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Going to a case conference: the medical contribution
Going to a case conference: the medical contribution
M. Miles
person has abused a child. That decision rests with the courts. Research shows that conferences are perceived to have other functions. They include gaining access to resources, and monitoring of vulnerable children and their families. 1 Once a registration has been agreed child protection review conferences are held at appropriate intervals to monitor the arrangements for the child and to consider whether registration should continue or not. Another form of child protection conference is one held before a baby is born, a pre-birth conference, when there is concern about the future risk to a child.
The conference process
Before considering in detail the role and contribution of the doctor at a child protection conference it is useful to review, briefly, the stages which precede the convening of a conference. Once concern about possible abuse has been referred to the appropriate statutory agency, usually the social services department, a decision is made about investigation unless urgent action is required to protect a child. At this stage the preferred option is to hold a strategy discussion which serves to inform the investigation process. A strategy discussion usually involves at the very least the police, social services and the referrer. When a medical consultation is requested, it may be met by the family practitioner or paediatrician depending upon the circumstances. An initial child protection conference is convened following investigation. The criteria used to decide whether to call a conference vary considerably but once the decision is made the conference is expected to take place within eight working days of referral although research suggests longer periods are usually involved. Approximately a quarter of referrals lead to a conference. 1 The conference brings together all those directly concerned with the care and protection of the child. It provides an opportunity to share and evaluate information, to decide whether the child's name should be entered onto the child protection register and, if so, to make a plan for the future and to appoint a key worker, in short how best to protect a child. It is not a forum whereby a decision is made that a particular
Who attends?
Having outlined the process it is relevant to consider who attends. In addition to members from all the agencies with specific responsibilities for child protection there may be others able to offer relevant specialist advice thereby stressing the inter-agency approach to child protection. At the same time it is important to avoid overlarge meetings and to ensure that those who attend have a relevant contribution to make. Recognising the importance of working in partnership with parents means that they are encouraged to attend conferences other than strategy discussions; currently they attend around 70 % of conferences. Rarely circumstances demand the exclusion of a parent. Increasingly older children and young people are invited to conferences. When this is not appropriate the child's views should be reported. Making the contribution
Marion Miles, Consultant C o m m u n i t y Paediatrician, The Medical Centre 7E Woodfield Road, L o n d o n W9 3XZ. Correspondence and requests for offprints to M M .
Curren t Paediatrics ( 1995)5, 243-245 © 1995PearsonProfessionalLtd
Bearing in mind the purpose of a child protection conference and the people likely to be present it is
243
244 CURENT PAEDIATRICS important for the paediatrician to take stock of his contribution and the way in which it is made. The presence of non-professionals means that the use of medical jargon should be avoided. It is also necessary to outline the relationship between the child, the family and the doctor since a family practitioner is likely to bring a different range of information from a paediatrician who may only know the child in the context of child protection issues; conference members, especially parents, need to know why a doctor is present. It is essential that a clear difference is made between the reporting of facts and the offering, if requested, of an opinion or conclusion based on knowledge or experience. If an opinion is requested then it is important to indicate the process by which that opinion has been reached. If for example the doctor concerned is a consultant an indication of the range of experience is helpful to the conference members. When junior doctors are involved, presenting factual information, their contribution should be supervised by more experienced colleagues. On occasions a doctor with particular expertise in child protection, for example the designated doctor for child protection, will be present to offer advice rather than a factual report and needs to explain his or her presence and contribution.
Confidentiality At the onset of the conference the chair is required to remind all those present of the confidential nature of the meeting and to obtain their intention to observe absolute confidentiality. Many doctors have doubts about sharing information with others who are not bound by professional codes of conduct. However it must be remembered that although doctors have a legal and ethical duty to maintain confidentiality they are also required to disclose information when they believe a patient to have been the victim of abuse or neglect. In these circumstances the needs of the child are paramount despite the doctor's wish to maintain confidentiality. Since the aim of child protection work is to ensure an optimum outcome for the child concerned any doctor unsure about what or how much to divulge needs to know from whom to seek advice. As stated above junior doctors should have ready access to a consultant for advice. At local level all doctors should take responsibility for identifying their advisory networks. In all situations where child abuse is alleged or suspected, doctors must avoid any promise of secrecy and make clear, in a sensitive way their responsibility to share relevant information on a 'need to know' basis. On other occasions a doctor will hold information about a third party which is relevant to child protection issues, e.g. violent behaviour, inappropriate sexual activities, mental health problems. In these circumstances disclosure can usually be justified.
Support and advice In Working Together, g Child Protection: Medical Responsibilities 3 and, more recently the consultation document, Child Protection: Clarification of Arrangement between the NHS and other Agencies 4 the roles and responsibilities of the designated doctor (DD) are defined. One important component is the provision of expert advice in child protection matters. It is envisaged that all NHS Trusts and units will identify a named professional for child protection matters who will relate to the DD. In the meantime advice should be available at local level from the DD so paediatricians wishing to air concern or seek advice about child protection matters need to know the name of the local DD and how to make contact. The local Area Child Protection Committee (ACPC) is responsible for the production of ACPC guidelines which should include information about the DD. Thus a DD can be consulted at an early stage when there is concern in order to decide whether that concern has reached a critical level that demands referral to a statutory agency. The DD can also advise on matters to be presented verbally or by a report at conferences. Similarly the chair of a child protection conference should be available to doctors before the conference takes place in order to discuss the relevance of confidential information and how best to share it. There may for example be concerns about the disclosure of certain information in the presence of a parent; discussion with the chair should resolve the problem. In some areas arrangements are made whereby advice from other senior members of the social services departments, for example child protection co-ordinators, is available. ACPC guidelines should clearly identify these pathways.
Presenting information There is a great temptation for doctors to present extensive information about a child and the family, regardless of relevance, and to leave it to the conferences members and chair to sift out the pertinent facts. This model has never been recommended and now, with wider representation at conferences, is totally unacceptable. Relevant information should be clearly and honestly presented. Whenever possible a doctor should advise parents and, if appropriate, the child before a conference about the information to be presented. During this discussion it is often possible to obtain consent to disclose personal and medical details in order to avoid distress at the conference. When a doctor is unable to attend a conference, a written report should be submitted. Under these circumstances the choice of words and avoidance of medical jargon is even more relevant. Some words are interpreted widely, sick can mean being ill or vomiting. There is a danger of sounding judgmental in a report and easy to confuse facts with
GOING TO A CASE CONFERENCE 245
opinion. Writing a report for a child protection conference requires different skills from writing medical case notes. It should briefly introduce the status of the writer and the nature and length of contact with the child and/or family. When conclusions are drawn the basis on which they have been made should be stated and, if appropriate referenced. It would be unwise to state as a result of hearsay and inference that a mother is inadequate; it would be perfectly acceptable to record concern about the quality of care taking account of a (confirmed) background of violence, alcohol misuse etc. On the other hand the value of a report containing well defined facts, observations and clearly reasoned conclusions is destroyed if the writer requests that the source of the information be kept secret. Since the nature of the information usually identifies the informer trying to contribute in this way means that no previous attempt has been made to discuss information sharing with the parent or family. In the second example a resolution could be achieved after discussion with the conference chair and the D D and a meeting between the doctor concerned and the parents. Since written reports are available at a conference it is always advisable to share the contents with the family in advance of the conference whenever possible.
alternative to attendance at a conference puts a paediatrician in a difficult position. ACPCs should address these issues bearing in mind research findings which demonstrate a low rate of conference attendance by doctors in general. 1 A recommendation has been made that the conference chair should identify those participants whose attendance is essential so that the conference can be convened at a suitable time and venue. Rarely is a medical perspective to conference discussions inappropriate. When a doctor cannot attend consideration should be given to presentation of a medical dimension by a health professional colleague especially at review conferences? Recognition of the resources required to prepare reports and/or attend conferences should be reflected in contracts agreed with purchasers.
Education and training Education and training in relation to child protection is a continuing process. The skills needed in relation to conferences have been outlined. At local level the designated doctor has a training remit in association with the ACPC. Since the importance of continuing education cannot be over emphasised its provision should be ensured by managers and subject to quality assurance control by purchasers.
Practical issues In some areas conferences are convened at fixed times during the week. Even so, others may be called at short notice and all doctors experience difficulties around attendance. Conferences take place most frequently on social services premises. The imaginative use of other venues can facilitate medical attendance. Faced with an out-patient clinic or ward round as an
References 1. Child Protection Messages from Research. London: HMSO, 1995. 2. Working Together under the Children Act 1989. London: HMSO, 1991. 3. Child Protection: Medical Responsibilities. London: Department of Health, 1994. 4. Child Protection: Clarification of Arrangements between the NHS and other Agencies. London: Department of Health, 1995.
M. Miles
person has abused a child. That decision rests with the courts. Research shows that conferences are perceived to have other functions. They include gaining access to resources, and monitoring of vulnerable children and their families. 1 Once a registration has been agreed child protection review conferences are held at appropriate intervals to monitor the arrangements for the child and to consider whether registration should continue or not. Another form of child protection conference is one held before a baby is born, a pre-birth conference, when there is concern about the future risk to a child.
The conference process
Before considering in detail the role and contribution of the doctor at a child protection conference it is useful to review, briefly, the stages which precede the convening of a conference. Once concern about possible abuse has been referred to the appropriate statutory agency, usually the social services department, a decision is made about investigation unless urgent action is required to protect a child. At this stage the preferred option is to hold a strategy discussion which serves to inform the investigation process. A strategy discussion usually involves at the very least the police, social services and the referrer. When a medical consultation is requested, it may be met by the family practitioner or paediatrician depending upon the circumstances. An initial child protection conference is convened following investigation. The criteria used to decide whether to call a conference vary considerably but once the decision is made the conference is expected to take place within eight working days of referral although research suggests longer periods are usually involved. Approximately a quarter of referrals lead to a conference. 1 The conference brings together all those directly concerned with the care and protection of the child. It provides an opportunity to share and evaluate information, to decide whether the child's name should be entered onto the child protection register and, if so, to make a plan for the future and to appoint a key worker, in short how best to protect a child. It is not a forum whereby a decision is made that a particular
Who attends?
Having outlined the process it is relevant to consider who attends. In addition to members from all the agencies with specific responsibilities for child protection there may be others able to offer relevant specialist advice thereby stressing the inter-agency approach to child protection. At the same time it is important to avoid overlarge meetings and to ensure that those who attend have a relevant contribution to make. Recognising the importance of working in partnership with parents means that they are encouraged to attend conferences other than strategy discussions; currently they attend around 70 % of conferences. Rarely circumstances demand the exclusion of a parent. Increasingly older children and young people are invited to conferences. When this is not appropriate the child's views should be reported. Making the contribution
Marion Miles, Consultant C o m m u n i t y Paediatrician, The Medical Centre 7E Woodfield Road, L o n d o n W9 3XZ. Correspondence and requests for offprints to M M .
Curren t Paediatrics ( 1995)5, 243-245 © 1995PearsonProfessionalLtd
Bearing in mind the purpose of a child protection conference and the people likely to be present it is
243
244 CURENT PAEDIATRICS important for the paediatrician to take stock of his contribution and the way in which it is made. The presence of non-professionals means that the use of medical jargon should be avoided. It is also necessary to outline the relationship between the child, the family and the doctor since a family practitioner is likely to bring a different range of information from a paediatrician who may only know the child in the context of child protection issues; conference members, especially parents, need to know why a doctor is present. It is essential that a clear difference is made between the reporting of facts and the offering, if requested, of an opinion or conclusion based on knowledge or experience. If an opinion is requested then it is important to indicate the process by which that opinion has been reached. If for example the doctor concerned is a consultant an indication of the range of experience is helpful to the conference members. When junior doctors are involved, presenting factual information, their contribution should be supervised by more experienced colleagues. On occasions a doctor with particular expertise in child protection, for example the designated doctor for child protection, will be present to offer advice rather than a factual report and needs to explain his or her presence and contribution.
Confidentiality At the onset of the conference the chair is required to remind all those present of the confidential nature of the meeting and to obtain their intention to observe absolute confidentiality. Many doctors have doubts about sharing information with others who are not bound by professional codes of conduct. However it must be remembered that although doctors have a legal and ethical duty to maintain confidentiality they are also required to disclose information when they believe a patient to have been the victim of abuse or neglect. In these circumstances the needs of the child are paramount despite the doctor's wish to maintain confidentiality. Since the aim of child protection work is to ensure an optimum outcome for the child concerned any doctor unsure about what or how much to divulge needs to know from whom to seek advice. As stated above junior doctors should have ready access to a consultant for advice. At local level all doctors should take responsibility for identifying their advisory networks. In all situations where child abuse is alleged or suspected, doctors must avoid any promise of secrecy and make clear, in a sensitive way their responsibility to share relevant information on a 'need to know' basis. On other occasions a doctor will hold information about a third party which is relevant to child protection issues, e.g. violent behaviour, inappropriate sexual activities, mental health problems. In these circumstances disclosure can usually be justified.
Support and advice In Working Together, g Child Protection: Medical Responsibilities 3 and, more recently the consultation document, Child Protection: Clarification of Arrangement between the NHS and other Agencies 4 the roles and responsibilities of the designated doctor (DD) are defined. One important component is the provision of expert advice in child protection matters. It is envisaged that all NHS Trusts and units will identify a named professional for child protection matters who will relate to the DD. In the meantime advice should be available at local level from the DD so paediatricians wishing to air concern or seek advice about child protection matters need to know the name of the local DD and how to make contact. The local Area Child Protection Committee (ACPC) is responsible for the production of ACPC guidelines which should include information about the DD. Thus a DD can be consulted at an early stage when there is concern in order to decide whether that concern has reached a critical level that demands referral to a statutory agency. The DD can also advise on matters to be presented verbally or by a report at conferences. Similarly the chair of a child protection conference should be available to doctors before the conference takes place in order to discuss the relevance of confidential information and how best to share it. There may for example be concerns about the disclosure of certain information in the presence of a parent; discussion with the chair should resolve the problem. In some areas arrangements are made whereby advice from other senior members of the social services departments, for example child protection co-ordinators, is available. ACPC guidelines should clearly identify these pathways.
Presenting information There is a great temptation for doctors to present extensive information about a child and the family, regardless of relevance, and to leave it to the conferences members and chair to sift out the pertinent facts. This model has never been recommended and now, with wider representation at conferences, is totally unacceptable. Relevant information should be clearly and honestly presented. Whenever possible a doctor should advise parents and, if appropriate, the child before a conference about the information to be presented. During this discussion it is often possible to obtain consent to disclose personal and medical details in order to avoid distress at the conference. When a doctor is unable to attend a conference, a written report should be submitted. Under these circumstances the choice of words and avoidance of medical jargon is even more relevant. Some words are interpreted widely, sick can mean being ill or vomiting. There is a danger of sounding judgmental in a report and easy to confuse facts with
GOING TO A CASE CONFERENCE 245
opinion. Writing a report for a child protection conference requires different skills from writing medical case notes. It should briefly introduce the status of the writer and the nature and length of contact with the child and/or family. When conclusions are drawn the basis on which they have been made should be stated and, if appropriate referenced. It would be unwise to state as a result of hearsay and inference that a mother is inadequate; it would be perfectly acceptable to record concern about the quality of care taking account of a (confirmed) background of violence, alcohol misuse etc. On the other hand the value of a report containing well defined facts, observations and clearly reasoned conclusions is destroyed if the writer requests that the source of the information be kept secret. Since the nature of the information usually identifies the informer trying to contribute in this way means that no previous attempt has been made to discuss information sharing with the parent or family. In the second example a resolution could be achieved after discussion with the conference chair and the D D and a meeting between the doctor concerned and the parents. Since written reports are available at a conference it is always advisable to share the contents with the family in advance of the conference whenever possible.
alternative to attendance at a conference puts a paediatrician in a difficult position. ACPCs should address these issues bearing in mind research findings which demonstrate a low rate of conference attendance by doctors in general. 1 A recommendation has been made that the conference chair should identify those participants whose attendance is essential so that the conference can be convened at a suitable time and venue. Rarely is a medical perspective to conference discussions inappropriate. When a doctor cannot attend consideration should be given to presentation of a medical dimension by a health professional colleague especially at review conferences? Recognition of the resources required to prepare reports and/or attend conferences should be reflected in contracts agreed with purchasers.
Education and training Education and training in relation to child protection is a continuing process. The skills needed in relation to conferences have been outlined. At local level the designated doctor has a training remit in association with the ACPC. Since the importance of continuing education cannot be over emphasised its provision should be ensured by managers and subject to quality assurance control by purchasers.
Practical issues In some areas conferences are convened at fixed times during the week. Even so, others may be called at short notice and all doctors experience difficulties around attendance. Conferences take place most frequently on social services premises. The imaginative use of other venues can facilitate medical attendance. Faced with an out-patient clinic or ward round as an
References 1. Child Protection Messages from Research. London: HMSO, 1995. 2. Working Together under the Children Act 1989. London: HMSO, 1991. 3. Child Protection: Medical Responsibilities. London: Department of Health, 1994. 4. Child Protection: Clarification of Arrangements between the NHS and other Agencies. London: Department of Health, 1995.