Healthcare professionals - supporting children and young people who may have experienced child sexual abuse: clinical pathway

7 Health assessment and examination

Prior to undertaking an examination or any follow up treatment, a number of points must be considered.

7.1 Purpose of the examination

The type of examination to be performed will be determined by the needs of the child or young person, whether or not the suspected sexual abuse is recent or non-recent and the likelihood of forensic findings being present. The purpose of an examination is:

• To establish what immediate treatment the child may need
• To gather relevant forensic evidence (joint paediatric forensic examination)
• To provide a specialist medical opinion on whether or not child sexual abuse is a likely or unlikely cause of the child’s presentation
• To support multi-agency planning and decision-making
• To establish if there are unmet health needs, and to inform any ongoing healthcare (including mental health), investigations, monitoring and treatment that the child may require
• To listen to and to reassure the child
• To listen to and reassure the family as far as possible in relation to longer term health needs

The main types of medical examination that may be undertaken are those that are detailed in Part 3 of the Child Protection Guidance. In brief they are:

a) Joint Paediatric Forensic Examination (JPFE). Examination by a paediatrician and a forensic physician. This is the usual type of examination for sexual assault and is often undertaken for physical abuse, particularly infants with injuries or older children with complex injuries.

b) Single doctor examinations with corroboration by a forensically trained nurse. These are sexual assault examinations undertaken for young people aged 13-16. Consideration should always be given as to whether a JPFE should occur.

c) Specialist Child Protection Paediatric/Single paediatrician /Comprehensive Medical Assessment. This type of examination is often undertaken when there is concern about chronic neglect or abuse and/or unmet health needs but may also be used for physical abuse and historical sexual abuse. Comprehensive medical assessment for chronic neglect can be arranged and planned within localities when all relevant information has been collated.

A comprehensive medical examination is performed by a single paediatrician if there are concerns about chronic neglect or abuse. A specialist paediatric examination is a single paediatrician examination performed when a specialist paediatric assessment is required. A joint paediatric forensic examination is carried out by a paediatrician and a forensic physician and will usually be required in cases of recent suspected child sexual abuse.

The Healthcare Improvement Scotland Standards for people who have experienced rape, sexual assault or child sexual abuse state that a paediatrician with child protection experience and skills, for example through accredited training from the Royal College of Paediatrics and Child Health, should always be available to provide, if necessary, immediate advice and subsequent assessment, for children and young people where there are child protection concerns. This should be extended to 18 years of age in specific circumstances, including looked after children, children and young people suspected of being sexually exploited and young people with vulnerabilities and mental health issues.

The decision to carry out a medical examination of a child will be made by a paediatrician with child protection expertise. The decision to conduct a medical examination may:

• Follow from an IRD and inter-agency agreement about the timing, type and purpose of examination
• Follow from a presentation of concern to health services

A medical examination should be carried out in a location which is age appropriate and child-centred, with access to clinicians with relevant expertise including the management of children and young people with complex conditions or additional needs^[39].

In accordance with the Standards of Service Provision for the Paediatric Medical Component of Protection Services in Scotland, a joint paediatric forensic examination should be carried out jointly by a paediatrician and a forensic physician. The paediatrician is responsible for assessing the child’s health, wellbeing and development and ensuring that appropriate arrangements are made for further medical investigation, treatment and follow-up. The forensic physician is responsible for the forensic element of the examination. The presence of two doctors in a joint paediatric forensic examination is important for the corroboration of medical evidence in any subsequent criminal or children’s hearings proceeding. In some cases, both the paediatrician and the forensic medical examiner may be cited to give evidence at a proof or trial. Where a clinician possesses the appropriate skills to undertake both roles then, with agreement of the health board involved, an examination by a single doctor witnessed by another healthcare professional, such as a nurse who has been trained in forensic medical examination techniques, rather than a paediatrician and a forensic examiner can take place with colposcopic recording.

The wishes of the child in respect of choice of sex of examiner for the examination will be considered and supported if possible in accordance with the Healthcare Improvement Scotland Standards.

7.2 Preparation

As far as can be achieved in the circumstances, the examining doctor must have:

• All relevant information about the cause for concern
• Information on previous concerns about abuse or neglect
• The inter-agency plan to meet the child’s needs at this stage
• Relevant known background of the family or other relevant adults
• Information from a JII if available
• A preparatory discussion with the relevant social worker and police officer
• A preparatory meeting with non-abusing parent/carer(s) and child

Social work services or the police should ensure that the child and non-abusing parent/carer(s) have the opportunity to hear about what is happening, why and where so that they have an opportunity to ask questions and gain reassurance.

7.3 Consent

Written consent must be obtained for the examination before it takes place. Consent must be obtained in one of the following ways:

• From a parent or carer with parental rights (Section 1(1) and 2(1) of the Children (Scotland) Act 1995)^[40]
• An adult who does not have parental rights and responsibilities but does have care and control of the child (Section 5 of the Children (Scotland) Act 1995)
• From a young person assessed to have capacity to give informed consent
• Through a court order

The Age of Legal Capacity (Scotland) Act 1991^[41] allows a child under the age of 16 to consent to any medical procedure or practice if, in the opinion of the qualified medical practitioner, the child is capable of understanding the nature and possible consequences of the proposed examination or procedure. Children and young people who are assessed as having capacity to consent can withhold their consent to any part of the medical examination, for example, the taking of blood, or a video recording and consent can be withdrawn at any time during the examination in accordance with the General Medical Council (GMC) and Managed Clinical Network (MCN) guidance. Consent must be documented within medical notes and must reflect which parts of the process have been consented to and by whom^[42].

When considering consent, a child or young person’s capacity to consent may depend on their condition at the time (e.g. intoxicated). This may lead to a delay but must be taken into consideration when obtaining consent.

In order to ensure that the person providing consent to an examination is properly informed, the examining doctor, assisted if necessary by the social worker or police officer, should provide information about any aspect of the procedure and how the results may be used. Where a JPFE is thought necessary for the purposes of obtaining evidence in criminal proceedings but the non-abusing parent/carer(s) refuse their consent, the Procurator Fiscal may consider obtaining a warrant for this purpose. However, where a child who has capacity to consent declines to do so, the Procurator Fiscal will not seek a warrant. If the local authority believes that a medical examination is required to find out whether concerns about a child’s safety or welfare are justified, and the non-abusing parent/carer(s) refuse consent, the local authority may apply to a Sheriff for a Child Assessment Order or a Child Protection Order authorising a health assessment.

Health boards must ensure that the processing of any personal data is done in compliance with the Data Protection Act 2018 and, where relevant, the General Data Protection Regulations (GDPR). Independent advice on how to comply with any duties or obligations should be taken if needed.

7.4 Timing of examination

Timing of the examination is agreed jointly by the paediatrician, the forensic physician in the case of a joint paediatric forensic examination and the other agencies involved^[43].

In recent sexual abuse (up to seven days):

• The immediate health needs of the child are paramount; these include the management of acute injuries, assessment of need for emergency contraception and post-exposure prophylaxis for blood-borne viruses
• Examination should occur as soon as appropriate to increase the likelihood of recovering any available forensic evidence as the likelihood of recovering forensic evidence decreases exponentially with time and the genital area heals extremely quickly
• Early evidence kits may be used by the police on children and young people (mouth/throat swab or mouth rinse) if the examination will be delayed until the following day
• These requirements need to be balanced with consideration of the wellbeing of the child, their ability to consent (for example if the child is intoxicated) and their general best interests
• The timing of the examination should be agreed as part of the IRD process. As set out in the HIS Quality Indicators, JPFEs following an IRD within the 7 day DNA capture window should commence within 12 hours
• It is not usually in the best interests of the child for this to take place between 22.00 and 08.00 unless there are medical needs of the child which require immediate attention

In non-recent sexual abuse:

• The referral should be assessed in the IRD according to the clinical need of the child or young person and requirements of the child protection process
• The timing of the medical examination should be decided by the best interests of the child in a trauma-informed way
• In some cases, when there is no forensic urgency, it may be a priority that the child has time to rest and prepare which may also allow more information to become available
• The majority of cases arise in working hours, and a comprehensive medical examination can be carried out locally and quickly
• Local arrangements must be in place for medical examinations out of hours where these differ from daytime and weekday arrangements

7.5 Photographic evidence

Images form part of the medical record and are retained by the NHS Boards. Therefore, NHS Boards are the data controller for the images. Images should be 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. Informed consent to share photographs with criminal justice agencies and the Children’s Reporter should be sought on every occasion that photographs are taken. Sharing of images that form part of the medical record should only be done where there is informed consent or an order from a judge.

7.6 Documenting the examination

The national pro-forma must be used to document a full medical history, developmental history and examination. This includes the use of line diagrams to document the extent, description and measurement of injuries^[44].

As set out in the HIS Quality Indicators, all relevant sections of the Child Protection Paediatric Pro-forma should be completed within 24 hours of the end of the examination. The Summary of Findings report should be completed within 28 days of the examination and should include interpretation of findings in light of current evidence and a clear final opinion. Good practice is that a joint forensic Summary of Findings report should be written and agreed by the paediatrician and forensic physician. Prior to that, the paediatrician and/or forensic physician may be contacted for information before the report is produced e.g. by the Reporter. There will also be a clinical letter to the child or young person’s General Practitioner summarising the examination including indications, findings, investigations and suggestions for ongoing care.