Clinical pathway for children and young people who have disclosed sexual abuse: consultation

6. Medical Examination

The primary purpose of the medical examination is to address the health and wellbeing of the child in a holistic manner. This includes considering the child’s physical health, sexual health needs, their immediate and long- term emotional wellbeing, and to arrange appropriate ongoing care. A secondary purpose is to collect forensic evidence for police and court proceedings including video documentation of the examination and appropriate forensic swabs in a timely way. This must be carefully managed.

It can be very hard for children and young people to reveal abuse. Often they fear there may be consequences. Some delay telling someone about abuse for a long time, while others never tell anyone, even if they want to. In cases of non-acute sexual abuse that is outside the forensic capture window, a medical examination will still be required for the child. How quickly a non-acute case needs to be seen may vary according to clinical need. It is envisaged that such cases would be seen for paediatric assessment within two weeks (Healthcare and Forensic Medical Services for People to have Experienced Rape, Sexual Assault and Child Sexual Abuse: Children, Young People and Adults Indicators (Interim) of a decision being made that such an assessment is required.

The joint paediatric forensic examination (JPFE)combines a comprehensive medical assessment with the need for corroboration of forensic findings and the taking of appropriate specimens for trace evidence including, for example, semen, blood or transferred fibres. The paediatrician is responsible for assessing the child’s health and development and ensuring that appropriate arrangements are made for further medical investigation, treatment and follow-up. The forensic medical examiner is responsible for the forensic element of the examination and fulfils the legal requirements in terms of, for example, preserving the chain of evidence. The presence of two doctors in the JPFE is important for the corroboration of medical evidence in any subsequent criminal or children’s hearings proceeding and is also good medical practice.

6.1 Considerations for the Medical Examination and Follow Up

When undertaking the medical examination and any follow up treatment, there are a number of points which must be considered:

1. Service locations for the medical examination should be flexible to provide age-appropriate and child and family centred care with access to clinicians with relevant experience for children and young people with complex conditions or additional needs. Further information on age-appropriate care can be found in ‘Delivering a Healthy Future: An Action Framework for Children and Young People's Health in Scotland’.

2. Written consent from an individual with parental rights (if child under 16) or child themselves must be obtained for the examination.

a. In the majority of cases, a parent / carer with parental responsibilities and rights (a person holding parental responsibilities and rights in terms of Sections 1 (1) and 2(1) and 5 of The Children (Scotland) Act 1995) will have the capacity to consent and agree to their child participating in JPFE. In cases where this is not clear please refer to MCN guidance on Consent for Joint Paediatric / Forensic Medical Examinations of Children and Young People. (Note a revised version will be available in spring 2019.)

b. The wishes of the child should be respected and consent can be withdrawn at any time during the examination in accordance with the GMC guidance on Consent: patients and doctors making decisions together and the MCN guidance on Consent for Joint Paediatric / Forensic Medical Examinations of Children and Young People.

c. The Victims and Witnesses (Scotland) Act 2014 and the Healthcare and Forensic Medical Services for People who have Experienced Rape, Sexual Assault or Child Sexual Abuse: Children, Young People and Adults Standards both support that the wishes of the child or young person in respect of gender of the examiner should be respected.

3. Timing of medical examination

a. In recent sexual abuse (up to 7 days)

i. The immediate health needs of the child are paramount. They include the management of acute injuries, assessment of need for emergency contraception and post-exposure prophylaxis for blood-borne viruses.

ii. Timing of the JPFE should be agreed as part of IRD process and would not usually place between 20:00 and 08:00 unless there are medical needs of the child which require immediate attention. For specific guidance on timings of examinations, please refer to the FFLM Guidance for the examination of children and the RCPCH “Purple book” (physical signs of child sexual abuse) (the website address is provided in the resources).

iii. Examination should occur as soon as possible to obtain forensic evidence. Guidelines indicate that likelihood of obtaining positive forensics decreases exponentially with time. This is also true for documentation of injuries as the genital area heals extremely quickly.

iv. These requirements need to be balanced with consideration of the wellbeing of the child, their ability to consent to examination (for example if the child is intoxicated) and of course their general best interests.

v. Pre-pubertal children are never examined internally unless the examination is deemed necessary for clinical assessment and done under general anaesthetic (for example if surgical treatment required at presentation).

b. Historic sexual abuse, neglect or emotional abuse:

i. The referral should be assessed according to clinical need and requirements of the child protection process. This can be discussed through the IRD. The timing of the medical should be decided by what is in the best interests of the child.

4. A standardised pro-forma (in use across Scotland and available within health services) must be used to document a full medical history, developmental history and examination. This includes the use of line diagrams to document extent, description and measurement of injuries. Examination technique and position should take place in accordance with guidance from RCPCH “Purple book” (physical signs of child sexual abuse) (the website address is provided in the resources).

5. A colposcope should be used for light and magnification with the facility to store recordings. Recordings are taken for quality assurance purposes at clinical peer review or for viewing by an expert witness out with court proceedings. It should be noted that colposcopic images cannot in themselves provide corroboration of the findings of forensic medical examinations.

6. In line with Guidance for best practice for the management of intimate images that may become evidence in court from the Royal College of Paediatrics and Child Health and the Faculty of Forensic and Legal Medicine, intimate images form part of the medical record and are retained by the NHS Boards (RCPCH and FFLM 2014). NHS Boards are therefore the data controller for the images. Images are stored in line with legislative requirements set out in the Data Protection Act (2018) and the General Data Protection Regulation (GDPR). All images should be coded and stored securely with password protection. Sharing of intimate images that form part of the medical record should only be done in circumstances where there is appropriate informed consent, or they are ordered to by a judge, or there is a public interest. Further work on the storage and retention of digital images is being developed at this time; within the pathway will be updated to reflect this.

7. Reports should be produced within four weeks, as per MCN Standards of Service Provision and Quality Indicators for the Paediatric Medical Component of Child Protection Services in Scotland and should include a clear summary of findings, interpretation of these findings in light of current evidence and a clear final opinion. Good practice is that the joint forensic report should be written and agreed by the paediatrician and Forensic Medical Examiner.

8. Follow up for health needs including sexual health screening and blood borne virus prophylaxis should be arranged by the attending paediatrician and communicated to the general practitioner with appropriate consent.

9. Follow up for other needs, for example referral to Children’s Reporter or other agencies, should be arranged and documented.

10. Consider giving a brief written summary of findings and outcome as well as a clear list of contacts for follow up at the end of the examination.

11. Sharing of information should follow local policies and guidance.

Useful Resources

General Medical Council (2012) Protecting Children and Young People – The Responsibilities of all Doctors

Scottish Government (2012) Child Protection Guidance for Health Professionals