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To outline best practice, to clarify roles and responsibilities, and to act as a practical guide for orthopaedic and paediatric doctors in training
Any child presenting to RHC Glasgow services
All medical staff involved with the care of orthopaedic patients
These children will be admitted under the orthopaedic consultant on call. If physical abuse or neglect is suspected, and the process below has not been started already by ED, then the admitting orthopaedic registrar will:
The Social Work referral needs to be made as soon as possible and should not wait for the next working day irrespective of the fact that the child is getting admitted. It is important to provide social work with information around home circumstances including whether there are any other children present at home.
Early referral to Child Protection is also useful (i.e. start of a working day) as this will allow the Child Protection Service to start to gather and share information early.
Children may present with injuries not requiring inpatient orthopaedic management (eg injuries which would normally be managed in fracture clinic). If physical abuse or neglect are suspected, especially in the under 1s, the child may nevertheless require admission for child protection investigations. Advice can be sought from the child protection team.
These children will be admitted under shared care of the acute paediatric team and child protection team. The on call orthopaedic registrar may sometimes be required to advise on plaster casts or the timing of fracture clinic appointment etc but would not routinely need to review the child.
An orthopaedic opinion regarding mechanism may still be required and would be sought by the child protection or ED team from the consultant orthopaedic surgeon on call
Some cases will not require admission but will require social work referral and risk assessment (including safe care arrangement) prior to discharge from the ED. This referral will be made by the ED team (as per the child protection pathways). Advice can be sought from the child protection team at any point.
Consultant to consultant discussion is best practice as there may be nuances and caveats which can be lost by channelling information through extra people. If requested, the Orthopaedic consultant should allow sufficient time for this discussion particularly if there may be difficulty in attending subsequent multi agency meetings due to theatre or on call commitments.
Following child protection review, the child may need further investigations (photographs, ophthalmology review, skeletal survey, bloods). Under normal circumstances the child protection consultant will obtain consent, arrange for these to be done and review the results. The orthopaedic team would not normally be responsible for obtaining consent for investigations, or reviewing the results of delayed skeletal surveys, but under some circumstances may be asked to help organise the investigations.
Ideally, children with concerning fractures will be referred at the time of presentation to ED. Fracture clinic is an extremely difficult environment in which to discuss child protection referral with parents.
Nevertheless from time to time a child will be seen with a concerning injury which was not previously recognised as such. In this situation the case will be discussed and normally seen by the consultant in fracture clinic.
The consultant in clinic will
The child protection service will provide advice and support (initially this may be from one of the Child Protection Advisors). If a child protection medical examination is required, this will be coordinated by the Child Protection Consultant who will aim to contact the orthopaedic team in a timely manner.
Possible outcomes to the discussion would be:
Same day child protection medical (wherever possible)
Arrangements for child protection medical the following day
No medical examination required and social work follow up only
Children from other areas:
Contact numbers and e-mails for social work offices can be found in appendix 1 and 2 of the guidance notes accompanying the NOC form on Staffnet. http://www.staffnet.ggc.scot.nhs.uk/Corporate%20Services/Child%20Protection/Documents/Notification%20of%20Concern%20(Final).pdf
Last reviewed: 02 March 2020
Next review: 30 November 2023
Author(s): Miss Alexandra Smith, Consultant Orthopaedic Surgeon, RHC Alexandra.Smith@ggc.scot.nhs.uk; Dr Owen Forbes, Consultant Paediatrician (Child Protection), RHC Owen.Forbes@ggc.scot.nhs.uk; Dr Lesley Nairn, Consultant Paediatrician, RHC
Approved By: Child Protection
Reviewer Name(s): Graham Bell