the courts for Parental Responsibility Request a copy of the order to remain within the child’s notes

c) There is a separate legal order providing PR to the male Request a copy of the order to remain within the child’s notes

d) None of the above – the male does NOT have parental responsibility and cannot provide consent Child born after 1st December 2003 and…

e) The male is jointly registered with the mother on the child’s birth certificate f) The male is married to the biological mother g) The male has registered with the courts for Parental Responsibility Request a copy of the order to remain within the child’s notes

h) There is a separate legal order providing PR to the male Request a copy of the order to remain within the child’s notes

i) None of the above – the male does NOT have parental responsibility and cannot provide consent

Checklist completed by: Name………………………………………………………………………….. Role…………………………………………………………………………… Date…………………………………………………………………………… CHILD’S NAME.…………………………………………………………….. DATE OF BIRTH……………………………………………………………. S NUMBER……………………………………………………………………




APPENDIX 2 Guide to Involving Parents and Carers in Safeguarding Children Cases


1. Introduction Initial contacts with families set the tone for future working relationships with them. It is good practice to be open, direct and as honest as possible about the nature of the concerns. This is likely to provide the best basis for a constructive working relationship and enables a thorough assessment of the protection needs. 2. Scope All staff in UHL NHS Trust who may be involved in safeguarding children cases. 3. Guideline statements 3.1

Remember most parents and carers understand that health professionals have to pass on concerns about children to other agencies, and they expect this to happen.

3.2

Parents or carers will feel let down if you say one thing to them and then offer a different opinion to others, therefore, always be honest about your concerns and discuss them.

3.3

If you have concerns make it clear that you are not accusing the parents, but have procedures to follow. You could say for example ‘I have guidelines which I am duty bound to follow’.

3.4

However the needs and safety of the child must remain paramount when determining what information is shared with parents/carers in these early stages, how this is done and when.

3.5

Relevant circumstances when the decision not to inform the parents/carers include where: • • • •

3.6

A child would be threatened or otherwise coerced into silence Important evidence would be destroyed The child did not wish for the parent/carer to be involved at that stage and is competent to make that decision It would pose an immediate risk to siblings

The UHL Safeguarding Children Team have developed a leaflet that should be provided and talked through with parents and carers when child protection concerns are raised called “The Child Protection Process in University Hospitals of Leicester NHS Trust – a guide for parents and carers”. This leaflet is available in the Children’s Emergency Department and in the Children’s Assessment Unit. If you are unsure regarding any of this advice then you should contact the UHL Safeguarding Children Team during office hours on x5770




4. Education and Training Training on this guidance is provided on the Safeguarding Children mandatory training modules within UHL. 5. Monitoring and Audit Criteria Please refer to section 8 of the Safeguarding Children Policies and Procedures document.




APPENDIX 3 Guideline to Obtaining Consent in Safeguarding Children Cases


1. Introduction It is good practice for those conducting child protection enquiries to secure consent for the child to be medically examined, treated or photographed. In the majority of cases this consent will be given by the parents or carers. 2. Scope This guideline is intended for use by all staff within UHL working in safeguarding children cases. 3. Guideline statements 3.1

Occasionally it will be necessary to gain consent by court order, or for the leading Paediatric Consultant to give assent for safeguarding procedures to take place. Any relevant documentation should be shown to the examining doctor.

3.2

A parent or carer’s refusal for a medical assessment should not be allowed to cause unnecessary delay. Legal advice should be sought urgently from the UHL Safeguarding Children Team (x5770) or the UHL Legal Affairs Team (x8960).

3.3

The welfare of the child is the paramount issue for UHL staff, and whilst the Trust must aim to work in collaboration with the parents/carers, the child’s needs will always be the primary consideration.

3.4

Some children under sixteen years old may be assessed by the Medical Practitioner to be Fraser Competent (also known as “Gillick Competent”) to give informed consent. Legal advice should nevertheless be sought if this is against the parent’s wishes.

3.5

Children must not be medically examined against their wishes unless the Medical Practitioner believes that there is a need for emergency medical treatment. In this instance the Consultant Paediatrician should be contacted as the first point of advice, and escalated to the Trust Legal Affairs Team (x8960) if required.




CHILD PROTECTION CONCERNS PRESENT

Request consent from the person with parental responsibility following discussion over concerns and actions required to address/ investigate these CONSENT GIVEN?

YES

NO

Is the child/ young person Gillick Competent?

Fully document within the clinical notes

YES

Continue with medical care

Clearly record assessment of competency CONSENT GIVEN? YES Continue with medical care

NO

NO

Seek legal advice: UHL Safeguarding Children Team x5770 UHL Legal Affairs x8960 Fully document outcome within the clinical notes

Only continue with medical care if a clear emergency medical need following discussion with the lead Consultant Paediatrician





APPENDIX 4 Completion of Medical Reports in Safeguarding Children Cases


1. Introduction These guidelines inform the UHL Paediatric Medical Staff of the internal process for compiling reports for safeguarding children cases. 2. Scope This guidance applies to Consultant Paediatricians and Paediatric Specialist Registrars who have been involved in a case where child protection concerns have been raised. 3. Guideline statements 3.1

A child protection medical report must be completed within five working days of child protection concerns being considered, irrespective of the final outcome of the case. The child must be assessed and the medical report completed by the Consultant Paediatrician or their nominated deputy, who must be a minimum of SpR level.

3.2 . 3.3

Digital dictation should be used, selecting “child protection team” as your recipient. Notify the Children’s Safeguarding Team on x5770 when you have sent a digital dictation giving the job number.

3.4

The report will be typed by the Safeguarding Team Medical Secretary and you will be notified using your UHL e-mail address when the report has been typed. It is then your responsibility to liaise with the Safeguarding Team Medical Secretary on x5770 or by e-mail regarding any alterations or amendments that are required.

3.5

Once approved by the SpR the report will be sent to the Lead Consultant for their approval. It is then their responsibility to liaise with the Safeguarding Team Medical Secretary on x5770 or via e-mail regarding any alterations or amendments that are required.

3.6

Once approval is received the report will be printed and left for the signature of both the SpR and the Consultant. Once completed notify the Safeguarding Team on x5770 that the report is complete and ready for collection.

3.7

The Safeguarding Children Team will then collect the report and ensure copies are sent to the relevant agencies and filed in the child/young person’s notes. A copy of the report will remain electronically on the child’s Safeguarding Electronics Notes System record in the Safeguarding Children Team

3.8

Arrangements will be put in place by the Safeguarding Children Team to cover the provision of secretarial support when the Safeguarding Team Medical Secretary is unavailable.

4. Education and Training Training on this guidance is provided on the Safeguarding Children mandatory training modules within UHL. 5. Monitoring and Audit Criteria Please refer to section 8 of the Safeguarding Children Policies and Procedures document. Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



APPENDIX 5 Guideline for Dealing with Disclosures and Avoiding Leading or Probing Questions in Safeguarding Children Cases


1. Introduction A disclosure about abuse from a child comes as a shock; you may not be expecting it and may feel you are not equipped with the time or skills to give this child the proper care. However the child has chosen you to confide in and you will want to do your best. A leading question is one which implies the answer or assumes facts which could be disputed. In safeguarding children cases, particularly child protection, it is important to avoid the use of leading or probing questions as this may have an impact on the information received and the future management of the case. This guideline is designed to direct your actions and is intended to assist staff in understanding how to avoid the use of leading or probing questions. All staff please note that relatives/friends of the child must not be used as an interpreter/translator. If translation services are required then the Service Equality Manager can be contacted. Please refer to the Trust Interpreting and Translation Guideline. 2. Scope This guideline is intended for use by all staff within UHL NHS Trust, in particular those staff who may come into contact with children in their role. 3. Guideline statements 3.1 Receive 3.1.1 3.1.2 3.1.3

Listen to what is being said, without displaying shock or disbelief. Accept what is said. Take notes.

3.2 Reassure 3.2.1 3.2.2 3.2.3 3.2.4

Reassure the child that they have done the right thing by telling you. Be honest and reliable. For example do not make any promises you may not be able to keep. Do not promise confidentiality; you have a duty to refer. Reassure and alleviate guilt if the child refers to it. For example you could say ‘you are not to blame’.

3.3 React 3.3.1 3.3.2 3.3.3 3.3.4 3.3.5

Once it has become clear the child and/or parent/carer has alleged that abuse has taken place, do not ‘interrogate’ for further details. Thank the child and/or parent/carer for disclosing the information although praise and congratulations should not be given. Do not ask leading questions (see 3.5). Do not ask open ended questions. Do not criticise the perpetrator, the child may love him/her and they may play an important part in the child’s life.




3.3.6

Explain what you have to do next and who you have to contact.

3.4 Record 3.4.1 3.4.2 3.4.3

3.4.4

Make some brief notes at the time and write them up as soon as possible. Do not destroy your original notes in case they are required as evidence. Record the date, time, place, any noticeable non-verbal behaviour, and the words used by the child. If the child uses sexual ‘pet’ words, record the actual words used rather than translating them. Record statements and observable things, rather than your interpretations or assumptions.

3.5 Leading Questions 3.5.1 3.5.2

3.5.3

Research indicates that a child’s answer to leading questions tends to be determined by the manner in which they are questioned rather than by valid remembering. Always remember a leading question could be challenged by an opposing counsel in court. A question must not a. contain a choice of answers b. name the suspected offender before the child has identified the person c. contain explicit details of the alleged offence d. contain any assumptions Examples of leading and non-leading questions

Leading Did it happen at your house? Did he/she tell you not to tell anyone? Were you sitting up or lying down? Was it your babysitter who touched you? Did they get you to touch them? What kind of car did you go in? I’m going to ask some questions about what happened to you.

Non-Leading Where did it happen? What was said to you? Where were you in the room? Who touched you? What did they do next? How did you get there? Do you know why you are here?

3.6 Summarise 3.6.1

3.6.2 3.6.3 3.6.4

The Senior Doctor/Paediatrician should check with the child and/or parent/carer that the evidentially important parts (if any) of the account have been correctly understood. This should be done using what the witness has communicated, not a summary provided by the interviewer. Care should be taken not to convey disbelief. The child and/or parent/carer should be thanked for their time and effort and asked ‘do they have any other information to share’. An explanation should be provided about what, if anything happens next, but no promises should be made about future developments. They should be asked if they have any further questions, and these answered as appropriately as possible.





APPENDIX 6 Procedure for Supervision of Patients in Safeguarding Children Cases


1. Introduction Following admission into hospital of children and young people there may be circumstances where Social Care deem it necessary for relatives and friends to be supervised in their contact with patients of UHL, over and above the minimum levels of supervision set by health in the monitoring of the child’s illness. 2. Scope All clinical areas within UHL. 3. Procedure statements 3.1 Supervision within the hospital setting is considered as the act of providing continual observation of interactions between the subjects to safeguard the child. At no point during supervision must the subjects be left unsupervised. UNDER NO CIRCUMSTANCES MUST UHL STAFF PROVIDE SUPERVISION This includes clinical areas where a child is nursed at a minimum one to one level. 3.2 Where Children’s Social Care assess that supervision is necessary it is vital that they advise the clinical staff of the names of the person(s) who are to provide the supervision. 3.3 This may include specific family members, foster carers or members of Social Care. This information must be recorded in the child’s medical notes and be shared with the core team caring for the child. 3.4 Monitoring by hospital staff is considered as the act of providing an overview of interactions between subjects over a set time period. This may include completing a parenting log of care carried out during the period of monitoring.

If you have any queries or concerns about this, please contact the UHL Safeguarding Children Team on x5770





APPENDIX 7

Guideline for the Management of Allegations of Sexual Abuse in Children and Young People

Safeguarding Children Team June 2016

1. Introduction The aim of this document is to guide members of nursing and medical staff working in the UHL Emergency Department and Children’s Admissions Unit, through the process of managing an allegation of sexual abuse of a child. This document will also guide staff members who do not work in those areas, regarding whom to contact if an allegation of sexual abuse of a child is made in their clinical area, thus ensuring the child receives efficient, effective and sensitive care and management from all staff involved. This guideline should be read in conjunction with the joint Leicester City and Leicestershire and Rutland LSCB procedures. 2. Legal Liability Guideline Statement Guidelines issued and approved by the Trust are considered to represent best practice. Staff may only exceptionally depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible healthcare professional’s it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes. 3. Scope This guideline is intended for use mainly by the Emergency Department and Children’s Hospital staff within UHL. Other clinical areas, in particular Midwifery and Paediatric Wards, may also find this document useful in guiding their practice. 4. The main body of the Guideline 4.1 Definition of Sexual Abuse Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children (Working Together to Safeguard Children 2015). Child sex abusers can come from any professional, racial or religious background, and can be male or female. They are not always adults; children and young people can also behave in a sexually abusive way. Often the abuser is a family member or someone known to the child, such as a family friend. Abusers may act alone or as part of an organised group. They sometimes prefer children of a particular age, sex, physical type or ethnic background. During and following the abuse, they may Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



put the child under great pressure not to tell anyone about it. They will go to great lengths to get close to children and win their trust, for example by choosing employment that brings them into contact with children, or by pretending to be children in internet chat rooms run for children and young people.

4.2 Signs of sexual abuse The signs of sexual abuse are not always apparent, are varied, and can often be linked with other forms of abuse. The following list is only a guide and cannot be relied upon to be exhaustive. Possible physical indicators • Difficulty in walking, sitting down • Stained clothing or blood on clothing • Pain or itching in the genital area • Bruising, bleeding, injury to the external genitalia, vaginal and/or anal areas • Vaginal discharge • Bed wetting • Pregnancy Possible behavioural indicators • Bizarre, sophisticated or inappropriate behaviour and knowledge • Promiscuity • Sudden changes in behaviour • Running away from home • Wary of adults • Feeling different from other children • Unusual avoidance of touch • Reporting of assault • Substance abuse • Emotional withdrawal through lack of trust in adults • Over-compliance with requests from others • Frequent complaints of unexplained abdominal pain • Eating disturbances • Poor peer relationships • Possessing money or ‘gifts’ that cannot be adequately accounted for.

4.3 ALL STAFF TAKE NOTE 

A history is required to establish information, but DO NOT ask leading or probing questions (see Appendix 5 Guideline to Dealing with Disclosures and Avoiding Leading Questions or Probing Questions in Safeguarding Children Cases)



A physical examination should take place to rule out any emergency health care requirements and the findings documented on body maps within the UHL Child Protection Examination Pack.



DO NOT carry out a sexual abuse examination on the child unless to provide emergency treatment.






Fully explain to the child and parent/carer the process of investigation and management (see Appendix Involving parents and carers in safeguarding cases).



Clear and concise documentation is vital.

If you require advice on dealing with a case then contact the Safeguarding Children Team office on x5770.

4.4 The Medical Examination a.

From October 2015 all CSA assessments for Leicester and Leicestershire children will be done at the local designated Sexual Assault Referral Centre (SARC) which currently is the Serenity Centre in Northampton. This is a relatively new service that has been commissioned by NHS England. Front-line practitioners may not be aware of this change and may contact UHL for advice.

b.

If Paediatric Registrars or members of the Paediatric Team are rung for advice about a child not at UHL, they should direct the enquirer, (e.g. GP, Health Visitor) to contact Social Care immediately. They should make it clear that the new pathway is not via UHL, or via the Community Paediatricians, as previously, but via Social Care to the dedicated SARC. If parents or carers bring an otherwise well child to UHL, or disclosure occurs within UHL, Social Care should be contacted by the Paediatric Team and the child managed as in step a. Examinations for CSA should not be done by untrained personnel.

c.

Children should only be managed as in-patients in UHL, if a disclosure or suspicion arises in a child already admitted, or if a child has genital (or other) injuries requiring emergency medical treatment, or they otherwise need emergency medical care that can only be provided in hospital.

d.

The child should be admitted under the Consultant Paediatrician on-call jointly with any specialist teams from whom input is needed. Further treatment should be co-ordinated within the hospital setting, including consideration of referral to other specialist teams, for example Gynaecology or Paediatric Surgery. The Paediatric Registrar or Consultant should assess the child according to the principles outlined above, and liaise with Social Care and Police (CAIU) regarding further care. See flow chart at end.

e.

At the time of writing this guideline, NHS England have not clarified the pathway for accessing a forensic medical examination on a child where sexual abuse is suspected and who needs urgent emergency hospitalisation or emergency surgery at LRI. The medical needs of the child are prioritised. If the child needs urgent surgery, the Police (CAIU or DI) should be contacted straight away to try and arrange for a forensic medical examiner to assess the child jointly with the surgeons in theatre, in order to secure as much evidence in a timely manner; but urgent treatment should not be delayed.

4.5 Follow-up Children from Leicestershire and Rutland will be followed-up for the purposes of post exposure prophylaxis (PEP) for HIV and infective hepatitis, by Dr. Bandi, Paediatric HIV Lead at LRI, so that families are offered follow-up as close to home as possible. Dr. Bandi may be contacted for advice, via switchboard, regarding post-exposure prophylaxis if an emergency presents out of hours, as this is a rare occurrence. In Dr Bandi’s absence, Dr Katja Doerholt, Paediatric Infectious Diseases Consultant at St George’s Hospital London, may be contacted via their switchboard (0208 672 1255) for advice in an emergency. If she and Dr Bandi are both not available, the Paediatric Infectious Diseases consultant at St George’s Hospital London will be happy to provide advice. All enquiries or referrals for suspected child sexual abuse must be directed to Social Care directly and children must be advised not to attend UHL unless emergency in-hospital treatment is needed Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



Child Sexual Abuse is suspected and the child is brought to UHL

NB If the young person is above 14 years and the assault is alleged to have been by a stranger, ED should contact Social Care and the Police directly. There is no need to admit to CAU unless medically indicated.

Emergency Department (ED) 1. Inform Senior ED Doctor (Dr) and Nurse in Charge. 2. Senior ED Dr to assess if any injuries present and refer to appropriate specialist teams as required. 3. Senior ED Dr to make initial referral to Social Care, 4. Commence UHL Safeguarding paperwork, document concerns and discussions. 4. Senior ED Dr to Inform Paediatric Consultant covering Children’s Admissions Unit (CAU). 5. Inform the UHL Safeguarding Team office on x 5770 6. Liaise with Nurse co-ordinator on CAU 7. Allocated Nurse to transfer child to CAU with a copy of the ED notes, the original Safeguarding paperwork and Form A. 8. Detailed handover to nursing staff.

Paediatric SpR 1. Inform Consultant 2. Obtain full medical history. Avoid leading questions. 3. Document findings on Safeguarding paperwork 4. Follow next flow chart

CAU Nurse 1. Obtain detailed handover from ED Nurse 2. Carry out nursing assessment 3. Chaperone and support the child 4. Ensure involvement of a Hospital Play Specialist 5. Continue Safeguarding paperwork




Child is on UHL Wards or transferred from ED when sexual abuse is suspected Paediatric SpR or Consultant informs Social Care City Children: 0116 454 1004 (24 hours) County Children: 0116 3050005 (24 hours) Rutland: 01572 758407 (out of hours 0116 3050005)

Immediate referral by Social Care to Police Child Abuse Investigation Unit (CAIU) and resulting strategy discussion with Paediatric Consultant covering CAU

Outcomes possible as below depending on whether the child needs to stay in hospital for emergency treatment

Well enough to be discharged?

Yes

No

Needs urgent surgery / examination

Needs an assessment for CSA

Yes Yes

Police and Social Care to arrange assessment

No Liaise with Police to arrange FME (forensic) assessment at LRI (for evidence)

No

Manage acute problem. Liaise with Police re: securing evidence

Discharge to place of safety as agreed jointly by Paediatrician, Social Care and Police 5. Education and Training Training on this guidance is provided on the Safeguarding Children mandatory training modules within UHL. 6. Monitoring and Audit Criteria Please refer to section 8 of the Safeguarding Children Policies and Procedures document.




APPENDIX 8 Guideline for the Management of Mental Health Issues and Deliberate Self Harm in Children and Young People


1. Introduction This guideline is designed to assist staff in ensuring that children and young people (up to their 18th birthday) who attend UHL with a mental health concern or deliberate self-harm are provided with the appropriate assessment and support. 2. Scope This guideline applies to all UHL staff who may encounter children and young people where there are concerns about their mental health. In particular, these guidelines are aimed at clinical staff in the Emergency Department (ED) and Children’s Hospital. 3. Guideline statements 3.1 What is Deliberate Self-Harm? Self-harm is when somebody damages or injures their body on purpose. The National Institute for Clinical Excellence (NICE, 2004) describes it as ‘self-poisoning, or injury, irrespective of the apparent purpose of the act’. Self-harm is not usually an attempt at committing suicide, but a way of expressing deep emotional feelings such as low self-esteem. It is also a way to cope with traumatic events, or situations, such as the death of a loved one, or an abusive relationship. Self-harm is not an illness, it is an expression of personal distress. There are many different ways people can intentionally harm themselves, such as: • • • • • •

cutting or burning their skin punching or hitting themselves poisoning themselves with tablets or toxic chemicals misusing alcohol or drugs deliberately starving themselves (anorexia nervosa) or binge eating (bulimia nervosa) excessively exercising (NHS Direct Wales, Accessed 25th August 2015)

Deliberate Self-Harm is a way of dealing with very difficult feelings that build up inside. People say different things about how they do it. •

Some say that they have been feeling desperate about a problem and don’t know where to turn for help. They feel trapped and helpless. Self-harm helps them to feel more in control.

•

Some people talk of feelings of anger or tension that get bottled up inside, until they feel like exploding. Self-harm helps to relieve the tension that they feel.

•

Feelings of guilt or shame may also become unbearable. Self-harm is a way of punishing oneself.

•

Some people try to cope with very upsetting experiences, such as trauma or abuse, by convincing themselves that the event(s) never happened. They say that they feel more




detached from the world and their bodies, and that self-harm is a way of feeling more connected and alive. •

A proportion of young people who self-harm do so because they feel so upset and overwhelmed by difficulties that they wish to end their lives by committing suicide. Often, the decision to attempt suicide is made quickly without thinking. At the time, many people just want their problems to disappear, and have no idea how to get help. They feel as if the only way out is to kill themselves.

3.2 Who is at risk? •

An episode of self-harm is most commonly triggered by an argument with a parent or close friend. When family life involves a lot of abuse, neglect or rejection, people are more likely to harm themselves. Young people who are depressed, or have an eating disorder, or other serious mental health problem are at greater risk. So are people who take illegal drugs or excessive amounts of alcohol.

•

Many young people self-harming with a wish to commit suicide also have mental health or personality difficulties; often the suicide attempt follows a stressful event in the young person’s life, but in other cases, the young person may not have shown any previous signs of difficulty.

•

Sometimes the young person is known to have long standing difficulties at school, home or with the Police. Some will already be seeing a Counsellor, Psychiatrist or Social Worker. There has been an increase in the suicide rate in young men over recent years. The risk of suicide is higher if the young person: o o o o o

Is depressed, or has a serious mental illness Is using drugs or alcohol when they are upset Has tried to kill themselves a number of times or has planned for a while about how to die without being saved Has a relative or friend who has tried or has killed themselves Discharged from a psychiatric unit within the last 7 days

3.3 All young people who attend hospital following an attempted suicide or after harming themselves must have a specialist mental health assessment prior to discharge. The aim is to discover the causes of the problem. It is often difficult to work out what prompted the young person to self-harm or whether they actually wished to commit suicide or not; mental health professionals have the expertise to make sense of these complicated situations. It is usual for parents or carers to be involved in the assessment and any treatment. This makes it easier to understand the background to what has happened, and to work out together whether help is needed. A lot of young people make another suicide attempt if they do not receive the help they need. 3.4 Processes to Follow Within UHL All professionals involved in the assessment and management of young people who self-harm, should ensure that good quality care is provided in a non-judgemental, confidential manner, respecting the young person and their family with a view to emotionally supporting recovery and treatment. At all stages, unhelpful critical comments can raise barriers to future help seeking and should be strictly avoided. (Recommendation 11, Royal College of Psychiatrists College Report CR192, Managing Self Harm in Young People, 2014)




The guidance on the following two pages has been divided into two distinct areas: a) Children and Young people up to the age of 16 years, and b) Young people aged 16 and 17 years. a) Children and Young people up to 16 Years This group of people will be seen in the Paediatric Emergency Department and the Children’s Admissions Unit. The flow chart below is designed to assist the clinical staff in these areas to ensure this group of patients are appropriately supported. Child/Young person up to 16 years attends Paediatric ED with mental health concerns

ED staff to check Alerts on NerveCentre in case further information is available and to follow “Frequent Attender Plan” if present

Carry out physical medical needs assessment e.g. bloods/assessment of injuries Medical staff may also find it useful to follow adult mental health checklist

Complete a Safeguarding A Form to notify UHL Safeguarding Children Team

If child/ YP known to CAMHS, ED staff may contact CAMHS directly to discuss this episode and establish the appropriate assessment route – this must be recorded in the ED notes

If child/ YP not known to CAMHS or requires clinical input, refer to Paediatric SpR on CAU for transfer for continuing medical assessment including mental health assessment CAU/Ward to notify CAMHS when child/young person is medically fit for mental health assessment

-Safeguarding A Form will be used to notify all agencies identified as involved with young person *Establish and record all agencies on A Form. *Referral to Social Care if:a) Repeated attempts, or b) Requested by family, or c) Additional information of concern/ meeting criteria d) Already known to Social Care – UHL Safeguarding Team will notify in office hours unless an immediate need to do so in which case the clinical area should contact the relevant Social Care immediately.

If Safeguarding Concerns are raised during any point of admission, the UHL Safeguarding Team and Social Care must be informed by the professional holding the information

Any information gathered in UHL to be shared with CAMHS on arrival Discharge planning may need to include: • Holding a Safeguarding Information Sharing Meeting (“SISM”) for multiple/escalating attendances or if known to Social Care • Follow up arrangements with CAMHS and other agencies • Approval from Social Care if known to them • Consideration of risk factors leading to initial admission, with onward referral if required


CAMHS to handover outcome of assessment to medical staff on Ward and document in notes including any following up arrangements

Ward staff to liaise with all involved agencies to plan discharge



b) Children and Young People aged 16 and 17 years This group of patients will be seen in the Adult Emergency Department, but legally (under the Children Act 1989) are defined as a child. The flow chart below is designed to guide clinical staff in the Adult Emergency Department and subsequent clinical inpatient areas, in managing this group of patients. Child/Young person 16 or 17 years attends Adult ED with mental health concerns

ED staff to check Alerts on NerveCentre in case further information is available and to follow “Frequent Attender Plan” if present

Carry out physical medical needs assessment e.g. bloods/assessment of injuries (Follow adult mental health checklist)

Complete a Safeguarding A Form to notify UHL Safeguarding Children Team

Transfer to Emergency Decisions Unit Discharge planning may need to include: • Holding a Safeguarding Information Sharing Meeting (“SISM”) for multiple/escalatin g attendances or if known to Social Care • Follow up arrangements with CAMHS and other agencies • Approval from Social Care if known to them • Consideration of risk factors leading to initial admission, with onward referral if required

Clinical Area to refer to adult duty Psychiatrist when child/young person is medically fit for mental health assessment Psychiatrist will determine if young person is to be seen by adult services or CAMHS dependent on any education service received by young person

Any information gathered in UHL to be shared with Mental Health Services on arrival

Mental Health Services to handover outcome of assessment to medical staff on Ward and document in notes including any following up arrangements

EDU/Ward staff to liaise with all involved agencies to plan discharge


-Safeguarding

A Form will be used to notify all agencies identified as involved with young person *Establish and record all agencies on A Form. *Referral to Social Care if:a) Repeated attempts, or b) Requested by family, or c) Additional information of concern/ meeting criteria d) already known to social care - UHL Safeguarding Team will notify in office hours unless an immediate need to do so in which case the clinical area should contact the relevant social care immediately.

• •

•

If already open to CAMHS, they will take the case. If in full time th education, (6 form college) will be seen by CAMHS If in a further education college, will be seen by adult

If Safeguarding Concerns are raised during any point of admission, the UHL safeguarding team and social care must be informed by the professional holding the







APPENDIX 9 Procedure for a Child Presenting with a Fracture and Responding to Safeguarding Children Concerns


1. Introduction This procedure aims to ensure staff in UHL can discharge their duties appropriately when they have safeguarding concerns about a child presenting with a fracture and safeguarding concerns are raised. 2. Scope The procedure applies to staff in UHL where a child comes to their attention and concerns are raised regarding the injury seen, compared with the history recorded. 3. Procedure statements 3.1 Where a child is present in UHL with a fracture 3.1.1 Consultant or SpR to review child, x-ray and history provided. Refer to Appendix 5 for details of questioning technique. 3.1.2 Document clearly, the history given, who is providing the history and your opinion of the injury. If your concerns remain 3.1.3 3.1.4

3.1.5 3.1.6

Notify the Paediatric Registrar on-call (via switch) and arrange for admission to the Children’s Assessment Unit. Inform the family of your concern about the injury and therefore the need to refer to the Paediatric Team for review, as per this UHL procedure. If you feel this may put the child at risk do not notify the family of your concern but ensure the Paediatric SpR is notified of this. Transfer child and family to the Children’s Assessment Unit with a full copy of the notes. Complete a Safeguarding Referral A Form

3.2 Where child is not present in UHL and concerns have been raised, e.g. post x-ray review 3.2.1 3.2.2 3.2.3

3.2.4 3.2.5

Notify the Orthopaedic Consultant or SpR of your concern. The Orthopaedic Consultant/SpR to review information available. Contact family to arrange attendance at Fracture Clinic as soon as possible. The family should be advised that due to concerns regarding the fracture the child needs to be reviewed. If child will return out of Fracture Clinic hours contact the Paediatric SpR (via switch) to arrange attendance to the Children’s Admissions Unit or Ward 11 for review. If child does not attend their appointment that you arrange with them please follow Appendix 13 Procedure for Children who Do Not Attend (DNA) Hospital Appointments.

If child returns to Fracture Clinic Follow steps 3.1.1 to 3.1.5 4. Education and Training Training on this guidance is provided on the Safeguarding Children mandatory training modules within UHL. 5. Monitoring and Audit Criteria Please refer to section 8 of the Safeguarding Children Policies and Procedures document. Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



APPENDIX 10 Guideline for Providing Written and Verbal Statements to the Police in Safeguarding Childrens Cases


1. Introduction All staff in UHL have a duty to co-operate with external agencies in the investigation of suspected child protection and child in need cases, under Section 11 Children Act 2004. In some instances it may be necessary to provide statements to these agencies. This guidance aims to support staff in this process. 2. Scope This guideline applies to all staff working within UHL. 3. Guideline statements 3.1 Principles: 3.1.1 All health professional staff have a responsibility to protect children. 3.1.2 All staff are accountable for their conduct to their professional bodies. 3.1.3 When making a verbal or written statement, staff are acting on behalf of the University Hospitals of Leicester NHS Trust. 3.1.4 Multi-agency working is essential to safeguard the well-being of children, and as such health professionals have an obligation, under Section11 of the Children Act 2004 to assist the Police with their child protection enquiries. 3.1.5 Information provided should only be facts. Opinions should not be provided except in medical diagnoses where appropriate. 3.1.6 Non-medical staff must not provide statements about medical decisions and treatments. 3.2 Giving Statements If staff are contacted directly by the requesting agency (usually the Police) to arrange to give a statement in relation to a safeguarding case, the following must occur. 3.2.1 The requesting agency should be directed to the Safeguarding Children Team (x5770), who will arrange a suitable date, time and venue for the statement to take place. 3.2.2 All UHL staff will be supported in any case by a member of senior staff. This should be either a senior member of the Safeguarding Children Team, or a senior Division/CBU staff member if appropriate. 3.2.3 Junior medical staff must have the permission of their Consultant before they are interviewed. Members of the Safeguarding Children Team are available to support medical staff if required. 3.2.4 The Safeguarding Children Team will ensure that the member of staff has the medical notes available when the statement is provided. Statements should not be provided without reference to the appropriate UHL notes.




3.2.5 Following a verbal statement, the Police will prepare a written statement. This should be read by the member of staff and signed after necessary amendments have been made. 3.2.6 A copy of the statement will be taken and stored securely by the Safeguarding Children Team on their Safeguarding Electronic Notes System (“SENS”) 4. Education and Training Training on this guidance is provided on the Safeguarding Children mandatory training modules within UHL. 5. Monitoring and Audit Criteria Please refer to section 8 of the Safeguarding Children Policies and Procedures document.




APPENDIX 11 Procedure for Requesting a Second Opinion in Safeguarding Children Cases for Independent Review if Concerns Remain


1. Introduction There may be occasions where a Doctor/Consultant/Paediatrician feels that a member of staff is unduly worrying about a safeguarding case and that no action is necessary (i.e. a referral to the appropriate agency is not required). In those instances where a staff member continues to have concerns he/she is entitled to request a second opinion. 2. Scope This procedure applies to all clinical staff working within UHL. 3. Procedure statements 3.1

In all cases where child protection or child in need concerns are raised the Safeguarding Referral A Form must be commenced, and the Safeguarding Children Team notified on x5770.

3.2

In cases where a staff member feels a concern is not being addressed then their immediate line manager should be notified to seek local resolution. If this cannot occur then the following guidance should be followed. 3.2.1

Where disagreement occurs, the Consultant Paediatrician on-call must be contacted to provide a second opinion.

3.2.2

In the event of continued unresolved differences of professional views, then the case should be referred to the Named Doctor or Named Nurse for Safeguarding in UHL on x5770.

3.2.3

The Local Safeguarding Children Board procedures, Resolving Professional Differences describes in further detail the process for resolving a professional dispute and should be followed.


.




APPENDIX 12 Guideline for the Emergency DepartmentChildren Accompanying Adult Patients Who Require a Hospital Admission


1. Introduction The following guideline is intended to guide UHL Emergency Department staff in managing cases where an adult patient requires admission and there is a need to ensure the accompanying child is cared for appropriately. 2. Scope This guideline is designed for use within the Emergency Department of UHL. general principles may be utilised by staff in any clinical area of the Trust.

However, the

3. Guideline statements 3.1 The following questions are provided as a guide for clinical staff to follow when assessing the child and adult in the department (this list is not exhaustive) Q1. Does the adult patient have parental responsibility (PR) for the child? If not, find out who does and contact them to care for the child, as defined in appendix 1. Q2. If the adult patient does have PR it is their responsibility to make arrangements for the child’s care, and where not physically able to do this, UHL staff should assist them. Q3. Does the patient need to be admitted or can they return as an elective patient? Q4. Is the patient able to provide you with a contact who could care for the child? Consider: • • •

The age of the child Gillick competence The social network of the adult (the adult should suggest anybody they would be happy to care for the child i.e. grandparents, relatives, neighbours, friends, parents of school friends)

Q5. Is the child in danger whilst in the department? Consider: • • •

The location of the child The ability of the adult to care for them The risk from others within the department

3.2 If the parent is unable to source a carer, involve the ED Nurse in Charge, Doctor in Charge and Social Care as early as possible. NB out of hours emergency foster care is unlikely to be available as an option but Social Care may know of other family members 3.3 Where the adult is able to provide an address but no contact telephone numbers, the Police may be contacted (via 0116 222 2222) to request they attend the address and contact the potential carers. 3.4 If the child has been in the ED more than 3 hours, place them on the Children’s Assessment Unit bed list and inform the Paediatric SpR, so that the child is in a more appropriate environment Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



while a solution is found; under no circumstances should the child be placed on the Emergency Decisions Unit, even with the parent, as this is a very high risk environment for children. At any stage where difficulties arise, the ED Consultant in Charge and Paediatric Consultant should be notified. The UHL Safeguarding Children Team must be notified using Safeguarding Referral A Form of the actions taken in all cases, regardless of the outcome. If at any time, there are concerns about the safety of the child, UHL child protection processes must be followed. 4. Education and Training Training on this guidance is provided on the Safeguarding Children mandatory training modules within UHL. 5. Monitoring and Audit Criteria Please refer to section 8 of the Safeguarding Children Policies and Procedures document.




APPENDIX 13 Procedure for Children Who Do Not Attend (DNA) Hospital Appointments


1. Introduction The aim of this procedure is to support clinical staff in the management of children who do not attend hospital outpatient appointments. It is recognised that hundreds of children miss appointments at hospital and clinic settings and are not available at home to be seen by health staff. Parents/carers have a responsibility to ensure children receive health care, but not all parents have the capacity to facilitate this. Whilst the NHS has good appointment systems in place, many systems do not recognise the organisational duty to safeguard children and promote the welfare of children as set out in the National Service Framework for Children, Young People and Maternity Services (2003-04), Working Together to Safeguard Children (2010), Section 11 of The Children Act (2004) and Public Protection Act (2006). Many Serious Case Reviews and Domestic Homicide Reviews, both nationally and regionally have featured children who do not attend hospital appointments as a precursor to serious child abuse and child death. 2. Scope This procedure applies to all staff in UHL who see children as patients through an appointment or booking system. 3. Procedure statements The following principles should be followed in all cases 3.1 Assessment • • • •

Following non-attendance at a hospital appointment with no cancellation by the family, the responsibility for any assessment of the situation rests with the practitioner to whom the child has been referred in conjunction with the referrer (Laming 2003) Consider the needs of child and parents/carers capacity to meet those needs Consider environmental context of the child’s situation Identify whether intervention is required to secure a child’s welfare, whether the patient is a child, young person or parent/carer

3.2 Communication • • •

Any verbal or written communication with the parents/referrer needs to outline the consequence of non-attendance at the appointment for the child. Where there are clear child protection concerns, discuss with the UHL Safeguarding Children Team on x5770 Where there are concerns relating to children, information should be shared with the UHL Safeguarding Children Team (x5770) or other members of the Health Care Team working with the family who can add to the information sharing process




3.3 Record keeping • •

The content of discussions should be clearly documented along with any actions and outcomes in the child or parent/carer record Analysis and conclusion should also be documented ensuring that any referral letters and context of previous records have been considered.

3.4 Action Patients who do not attend their appointment should be managed in accordance with the UHL Access Policy for Elective Patient Care:. “If patients DNA their appointment or admission once, the Trust policy is to discharge patients back to their referrer. All such patients’ notes must be clinically reviewed prior to discharge.” “All vulnerable patients will be followed up” UHL Access Policy for Elective Patient Care Accessed 2nd December 2015 The Children’s Hospital provides a “partial booking system”. As such, the following action should be taken •

New Patients: The patient/relative will be asked to contact the hospital to make a mutually agreed appointment time once their referral letter is received. If the patient fails to contact the hospital, the referral letter will be reviewed by the Consultant. Should no further appointments be required within UHL, a letter will be sent to the referrer advising them of this.

•

Re-attending Patients: The flowchart below is intended to be a guide for clinical staff when a known child fails to attend a follow-up appointment. All reviews should take into consideration the points as above.




Guide to Management of re-attending Children who Do Not Attend (“DNA”) an Appointment Child fails to attend outpatient appointment

Consultant or nominated deputy to assess and clearly document risk to child of non-attendance

Is another appointment required?

Refer back to original referrer. Copy family into letter

No

Yes – set new appointment

Is there an identified safeguarding risk if child does not attend? (Discuss with UHL Safeguarding Children Team (SCT) for advice if required, x5770) Yes

No

- Notify UHL SCT of • Appointment date, time venue • Reason for appointment and risk of non-attendance • Child’s full details including GP (& School if >4 years)

Notify child/carers of appointment through usual clinic system

UHL SCT will: - notify community contact to request home visit to family to:a. check appointment time/date is possible for family b. ensure family understand need for appointment, risks to child & action if non-attends

Child does not attend: - Notify UHL SCT who will: - refer to Social Care - notify HV &/or SN


Child attends – no further action Notify UHL SCT for record completion







APPENDIX 14 Guideline for the Provision of Data to External Agencies in Safeguarding Children Cases


1. Introduction These guidelines describe the process to be followed when a member of an external agency requests data held by UHL in relation to a safeguarding child case. 2. Scope This guideline applies to all UHL staff, and will have implications for external agencies requesting information. These agencies will predominantly include Children’s Social Care and the Police. 3. Guideline statements Safeguarding children enquiries fall into two main sections of the Children Act 1989; Section 17 and Section 47. Enquiries under Section 17 of The Children Act, 1989 Section 17 of The Children Act, 1989, deals with children described as being ‘in need’. Under Section 17, work is carried out in partnership with the child/young person and family. In such cases consent must always be obtained from the child or parent before it can be shared. In such cases therefore UHL will require the consent of the child or appropriate family member to share the data requested. •

Data should not be shared without the consent of the child or appropriate family member.

•

Child or appropriate family member consenting to a LSCB Multi-Agency Referral to Children’s Social Care Form being completed and referral made to Social Care may be considered consent to sharing relevant information.

•

Consent is not required to share information with other health partners.

•

Is the request appropriate or is there an alternative method of providing the information.

•

If in doubt seek advice from the o Named Nurse for Safeguarding Children, UHL (x5770) o Manager, Access to Health Records, UHL (x5192) o Data Protection Manager, UHL (x6053)

•

Information that is not relevant to the safeguarding issue should not be released

Enquiries under Section 47 of The Children Act, 1989 Section 47 of The Children Act, 1989, deals with children described as being ‘in need of protection’. In such cases all agencies must act in the best interests of the child, and in doing so, should share relevant information to enable agencies to act in a way to safeguard the child. A flowchart has been compiled to guide both staff within UHL and those from external agencies in the processes that will be employed for the issuing of data by UHL in cases relating to safeguarding children. In addition, guidance for the UHL Safeguarding Children Team has been compiled, which aims to support their decision making when reviewing a request for data disclosure. Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



Key questions to ask when reviewing a request for information •

Who/which agency is requesting the information?

•

What purpose will the release of notes achieve? For example to aid the Police in an investigation or for Social Care to carry out an assessment under Section 47.

•

Is the request appropriate or is there an alternative method of providing the information? For example the Safeguarding Children Team providing a summary of health admissions as oppose to releasing the full medical information.

•

If in doubt seek advice from the o Named Nurse for Safeguarding Children, UHL (x5770) o Manager, Access to Health Records, UHL (x5192) o Data Protection Manager, UHL (x6053)

•

Information that is not relevant to the safeguarding issue should not be released. For example, if Social Care request confirmation an adult attended the Emergency Department with deliberate self-harm and that adult also attended with a Gynaecology issue, the Gynaecology issue should not be disclosed. Only the details of the deliberate self-harm should be disclosed.

Note: In some cases external agencies may request information under Section 29 of the Data Protection Act. Where this is stated the request should be passed to the Access to Health Team and not managed by the Safeguarding Children Team.




Enquiry from outside agency for UHL data relating to Safeguarding Children

Completion of Safeguarding Information Release request form

Form received by UHL Safeguarding Team

Named Nurse for Safeguarding or nominated deputy filters form using guidelines

Appropriate for release of information

Not appropriate to release information

Child not an inpatient of UHL

Child an inpatient with UHL

UHL Safeguarding Team liaise with requesting agency to advise of decision

Complete approval on form and forward to Access to Health Records (AtHR)

UHL Safeguarding Team copy data, record on request form and in patient notes

Establish if alternative arrangements can be made

AtHR will copy appropriate notes and share with requesting agency

Copy of form sent to Access to Health Records (AtHR) for their records

Record of notes provided to agency held by AtHR, copy of request held by Safeguarding Team

Record of notes provided held by AtHR and record of request held by Safeguarding Team




University Hospitals of Leicester NHS Trust Request for Release of Data by an Outside Agency Where there are Safeguarding Children Concerns When completed, fax to: University Hospitals of Leicester NHS Trust Safeguarding Agency Requesting Information Name of Requester & Role: (person completing form) Agency: Base Address: Contact Numbers: Tel:

Fax (secure haven only):

Date Information Requested from UHL:

Date Information Required By:

Information Required: Name of Subject (include any other names they may be known by) Address: Hospital or NHS Number:

Date of Birth:

Date of attendance at UHL: Reason for Request:

Clinical Area attended:

□

□

Children Act (1989): Section 17 Enquiry S47 enquiry Details:…………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………………. Data Being Requested: (please tick all those required)

□ Radiology Films (eg xrays): Please state:…………………………………………………………. □Photographs: Please state date taken:……………………………………………………………… □Main Hospital Records □ Orthopaedic Notes □ Fracture Clinic Notes □Emergency Dept Notes □ Maternity Notes □ Other (please state):……………………….. UHL Safeguarding Team Use: Date received:……………………………………Reviewed By:………………………………………...

□

□

Decision: Approved Not Approved Reason:……………………………………………. ……………………………………………………………………………………………………………….. Action: (e.g. inpatient= provision of notes/not an inpatient = passed to access to health records for action):……………… ……………………………………………………………………………………………………………………. . ……………………………………………………………………………………………………………………. . Children Team OfficeTelephone: 0116 258 5770 Secure Haven Fax: 0116 258 6701








APPENDIX 15 Guideline for holding Safeguarding Information Sharing Meetings


1. Introduction These guidelines describe the process to be followed when a child protection have been raised regarding a patient in University Hospitals of Leicester NHS Trust 2. Scope This guideline applies to all UHL staff, and will have implications for external agencies who are requested to attend the meetings. 3. Guideline statements Safeguarding children enquiries fall into two main sections of the Children Act 1989; Section 17 and Section 47. Enquiries under Section 47 of the Children Act, 1989 Section 47 of The Children Act, 1989, deals with children described as being ‘in need of protection’. In such cases all agencies must act in the best interests of the child, and in doing so, should share relevant information to enable agencies to act in a way to safeguard the child. In order to facilitate information sharing with other agencies, the UHL Safeguarding Children Team will call a Safeguarding Information Sharing Meeting (“SISM”) for all children aged under 2 years where child protection concerns have been raised. Consideration will also be given to holding a SISM for children over 2 years, on a case-by-case basis. The purpose of the SISM is to ensure that all information about the child/family is shared with Social Care and the Police to inform their enquiries, and for the hospital to be updated on the enquiries to ensure they carry out their duty to safely discharge the child. This meeting provides an arena for questions to be asked of the medical investigations and for opinions to be given where appropriate The meeting must not take the place of a strategy discussion or meeting, if information comes to light in the meeting that affects the investigation, the SISM will be stopped and a strategy meeting convened, in line with Local Safeguarding Children Board procedures for Leicester, Leicestershire and Rutland. Discharge arrangements for the child are the responsibility of Social Care as the lead investigating agency. UHL will provide all relevant information to Social Care to assist them in this decision making and ensure the role of the Consultant Paediatrician to safely discharge the child is carried out. The meeting will also confirm any further medical contacts that are required. Minutes of the meeting will be taken by the Safeguarding Team and copies sent to all those present and those who sent apologies 4. Education and Training Training on this guidance is provided on the Safeguarding Children mandatory training modules within UHL. 5. Monitoring and Audit Criteria Please refer to section 8 of the Safeguarding Children Policies and Procedures document. Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



APPENDIX 16

Guideline for obtaining photographic evidence in child protection cases


1. Introduction These guidelines describe the process to be followed by staff in University Hospitals of Leicester NHS Trust when photographic evidence is required to record an injury / mark on a child that is believed to be non-accidental. 2. Scope This guideline applies to all staff working with University Hospitals of Leicester NHS Trust 3. The main body of the Guideline Where a child attends University Hospitals of Leicester NHS Trust and child protection enquiries are commenced the UHL Child Protection (“RED”) cases process must be followed and the child must be admitted to the Children’s Hospital for review by the Paediatric Team. Where child protection concerns are initiated, consideration must be given to the need to obtain photographic evidence of any marks or injuries noted on the child. Appendix 3 of these procedures, “A guide to obtaining consent in safeguarding cases” should be followed. The flowchart below is intended to guide staff in obtaining photographs of the marks while the child remains an inpatient.




Photographs must only be taken by Medical Illustrations or the Police. Staff must NOT take photographs themselves

NB in child protection cases, if family will not consent, Paediatric Consultant can override this by acting in best interests of the child and completing the consent form It must be clearly indicated on the back of the bottom copy of the consent form that the Consultant authorises the Clinical Photographer to proceed without parental consent.

Child/Young Person attends with physical marks where Non Accidental Injury (NAI) is being considered (Trust child protection process must be followed) Photographs of marks must be taken as soon as possible to provide photographic evidence of the marks

In office hours  

Out of office hours 

Contact Medical Illustrations Request person with parental responsibility completes medical illustrations consent form

  USEFUL CONTACT NUMBERS UHL Safeguarding Children Team: Office: 0116 258 5770 Safe Haven Fax: 0116 258 6701 Medical Illustration: Main Reception:



0116 258 6369


Medical Illustrations do not have an on-call service but will accommodate reasonable requests relating to child protection where possible. Contact Medical Illustrations via switchboard. If Medical Illustrations are not available, the Paediatric Consultant or Nominated Deputy should liaise with the attending Police Officers to request a Scenes of Crime Officer take the photographs. Copies of these photographs will be made available to UHL by the Police on request







APPENDIX 17 Guideline for managing cases of adults attending suffering from mental health issues


1. Introduction These guidelines describe the process to be followed in University Hospitals of Leicester NHS Trust when an adult attends with mental health issues and they are known or believed to have contact with a child/ children. 2. Scope This guideline applies to all staff working with University Hospitals of Leicester NHS Trust 3. The main body of the Guideline The majority of parents who suffer mental ill-health are able to care for and safeguard their children and/or unborn child. Some parents, however, will be unable to meet the needs and ensure the safety of their children. The mental health of a parent or carer does not necessarily have an adverse impact on a child but it is essential to assess the implications for the child. To determine how a parent/carer’s mental problem may impact on their parenting ability and the child’s development the following questions need to be considered within an assessment: •

Does the child take on roles and responsibilities within the home that are inappropriate?

•

Does the parent/carer neglect their own and their child’s physical and emotional needs?

•

Does the mental health problem result in chaotic structures within the home with regard to meal and bedtimes, etc?

•

Does the parent/carer’s mental health have implications for the child within school, attending health appointments etc?

•

Is there a lack of the recognition of safety for the child?

•

Does the parent/carer have an appropriate understanding of their mental health problem and its impact on their parenting capacity and on their child?

•

Are there repeated incidents of hospitalisation for the parent/carer or other occasions of separation from the child?

•

Does the parent/carer misuse alcohol or other substances?

•

Does the parent/carer feel the child is responsible in some way for their mental health problem?

•

Is the child included within any delusions of the parent/carer?

•

Does the parent/carer’s mental health problem result in them rejecting or being unavailable to the child?

•

Does the child witness acts of violence or is the child subject to violence?

•

Does the wider family understand the mental health problem of the parent/carer, and the impact of this on the parent/carer’s ability to meet the child’s needs?

•

Is the wider family able and willing to support the parent/carer so that the child’s needs are met?

•

Does culture, ethnicity, religion or any other factor relating to the family have implications on their understanding of mental health problems and the potential impact on the child?

•

How the family functions, including conflict, potential family break up etc.




Adult attends ED with mental health issues

Children known or reported to be in contact with the adult

Is the child in a “safe place” i.e. in care of a family member/friend. Full details of this person needed & verify this information

YES

NO

1. Complete A form for welfare with patient details & details of all children including names, DOB & where appropriate school. 2. Notify adult (when appropriate) of referral to Social Services for support. Social Care will not accept a referral where there are no immediate child protection concerns about a child without the adult being aware and recorded on the A form 3. Notify Safeguarding Team with message on 5770 & fax form (6701) for NB – where children are accompanying adult patient complete Form A & refer to Children Accompanying Adults guidance (appendix 12)

Where are they?

1. Notify Social Services: Leicester City: 0116 4541004 (24hrs)

Leicestershire: 0116 3050005 (24hrs)

Rutland : 01572 758 407 (office hours only, call Leicestershire outside of office hours) 2. Utilise Police if necessary to locate children 3. Form A must be commenced & faxed to Social Services & Safeguarding Team within 24 hours of referral





APPENDIX 18 Guideline for Managing the Safeguarding Children Safeguarding Children Team September 2015

concerns where an adult reports domestic abuse

1. Introduction These guidelines describe the process to be followed in University Hospitals of Leicester NHS Trust when an adult reports domestic abuse and they are known or believed to have contact with a child/ children. 2. Scope This guideline applies to all staff working with University Hospitals of Leicester NHS Trust 3. The main body of the Guideline As from March 2013, the term ‘domestic violence and abuse’ should be used. The Government’s definition of domestic violence and abuse has been widened to include those aged 16-17 and now includes coercive control. The revised definition is: Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: Psychological; Physical; Sexual; Financial; Emotional. Where there is domestic violence, the wellbeing of the children in the household must be promoted and all assessments must consider the need to safeguard the children, including unborn children. Prolonged or regular exposure to domestic violence can have a serious impact on a child's physical, emotional and educational development and well-being, despite the best efforts of the victim(s) to protect the child. The impact is more likely to be exacerbated when the abuse takes place in families where there is substance misuse, mental ill health problems, personality disorders and any combination of these.




The following flowchart is designed to assist in following the appropriate process: Adult reports an incident of domestic abuse

YES

Establish if there are children known to be within the family

Is there any concern they could have been physically harmed?

YES

1. If child is within UHL book into Paediatric ED as patient

NO

Adult patient – treat for injuries

NO

Are they in safe place now (i.e. with family/friend identified by patient)

Offer: - domestic violence support group details

NO SpR to review child/children to establish if any injuries

Complete A form (informing adult)

No injuries Establish a safe place i.e. with family/friend identified by patient) Injuries seen: Follow the child protection process

YES

Complete A form with patient details – name, DOB, (school where appropriate) of all children, stating where placed at time of patient admission

Notify the UHL Safeguarding Children Team Leave message on x5770 Safeguarding Team answer phone (name, DOB of victim), fax Form A to x6701


Establish where children are.

If immediate concerns re: safety, contact Police to request they attend address where child is

If in A&E with patient to be admitted refer to children accompanying adult patient guidance in appendix 12







APPENDIX 19 Guideline for Managing Paediatric Patients who Safeguarding Children Team September 2015

Leave Hospital prior to medical discharge

1. Introduction These guidelines describe the process to be followed in University Hospitals of Leicester NHS Trust when a child leaves hospital prior to medical discharge, with or without their carer. This includes children who “abscond” from a department. 2. Scope This guideline applies to all staff working with University Hospitals of Leicester NHS Trust 3. The main body of the Guideline On occasion a child may leave the hospital prior to being clinically discharged. This may be a young child with a parent or carer, or an older child on their own. It is important to establish whether there are safeguarding or medical concerns regarding their departure. The following flowchart should be followed by staff in paediatric clinical areas to guide them in the management of such cases: Child leaves the clinical area without being clinically discharged Clinical staff to clearly record in the child’s notes, the clinical needs of the child and whether they require ongoing treatment, and the risk to them if they do not return If there is no clinical need to return, inform the person with parental responsibility of this, and advise of the actions to take if a clinical need arises Document this in the notes Notify the GP by recording this in the discharge letter (NerveCentre or ICE)

Attempt to contact the child or carer as appropriate

If there is a clinical need to return, inform the person with parental responsibility of this, and request they return immediately. If required, advise if they do not return the Police will need to be contacted.

If unable to contact the person with Parental Responsibility or they do not return, notify the Police and Social Care, Complete an A Form and notify UHL Safeguarding Children Team on x5770, faxing the form to x6701








APPENDIX 20




APPENDIX 21 UHL Safeguarding Children Team Traffic Light System Guidance for Referrals The Traffic Light system can be summarised as follows: a) RED - Child Protection Concerns: Under the Thresholds for Access to Services Document, these would be considered Specialist Services (high risk) working alongside universal and targeted services to meet the complex and/or multiple needs of vulnerable children. This would include: • Statutory services • Section 47/ Child Protection/ Looked After • Youth Offending • Under the NHS Early Help Framework the Universal Partnership Plus level applies b) AMBER - Child Safeguarding Concerns and Early Help: Under the Thresholds for Access to Services Document, these would be considered Targeted Services (medium risk) working alongside universal services to meet the complex and/or multiple needs of vulnerable children. This would include: • Specialist assessment may be required • Children in Need (Section 17) assessment • Panels under the “Troubled Families” Programme • Under the NHS Early Help Framework, the Community and/or Universal Plus levels apply c) GREEN - Information Only: Under the Thresholds for Access to Services Document, these may include Early Help (low risk) working alongside universal services to meet a single additional need it several additional needs. This would include: • Early Help • Lead Professional required • Team Around the Child • Under the NHS Early Help Framework the Universal Plus level applies Under this level, UHL staff can also refer children and families for Information Only. This would include: • Children who have an allocated Social Worker where there are no concerns regarding the reason for attendance at the hospital • Children aged under 2 years who have attended with a burn, scald or fracture where safeguarding concerns have been considered and ruled out during attendance d) BLUE - Liaison Support: These cases fall below the safeguarding processes for multi-agency working and instead focus on good information sharing practices with health colleagues outside of UHL. Under this level, this would include: • Where the child/ family do not have an allocated Social Worker Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



• • • • • • •

There are no concerns regarding the reason for admission Any child who has been admitted to PICU/ CICU Any child admitted from out of area Any child that meets the criteria for an Emergency Department Community Liaison Form Any child of school age not in education Any child not registered with a GP Any child who has been an in-patient for 3 days or longer

e) PURPLE- child death processes: These cases fall under the requirement in Working Together to Safeguard Children 2004 to carry out Child Death Overview Processes (“CDOP”). The UHL Safeguarding Children Team work with the CDOP by collating information and supporting clinical staff following the death of a child. Under this level, referrals would include: • All child deaths within UHL • Where a child is brought in to hospital in arrest – unexpected / suspicious • Where a child attends hospital with an illness such as meningitis and dies a few days later - unexpected • Where a child has a known condition with poor prognosis and palliative care is provided - expected • Where a baby is born as a registerable live birth but dies shortly after birth expected / unexpected




RED – Immediate Protection Concerns Examples of types of ‘red’ cases: • • • • • • •

The child is deemed to be at immediate risk as is thought to have suffered abuse, either physical, sexual, emotional or neglect A child under 2yrs who has suffered a significant injury for which there is no clear acceptable explanation A non-mobile child who has an unexplained injury, marks or bruising Where the child is deemed to be at immediate risk of harm because their parent/guardian is displaying behaviour or has a history of concern that would affect their ability to care for the child Domestic violence where the child was present and may be injured Pregnant women using illicit substances who are deemed by their actions to be putting the child at risk The death of any child from birth to 18 years (excluding stillbirths), including expected deaths

Actions for UHL Staff: • • • • • • • • •

Complete A Form Commence the Child Protection Checklist Inform the family of your concern (unless to do so would put the child at risk) and advise them of the Safeguarding processes, providing them with the Guide to Child Protection Investigations Leaflet, if appropriate Refer to the Paediatric SpR on Children’s Assessment Unit if a medical is required, and NAI Paperwork pack is commenced DOCUMENTS ALL CONVERSATIONS AND OBSERVATIONS Ensure body maps are completed of any marks and injuries using the Child Protection Medical Examination Pack Make immediate referral to social services Follow appropriate UHL Safeguarding Children Team Procedure (available on INsite) Notify UHL Safeguarding Children Team on ext 5770

Actions for UHL Safeguarding Team: • • • • • •

Liaison with social services and police on behalf of clinical area Arrangement and chairing of safe discharge planning meeting where appropriate Typing of medical reports and provision to appropriate outside agencies Supervision of UHL staff in managing the case Notification to health visitor/ school nurse/ midwife and collation of previous information Review of previous health records held within UHL

DO NOT DISCHARGE THE CHILD WITHOUT THE APPROVAL OF THE POLICE, SOCIAL CARE AND THE UHL SAFEGUARDING TEAM




AMBER – Welfare Concerns Examples of types of ‘amber’ cases: • • • • • • •

An adult with mental health issues where the child is deemed to be in an appropriate safe place with an alternative carer at the time of admission A child with mental health issues Families where a child has complex needs and further support may be required Domestic violence cases where the child was not present and is currently in a safe place Pregnant women using illicit substances who are complying with their treatment programme Parents requesting support in coping with their child’s care Children attending UHL where their parents are unwilling to take their child home

Actions for UHL Staff: • • • •

Gain consent from the child/ person with parental responsibility to make referral Complete an A Form IN OFFICE HOURS: notify the appropriate social work team of your concern (contact numbers on the A form), and notify the UHL Safeguarding team (x5770), faxing the A form to both OUT OF OFFICE HOURS: leave a message for the UHL Safeguarding Team (x5770) and advise of the patient’s on going care plan or discharge arrangements

Actions for UHL Safeguarding Team: • •

Assess the A form within the working day of receipt to assess actions to take Actions may include: liaison with social care and/ or police; Notification to Health visitor/ school nurse/ midwife of concerns raised and actions taken, and collation of their information • Provide supervision and support to clinical staff in managing case • Feedback action taken to person completing A form if they are to have ongoing contact




GREEN – Information Only Examples of Types of ‘Green’ Cases • • •

Where there are no concerns which meet RED or AMBER level A child/ family who are allocated to a social worker where there are no concerns about the reason for admission Where a child is “Looked After” ie living in local authority care or in foster care but there are no concerns about the reason for admission

Actions for UHL Staff: • • •

Complete an A Form IN OFFICE HOURS: notify the appropriate social worker and UHL Safeguarding Team (x5770), faxing Form A to them to confirm information OUT OF OFFICE HOURS: notify the UHL Safeguarding Team (x5770) via answerphone, advising whether the patient is to be admitted or discharged

Actions for UHL Safeguarding Team: • •

Ensure allocated social worker has been notified of the attendance Notify the health visitor/ school nurse/ midwife to advise them of the attendance




BLUE – Liaison Cases Examples of Types of ‘Blue’ Cases • • • • • • •

Where the child/ family do not have an allocated social worker There are no concerns regarding the reason for admission Any child who has been admitted to PICU/ CICU Any child admitted from out of area Any child that meets the criteria for an Emergency Department Community Liaison Form Any child of school age not in education Any child not registered with a GP

•

Any child who has been an in-patient for 3 days or longer

Actions for UHL Staff: • • • • • •

Gain consent from the child/person with parental responsibility to share the information PICU/CICU complete a Liaison Communication Form and fax to 6701 Emergency Department complete a Paediatric Community Liaison Form and leave for collection Wards phone 0300 3000 007 on day 3 of admission and leave a message with patient details If any child is not registered with a GP; give advice on how to register and send discharge letter to the safeguarding team If any child attends hospital from out of area or is of school age and is not in education send the discharge letter to the safeguarding team

Actions for UHL Safeguarding Team: •

Ensure effective and accurate information is sent to community health care professionals in a timely manner (Leicester, Leicestershire, Rutland and out of area HV & SN teams

•

Ensure School Admissions or Education Welfare are contacted regarding school aged children not in education

•

Ensure Health Visiting Teams are made aware of children in their are not registered with a GP

•

Ensure the Community Contacts Database is maintained and any changes are made promptly


area who



PURPLE – Child Death Information Examples of Types of ‘Purple’ Cases • • • • •

All child deaths within UHL Where a child is brought in to hospital in arrest – unexpected / suspicious Where a child attends hospital with an illness such as meningitis and dies a few days later - unexpected Where a child has a known condition with poor prognosis and palliative care is provided - expected Where a baby is born as a registerable live birth but dies shortly after birth expected / unexpected

Actions for UHL Staff: • • • •

Complete CDOP notification form Fax CDOP notification form and coroner referral to safeguarding children team 6701 Phone safeguarding x5770 leaving details of referral Once completed forward discharge summary to safeguarding: Fax x6701 E-mail: [email protected] Post Knighton Street Offices Level 1, Room 240, LRI.

Actions for UHL Safeguarding Team: • • • • •

Collect all required details Phone CDOP office and inform of child death Complete LSCB Form ‘A’ and e-mail to CDOP office Obtain discharge summary’s and send to CDOP office Be the central liaison point between CDOP and UHL ensuring all relevant information is shared

If at any time you are concerned that this process is not being followed, please contact the Named Nurse or Named Doctor for Child Protection at UHL on x5770 to discuss your concerns Katharine Bouch Named Nurse for Safeguarding Children University Hospitals of Leicester NHS Trust


June 2008 Updated April 2015



APPENDIX 22 UHL SAFEGUARDING CHILDREN REFERRAL “FORM A” 1. DETAILS OF PATIENT: First Name

Surname

Date of Birth

Gender

S Number

NHS Number

Ethnicity

Person With Parental Responsibility (“PR”)

Language

Y/N

Is an interpreter required?

NB. This must not be a family member or friend in safeguarding cases – please state who used

Is person with PR aware this form is being completed?

Address

Y/N NB if no, you must record why. Social care will not accept referrals for any case other than child protection without the awareness of the person with PR. Forms must be completed at the time of the concern being raised and NOT in retrospect.

Telephone Numbers

2. FAMILY COMPOSITION / SIGNIFICANT OTHERS (please use a continuation sheet if required): Name

DoB

Relationship to Subject

Address

Where is this person at the time of admission of the patient?

School/Occupation

3. OTHER AGENCIES INVOLVED WITH THE CHILD/YOUNG PERSON/ FAMILY (please use a continuation sheet if required)

Agency GP

Name

Base

Telephone Number

(must be completed for all patients)

School/ Health Visitor (must be completed for all patients under 16 years)

Please provide name of school here if applicable:

Social worker (if already allocated prior to admission)

Other (please state) Other (please state) Other (please state)




4. UHL ADMISSION/ATTENDANCE INFORMATION(please use a continuation sheet if required) Date and Time of Attendance at UHL

Clinical Areas attended:

Method of Arrival

Accompanied by (name and relationship)

Clinical Reason for attendance and clinical teams involved: Clinical Treatment Provided/Required

Date and Time Discharged/ Transferred

Place Discharged/ Transferred to

Follow up/ discharge arrangement details: 5. DETAILS OF SAFEGUARDING CONCERNS/ REASON FOR REFERRAL (please use a continuation sheet if required) (please give as much detail as possible, using the “Traffic Light” system to guide you on actions to take based on your concern)

What is your safeguarding concern

Action taken by you to address concern 6. REFERRAL TO UHL SAFEGUARDING CHILDREN TEAM (these are nursing staff working within UHL to support you with safeguarding children cases)

Date Call to notify team of case (x5770)

Time

Date Form faxed to UHL safeguarding Team (x6701)

Time Signature of person completing all of Section 6

Agreed Actions with UHL Safeguarding Team

7. REFERRAL TO SOCIAL CARE SERVICES Leicester City (0116 454 1004) Leicestershire (0116 305 0005); Rutland (01572 758 407) Date Person Spoken To Agreed Actions Time: Base: 8. REFERRER DETAILS Forms must be completed by the person with the concern at the time of the concern/attendance Name: Role Clinical Area If you would like to receive feedback on this case, please provide your work contact details and availability:




APPENDIX 23


Dr M Venkataraman

1. Introduction This appendix provides guidance to Children’s Hospital medical and nursing staff when dealing with safeguarding children referrals for a medical examination from Social Care, the Emergency Department (ED), Paediatric Intensive Care or from other areas within UHL a) The LRI Paediatric Team has responsibility for performing non-accidental injury (NAI) Child Protection medical examinations for any child presenting to LRI out of hours, i.e. after 5 PM Monday to Friday, and during weekends and Bank Holidays. Referrals outside these hours should be directed to the LPT Safeguarding Service at Bridge Park Plaza in the first instance. b) It also has responsibility to respond to concerns raised by other medical teams (e.g. Paediatric ENT, Paediatric Orthopaedics, Paediatric Surgery, Paediatric Intensive Care) regarding safeguarding concerns about a child under their care c) Referrals for suspected Sexual Abuse must be managed according to Appendix 7 of the UHL Safeguarding Children Policies and procedures guideline. 2. Accepting a referral from Social Care for a Medical Examination Where a child or young person is referred by Social Care for a Child Protection medical examination the following must happen: a) Social Care must gain consent from the person with parental responsibility for the medical examination (Please check this is the case and document, before accepting the referral) b) Social Care must contact the Paediatric Registrar on CAU or the Paediatric Consultant on-call and discuss the case. c) The Paediatric Registrar on CAU or Paediatric Consultant on-call must inform Social Services that there is no appointments system on CAU and that patients will be seen based on clinical priority, although every effort will be made to see families in a timely manner. d) Social Care must be informed that a member of their staff must wait with the family until the child is seen and a decision is reached as to outcome. e) All Child Sexual Abuse referrals must be directed back to Social Care and should be advised not to present directly to UHL, as outlined in Appendix 7 of the UHL Safeguarding Children Policies and procedures guideline. 3. Responding to a Safeguarding Concern a)

Follow the “Traffic Light” system to guide you in your level of concern and the action to take (i.e. protection concern, welfare concern and for information only). This should be highlighted in the Form A .

b)

A Form A must be commenced, to record the initial concern that has been raised. More information on the Form A is available in Appendix 22 of UHL Safeguarding Children Policies and procedures guideline.




c) Discussions with Social Workers or other referring specialties must be undertaken only by a Paediatric Registrar or more senior Doctor. d) Ascertain and document on Form A, who has parental responsibility for the child/young person. Refer to Appendix 1 of UHL Safeguarding Children Policies and procedures guideline for guidance on who has Parental Responsibility (PR). e) Consent should be obtained to carry out a medical examination from the person with parental responsibility, and/or where appropriate, from the child/young person, if deemed Fraser Competent. Verbal consent must be documented in the medical notes.

4.

f)

Those with parental responsibility should be informed of the concern and your plan of action, unless to do so would put the child/young person at further risk e.g. Child Sexual Abuse, FII. This must be documented.

g)

If once examined, the injuries are deemed to be accidental, this should be clearly documented in the report template and on Form A. Social Services should be notified of the examination and the findings. Form A must be faxed to Social Services and the UHL Safeguarding Children Team (6701) within 24 hours of the verbal referral.

h)

If once examined, the injuries are deemed to be non-accidental, an immediate conversation must take place with Social Services. This conversation should include discussion about the medical needs of the child/young person and when they are likely to be medically fit for discharge. Form A must be faxed to Social Services and the UHL Safeguarding Children Team (6701) within 24 hours of the verbal referral.

The Child Protection Medical Examination: a) The child protection medical examination should be completed only by a Paediatrician trained in child protection at ST4 level (Registrar) or above. b) The history, documentation and conclusions should be completed using the Child Protection Medical Examination Pack, copies of which are available on all the Wards including CAU, Paediatric ED and on INsite http://insitetogether.xuhltr.nhs.uk/Divisions/Corporate/Safeguarding-Children/Pages/default.aspx c) All pages of the body map must have the child’s name and identification and should be signed and dated with the time of examination (as bruises may change with time). d) All cases must be discussed with the Consultant General Paediatrician on-call at the time the referral is received, or at the very latest, after the Registrar’s examination, but before the initial discussion with Social Care about outcome and medical opinion. e) Bear in mind that you are not at liberty to discuss the exact specifics of the injury or its mechanism until the CAIU (The Child Abuse Investigation Unit, or DI on call) have agreed that you may do so, as carers may subsequently use this information to proffer explanations for the injuries f)

At the same time ensure that carers are treated empathetically and are given reassurance and clear medical explanations about the medical well-being of the child.

5

Investigations in children admitted with suspected Non-Accidental Injury (NAI)

5.1

Blood tests a) In children under two years of age admitted with suspected NAI, blood tests should include a •

Full blood count (FBC) including platelets

•

Liver function tests (LFT)

•

Calcium, Phosphate, Alkaline phosphatase, Vitamin D




•

Coagulation screen to include PT, APTT and ratios, Fibrinogen level and thrombin time in all cases

•

Consideration given to performing an extended clotting screen (Consultant decision) especially with an abnormal APTT or immobile babies with bruising. This can be organized by liaising with the special Haematology Lab and Dr Richard Gooding, Consultant Haematologist or with the Consultant Haematologist on-call.

b) The decision to perform an extended screen is a Consultant decision. If the Consultant is not sure whether to perform an extended clotting screen please feel free to discuss the case with the Named Doctor. •

5.2

Consider whether other tests like U&E, creatinine, CRP are clinically indicated. If in doubt, perform the test.

Skeletal survey a) A skeletal survey, with follow up chest radiograph at two weeks should be performed in all children under two years of age with suspected NAI. If this is not performed, then reasons must be documented. b) Acute rib fractures are often difficult to detect and the follow-up chest X-ray at two weeks allows the detection of healing rib fractures. c) This also allows us to look for other injuries which might substantiate NAI, evidence of bony dysplasia and possible time frames to help in the investigation.

5.3

Neuroimaging a) A cranial CT scan should be obtained in any child under one and most children under two where NAI is suspected. b) In addition, consideration should be given to performing a cranial MRI in any child with retinal haemorrhages, focal neurological signs and/or encephalopathic features. c) If there are unexplained encephalopathic features, please also send urine for toxicology in addition to standard medical investigations. d) Consideration should be given to performing both cranial and spinal MRI if neurological signs persist after a few days.

5.4

Ophthalmology All children under two years of age admitted with NAI concerns must have retinal examination by a Paediatric trained Pphthalmologist to look for retinal haemorrhages.

5.5

Medical Photographs a) If physical injuries are seen, they must be photographed by Medical Illustrations for documentation both for evidential purposes and for peer review. This should be carried out as soon as possible within office hours. b) On the pink request form please put a date for photographs to be produced by so that they are available to take to case conferences. c) If Police are involved and require immediate photographs of injuries out of hours, they will have to arrange for Police photographs to be taken, following the guidelines for photography in children. d) Guidance on obtaining photographic evidence can be obtained from Appendix 16 of the UHL Safeguarding Children Policies and procedures guideline.




6

Communication a) After the child protection medical examination, the Social Worker, Police if present, and the Paediatrician (Registrar or Consultant) should discuss the child away from the family to allow a free and frank exchange of views. b) Please note that the Paediatric Registrar must speak to the Consultant covering, before the conversation with Social Care, to allow senior input and clarity of medical opinion. The conversation should be clearly documented. The medical opinion should be based on the statements as in the medical Proforma. The welfare of other siblings must be considered and decisions made as to whether they need to be examined urgently and safeguarded. c) The child and family should then be informed of the findings and the plan. This responsibility for the plan is shared between the Paediatrician and Social Care. d) All episodes of communication must be contemporaneously documented.

7

Safeguarding Information Sharing Meeting (“SISM”) a) In order to facilitate information sharing with other agencies, the UHL Safeguarding Children Team will call a Safeguarding Information Sharing Meeting (“SISM”) for all children aged less than two years where child protection concerns have been raised. See Appendix 15 of the UHL Safeguarding Children Policies and procedures guideline for guidance on SISMs. b) Consideration will also be given to holding a SISM for children over two years, on a case-by-case basis. c) Children under two years of age must not be discharged without the agreement of the child’s Named Consultant and the Safeguarding Team at UHL (extension 5770). d) The SISM will take into account not only the formal medical examination report and investigation results, but also Ward reports including any positive or negative parenting reports from the Ward staff. Any concerns or incidents which occur during the admission should be documented and shared with Social Care. The sharing of information should be clearly documented in the notes.

8

The Medical Report a) The Medical Report Proforma identifies the types of medical opinions possible and this should aid multi-agency communication. b) A verbal report should be given to the Social Worker at the time of the medical examination and a written report should be available within 5 working days. c) Further guidance on completion of Medical Reports can be obtained from Appendix 4 of the UHL Safeguarding Children Policies and Procedures Guideline.

9

Further information / References 1.

Child Protection Companion (2005, 2006)

2.

Child Protection Reader 2007- RCPCH

3.

Standards of Radiological Investigations of Suspected NAI (RCR and RCPCH) Mar 2008

4.

Welsh Child Protection Systematic Review Group: www.core-info.cf.ac.uk


-



APPENDIX 24

Guideline for Staff Requesting Covert Safeguarding Children Team May 2016

Video Surveillance (CVS) in Children’s Safeguarding Cases

1. Introduction The following guideline is intended to inform UHL staff involved in children’s safeguarding cases and where Covert Video Surveillance (CVS) may be requested. 2. Legal Liability Guideline Statement Guidelines issued and approved by the Trust are considered to represent best practice. Staff may only exceptionally depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible healthcare professional’s it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes 3. Scope This guideline is designed for use by all UHL staff who are involved in child protection cases. 4. The main body of the Guideline It is only in very exceptional circumstances that CVS may be considered for use within the acute hospital setting. Under the Regulation of Investigatory Powers Act 2000 there are a number of legal steps that must be taken prior to CVS being authorised. UHL Trust staff must also go through a number of stages before CVS will be considered. •

If UHL staff considers that CVS is required then an immediate referral should be made to the UHL Safeguarding Children’s Team (SCT).

•

Following assessment by the SCT a decision will be taken if the case needs to be referred to Children’s Social Care.

•

A strategy discussion, attended by all relevant agencies, should then be held as per Leicester, Leicestershire and Rutland Local Safeguarding Children’s Board (LLR LSCB) procedures.

•

If a decision is made to go ahead with CVS and an application is made to the courts, the UHL SCT will be guided by the relevant Police Authority for the case. Under LLR LSCB procedures the Police are the lead investigative agency in any case requiring CVS.

•

The SCT will take the lead in UHL for any CVS, and will guide Trust staff on their roles and responsibilities.

5. Further information / References Leicester City and Leicestershire & Rutland Safeguarding Children Board Procedure for Covert Video Surveillance is available at www.lscb-llr.org.uk and www.lrlscb.org.uk Regulation of Investigatory Powers Act (2000)




APPENDIX 25

Guideline to be Followed in the Event of an Unexpected Death of a Child (SUDIC) on Intensive Care, Inpatient wards and All Other Areas in UHL, Excepting ED

Safeguarding Children Team June 2016

1. Introduction The death of a child is always an emotive process. This guideline is aimed at ensuring you follow the right processes at the time of and immediately following the death of a child. The SUDIC Process: describes the process of communication, collaborative action and information sharing following the unexpected death of a child. The SUDIC process should be followed when a decision is made that the death of the child is unexpected, or there is a lack of clarity about whether the death of the child is unexpected. A death need not be suspicious to be unexpected. All unexpected deaths must be reported at the time they occur. 2. Legal Liability Guideline Statement Guidelines issued and approved by the Trust are considered to represent best practice. Staff may only exceptionally depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible healthcare professional’s it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes 3. Scope 3.1 This guideline applies to all staff members who work within University Hospitals of Leicester NHS Trust (“UHL”) except for staff who work in ED, who need to follow the ED SUDIC protocol. 3.2 This includes all staff that work in a bank/locum capacity or have honorary contracts. 3.3 This also includes “satellite” units which work as part of UHL, including the Loughborough Sports Injury Clinic and The Alliance. 3.4 This guideline must be read in conjunction with local joint Local Safeguarding Children Board (“LSCB”) policies and procedures. Electronic policies should be consulted as these will provide the most up to date guidance. Available via http://llrscb.proceduresonline.com/index.htm. 4. The main body of the Guideline An UNEXPECTED DEATH is defined as the death of a child which was not anticipated as a significant possibility, (for example), 24 hours before the death, or where there was an unexpected collapse or incident leading to or precipitating the events that led to the death. Unexpected deaths include: •

Road traffic collisions, suicides and murders, and any sudden unexpected/unexplained death in infancy and early childhood.




•

The unexpected death of a child who has a life-limiting condition but whose death was not anticipated within the previous 24 hours.

•

Any child admitted to a hospital Ward and who subsequently dies unexpectedly in hospital.

All UNEXPECTED cases should be thoroughly investigated according to a standard protocol involving a joint Paediatric–Police approach and incorporating a careful history, a detailed scene examination, a post-mortem examination, and a final case review to pull together all relevant information. Suspicious Deaths: If the death is in any way suspicious, the Police will assume the lead investigation. This includes those cases where the suspicious circumstances are thought to have arisen within the hospital. If at any time emerging information gives rise to child protection concerns about remaining children in the household, the LLR LSCB Child Protection Procedures must also be followed. All agencies need to follow five common principles: Sensitivity, an open minded/balanced approach, an interagency response, sharing of information, appropriate response to the circumstances and preservation of evidence. At any stage if significant concerns are raised by the medical staff, nursing staff, family members, or from any of the involved agencies, that neglect or abuse may be a cause of the child’s death, the decision may be made that there is sufficient evidence to suspect that a crime has been committed against the child. The Police will then take the lead role and instigate a criminal investigation. The Designated Doctor for Child Death (DDCD) along with the Child Death Overview Panel (CDOP) team will take the overall lead in co-ordinating the ongoing investigation and family support following a sudden unexpected infant / child death. The DDCD is available, in office hours, for advice or support via the CDOP office (0116 2958715). Resuscitation: Nothing in this protocol should interfere with the priority of effective resuscitation and medical management. It is most likely that in-hospital cardiac arrests will be witnessed. Resuscitation should always be attempted, unless there is a specific legally dated and signed directive that contradicts this, like a DNAR document. In most cases resuscitation should be continued according to the APLS Protocol or the specific clinical situation until there has been a thorough appraisal of the situation, taking account of the clinical features, the response to appropriate resuscitation, and any immediately available results of investigations. As per guidance, if a DNAR document is in place it must be seen physically and checked and appropriate action taken. Parents or carers must be consulted and updated so that they feel involved in the resuscitation, unless to do so will jeopardise the child’s care. When to stop resuscitation: Resuscitation is discontinued if there is no return of circulation after a period of effective resuscitation (guided by the APLS protocols) and an experienced clinician has made a decision to stop. Post-mortem sampling: No post mortem samples may be taken in obvious or suspected non-accidental injury. In these cases, the forensic samples will be taken by the Home Office Pathologist. Once death has been confirmed, the coroner assumes immediate responsibility for the body. Photography of the child (Appendix 25e): A Police photographer should take the photographs in suspicious deaths or cases of suspected NAI Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



Photographs of skin discoloration may be useful in assessing the time of death/ position in which the child was lying. Photographs for bereavement purposes and locks of hair, foot prints and hand prints may be taken after consent from parents (See Appendix 25e for details) Parents may take photos of their child using their personal phones and cameras. Tubes and lines: Intravenous/Intraosseous lines should be left in place, but the tubing removed. Chest drains/ IV cannulas left in place, but may be clamped Endo-tracheal tubes must be left in place but may be cut off at the mouth and the cut end placed inside the cheek if possible (Coroner and pathologist advice) A complete documentation of all cannulation attempts, sites of venepuncture or IO needling, monitors and tubes should be made before their removal. In suspicious or criminal deaths (e.g. stabbing) the body MUST NOT be cleaned in any way. Care of Parents and sibling: It should be borne in mind that the parents will be shocked and distraught. The parents or carers should be allocated a member of staff to care for them, explain what is happening and provide them with facilities to contact friends, other family members and cultural or religious support. When the child has been pronounced dead, the Consultant or Paediatric Registrar should break the news to the parents, having first reviewed all the available information. They must explain that possible medical causes of the child's death will also be very carefully and thoroughly sought. Unless the cause of death is immediately apparent to the Paediatrician (e.g. the typical rash of meningococcal septicaemia or in RTC cases), it is important to explain to the parents that the cause of the death is not yet known and that an investigation to establish the cause of death will need to take place. Unexpected deaths, Multi-agency process: The first stage in the multi-agency approach to investigation and family support is a strategic discussion involving the relevant Consultant Paediatrician on-call with the Police (DI). This enables sharing of information, identification of any initial concerns, a clear division of responsibilities, and a plan for investigating the case and for giving information to and supporting the family. At this stage or at any stage if distinct child protection concerns are identified, a formal strategy discussion/meeting should be convened by Social Services under Section 47 of the Children Act. The CDR Manager should be informed as soon as possible (during office hours) to allow coordination of any necessary home visits and to provide support in contacting partner agencies (i.e. GP, schools, Diana Nursing Team.) The parents and other close relatives should normally be given the opportunity to hold and spend time with their child (ALL contact should be supervised by a member of nursing staff who will stay with the child throughout). The CDOP process: The CDOP team take the overall lead and responsibility, in office hours, in co-ordinating the investigation and family support following a sudden unexpected infant/child death. Out of hours a message should be left on the CDOP answer machine. The Named SUDIC Nurse will be responsible for ensuring that the CDOP process is discussed with the family during the home visit. Ongoing support to the family will be assessed & managed. Safeguarding Children Policies and Procedures Page V3 Approved by Policy and Guideline Committee on 17 June 2016 Trust Ref: B1/2012



Phase 2 meeting within 5 – 7 days (usually by phone): The aim is to ensure that all agencies are informed and updated; any concerns are identified & managed with an agreed action plan, including ongoing support to the family. The coroner will be kept informed of all outcomes by the CDOP Team. Phase 3 meeting within 16 – 20 weeks once the PM is available: A meeting will be convened where all relevant agencies are invited to attend to share information and identify the cause of death, ongoing support to the family and identify any lessons learned. A case summary and recommendations using Department for Education Analysis Proforma template will be completed and ready for presentation to the final CDOP Panel. Home/Scene visit (unexpected deaths) If the child’s death is felt to be unexpected the SUDIC process will be followed The Paediatric Consultant will discuss with the Detective Inspector on-call about each case. The DI will liaise with the CDR Manager to confirm if, when and how a visit will be conducted. The Coroner will be notified of ALL deaths. If a home visit is required the DI on-call will contact the CDR Manager (in hours) to discuss the circumstances of the child’s death and request a planned joint home visit with the Police. Outside these hours an urgent home visit may be undertaken by the Police as a single agency response. The parameters around each home visit will be discussed and agreement on who will lead will be decided on by a case by case basis. The Named Nurse: The Named Nurse will be responsible for ensuring that the CDOP process is discussed with the family during the home visit. On-going support to the family will be assessed & managed. The CDOP Team is also responsible in liaising with the Police, Social Services, Coroner, Pathologist and other agencies to organise the SUDIC review meetings and to provide the written report after the final results of the post-mortem are available. Follow-up arrangements: The CDOP Team will organise the follow-up visits with the parents and the family as necessary. Please read the LSCB multi-agency SUDIC protocol for further information.

Key Points to remember when a child dies 1. Inform the relevant Consultant on-call immediately and ask them to come in if they are not already attending to the patient. 2 Decide whether the death is Expected or Unexpected according to the definition above. Remember a death does not need to be suspicious to be unexpected 3. In Unexpected deaths, ensure a detailed history and examination, documentation is performed as per appendix 25a. 4. Check that samples for investigation have been taken as per appendix 25b. Post mortem samples may not be taken in NAI cases. Urine may not be collected by supra-pubic aspiration. 5. Liaise with appropriate agencies as per check-lists in appendices 25c to 25d. 6. Contact the CDOP Team - During office hours please contact the CDOP Office on 0116 295 8715. Out of hours leave a message on the answer phone (same number). 7. Contact the relevant Social Care Team to determine if the family are known to Social Care. City Children: 0116 454 1004 (24 hours) County Children: 0116 3050005 (24 hours) Rutland: 01572 758407 (out of hours 0116 3050005)




8. Contact the Police to speak to the DI on call for SUDIC via Force Control Room, and make arrangements for the senior detective designated to lead the investigation into the death to attend (0116-222-2222) 9. Death of a child in suspicious circumstances in hospital. It is important to remember that suspicious or unexplained events may arise in hospital. In this case it is essential to preserve the scene without interference. The clinical area should be cordoned off, with no unauthorised persons allowed to enter, the body must not be interfered with in any way and the duty manager must be informed, in addition to following the SUDIC protocol (Appendix 25g). 10.Ensure that all families are offered a bereavement follow up appointment at an appropriate interval 11.In expected deaths, follow the advice given in the Child Bereavement Pack, copies of which are kept on CICU, Ward 12 and Ward 27. 5. Further information / References 1. Sudden unexpected death in infancy. Report of a working group convened by the Royal College of Pathologists and the Royal College of Paediatrics and Child Health. Chair: Baroness Helena Kennedy QC, September 2004, London. 2. Childhood death reviews: Working Together to Safeguard Children 2010, Chapter 7 3. Responding to the unexpected death of a Child- Chapter 10 LSCB (LLR) procedures 4. Child Death Rapid Response Procedure- LLR LSCB- March 2011 5. The Children and Young Persons Act 2008 6. The Coroners (Amendment) Rules 2008 7. Sidebotham P. Investigation a case of sudden unexpected death in infancy. Arch Dis Child Edu Pract Ed 2005; 90: ep40-ep45. Acknowledgements: This document is modified from the previous UHL SUDIC guideline and the UHL SUDIC ED guideline produced by Dr R Rowlands. UHL and SCCHS Safeguarding Teams, CDOP Team

Prepared: Jan 2007 Revised: Apr and Nov 2009, Nov 2010, Jan 2011, June 2011, Feb 2016, January 2017 Next revision: January 2020 Authors: A Sridhar, F Davies, M Williams, R Rowlands, M Venkataraman Appendices: Appendix 25a: History and examination in unexpected deaths

Page 81

Appendix 25b: Sampling in Unexpected deaths

Page 83

Appendix 25c: Doctor’s check-list

Page 85

Appendix 25d: Nursing Check-list

Page 86

Appendix 25e: Photography of the child

Page 88

Appendix 25f: Chain of evidence forms

Page 89

Appendix 25g: Death in suspicious circumstances arising in hospital

Page 90




APPENDIX 25a (Detailed history and Examination) History The following is intended as an aide memoire; it is important to keep sight of the fact that the majority of the history as outlined below will normally be obtained as part of standard good history taking and documentation in practice. • Presenting History: Record parent’s or carer’’ accounts of events. Ideally, information should be recorded verbatim - use their own words as far as possible. Detailed history as for any critically ill child. • Basic details of baby/child, the parents, and other family members (construct a family tree if possible) • A narrative account of the 24 hours leading up to the child’s death. In children less than two years of age, a full description of when and how the baby slept and fed, any activity, who was with the baby at different times, the baby’s health and activity levels, the final sleep and any changes to routine. Where and how the baby was sleeping, clothing, bed coverings, position; any changes in that during the course of the night; if bed sharing, who else was in the bed and their positions relative to the baby; when and by whom the baby was checked during the sleep; description of the last feed and any night time feeds; heating and ventilation. In older children obtain information regarding any social issues, drug and alcohol use, bullying or mental health issues. • Where and how the child was found, position, coverings, appearance and any unusual features; any action taken after the child was found, especially in deaths occurring within a short period of time of the child arriving in hospital. • Past medical history: Relevant to age - consider including pregnancy and delivery, birth weight, post-natal problems, growth and development, normal routine and feeding, any illnesses, immunisations, medications, drug allergies, routine surveillance; Also details of normal routine for the baby, including feeding, sleeping patterns and practices. Check previous OPD/ hospital, ED, HV and GP visits. Look at the Red Book (if brought) and neonatal records. • Family medical history, including any medical or psychiatric history of the parents and other immediate family members; infectious contacts; any history of respiratory, cardiac, neurological disorders or metabolic disorder in the family and any previous infant or other sudden deaths in the family. The second twin MUST be examined and investigated appropriately by a Paediatrician • Social history, family structure and dynamics, housing, use of alcohol, recreational drugs, and tobacco; parent’s occupations; any Social Services involvement in the past, including any child protection concerns. Examination It is most likely that a detailed examination has already been performed as part of standard clinical care. However, the following specific examination and it’s documentation in all unexpected deaths, must take place, as it may prove very useful in further investigations. • A detailed examination should be performed • A rectal temperature should be taken to aid the Pathologist in estimating time of death • Head to toe examination and front to back for bruising/ injuries/ visible signs of bleeding/ discharge: use body diagrams to document the injuries (Sheet C of the UHL Standard Child Protection Paperwork). Please date, time and sign each page. • Examination: spine, skull, chest, upper limbs, lower limbs, genitalia, anal region • Abdomen: Hepatomegaly • Signs of dehydration, Weight/Length/HC, State of nutrition and cleanliness • Petechiae




• Eye exam: retinal haemorrhages may be difficult to see if cornea clouded but should be commented on if present • ENT exam: frenulum/ bleeding/pink fluid from the nose. Frothy fluid, commonly blood stained, is often present around the nose and or mouth and its presence should be documented. • Sites of medical intervention: IV lines, IO lines etc. need to be documented in detail • The presence and distribution of any discolouration of the skin, particularly dependent livido, if the child has been found dead. Skin livido and pallor from local pressure (e.g. on the nose in a child who has been face down). In older children signs of self-harm (i.e. cutting).




APPENDIX 25b (Samples) in SUDIC cases In the majority of cases on the Wards, initial blood tests and other investigations are likely to have already been performed and the guidance below should be taken in context. However if the following tests have not been done and there is no reasonable suspicion of an underlying cause (e.g., meningococcal septicaemia, sepsis, etc.), then these tests must be considered. • Samples taken during resuscitation should be prioritised for the tests below, if not already done, especially if clinical assessment has not led to a suspicion of an underlying cause, e.g. meningococcal septicaemia. • If only a small amount of blood send for culture only. • Blood samples taken DURING resuscitation: Maintain strict chain of evidence for all the samples taken if the death is considered suspicious (chain of evidence forms - Appendix 6). No samples should be sent via the CHUTE. • No supra-pubic punctures should be attempted for urine samples. • Urine/stool stained nappy should be preserved and sent for analysis for organisms and considered for toxicology. • Post mortem samples should NOT be taken without discussion with a Consultant AND consent of the Coroner. • Post mortem samples should NOT be taken in cases of suspected NAI.




SUDIC investigations suggested list Patient’s details: Name, sex, DOB, Address/ patient’s label Name and designation of doctor completing the form:

Sample

Test

Send to

Handling

Blood cultures aerobic 1 ml

Culture and sensitivity

Microbiology

Normal

Blood (serum) 0.5 ml Blood (serum) 1 ml

Urea and electrolyte Toxicology

Normal

Blood (lithium heparin) 1 ml

Inherited metabolic diseases

Clinical chemistry Clinical chemistry Clinical chemistry

Blood EDTA 0.5 ml Blood from syringe onto Guthrie card

FBC Inherited metabolic diseases

Heamatology Clinical chemistry

Normal Normal (fill in card—do not put into plastic bag)

Urine (if available) Wet Nappy (But No SPA)

Toxicology, inherited metabolic diseases

Clinical chemistry

Spin, store supernatant at –20°C

Urine (If available) (No SPA)

Microscopy, culture and sensitivity

Microbiology

Normal

Naso-pharyngeal aspirate (NPA) and Nasal Swab **may be taken post mortem if indicated**

Virology (Immunofluorescence )

Virology

Normal


Sample taken Yes or No

Spin, store serum at –20°C Spin, store plasma at –20°C



Appendix 25c Doctor Checklist

Name

Sex

Date of Birth

Hospital Number

Date of Death

Time of Death

Action

Contact details

Comment

Parents informed of death Consultant informed Police informed

Attending Doctor to contact: 0116 222 2222 and speak to Duty Sergeant.

Coroner informed

In hours (via bereavement office) Out of hours by UHL Duty Manager Liaise with police to ensure no unnecessary duplication

Parents/Carers seen and a detailed history taken if not taken at admission

See appendix 1

Detailed examination of the child if not done within previous 24 hours Child Death Overview Process (CDOP)- inform of ALL deaths

See appendix 1, Use UHL Body Maps (form C) to record all marks, bruises and injuries, 0116 2958715 Out of hours- leave message on answer phone

MBRRACE Form completed for infants less than 28 days with as much information as Any samples taken during resuscitation

Inform Maternity Bleep holder via switchboard Send Form to: MBRRACE Coordinator, Chain of Evidence completed for each sample

Name of person completing doctor’s check-list form: Role and grade:

Contact number:

Date:




Appendix 25d Nursing Checklist Name Date of birth

Hospital number

Sex

Date

Action

Contact/details

Parents supported when informed of death Interpreter contacted for family if required, NB Do not use a family member if possible

Pearl Linguistics- see INsite for details Code available on CAU or via Nurse in Charge

Comment

Time

Sign when completed

Name bands X2 placed on child Other family members informed at request of family Social Care notified and checked if family known

City 0116 454 1004 County 0116 305 0005 (Police may have already completed)

UHL Safeguarding Team informed and UHL Child death notification completed & faxed. Parents given opportunity to hold child, Nurse to maintain discreet but constant presence. Appropriate religious representation contacted at family’s request. Family given time to carry out religious ceremony Child laid out appropriately

In hours: 0116 258 5770 Out of hours: Message on answer phone at above number Fax: 0116 258 6701

Do not remove lines etc. Do not wash body if criminal activity suspected

Name of person completing form:

Role and Grade:

Contact number:

Date:




Appendix 25d Nursing Checklist continued: Name Date of birth Sex Action

Hospital number Date Contact/details

Comments

Family offered lock of hair & hand & footprints

Record where lock of hair taken from. (Kits available in bereavement boxes on ED and CICU, ward 12 and 27

Family given Bereavement pack and information (in ED and wards bereavement boxes)

LSCB leaflet CDOP information Post mortem Information ‘Following the Death of Your Child’ booklet

Property & valuables

Delete as appropriate: (Given to) • Family

Mortuary contacted Porters contacted Documentation completed

Photocopy of notes

•

UHL Bereavement Services

•

Police (record collar number of receiving officer)

Time

Sign when complete

Ext 5596 Ext 6310 • UHL Safeguarding Child Death form.

•

UHL Notification of Death.

•

Bereavement checklist

•

copy with child to mortuary

•

copy to Bereavement Services

Suitable transport arranged for family Reception notified to cancel appointments Person completing form (Please print name)………………………………………….. Role/Grade……………………………………Contact number…………………………




Appendix 25e Protocol for taking photographs of a deceased child • Under no circumstances should photographs be taken using the departmental camera, or staff camera / mobile. • Parents and family members are allowed to take photographs on their own personal cameras or phones. • Hospital photographs can only be taken by a member of staff from Medical Illustrations. • Photographs are to be taken for bereavement purposes only. NEVER for forensic, personal or educational reasons. • In obvious or suspected non-accidental injury cases the Police photographer (contactable via the Police team) should take photographs. • Photographs should only be taken once consent has been gained from the parents. Initial discussion must take place followed by the completion and signing of the green consent card (available from Medical Illustrations). • Phone Medical Illustrations (Ext 6369/ 5745) to arrange for the photographs to be taken. Opening hours (Mon- Thurs 08.45-17.00, Fri 08.45-16.30) • Outside opening hours and weekends but NO LATER THAN 10PM, refer to Medical Illustrations’ emergency contact list. Please note, Medical Illustrations does not operate a formal on-call service, this is purely dependent on goodwill and they are not obliged to attend the department. • If a photographer is unable to attend or, it is after 10pm, phone Medical Illustrations upon opening the next working day. They will then contact the mortuary and arrange a suitable time to photograph the child. Green form to be delivered to Medical Illustrations by hand. • Medical Illustrations to develop photographs. Send GP details and standard letter to Medical Illustrations, who will send the photographs to the family’s GP by Royal Mail Special Delivery. Emergency contact Numbers for Medical Illustrations: Contact via switch board Protocol for collecting hand/ foot-prints and hair locks from a deceased child • The Coroner has said she is happy for prints to be taken in ANY case as the wipes used do not cause staining. HOWEVER in cases of suspected abuse please discuss with Police prior to taking. • Obtain consent from parents and document in the patient’s notes. • Collect the imprint wipes, sensitised certificates and sample bag from the bereavement box in ED, Ward 12 and Ward 27 • Ensure the child’s feet are clean and dry. • Open the foil-sealed wipe, and wipe the child’s foot. NB the wipe feels dry - this is normal. • Gently, but firmly press the infant’s foot onto the sensitised certificate. • Repeat the process for the other hand or foot. • The wipe can be used for several prints. • Cut a small sample of hair from the child’s head and place in sample bag. • Hand over the prints and/or hair lock to the next of kin. If they would prefer not to take them at the time please pass to ED lead for child death to offer again at bereavement follow up The use of clay in unexpected deaths is not permitted.




Appendix 25f Laboratory ‘chain of evidence’ form (LCOEF) Please complete a separate LCOEF for each specimen. Staple LCOEF to request form Date taken

Time taken

Doctor’s name

Patient’s details (name/number, date of birth, sex)

Doctor’s signature

Specimen Type: Test(s) ALL NAMES MUST BE ACCOMPANIED BY A SIGNATURE

Procedure

Name

Signature

Date

Time

Specimen taken by: Specimen delivered to laboratory by: Received by lab (On-call? Y/N) Senior Lab personnel check at receipt

Senior Lab personnel on completion Medical staff check on completion For each sample a separate laboratory ‘chain of evidence’ form (LCOEF) must be completed and stapled to the request form The haematology, biochemistry and microbiology samples must be sealed in separate bags. Samples must be sent to the laboratory with the porters and not through CHUTE




Appendix 25g Additional procedures to follow in the event of the death of a child in suspicious circumstances in hospital When a child dies in hospital under suspicious circumstances, all the steps in the management of a SUDIC must be followed. In addition the following precautions must be taken: 1. The scene of death must be treated as a potential scene of crime and maintained intact and untouched. 2. The Paediatric Consultant should be called in and apprised of the situation if not already involved. 3. Access to the scene should be withdrawn from any unauthorised persons except the certifying and reporting Paediatrician (usually the Consultant).The Police (CAIU) should be contacted as soon as possible as per SUDIC guidelines. In the context of an in-hospital suspicious death, liaison with Police must only be via senior managers or Consultants. 4. The incident should be managed as if it were a Serious Adverse Event and senior managers should be involved (both medical and nursing).The Line Manger and Duty Manager should be informed immediately and should attend. 5. The child’s carers should be supported and their distress acknowledged as they may not be allowed to have access to the body pending Police investigations. They may be updated only after liaison with Police. 6. There should be immediate reporting to the Directorate Clinical Governance Manager, Corporate Clinical Risk Team and Duty Manger within normal working hours. The Corporate Clinical Risk Team and Duty Manger should ensure that there is onward reporting to all designated Trust individuals with responsibility, as required in the management and investigation of a Serious Adverse Event. 7.The Corporate Clinical Risk Team should then ensure that other interested parties external to the Trust are informed, as appropriate, such as the Strategic Health Authority, Health and Safety Executive, HM Coroner, National Patient Safety Agency and, if appropriate, the relevant PCT. 8. The Safeguarding Children Team must be contacted and informed via extension 5770. The UHL Child Death Notification form must be completed and faxed to 6701 9. Appropriate staff debriefing and counselling must be provided, which should include debriefing by an appropriately trained senior individual, involvement of AMICA at an early stage, and consideration of special leave for staff unable to finish their shift. 10. Investigation and management of these types of incidents should follow the UHL Guidelines for the Management of Serious Adverse Clinical Events. The Trust’s internal investigation should be conducted in the same way as normal, irrespective of any criminal investigation that may be carried out simultaneously. 11. A senior manager should be nominated to co-ordinate events and take overall charge of the situation. They should ensure that an Incident Report Form has been completed


