Abuse and Neglect
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This guideline is intended to help you in the appropriate assessment and initial management of children and young people where you become concerned about possible abuse or neglect.
Child abuse and neglect (CAN) is a serious health issue in New Zealand society and preverbal children are at particularly high risk. Health care providers need to be alert for signs and symptoms that require further assessment, or that might be indicative of violence and abuse. Health care providers also need to be able to respond appropriately if a child makes a disclosure of abuse.
"Our children are our taonga. All children have a right to full emotional, spiritual and physical well-being, to develop their own potential in an environment which is nurturing and protective and in which they feel safe from abuse." (Auckland Area Health Board Child Abuse Policy, 1990).
This clinical guideline should be read and used in conjunction with the ADHB Policy (Child Abuse Neglect, Care & Protection) and the Ministry of Health Family Violence Assessment and Intervention Guideline, (FVAIG) 2016 (Family Violence Guidelines).
Assessments and interventions should be carried out with regard to the Principles of the Treaty of Waitangi and relevant legislation (see Child Abuse and Neglect, Care and Protection Policy).
Who to consult about suspected CAN
See pages 43-49, Family Violence Assessment and Intervention Guidelines 2016
Te Puaruruhau is the ADHB multi-disciplinary child protection team, co-located with Police and Child, Youth and Family (CYF) in a multi-agency centre (Puawaitahi) beside Starship, at 99 Grafton Road. Te Puaruruhau is always available to be consulted. However, unless it is an emergency, first discuss the situation with your consultant, team or supervising clinician. You are welcome to come over any day during the week to discuss a case (we suggest you ring first).
In hours, contact Te Puaruruhau on the referral cellphone (021 492 365). This is carried Monday to Friday from 0800 to 1700, except Public Holidays. Alternatively, try 09 307 2860. DO NOT leave a message on these phones if it is after hours and you need urgent assistance. After hours (including weekends), contact the Te Puaruruhau Paediatrician on call, through the operator. After talking to Te Puaruruhau, ADHB staff should also email a referral form to TEP@adhb.govt.nz, or fax it to 09 307 4930. NEVER EMAIL OR FAX A REFERRAL WITHOUT TALKING TO A CLINICIAN.
Is the child or young person already coming to harm?
If you suspect that a child or young person has already come to harm, they will often require a comprehensive multi-disciplinary assessment by Te Puaruruhau. In such situations, ALWAYS consult directly with Te Puaruruhau. Examples include a child with an injury which you suspect may have been inflicted; a caregiver worried about sexual abuse or a child or young person who has made an apparent disclosure of sexual abuse; a child injured in the cross-fire of intimate partner violence (IPV); or a child or young person who has suffered a consequence of neglect so serious that they require hospitalisation and it may be unsafe for them to return home. Te Puaruruhau works in close collaboration with both CYF and the Police. Any form of CAN which may possibly require that degree of collaboration should be discussed with Te Puaruruhau.
This is particularly true of possible non-accidental injuries (NAI) seen in hospital. If you can't be certain in your own mind that the mechanism explains the injury, talk to Te Puaruruhau. A social work assessment for "risk factors" does not resolve a question as to how this particular injury occurred, nor is a social work assessment a screening procedure for referral to Te Puaruruhau. If it is agreed that Te Puaruruhau should be involved, Te Puaruruhau will conduct a multi-disciplinary assessment involving a Te Puaruruhau paediatrician and/or nurse specialist and social worker.
Consult as soon as possible. Time is often of the essence, particularly if involvement of the statutory authorities is likely to be needed. You must always consult before discharging the child.
Is the child or young person at risk of harm?
If you do not believe that a child has come to harm, you may still be concerned that there is a risk of harm - stressed or unsupported caregivers, behaviours that cause concern, or other reasons (housing issues, intoxicated caregivers, missed appointments/lost to follow-up, transience, parents failing to visit in hospital, young people with high risk behaviours etc). The ADHB may have access to hospital or community services which can work with the child or young person and their family to reduce that risk. These situations require a multi-disciplinary assessment of risk and protective factors, but probably will not require the involvement of Te Puaruruhau or the statutory authorities.
A positive response by an adult to routine enquiry about IPV may raise the possibility of a risk of harm for children in their care. ADHB provides a risk assessment tool to be used in that situation, and a specific form (CR0018) on which that risk assessment should be documented. You should attend ADHB Family Violence training to learn how to use it.
However, risk assessment around CAN is not a reliable science. The more information one has the better, but safety lies not so much in a particular risk assessment tool, but in following a safe process - especially, never to make decisions about risk in isolation. In many situations, referral to an ADHB social worker is an appropriate step where identified risk factors are causing concern but you do not at this stage believe that the child or young person has come to harm.
Many teams within ADHB have access to a social worker. On the weekends, there is also a health social worker and supervisor on call for Women and Children's Health. The supervisor can be contacted through the ADHB operator or the duty phone (021 442 142). If your concern is possible CAN, the weekend social worker will work alongside the Te Puaruruhau paediatrician on call.
The team social worker can also act as a support person for the child and family during a Te Puaruruhau assessment, in close consultation with Te Puaruruhau and cultural support staff.
Intimate partner violence (IPV)
Routine enquiry for IPV should be completed with the accompanying caregiver of any child you see, whether or not you suspect abuse. There is a strong association between child abuse and neglect (CAN) and IPV. If you have not been trained, training is available. Check the schedule through the Family Violence website (Family Violence).
All Junior Resident Medical Officers in Starship are expected to attend the one-day training course in IPV and CAN at some point during their training in Starship. If you are a JRMO and have not yet attended this training, check the schedule and book a day in consultation with the Chief Resident.
If a child is being abused, there is a significant risk of associated IPV (often directed at the mother), affecting the ability to parent. The process of responding to CAN should also ensure that specialist support is provided for any caregiver who is also a victim of abuse.
It is important to be sensitive to every family's cultural needs. If language is an issue, always use an interpreter. Do not use family members or cultural support staff as interpreters.
Staff are recommended to complete training on bicultural practice (Tikanga in practice and Treaty of Waitangi) and Cultural and Linguistic Diversity (http://adhbintranet/Learn_and_Development)
When working with Māori whanau, it is always appropriate to consult with Kaiatawhai. He Kamaka Waiora Māori Health Service and on call Kaiatawhai are available from 0800 to 2100, Monday to Friday, and on the weekends 0900 to 2100. This includes Public Holidays. The single contact number is extension 29200, which goes automatically to the cellphone (021 938 580). Kaiatawhai/ Kaumatua will inform the whanau about He Kamaka Waiora services, from a cultural perspective e.g. karakia, whakapapa, manaaki, awhi, tautoko the whanau.
When child protection issues arise for Māori, a referral should be made to He Kamaka Waiora, extension 2900 which will be followed up by Kaiatawhai. In consulting with Te Puaruruhau, you can decide whether this contact is best made by you, or by Te Puaruruhau. It is desirable for Kaiatawhai to be present when the Te Puaruruhau team meet the whanau.
For Pacific families, Pacific Health Navigators from the Tautai Fakataha Service are available 0800 to 2000, Monday to Friday, through the ADHB operator extension 29500.
Protective factors for Pacific families
- observance of tapu relationships
- language and belonging are concepts that are shared across the seven ethnic specific communities as elements that protect and strengthen family and individual wellbeing.
Flow chart for suspected child abuse or neglect
The guidelines below are to be used in conjunction with the flow chart.
Identification of signs and symptoms
See pages 31 to 39, Family Violence Assessment and Intervention Guidelines 2016.
Non-accidental injury (NAI) includes physical injury and violence to a child or young person. Neglect is failure to provide adequately for the health, safety and well-being of a child or young person. Sexual abuse is often defined as "the involvement of dependent, developmentally immature children and adolescents in sexual activities that they do not fully comprehend, to which they are unable to give informed consent and that violate the social taboos of family roles" (Schechter MD, Roberge L. Sexual exploitation. In: Helfer RE, Kempe CH (eds). Child abuse and neglect: the family and the community. Ballinger, Cambridge, Massachusetts, 1976). Emotional abuse may occur in conjunction with any of these, or by itself. Exposure to IPV, even when it does not result in physical harm to the child, is a form of emotional abuse.
Specific guidelines for Neglect of Medical
Care can be found in the Starship Clinical Guidelines.
Very few signs and symptoms are specific for abuse. Conversely, children may experience CAN but show no obvious signs or symptoms at all. If you are concerned about CAN, CONSULT.
If a child has come to harm from abuse or neglect, and the diagnosis is not made, there is a risk of further harm or even death. Therefore, if you suspect CAN, a careful evaluation is critical. Although very obvious presentations of CAN do occur, often the presentation is more subtle. In the case of NAI, the caregiver will almost invariably conceal the true cause of the injury. CAN must therefore be included in the differential diagnosis of a wide range of signs and symptoms.
Any member of the clinical team (medical, nursing or allied health) may develop a concern about possible CAN. It is important that this concern is discussed with senior members of the clinical team, and a clear decision is made to consult.
Screening for CAN
There is no validated screening tool for CAN so (unlike IPV) routine enquiry is not recommended. You need to be alert for signs and symptoms that require further assessment, and need to know how to respond if a caregiver raises a concern, or a child or young person makes a disclosure.
It is good practise with all childhood injuries (regardless of cause) to take a clear and highly detailed history of the mechanism of injury. Health professionals must ensure that they understand who saw an incident resulting in injury and exactly how it is said to have occurred. In many cases, a diagram of the layout of the scene (room, driveway etc) is very helpful.
A Child Protection Checklist must be completed for all children 2 years and under presenting to Children's Emergency Department (CED), whether or not they present with an injury (see bottom of page 1 of the CED Assessment Record for children under 2 years, CR 1005). The reason why this is completed for all children under 2 years is that preverbal children are the most at risk, and an injury may be found on assessment even when it was not the reason for presentation.
The checklist is not a screening tool - it is a guide to assist good quality assessment and safe process. It should be used as a prompt, not a diagnostic algorithm. Never jump to conclusions.
Many abused or neglected children have presented before. Always try to review every child's previous medical records. There may be a child protection ALERT. If so, look for the information to which it is alerting you (see Alert section). It is important to appreciate that the presence of an ALERT does not mean that the child is currently experiencing CAN, nor does the absence of an ALERT mean that the child is not at risk. Read the information and incorporate it into your decision-making, as appropriate to the circumstances for which the child has now presented.
Some general observations that should cause concern
- You observe evidence of violence (verbal or physical) between caregivers or towards children, or a caregiver discloses IPV during routine enquiry.
- A caregiver has an unusual response to a child's injury or illness, such as a significant delay in seeking help (without an adequate explanation) or other inappropriate behaviour
- A caregiver fails to heed obvious signs of serious illness or fails to follow the health care plan once medical advice has been sought (see Neglect of Medical Care guideline)
- You observe other child-caregiver interactions which concern you. These may be non-specific, but can provide helpful information (e.g. clues about who the child is comfortable with and seeks support from). Observations which raise concern should be documented objectively, prospectively and in detail, even if you are uncertain of their significance at the time. The presence of a documented pattern of concerning behaviour over time may at some stage become very important in enabling Starship to take effective action on behalf of a child at risk.
- You observe possible signs of neglect or emotional abuse (failure to thrive, poor hygiene or clothing, "frozen watchfulness" - although the latter is rare).
- A child comes repeatedly for symptoms and signs never witnessed by staff, or whose pattern of presentation requires multiple investigations but does not fit any recognised diagnosis (the term recommended by the American Academy of Pediatrics is "Caregiver-Fabricated Illness")
However, it is very important to recognize that CAN may be occurring with NO obvious behavioural concerns or disclosures of the type described above. CAN may occur in any household, and health professionals are most likely to miss it in families who have no apparent "risk factors".
Observations of particular relevance to children with injuries
Unless there is from the outset a very clear and corroborated accidental mechanism of injury, CAN should never be completely left out of the differential diagnosis when a child presents with an injury. The younger the child is, the more important it is that the possibility is at least considered.
For children who present with an injury, the following factors should raise particular concern:
- Delay in presentation, with no reasonable explanation
- No history of injury, or a history which is uncorroborated, vague, changes over time or differs between caregivers.
- The injury is inconsistent with the developmental age of the child. For example, any infant who has any bruise or fracture and is not yet cruising, climbing or walking.
- Discrepancy between the history and the type of injury, e.g. a spiral fracture of the humerus from a fall. Your ability to recognize this depends almost entirely on the quality of the history you take in every injured child. Any injury may be abusive. (Note: undisplaced hairline spiral fractures of the lower limbs are common accidental injuries in toddlers).
- A history or findings of repeated trauma.
- A young child presents with a skull fracture or head injury (up to 80% of deaths from head injury in children < 2 years may be due to abuse). Note that an apparently trivial bruise to the head of a young infant with no signs of concussion may be a marker of serious risk.
- Injuries which (in the absence of complex and/or serious accidental mechanisms) have a particular association with abuse:
- Head injuries associated with complex skull fractures, subdural bleeding, hypoxic-ischaemic brain injury or retinal haemorrhage
- Bite marks (although bite marks are difficult to assess and may be inflicted by toddlers)
- Lots of bruises, patterned bruises or bruises in clusters
- Bruises in unusual places (cheeks, ears, neck, hands, trunk, genitalia, buttocks) or places usually shielded from accidental injury (axilla, inner aspect upper arms / thighs)
- Burns if sharply demarcated or in unusual areas. Accidental scalds tend to involve the head and face, neck, shoulders and anterior trunk. They are typically asymmetric and irregular in outline. Intentional scalds are often symmetric and bilateral, involve the lower limbs and may involve the posterior body, buttocks and perineum. They often have clearly defined margins and a uniform scald depth. Contact burns may be located on the back of the hands (uncommon for accidental scalds) or patterned to reflect the object which caused the burn. Other forms of inflicted burn may occur (flame, caustic).
- Contusion, laceration or rupture of internal organs without major accidental trauma
- Fractures of the ribs or metaphyses ("corner" or "bucket-handle" fractures) - although these are usually only detected once you go looking for them (on skeletal survey)
- Fractures in unusual places (end of clavicle, hands, feet, sternum, scapula, spine)
- Ligature marks
- Oral injuries
- Trauma to the genital or perianal areas, without a straddle injury
Remember, virtually any type of injury can be caused by CAN. Always ask yourself - does this make sense? If you have taken a careful and comprehensive history from a first-hand observer and the injury still doesn't make sense, you have a problem that needs to be resolved.
Concern about sexual abuse
This usually arises either when a young person makes a disclosure, or when a child presents with behaviour changes or physical symptoms or signs that worry a caregiver. Caregivers may be extremely distressed, and you should have a low threshold for consultation with Te Puaruruhau.
Young children go through stages of sexual play and exploration as part of normal development. If you have concerns about a child's behaviour, and are unsure whether you should be concerned about sexual abuse, feel free to discuss with Te Puaruruhau or the Starship Consult Liaison Team.
- Behaviours that cause concern are often either unexplained changes (aggression, anxiety, attention-seeking, changes in sleeping or eating, depression, fear of places or people, psychosomatic symptoms, regression, withdrawal) or sexualised behaviour (acting out explicit sexual acts, explicit artwork, obsessive masturbation, precocious sexual knowledge etc).
- Symptoms or signs that may cause concern include anogenital symptoms (bleeding, difficulty in walking or sitting, discomfort on going to the toilet, unusual odours, vulval rash or discharge), vaginal foreign bodies, genitalia that appear abnormal to a caregiver or health professional, missing or torn underclothing (for example, in an intoxicated adolescent).
- Anogenital injuries are an obvious reason for concern. Straddle injuries in girls do not usually penetrate the introitus or vagina and in boys do not usually involve the penis alone. If there is a possibility of sexual abuse, there may be forensic issues to consider. If in doubt, talk to Te Puaruruhau. In some situations, a combined assessment by the paediatric surgical team and Te Puaruruhau is the safest approach. Remember that not all inflicted injuries to the anogenital region are sexual in intent. Physical assaults may also be directed at the genitalia.
All of the above features are non-specific, and must be evaluated carefully in the context of the presenting history and circumstances of that child or young person. One must never jump to conclusions. There are of course findings that are diagnostic of sexual contact (pregnancy, sexually transmitted infections) or penetrating genital injury, but even these must be interpreted in the light of a young person's age, history of consenting sexual activity or precise history of injury.
Talking to children and young people
See page 35-37, Family Violence Assessment and Intervention Guidelines 2016.
If a child has an injury, it is perfectly all right to ask open,
non-leading questions eg, 'how did
this happen?' They may or may not tell you the truth, depending on a variety of factors which may be unknown to you, but might include who is present in the room. However, no harm is done by asking the kind of question you would ask of any child you see for treatment of an injury.
If you have concerns about possible CAN, but there are other possible explanations for the things causing you concern, then you may want to give the child an opportunity to talk about what might be happening. However, always ask yourself whether or not this is an appropriate thing for you to do. If you have never had this kind of conversation, it may be better for someone else to speak with the child, or to do it with an experienced colleague. Seek advice.
Privacy is just as important as with adults. Giving an adolescent a chance to talk to you alone and conducting a HEEADDSS assessment (see Appendix 4, from the Family Violence Intervention Guidelines) should be part of routine practice. If concerned about possible suicidality, assessment guidelines are available in the Family Violence Intervention Guidelines (Appendices C and G).
What do I do if a child discloses abuse?
Listen. Do not put words in a child's mouth. Allow them to tell only as much as they want. It is not your role to judge whether a child is telling the truth. Although false allegations can occur, they are uncommon, and it is far safer to act on the assumption that the child is telling the truth.
A child old enough to disclose is probably old enough to be evidentially interviewed at a later date. It is therefore important not to interrogate the child, which may only cause distress and may confuse any subsequent evidential process. Keep questions to a minimum, keep them open-ended, and document the conversation carefully in the clinical notes immediately afterwards.
If appropriate, there are five good principles to follow:
- Let them know you believe them
- Let them know you're glad they told you
- Let them know you're sorry it happened
- Let them know it's not their fault
- Let them know you'll help
Do not over-react. A child's first disclosure is a critical moment. He or she will be monitoring every reaction, and may well be very frightened if the abuser has threatened them or said no-one will believe them. The abuser may have involved the child in "our secret", or may have threatened the safety of other members of the child's family.
Do not panic. If the child judges you unable to handle the situation, he or she may stop talking. Good listening with supportive, minimal encouragers allows the child space to say all they need.
Do not criticise. Don't say "You should have told me sooner" or "Why did you let him?". It may help to say that these sort of things happen to other children too sometimes.
Ensure the child's immediate safety. Try not to alert the alleged offender. Seek advice and assistance, and find support for yourself.
Talking to Families
See page 40-42, Family Violence Assessment and Intervention Guidelines 2016.
If you have concerns about the safety of a child, then you need to act on them. Sooner or later (depending on the urgency of the situation) someone has to have a frank conversation with the caregivers and (if old enough to understand) with the child or young person.
You should not assume that raising care and protection concerns with a family will result in a hostile reception. Some caregivers may appreciate your honesty and be willing to accept help. The family member who is with the child may actually have brought the child for medical attention because they also have concerns, and are waiting to see if you share those concerns. It may not be apparent until you raise your concerns, which adults in the family are protective.
Honesty is the best policy. The family must be told of your concerns, the reasons for those concerns and the actions that will need to be taken, including referral to Te Puaruruhau. Generally, if you are making an internal referral to Te Puaruruhau, you can leave the discussion about CYF or the Police to Te Puaruruhau. However, you need to be sure that families understand that Te Puaruruhau is the Starship Child Protection Team.
Do not discuss your concerns with the child's family if you believe that doing so will endanger the child. In that case, discuss the case with Te Puaruruhau or the statutory authorities before you speak with the family. However, it is very uncommon for families to walk out of Starship in these situations if your approach is thorough, reasonable and transparent.
Do not leave this conversation to junior staff. It is best done with another staff member present.
It is essential that all interactions with the child and family should be non-judgmental. This is a particularly stressful and threatening situation for families. The basic principles are:
- Create time and space for a private conversation
- Use interpreters (not family members) if there are language barriers
- Use other cultural support if available and appropriate. For example, with a Māori whanau, consider including Kaiatawhai or for a Pacific family, the Pacific Tautai Fakatha Service.
- Be professional. Be calm, start with the facts of the child's presenting symptoms or findings, then explain the reasons for your concern and actions you need to take.
- Be ready for the possibility of anger or distress and be prepared to deal with it in an empathetic, honest and non-confrontational fashion.
- Don't accuse anyone. For example, if a child has an injury, you have reached the appropriate point in the consultation and have explained the features of the injury that are unusual, you might use phrasing such as 'I am concerned that someone may have injured your child'
- Be transparent about what happens next
- Check if the caregiver(s) with the child have supports available to them (family, friends)
- Be aware of possible issues that may need to be addressed such as other children who need to be taken home or picked up from school, letters for work, transport, accommodation
If you are unsure about how to approach a family, your senior or Te Puaruruhau will advise you.
Examples of how to tell the family of your concerns:
"In our experience an injury like this is very unusual after such a minor fall. We are worried that the injury might have been caused some other way. In particular, we are worried about the possibility that someone may have injured your child. The policy in Starship is that whenever we have this concern, we must involve the Starship Child Protection Team. They are experts in this area. They will talk to you, examine your child and arrange other tests. We realise that this is very upsetting for you, and we want to make it very clear that no-one is jumping to any conclusions. However, we do have a responsibility to check things out, to make sure everything is OK for you and your child".
"From what you have told me I am concerned about the possibility that someone may have sexually abused your child. However, I am not an expert in that area. It's really important we don't jump to any conclusions, and it's really important for her that we do things right. I will go and ring someone from our child protection team, and they will probably need to arrange to see you."
A pamphlet about Te Puaruruhau (SSH/3021/013) is available for you to give to the family
Assessment for non-accidental injury or neglect
Use Te Puaruruhau Record Booklet (CR3773)
A complete medical assessment is likely to take several hours. If it is apparent at the outset that this is a case of probable NAI, contact Te Puaruruhau as soon as possible. After hours, in discussion with Te Puaruruhau, the call-back paediatric registrar will normally perform this initial assessment.
History and examination need to be thorough and to be documented completely. Record the date and time with all documentation, and document clearly who gave you the history. Record who was present for the conversation (by full name). If there were several historians, record who said what.
While informed consent should be obtained for all physical examinations and investigations, this does not need to differ from the usual manner in which you obtain or infer consent for routine clinical practice. Consent does not need to be written, if that is not standard practice for the procedure. However, it is wise to record the manner in which you satisfied yourself that consent had been given. Some relevant aspects of the law are summarized in 'Informed Consent for Medical Examination'.
All children assessed for possible CAN must be discussed with the Te Puaruruhau Paediatrician on call, and if they have physical injuries, these must be seen in person by a consultant.
A general approach for suspected abuse includes:
- Initial assessment to determine whether there
is actual or suspected CAN. Ensure that the child has adequate
first aid and pain relief. Discuss with your senior / team.
- Contact Te Puaruruhau. In normal working
hours, ring direct on (09) 307 2860 or cell 021 492 365. After
hours, contact the Te Puaruruhau paediatrician on call through the
- Take a thorough history. A thorough history
includes the timing and nature of any injuries, a full past medical
/ family medical / developmental history, and a full social
history. Ideally, the social history should be taken as part of a
full assessment by a trained health social worker (see below).
After hours, this may not be possible.
Risk factors for CAN are sometimes categorised as including:
- Factors relating particularly to specific vulnerabilities of the child, such as age, gender, preterm delivery, disability, issues of behaviour or temperament
- Factors relating particularly to the caregivers, such as spacing of pregnancy, unplanned pregnancy, young age, absence of support (e.g. single mother), alcohol or drug abuse, untreated depression or other mental illness, mother with a male partner who is not the father of the child, IPV, distorted perceptions of the child based on the caregiver's past experience or on other factors unknown to you (such as how the child was conceived or by whom), a past history of abuse or neglect, no fixed abode
- Wider community or environmental factors, such as poverty
However, risk factors by themselves have a relatively low predictive value for abuse - that is, abused children may present with no risk factors at all, and non-abused children with multiple risk factors. There is evidence that health professionals are more likely to miss a diagnosis of CAN in families with no apparent "risk factors". A decision to perform a thorough assessment for CAN should not be made on the basis of the presence or absence of "risk factors" alone.
- Don't forget the family history. That includes matters of relevance to inherited disorders (such as bruising or bleeding disorders, bony fragility or sudden death).
- Don't forget the siblings. You should always obtain the names and dates of birth of the child's siblings (especially those under 5 years old), and look up their NHI.
- Contact primary healthcare providers. If possible, contact the child's usual GP or, in the case of a young infant, the midwife and/or other Well Child provider.
- Conduct a thorough examination
- This must be a complete physical exam including percentiles for height and weight (and head circumference if less than 2 years old).
- Careful physical inspection from top to toe, including scalp, ears (including behind the pinna and the side of the scalp), oral cavity (including the frenula and the teeth), trunk (including axillae and buttocks) and limbs (including the inner aspect of the upper arms).
- Careful documentation of all bruising and external injuries on a diagram. Comment on colour, outline, shape, size, swelling, tenderness and any underlying structures (such as ribs or iliac crest). Describe in detail any pattern. Measure the dimensions and record them on the diagram. With multiple injuries it is helpful to number them, put the number in the correct location on the diagram and the full description for that numbered injury beside the diagram or in the text. Whether or not photographs will be taken, always document on the premise that photos may be inaccurate or misleading. Do not make any statement about the age of bruises based on their colour (this is unreliable).
- In infants under the age of 2 years, consider examining the fundi through dilated pupils (Cyclopentolate 1% and Phenylephrine 2.5% are available in CED and 25B). In infants requiring hospital admission, this examination is best done by the ophthalmology registrar on call, using an indirect opthalmoscope. If retinal haemorrhages are found, urgent confirmation by a consultant ophthalmologist is mandatory, and the ophthalmologist will arrange for Retcam photographs to be taken.
- Investigations. These will vary according to the specifics of each case
- FBC and coagulation screen (APTT, INR) if bruising or bleeding. If a strong personal or family history suggestive of a bleeding disorder, consider a Von Willebrand's screen (establish the child's blood group, as VW Factor levels vary). Do not perform a bleeding time - the sensitivity and specificity of this test is poor. If you remain concerned about the possibility of a bleeding disorder, discuss with a haematologist.
- Urine organic acids. This is a screening test for Glutaric Aciduria Type I, a condition that may rarely be confounded with abusive head trauma.
- Skeletal survey in infants less than 2 years old (and some older children). A SKELETAL SURVEY IS NOT A SCREENING TEST FOR CAN.The Paediatric Radiology Department will decline a request for skeletal survey if the child has not been referred to Te Puaruruhau, who will organise it (if indicated) as part of a complete assessment
- No skeletal survey for suspected NAI should ever be performed without a full explanation to the family, beforehand, of the reasons why it is being done. Te Puaruruhau have a parent information pamphlet about this (SSH/3021/013). Skeletal surveys can be done on weekends by special arrangement, but never overnight.
- Nurse Specialists from Te Puaruruhau assist the radiographers to position the child and support the caregivers for the survey, but the ward may need to supply another nurse. Parents, social workers and other staff are not asked to help restrain the child. For children > 1 year, sedation may be advisable. If an abnormality is reported on X-ray, always obtain a consultant radiologist's opinion before you speak with the family.
- In infants, a repeat skeletal survey 2 weeks later is usually indicated - this may detect recent bony injury not visible on admission.
- Rarely, an acute bone scan may also be indicated. These are particularly helpful with rib fractures (where a bone scan may be positive a week or more before rib fractures become apparent on plain x-ray), and with fractures in unusual places (scapula, pelvis). However, they are not specific around the physes of the long bones, false negatives may occur and there is a significant radiation dose. Currently in Starship, many children will receive two skeletal surveys and very few will have a bone scan.
- CT head scan (without contrast) is always indicated along with skeletal survey for non-accidental injury in an infant < 12 months, even if the infant has no signs of head injury. It should also be considered as a possible investigation in all children 1-2 years old with suspected non-accidental injury. If there is a skull fracture, always ask the radiographers to perform a 3-D reconstruction of the skull. In Starship Radiology in a young baby, CT scan can often be performed as a rapid "feed-and-wrap" procedure, if there is good co-ordination between the ward and the radiology department.
- MRI brain scan if you suspect abusive head trauma. If neurosurgery is expected, the MRI should be done prior to surgery if at all possible. Include the entire spinal cord, and a full set of sequences appropriate for NAI (including gradient echo sequences, diffusion-weighted images and susceptibility-weighted images). MRI is much more sensitive than CT for parenchymal injury and small subdural collections, and often more useful in assessing the possibility of repeated injury. Any child with non-accidental injury who has equivocal or positive findings on CT, will also require MRI. Although "fast MRI" can sometimes be used for other purposes, in the context of suspected NAI the kind of detail required will almost always require a general anaesthetic.
- Other investigations as appropriate.
Photographs are usually helpful to document soft tissue injuries, especially if they are complex. They are often very helpful in explaining the injuries in a Family Group Conference or Court. However, thorough written documentation and body diagrams are always required, and cannot be replaced by photographs.
Photography is just another form of medical documentation and does not require written consent, although obviously it should be explained to the family just as you should explain everything you do. As the examiner you can photograph the injuries yourself, although sometimes the ADHB Photography Department (25166) may be able to assist. Ideally, incorporate a scale measure and a staging photograph (which puts each bruise or abrasion in the wider context of the part of the body where it was seen) as well as close-up photographs.
If photographs are taken, record the fact in the notes, including the name of the photographer, the time and date and the device on which they were taken. Photographs may be taken on any camera (including a mobile phone), as long as it is explained to the child and family that the photographs will be transferred to ADHB clinical records at the first opportunity and deleted from the digital device on which they were taken. Name the digital images with the patient NHI and forward them to clinical records (Medphoto@adhb.govt.nz) as soon as possible.
Every week on Thursday, Te Puaruruhau peer reviews all photographs of cases seen for suspected CAN that week. It is recommended that you inform Te Puaruruhau of any photographs taken for suspected CAN, and attend the next Te Puaruruhau peer review to discuss the case. Te Puaruruhau will ensure that any photographs forwarded to them for peer review (TEP@adhb.govt.nz) are forwarded on to ADHB clinical records.
If the Police are involved, they may be able to arrange photographs through their on call photographer, in which case the photographs will be the property of the New Zealand Police. You may be able to request a copy from the Police for the hospital record. Record in the clinical notes the name and contact details of the Police officer involved.
- Relieve symptoms and provide support for the child and family
- Provide appropriate health care
- Determine if admission is necessary
- If there is injury, complete an ACC form
If the child needs admission in the context of suspected NAI, a Watch will be required, who must be in the room with the child at all times. This is the default policy, although in exceptional circumstances, a variation can be agreed by the Te Puaruruhau paediatrician
If, for exceptional reasons, there is a decision by Te Puaruruhau not to place a Watch in the room, this will be documented very clearly in the notes by the Te Puaruruhau consultant.
You must clearly explain to the family at the time of admission, the reason for the Watch. It is not the role of the Watch to explain to the family the reason why they're there.
In addition to the Watch, safety can only be addressed as a carefully planned collaborative procedure between ADHB, Police and CYF. Further details are provided below, but this will usually be managed by staff from Te Puaruruhau who are familiar with the procedure.
Assessment for sexual abuse
If you are dealing with concerns about sexual abuse (for whatever reason), always discuss the matter with Te Puaruruhau before the family leave the hospital.
The approach to suspected sexual abuse is similar to that for other kinds of CAN, except that all examinations for sexual abuse require the presence of the Te Puaruruhau Paediatrician on call.
If forensic evidence of sexual assault is required, this will be collected by the Te Puaruruhau doctor on call using the Police Medical Examination Record.
- Initial assessment of concerns about sexual
This may be simply a brief history. You need a description of the timing and nature of an alleged assault, injuries or symptoms. If the source is the child / young person or caregiver, take the briefest history necessary to determine whether there is in fact a sexual abuse concern and its severity and acuity. This needs to be done in a non-judgmental style using open questions as opposed to leading questions. If the child or adolescent is Māori, consider involving Kaiatawhai.
- Open questions allow the child / young person to provide the answer: "What happened then?", "How come your fanny is sore?", "Is there any part of your body you're worried about and you'd like me to check?"
- Avoid leading questions, which suggest the answer: "Did Uncle Bob touch your fanny?", "Did he pull your pants down?"
- Avoid "did" questions. Try to use "what" or "how". Try to record verbatim what you ask, and the response.
- Deciding if assessment by Te Puaruruhau is
If you have a concern about sexual abuse, always talk it over with Te Puaruruhau. Factors influencing the urgency of a Te Puaruruhau assessment include:
- Acute symptoms (e.g. bleeding, pain, vaginal discharge)
- Forensic Issues. Forensic evidence may be obtained up to one week after acute sexual assault, but the best chance is within 72 hours (in children, 24 hours). If there may be semen or saliva on the skin, a few hours make a big difference. Note: If the young person has not changed or washed, evidence may be obtained from clothing and skin. If he or she wishes to urinate while awaiting their forensic exam, ask them not to wipe the genital area.
- Child or family distress. Sometimes, there may be no physical symptoms or forensic issues which demand an urgent response, but the child / young person or their family are so distressed or anxious that an urgent assessment is still indicated.
- Safety. Sometimes there are complex issues of safety which need to be addressed (which may be wider than sexual abuse, such as associated IPV), even when the circumstances of what actually happened remain unclear.
- Age of the child. In verbal children (able to be evidentially interviewed), if there are no urgent issues it is generally preferable for the child to have their evidential interview prior to their medical examination. In pre-verbal children or children whose verbal abilities are limited, the medical examination may take place without a preceding evidential interview.
- Involving Te Puaruruhau. Decisions about initial management should be made in conjunction with Te Puaruruhau. During the day contact the team directly. After hours contact the on call Te Puaruruhau paediatrician. If the child or young person has been referred into Starship (whether by a GP, CYF or the Police), in most cases, Te Puaruruhau will also need to speak to the referrer direct.
See pages 45-49, Family Violence Assessment and Intervention Guidelines 2016.
Ultimately, particularly after discharge, ensuring the safety of the child is the responsibility by law of CYF and the Police. However, you also must consider the child's safety (including in hospital) and contribute to safety planning, in conjunction with Te Puaruruhau.
Generally, children presenting to Starship and considered to be at serious risk from CAN, should be admitted. However, admission does not ensure safety (see below). It must be followed by close liaison with CYF and the Police to develop and implement detailed plans to ensure safety.
In most cases, this liaison will be undertaken by Te Puaruruhau. Unless it is an emergency, your first step should be to consult with Te Puaruruhau. Puawaitahi (the multi-agency centre of which Te Puaruruhau is a part), has a detailed set of operational guidelines to guide the process of liaison with CYF and the Police. For inpatients with NAI, these guidelines have been incorporated as Schedule One under the National MOU between DHB, CYF and the Police.
In the case of children admitted with suspected NAI, Schedule One requires a face-to-face inter-agency case conference within 24 hours of admission. At this Case Conference, the first draft of an inter-agency Multi-Agency Safety Plan (MASP) is developed.
The case conference process and MASP format can also be used for other presentations of abuse and neglect, including antenatal concerns (through Wahine Ora).
There are often situations where, after assessment by Te Puaruruhau, ADHB is able to conclude that there are no child protection concerns. In these cases, the matter may not require a case conference, and the Watch (see below) may be discontinued after a day or two of assessment.
- The child who is seen not admitted.
A child where abuse is suspected may only be discharged if the discharge checklist (see below, and in the Te Puaruruhau Record Booklet) can be completed. If hospital staff are not confident that the arrangements proposed for safety are adequate (even if those arrangements are proposed by a statutory social worker), the child should not be discharged.
- Caregivers who threaten to walk out with the
In an emergency, alert the Duty Manager, call Code Orange and the Police. It is very rare for caregivers actually to remove a child once ADHB staff have raised a concern with a family about possible CAN. However, if a family threaten to do so, you cannot physically prevent them unless you form the view that their action will result in "immediate and serious injury" to the child. Although what this means is not clearly defined in law, you can almost always negotiate successfully with a family - if necessary pointing out that if they leave, you will be asking the Police to bring them back.
- Caregivers who threaten the child or staff in
Again, call Code Orange and the Police. The ADHB Duty manager can issue a Trespass Order against a parent or caregiver who is behaving in a threatening fashion.
- The reason for a Watch: admitting a child to hospital
does not ensure their safety
It may temporarily reduce the risk. Usually, we do not know at the time of admission who caused the injuries. Children have (rarely) been assaulted by their caregivers even in hospital. Hospital staff do not have the statutory authority to prevent a child's removal from hospital (except in extreme circumstances) nor to prevent the visit of persons who may pose a risk to the child.
Any child admitted to ADHB for concerns about possible NAI must have a Watch in the room at all times. A rare exception might be a circumstance where NAI is such a remote possibility that a Watch is not justified. Such a decision can only be made by the Te Puaruruhau team, and the Te Puaruruhau consultant will ensure that the reasons are clearly recorded in the clinical notes and communicated to the hospital team under whose care the child is admitted (Watch Policy).
In the ADHB, the Watch is usually an enrolled nurse or a nurse aide. It may be helpful to point out that the Watch is there to watch the child, not the family, and the presence of a Watch offers benefits to the family as well as the child (one-to-one attention and supervision for the child).
You must clearly explain to the family at the time of admission, the reason for the Watch. It is not the role of the Watch to explain to the family the reason why they are there.
The Watch should receive clear instructions from the Charge Nurse or Midwife or Duty Manager and will record observations on a watch record sheet which will become part of the Clinical Record.
The Te Puaruruhau information handout provides written information about the Watch.
For inpatients, the Te Puaruruhau paediatrician, nurse specialist and social worker involved will leave their contact details (including their cellphone numbers) clearly recorded in the clinical notes.
Every inpatient under assessment by Te Puaruruhau where a decision has been made to make a Report of Concern to CYF should have a Paediatric safety plan (CR9118) on the ward clearly recorded in the clinical notes, a copy of which is sent to the Duty Manager.
Staff should explain to a child old enough to understand how they can seek help if they feel unsafe (e.g. press the buzzer for a nurse). If, in exceptional circumstances, a Watch is not deemed necessary, the reasons will be stated clearly.
Inform security if there are identified safety concerns regarding a person visiting a child.
The Paediatric Safety Plan is usually completed by a health social worker, as follows:
|Current Situation:||Brief summary of current care and protection concerns|
|Custody / Guardianship:||Who will be signing consent forms|
|Previous Safety Plans and dates:||Antenatal. Multi-Agency Safety Plan, other|
|24 Hour Watch:||Details|
|Plan (if family try to remove the child)||Code Orange / Police / CYF|
|Access/visiting arrangements:||How it will be managed, requirements|
|Te Puaruruhau contacts:||Including after-hours social work|
|Who to contact if child is likely to die:||Police / CYF / Te Puaruruhau|
|Social Work support:|
The CYF Information Sheet CR2150 (Forms Library) should be placed in the hospital records for children where CYF is involved. This contains the CYF social worker's contact details, a description of the child's legal status with CYF, etc. It also provides an opportunity for the CYF social worker to provide additional information to be incorporated in the ADHB inpatient records. If the CYF social worker visits the hospital, they can add to the CR2150 by requesting hospital staff to remove it from the chart, allow them to update it and then replace it in the chart.
After a Report of Concern to CYF is made, Te Puaruruhau (usually the social worker) will:
- Continue to liaise with CYF until the child or young person is safe.
- Provide any written requested information from ADHB, after CYF has provided a written request under section 66 of the Children, Young Persons and their Families Act.
- Keep hospital staff informed of developments relating to the care and protection concerns.
- Ensure a comprehensive safety plan (as above) is placed on the child's inpatient file for all ADHB staff, and update this plan at regular intervals.
- Invite the CYF Social Worker to relevant hospital meetings.
- Work with CYF to ensure completion of a Multi-Agency Safety Plan (MASP) prior to discharge, with an agreed set of recommendations for follow-up after discharge.
- Provide a provisional discharge date for the CYF Social Worker as early as possible
- Consult with the ADHB CYF Liaison Practice Leader if concerns arise that they cannot resolve
Working with Child, Youth and Family (CYF) and the Police
See pages 45-49 Family Violence Assessment and Intervention Guidelines 2016.
Interagency practice between ADHB, CYF and the Police is guided by the Memorandum of Understanding (August 2011) and associated schedules, including:
- Children admitted to hospital with suspected or confirmed abuse or neglect
- Child, Youth and Family/District Health Board Liaison Social Worker.
- Joint Standard Operating Procedures for Children in Clandestine Laboratories
- Neglect of Medical Care
Additional schedules are likely to be added over time. The above documents are or will be available from the Clinical Network for Child Protection (Clinical Network).
ADHB policy is that all cases of suspected CAN must be notified to CYF. For cases being managed by Te Puaruruhau, this is usually done by Te Puaruruhau.
However, there are also children and young people who come through ADHB who are already involved with CYF, or who have been referred to CYF because of their degree of apparent risk, without the involvement of Te Puaruruhau. In such cases, the team social worker will often be the key liaison person between ADHB and CYF.
Any ADHB clinician, after internal consultation, can make a Report of Concern to CYF.
Child Youth and Family
Child, Youth and Family has the statutory responsibility for ensuring the safety of children. If you suspect abuse, after consultation within the ADHB as described above, the matter must be referred to CYF. CYF terminology for this is a "Report of Concern" (ROC).
This table summarises some key differences between statutory and health social workers. However, CYF social workers also work in partnership with families/whanau, and under the "Partnered Response" approach, work with community agencies to support families.
|Child Youth and Family||Health or community social workers|
|Non voluntary involvement||Voluntary involvement|
|Statutory obligation (CYPF Act 1989)||Partnership with client|
|Powers of investigation||Facilitate empowering processes|
|Powers to uplift / over-ride parental rights||No statutory powers|
|Investigative / assessment approach||Therapeutic approach, psychosocial support|
The role of the ADHB CYF Liaison Practice Leader (917 5391).
This is a CYF Social Work Practice Leader - a senior position within CYF (similar to a clinical director), based in Puawaitahi and available to all services within the ADHB.
The position exists primarily to address systemic issues of communication and case management between the two organisations (see 'Resolving problems with CYF'). During business hours, the liaison Practice Leader is available for consultation by staff of either ADHB or CYF in relation to these issues. He / she may also be involved in assisting the referral process and working through any issues or areas of concern that arise. Feedback will be given to all staff involved in the concerns.
Reporting to CYF
In the legislation, there are two ways to notify CYF:
- ROC under section 15 of the Children Young Persons and Their Families Act (CYPFA). This is the usual path from ADHB. All such referrals go through the National Contact Centre. The call centre will identify which office will be responsible. (There are 14 site offices in metropolitan Auckland, and a case will go under a particular site according to residential address).
- Under section 19 of the CYPFA to a Care and Protection Co-ordinator. Seldom used by ADHB.
If concerns arise for someone already involved with CYF, contact the relevant site office through the Contact Centre. When ADHB social workers are available, they often manage this.
If the child or young person is from outside the Auckland area, Grey Lynn CYF will assist with the case (by negotiation) with the originating office retaining on-going responsibility. If the referral occurs after-hours, Grey Lynn will take interim responsibility for the case.
How to contact the Contact Centre
Ring 0508 326 459 (FAMILY) and request the site or staff member you are after. The Contact Centre now operates 24 hours, 7 days per week. If unable to contact the on-call social worker, ask for the CYF Social Work Supervisor. If this person is also unavailable, ask them to contact the Site Manager for the office involved, or if necessary the Regional Manager.
If you can't contact CYF and you are concerned for the safety of a child, contact the Police.
Making a Report of Concern
Urgent ROC should be made by phone. However, all ROC must also be made in writing. Find the ROC template under Clinical Forms on the Intranet (Clinical Forms). Click on Forms Library, click on Search, enter CR2692, download it and fill it in.
Te Puaruruhau social workers are available to assist you with completing a ROC if you are unfamiliar with the process or would like some moral or technical support.
Email the ROC to the CYF Contact Centre (email@example.com), copied to Te Puaruruhau (TEP@adhb.govt.nz). This enables audit of ADHB referrals to CYF and also enables linkage (where appropriate) to the Child Protection Alert System.
The ROC (CR3692) is barcoded and will be forwarded by Te Puaruruhau to Medical Records, where it will be entered into 3M and be available in the "Child Protection" document subcategory.
Specify an ADHB contact person
ADHB must tell CYF who the designated contact person within ADHB is, and their contact details (email address, mobile phone number). This is often the person who makes the ROC. If not, it should be a key clinician in the case who is usually available.
Child, Youth and Family Process
Child Youth and Family will respond to a section 15 report from ADHB within the time frames established for the service (CYF Intake Decision Response Tool).
- Critical. Response time: immediate (within 24 hours)
- Very Urgent. Response time: within 48 hours
- Urgent. Response Time: within seven working days
- Low Urgency. Response time: within 20 working days
The Contact Centre acknowledges and triages the ROC. If they believe the child needs care and protection, they refer it to a CYF site office for Assessment or Investigation. Assessment is the responsibility of CYF. Investigation is a joint process between CYF and the Police for concerns of serious harm, and is governed by the CPP (Child Protection Protocol).
Once the ROC is received on site, it should be allocated to a specific social worker within the time-frame of the designated response category.
The allocated social worker should:
- Contact the notifier to get any update of the concerns
- Be responsible for investigating the concerns and determining if they are substantiated. CYF acts as the lead agency in that regard.
- Liaise closely with the notifier throughout the assessment or investigation. The CYPFA (Section 17, 3) states that the notifier must be informed as soon as practicable after a ROC has been investigated or a decision has been made not to investigate. The social worker should communicate the outcome by talking with the notifier (not by leaving a message), or in writing.
- Provide a written request for information under section 66 if asked to do so.
- Be clearly identified on a CYF Information Sheet (CR2150) in the hospital records (if the child is admitted), with their contact details.
- Inform hospital staff at the beginning and end of a visit to a child or young person on the ward and be able to produce CYF Identification.
- Inform hospital staff of the plan after each visit. CYF social workers will ensure that as plans develop and after each visit, they discuss what is to occur with the relevant ADHB staff member and ensure that the information is recorded clearly on the CR1250.
- Recognise that the ADHB has specialist expertise in the identification of CAN
- Invite relevant hospital staff to any case conferences.
- Contact the CYF ADHB Liaison Practice Leader if any concerns arise about the relationship between ADHB and the Department.
- Find a placement for the child or young person once he/she is medically ready for discharge and it is not safe for the child or young person to return home.
Case Conferences and Discharge Meetings
These are vital to help ensure that:
- All professionals involved are aware of, and in agreement with, the child protection concerns
- There is a clear plan for who is going to do what and when, and how the inter-agency plan will be monitored and reviewed. This should be specified in a Multi-Agency Safety Plan (MASP)
CYF social workers should be invited to all discharge meetings and relevant case conferences for a child or young person where care and protection concerns exist, and are expected to attend if the child/young person is in the custody of CYF.
Planning for discharge when a child is to be discharged into the care of CYF
Sometimes, a child will not be able to return home to the circumstances from which they were admitted. When discharged, they will go into the care of caregivers appointed by CYF, who may or may not be members of the extended family. This can be a very difficult and stressful time for children, families and staff, and requires careful planning. This will require a planning meeting involving Te Puaruruhau / social work staff, CYF, ward staff and others (such as cultural support, mental health support) which should take place no less than 24 hours before discharge.
As a general rule, discharges into the care of CYF should be planned for the morning shift when the Charge Nurse or other senior nurses can be present to assist with a smooth process.
Should the Police be notified?
For children admitted to hospital with suspected CAN, the simplest answer is "Yes". Children who are not admitted may or may not need to be referred to the Police, depending on the precise circumstances (the type of abuse alleged, immediate safety concerns, etc). Usually, the decision to involve the Police will be made either by Te Puaruruhau, or in consultation with Te Puaruruhau.
If there is a critical issue of safety, such as a child who is about to be removed from the Starship and in your opinion is in imminent danger, call the Police.
When a child presents with severe or potentially fatal injuries, notify the Police at once. Although it may not be possible for them immediately to interview family, inspecting the scene where the injury took place may be crucial to success in identifying the person responsible.
By agreement, CYF and the Police should notify each other of any case meeting the criteria set out in their Child Protection Protocol (CPP). This does not always occur in a timely fashion. If in doubt, it is safe practice to notify both agencies of any case that you think may need the help of both.
There are specialist Police Child Protection Teams covering Waitemata - two teams (09 477 5234), Auckland (09 367 0291) and Counties Manukau - two teams (09 353 0033). They are not available after hours, when the CIB deals with the case initially. There is one 24-hour number for the Northern Communications Centre (302 6400). If there is no urgency to contact the police you may wish to leave this to Te Puaruruhau.
Release of information to Statutory Authorities
A central principle of the MOU between ADHB, CYF and the Police is that all three agencies agree to "share information with any party that could help to keep a child or young person safe and well, in a manner that is consistent with the law."
ADHB staff can release information to CYF or the Police if we hold concerns for the safety of the child or young person, or if ADHB holds information relevant to care and protection issues that are under investigation by CYF or the Police.
If ADHB is making a ROC then we should provide all relevant information in the ROC. If CYF approach ADHB for information, they will usually do so under Section 66 of the Children, Young Persons and Their Families' Act. This states that every government department or statutory body must supply information about any child or young person to a Care & Protection coordinator, a statutory social worker or a member of the Police for the purposes of:
- determining whether the child or young person is in need of care or protection (other than on the grounds of section 14(l)(e))
- Any proceeding under the care and protection provisions of the CYP&F Act.
No application to the Court by CYF is required, but we should review the documents to ensure that there is no information that should not be released (such as the private health information of a parent or caregiver, or private information concerning a third party).
If you are uncertain, seek advice prior to release of information (refer to Privacy policies)
Maintaining medical records on the ward
The child's medical record is the property of the ADHB. The contents of that record are private to that child. In the context of CAN, the caregivers do not have automatic right of access. It is recommended that the medical record is kept in a secure place where caregivers cannot read it without seeking permission (not, for example, at the end of the bed).
It is important that all staff observations are recorded in the notes. If you observe verbal abuse, unusual parent-child interaction or aggressive behaviour, document it. Documentation of the facts of what was observed is legitimate, and may be extremely important in ensuring safety of the child.
In most cases, good communication between hospital staff and caregivers should ensure that there is nothing in the hospital notes that the caregivers do not already know.
If caregivers formally request copies of the notes, this request should go through Medical Records and the Release of Information Officer. The consultant or other senior clinician involved in the child's care should screen the records to determine whether there is anything in the record that needs to be explained to the caregiver in person, or which should not be released.
Even in cases of confirmed CAN, it is generally appropriate to release the clinical records to the parents, once the above process has been followed. In cases which proceed to a criminal trial, the contents of the records will eventually become available to the defendants through their lawyer.
There is a Board Policy which discusses when information may be withheld from a guardian (Legal Issues relating to Children - ADHB only). If the request is refused, the child's guardians have the right to appeal to the Privacy Commissioner for a review of that decision.
The child who dies
Every year, several children die in Starship (usually in PICU) from CAN. The death automatically becomes a Coroner's case, and a post-mortem will be required. The procedures followed in the case of any death should of course be followed here also. Points to note are as follows:
- Even if the child is expected to die soon after admission, always notify Te Puaruruhau as soon as possible on admission, so they have the opportunity to become engaged with the family prior to death. They can work with CYF and Police to ensure the safety of siblings, and liaise with the pathologist and paediatric radiology concerning post-mortem CT and skeletal survey.
- Notify the Police early in the admission, so a scene inspection can be conducted if indicated. This notification is usually done through Te Puaruruhau.
- The Police will treat this as a homicide. They will put in place a designated investigation team. If Starship has contacted the Police well in advance of death, we can plan how the Police will be introduced into the scene and how the transfer of the body to the Police will be managed.
- The Police have an Iwi liaison officer, whom they will involve when dealing with Māori whanau. Once again, this should be planned in conjunction with Kaiatawhai and ADHB social workers.
- The Te Puaruruhau Paediatrician involved will usually attend the autopsy, to facilitate full communication and co-ordination with the pathologist.
- These cases may be reviewed at an Inter-Agency Case Review meeting. Hospital personnel involved in the case are welcome to attend, and this provides a forum where any difficulties in the management of the case can be addressed.
Adequate follow-up by health-care services must be arranged prior to discharge, either through Te Puaruruhau or ADHB outpatients, or by referral to locality-based health services.
This should be included in the Multi-Agency Safety Plan (MASP), developed collaboratively with CYF, other agencies, family and disseminated to everyone involved at discharge.
Infants with non-accidental head injuries must be followed up comprehensively, as would be the case for any infant with a severe head injury. This involves lodging an ACC claim, adequate education of proposed caregivers prior to discharge, provision of car seats, formal referral via ACC to visiting therapists, and regular follow-up through outpatient clinic. It may also require the co-ordination of ophthalmology follow-up, outpatient audiology and sub-specialist appointments.
In most cases, a formal discharge planning meeting will be required, and strenuous efforts should be made to have the CYF caseworker (and the prospective caregiver) present at this meeting.
It is important to document thoroughly in the MASP the names, addresses and phone numbers of CYF social workers and caregivers likely to be involved in the child's care after discharge.
Copies of all appointments should be sent to the allocated CYF social worker. If a child leaves hospital in the custody of CYF, then the postal address and phone number recorded in the hospital information system should be the address of the CYF site office involved, and the DDI (Direct Dial- In phone number) and mobile number of the allocated CYF social worker. This information should be incorporated in the MASP, along with email addresses and the names and contact details (both telephone and email) of all health professionals and others (such as Police officers) with responsibilities for the plan of action after discharge.
In most circumstances, discharge letters and medical reports where there has been a concern about CAN should be as comprehensive as possible. Your colleagues may rely on them in the future to help guide their decision-making. Unless you have a very good reason to leave a piece of information out of your report, you should put it in. "Social concerns" is a euphemism which is unhelpful to just about everyone: child or young person, family and other professionals.
Any child or young person who is examined by a medical officer within the ADHB and diagnosed with any form of CAN should have a formal typewritten Child Protection Report. This is a specific document category on Winscribe which (after approval) is transferred automatically into 3M, where it appears under the Child Protection document subcategory.
This includes children and young people who are seen not admitted from Children's ED. If such a child has been discussed with Te Puaruruhau, the Te Puaruruhau paediatrician involved will either write the Report or supervise the Registrar who saw the child to write the Report.
Such Child Protection Reports are visible regionally on Concerto, and are an important part of ensuring that other health professionals in the Auckland region have ready access to comprehensive child protection information. They should be dictated and approved as soon as practically possible after the child or young person has been seen and should be sent to CYF and the Police as well as the primary healthcare provider.
One example of how to write a Child Protection Report is available here, and Te Puaruruhau Paediatrician can provide guidance or peer review for the text of these reports.
Child Protection reports should be dictated on Winscribe, using the Soprano MedDocs Child Protection Report format. This is accessed as Department 112, and the Job Type ID is 34. These reports must be read and counter-signed by the consultant with whom the child was discussed.
In a Child Protection Report, you should always include the names, dates of birth and NHI of the child's siblings, especially if the siblings are under 5 years old.
If you are later asked to provide a formal statement for the Police, always discuss with the consultant paediatrician or other senior clinician who supervised you, and never sign such a statement without having had that discussion first. An example of what a formal statement looks like is provided here.
Four days a week at 0830 (Monday, Tuesday, Thursday and Friday), Te Puaruruhau discusses all referrals received in a multi-agency referral meeting with CYF and the Police in Puawaitahi.
Every Thursday morning, beginning at 0900, the Te Puaruruhau team reviews all children and young people seen by the team in the previous week.
If you have referred a case to Te Puaruruhau, you are welcome to attend the referral discussion. You are also welcome to join the peer case review on Thursday. This is an essential part of quality assurance in an often difficult area of practise, and you are encouraged to attend.
At these meetings, the team decides whether to register a "Child Protection Alert", including siblings (see below). If you believe an ALERT is warranted, follow the process detailed in the ADHB Policy. Once again, you are welcome to join Te Puaruruhau for this discussion.
If you have any concern about a breakdown or failure in ADHB processes that have led to difficulties in management of a case of suspected CAN, lodge an "Incident Report" through the ADHB system for monitoring and responding to quality issues.
All DHB belong to the National Child Protection Alert System. This system exists because child abuse is serious, it recurs, is often missed and many children move between DHB.
The system alerts us that there have been care and protection concerns in the past, and prompts a thorough assessment to ensure we do not miss any indicators of continuing abuse or neglect.
DHB place Alerts on children and young people under 17 where three criteria are met:
- The DHB made a Report of Concern to CYF (or we have become aware that the child or young person is currently a client of CYF for care and protection).
- The decision to place an Alert is agreed by a child protection multi-disciplinary team meeting
- There is information on the clinical records good enough to provide useful information to another health professional who accesses the record in response to the Alert
Most children and young people reported to CYF by ADHB will meet criteria for an Alert. Sexual assault is an exception. This is because the information is often highly sensitive, the victims are often adolescents, and the circumstances may be such that continuing care and protection issues do not arise. Unless there are continuing safety issues, an Alert is not placed routinely on victims of sexual abuse. Their records are not incorporated into 3M but held separately in Te Puaruruhau.
The Alert comes off when the child turns 17 years, and can be taken off earlier at the request of a child or their caregiver, following the same MDT process that put it on.
Placing an Alert
When you make a ROC to CYF and copy it to Te Puaruruhau, that initiates an Alert discussion. Te Puaruruhau will make the decision and inform Medical Records by lodging a "Clinical Alert Notification" (CR0008), along with the documentation behind the Alert.
You can also explicitly request an Alert be placed by forwarding a CR0008 to Te Puaruruhau, accompanied by a copy of the appropriate documentation.
Siblings and Child Protection Alerts
Siblings may also be at risk, particularly siblings under 5. Every such sibling of a child reported to CYF by ADHB for possible CAN, should also be assessed for CAN. If a sibling is identified to be at risk, reporting to CYF is mandatory and a Child Protection Alert must be placed.
Checking for a Child Protection Alert placed by the ADHB
When the child or young person presents to ADHB services, a red exclamation mark will appear on the electronic whiteboard. This exclamation mark is used for a wide variety of Alerts, e.g. "Medication Allergy". If you click on the exclamation mark, you will find out what type of Alert this is.
Alternatively, on the Concerto home screen you will see "Clinical Alert" in red type on the blue Menu Bar next to the child's name. If you click on the Orange Triangle icon to the right of the Menu Bar, it will tell you what type of Alert it is. This only pulls up Alerts lodged by the ADHB.
Checking for a Child Protection Alert placed by other DHB
For Alerts lodged by other DHB, you need to scroll down to the section entitled National Medical Warnings, and click on the option to Display updated NHI Medical Warnings. This will upload any warnings loaded on the National Medical Warning System.
Getting the information behind an ADHB Child Protection Alert
You need to access the comprehensive information behind the Alert, which will be under the Document SubCategory column in 3M - order it alphabetically and look under Child Protection:
- A Report of Concern
- A Child Protection Report (Soprano Meddocs, also be visible on Concerto)
- An Alternative Child Protection Report (for children already in the care of CYF, or sometimes for a young person with confidential information who has ongoing risk, e.g. family violence).
If there is no child protection information in 3M, contact the clinician who requested the Alert (the name on the Alert Notification / Cancellation Form in the Alert under Document Category in 3M). Please also email Te Puaruruhau (TEP@adhb.govt.nz), so we can follow this up.
Getting the information behind a Child Protection Alert from another DHB
You will need to get Medical Records to contact the other DHB and obtain the information behind the Child Protection Alert which they placed.
What do I do if I find a Child Protection Alert?
Don't panic, jump to conclusions or be judgmental. Most parents will not know an Alert exists. Find the information which prompted the Alert, take it into consideration, perform a thorough assessment and discuss the patient with a senior clinician prior to discharge.
Have a low threshold for discussing these cases with the Te Puaruruhau team
If a mother providing care for a child, discloses intimate partner abuse during family violence routine enquiry a family violence alert may need to be placed on the mother's health record. If this occurs please refer to Partner Abuse Intervention - Family Violence Policy
Discharge Safety Checklist
If you suspect CAN, the child should only leave hospital if ADHB can answer "YES" to all of the following:
|Is the child safe at home?||Yes||No|
|Is the child medically fit for discharge?||Yes||No|
|Have you discussed discharge with a Senior Medical Officer?||Yes||No|
|NAME OF SMO:|
|Have you completed an ACC form?||Yes||No|
|Have you discussed with Te Puaruruhau?||Yes||No|
|Has a referral been made to Child, Youth and Family?||Yes||No|
|NAME OF CYF SITE:|
|NAME OF CYF SOCIAL WORKER:|
|Have you tried to act with cultural safety?
(For example, have you tried to involve Kaiatawhai if the child is Maori; or the Pacific Tautai Fakatha Service if the child is of Pacific Island ethnicity)
|Has someone been appointed to write a Child Protection Report?||Yes||No|
|NAME AND MOBILE NUMBER OF REPORT WRITER:|
|Have you tried to contact the Primary Care Provider (eg LMC or GP)?||Yes||No|
|NAME AND PHONE NUMBER OF PRIMARY CARE PROVIDER:|
|Has appropriate follow-up been arranged?||Yes||No|
|Have the caregiver and CYF been told the follow-up arrangements?||Yes||No|
DATE AND TIME:
|Do you have a reliable address and telephone number?||Yes||No|
|Do you have an alternative contact address and/or phone number?||Yes||No|
|ALTERNATIVE CONTACT NAME:
ALTERNATIVE CONTACT ADDRESS:
ALTERNATIVE CONTACT PHONE NUMBER:
A Summary of Guardianship, day to day care and contact
This is a summary. For further information (ADHB staff only) see the Legal Issues Relating to Children Policy on the intranet under Policies and Procedures.
NOTE: From 1 July 2005 the Guardianship Act 1968 was replaced by the Care of Children Act 2004. Custody and access were replaced by 'day to day care' and 'contact', with a greater emphasis on shared care arrangements. Parents may agree an arrangement or the courts may impose it through a parenting order. Existing custody and access orders continue with the terminology changed accordingly.
|Duties, powers, rights and responsibilities of a parent in
relation to the upbringing of a child, including:
- day to day care of a child (except in the case of a testamentary guardian)
- contributing to the child's intellectual, emotional, physical, social cultural and other personal development
- determining, for or with the child, questions about important matters such as medical treatment (not of a routine nature - routine medical
care falls within 'day to day care')
- Other rights and responsibilities vested by statute
|Day to Day Care||Contact|
|Rights and responsibility for routine care of a child, for a
Includes care for specified days or parts of days (unlike custody both parents are likely to have day to day care for specified periods).
Includes medical treatment that is routine in nature.
May be agreed by the child's guardians or dictated by a parenting order.
|Direct or indirect interaction with the child, for
a guardian who has no day to day care responsibility for the
A guardian with contact only, retains their residual guardianship rights and responsibilities
Who is Guardian?
(Note: the identity of mother and father can be presumed if recorded on the child's birth certificate)
- The Mother
- The Father, unless:
- Where the child was conceived before 1/7/05, the parents were not married at any time from conception to birth, and were not living together as de facto partners at birth;
- Or, where the child was conceived on or after 1/7/05, the parents were not married or living as de facto partners at any time from conception to birth;
- A testamentary guardian (appointed to be guardian after parent guardian's death);
- The partner of a parent where appointed by the parent(s) - appointment must be documented in prescribed form and approved by a Court Registrar;
- A person appointed by the Court as guardian in general or for a specific purpose.
- The Court, in cases where the child is placed under the guardianship of the Court. The Court may appoint one or more persons to act as agent of the court, e.g. a clinician for treatment purposes and the parents for all other care.
Consent to treatment
Consent to treatment for an incompetent child under 16 must be provided by a guardian, if one is available (see Informed Consent policy).
For health information purposes the representative of a child under 16 is "parent or guardian". Information must be provided to a representative unless disclosure is contrary to the interests of the child. A guardian with no day to day care responsibility still retains the right to be involved in important decisions and should be provided sufficient information to do so.
Visiting a Child in Hospital
When a child is in hospital, ADHB controls access to the
hospital and therefore the child.
The day to day care arrangement should be taken as a guide to parent/guardian involvement.
Where necessary to ensure the safe and efficient provisions of services, the Duty Manager may authorise restriction of access (to the service/ward) to certain times or under conditions.
Only where there are direct safety concerns or the child's clinical condition will be significantly compromised (and the risk cannot be avoided by limiting contact), or a protection order exists, should a guardian be excluded entirely.
Children, Young Persons and Their Families Act 1989
The Chief Executive of Child, Youth and Family Services or any other person / agency may be appointed by the Court as:
- Additional guardian
- Sole guardian (natural guardian rights are suspended)
- Guardian for a specific purpose
Adoption Act 1955
When a final adoption order is made, the adoptive parents become parents and guardians as if the child was born to them in lawful wedlock.
Refer also to ADHB Policy Adoption: Statutory; non-statutory, surrogacy and family placements of babies (Policies and Guidelines library).
Informed consent for medical examination
Permission of a parent or guardian is normally required for any medical examination of a child under 16 years. There are exceptions to this, both general and in suspected child abuse.
The Care of Children Act provides that, if there is no guardian in New Zealand, or no such guardian can be found with due diligence or is capable of giving consent, a person who has been acting in the place of a parent can give consent.
Under the Code of Health and Disability Services Consumers' Rights (Right 7(4)), it is possible to examine and treat without guardian / substitute consent if:
- No-one legally entitled to consent is available
- It is in the best interests of the child, and
- Reasonable steps have been taken to ascertain the views of the child, and:
- Either, if the child's views can be ascertained, the proposed treatment is consistent with the informed choice she would make if she were competent
- Or, if the child's views cannot be ascertained, you take into account the views of other suitable persons who are interested in the welfare of the child and can advise you (if none are available there is no obligation to find them).
"Gillick principle" (common law). A child does not, merely by reason of being under a certain age, lack legal capacity to consent to medical treatment. A child or young person has a right to make decisions for himself or herself when he or she reaches a sufficient degree of understanding and intelligence to be able to make up his or her own mind. This principle is of particular relevance in adolescents.
It should be noted that the Gillick principle has not yet been formally tested in a New Zealand court.
Children and Young Persons Service social workers can seek a medical examination under a warrant taken out under the CYP&F Act, or under a court order. [CYP&F Act 1989 s.49-55].
No examination under section 53 shall include an internal examination of the genitals or anus, unless the doctor believes the child or young person may have been subjected to recent physical or sexual abuse and the child or young person consents to examination. The need for their consent is waived in cases where the child or young person is too young to consent.
Examinations of the genitals or anus carried out under section 53 of the CYP&F Act may not be carried out under General Anaesthetic.
A child is entitled to nominate, and to have a supportive adult
to be present during a medical examination. [CYP&F Act 1989
The Court may impose conditions regarding medical examination that must be complied with.
If the child or young person is placed in custody of the Director-General by sections 39, 40 or 42 of the CYP&F Act, the restrictions under sections 53 to 55 of the Act still apply. A CYP&FS Social Worker can give consent for medical examination if the Social Worker has made reasonable efforts to obtain the consent of a parent or guardian.
When the Director-General of Social Welfare has custody of a child or young person (under a section 139 Temporary Care Agreement, a section 78 or 101 Custody Order, or a Section 110 Guardianship order), the Director-General is not required to obtain parental consent to medical examinations.
- The opinion of CYF is that the usual restrictions on the nature of the medical examination, or the procedures to be used in carrying out that examination (see 2.1) would not apply.
- However, the opinion of the ADHB differs. In the opinion of the ADHB, examinations of the genitals or anus under s 53 of the CYPFA 1989 may not be carried out under general anaesthetic without the consent of the child's guardian (subject to the general exceptions already noted above). This is regardless of who has custody of the child. It is recommended that legal advice is obtained on a case by case basis where a CYF social worker requests examination of the genitals or anus under general anaesthetic.
Authorised persons working under section 125 have the statutory power to enter a school or early childhood centre to examine a child without a court order or parental consent (Health Act 1956 s125 part 2, Ministry of Health Guidelines July 1993). These authorised persons are:
- A medical officer employed by the ministry
- A person authorised by the ministry (e.g. Public Health Nurses of Auckland Healthcare)
- A person employed by the Royal New Zealand Society for the Health of Women and Children (Plunket Society)
Resolving Problems with CYF
NOTE: When concerns are referred to the CYF DHB Liaison Practice Leader, he/she will liaise with the relevant ADHB staff and CYF staff to address the issues. If concerns continue to exist, the CYF Liaison Practice Leader will consult with the site manager at Practice Leader level.
Click on the image below to access a pdf copy of the HEEADSSS Assessment
A number of resources are available on the Ministry of health website, including the Ministry of Health Family Violence Intervention Guidelines
ADHB Policies and Procedures (accessed through the Intranet Policies and Guidelines Library), particularly under the sub-heading of Child Protection. Policies include:
- Bicultural Policy
- Child Protection Alerts
- Child Abuse Neglect Care and Protection Policy
- Child Protection Suspected Child Abuse - Siblings Assessment
- Clinical Record Management
- Critical Incident Stress Management
- Informed Consent
- Legal Issues Relating to Children
- Partner Abuse Intervention - Family Violence
- Privacy of Patient Information
- Referral - Child Youth and Family
- Te Puaruruhau Consultation Process within Board
- Tikanga Best Practice
- Watch Policy for Inpatient Children At Risk From Possible Child Abuse or Neglect
- Witnesses - Giving Evidence
- Christian, Committee on Child Abuse and Neglect. The Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015;135(5):e1337-e1354.
- Fanslow, J. & Kelly P. Family Violence Assessment and Intervention Guidelines; Child abuse and intimate partner violence. Wellington, Ministry of Health, 2016.
- Jenny C; Committee on Child Abuse and Neglect, American Academy of Pediatrics. Recognizing and responding to medical neglect. Pediatrics. 2007; 120(6):1385-9
- Jenny C; Committee on Child Abuse and Neglect, AAP. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics 2013;132:e558
- Kleinman PK (ed). Diagnostic imaging of child abuse (3rd Edition). Cambridge University Press, 2015.
- Maguire S, Mann M. Systematic reviews of bruising in relation to child abuse-what have we learnt: an overview of review updates. Evid Based Child Health. 2013 Mar 7;8(2):255-63.
- Reece RM, Christian CW (eds). Child abuse. Medical Diagnosis & Management (3rd Edition). American Academy of Pediatrics, 2009.
- Roesler TA, Jenny C. Medical Child Abuse: Beyond Munchausen Syndrome by Proxy. American Academy of Pediatrics, 2008
Many other references are available in Te Puaruruhau and Puawaitahi (99 Grafton Road)
Did you find this information helpful?
- Date last published: 21 October 2016
- Document type: Clinical Guideline
- Services responsible: Te Puaruruhau
- Author(s): Laurel Webb, Patrick Kelly
- Editor: Greg Williams
- Review frequency: 2 years
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