Child Protection referral pathways

* Mon-Fri 09:00-17:00 contact CPS on 0141 451 6605.
Out of hours contact Child Protection Consultant via RHC switchboard 0141 201 0000

** See Appendix 1 for telephone numbers and access to NOC form.

Recognition of Physical Abuse

• The explanation for an injury should always be considered in the context of the child’s development and the child’s wider world.
• Children under 2 yrs are at increased risk and rarely able to contribute to the history themselves.
• Evidence is that we cannot accurately age a bruise.
• Bruising is strongly related to mobility however is the most common injury to a child who has been physically abused.
• Features in a history about an injury that must raise concern are:-
  • There is no adequate explanation for injury or does not fit pattern seen.
  • The injury is not consistent with developmental stage of the child.
  • There has been a delay in presentation.
  • Family already known to SW or previous concerns raised about care of the child.
  • ‘Rough handling’ or ‘difficult feeders’ are not acceptable explanations for injuries.

* Mon-Fri 09:00 -17:00 Contact CPS on 0141 451 6605.
Out of hours contact Child Protection Consultant via RHC switchboard 0141 201 0000

** See Appendix 1 for telephone numbers and access to NOC form

Non-recent (historical) Sexual Assault

Children and young people who disclose non-recent (historical) sexual assault do not normally require an acute forensic medical.  The professional (GP) being informed of the assault should contact the CPS and SW as per guidance.

It is not uncommon in general practice for adults to disclose previous sexual and other forms of abuse when a child. In such circumstances GPs and other professionals are required to consider if any child or children are currently at risk of harm and therefore may require to share relevant information with police and SW in order to protect those children.

Clinical presentations of possible CSA

Children who have been sexually abused may present in many ways and often may not make an allegation at an early stage.

Certain clinical presentations may raise the suspicion of CSA and require further assessment and consideration. They include-

1. Any pregnancy or sexual activity in a child under the age of 13 is unlawful and must be reported to statutory agencies even if the child suggests they have consented to the activity.
2. Consider CSA in all children presenting with sexually transmitted infections unless clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household or blood contamination.
3. Suspect CSA in child younger than 13 yrs with gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection and no clear evidence of mother-to-child transmission during birth or blood contamination.
4. Ano-genital injury with no clear history or explanation.
5. Unexplained vaginal bleeding – in the absence of accidental trauma or medical diagnosis. ***
6. Unexplained rectal bleeding – after excluding other medical causes- anal fissures, constipation, IBD or accidental injury.
7. Recurrent or resistant to treatment vaginal discharge/vulvo-vaginitis. ***
8. Soiling/enuresis- are common paediatric presentations usually with developmental/behavioural cause. CSA should be considered as part of the differential diagnosis.
9. Behavioural presentations- any significant and major change in a child’s behaviour should prompt further assessment regarding any form of maltreatment.

*** See section 4

The following clinical presentations can be associated with CSA.  It is, however, important to consider other potential causes such that a robust history with appropriate examination and investigations undertaken to exclude such causes where possible.

When there is recurrence or resistance to treatment or other concerning features, expert advice should be sought via the CPS to discuss the possibility of CSA and requirement for a specialist medical as part of a multi-agency process.

a) Anogenital Warts (AGW)

Anogenital warts can be acquired by four mechanisms in children: vertical transmission from an infected mother; autoinoculation from non genital warts; hetero-inoculation (contact between anogenital region and infected second party) and sexual.  Sexual abuse must be considered in all children presenting with AGW.

GPs should refer to dermatology using SCI gateway for children with AGW. It is important that all relevant social information including any known child protection concerns are highlighted in the referral.

On receipt of this referral a health system check is undertaken to identify any known child protection risk for the child. The child protection consultant will decide if they are to be seen by dermatology alone or if there are concerns a joint examination between dermatology and child protection will be arranged.

b) Vaginal discharge/itch/vulvovaginitis

Both are commonly reported in CSA; however discharge and itch is very common in young girls, usually culture negative and not significant.  Most of the irritation causing itch can be resolved with hygiene measures and appropriate clothing/underwear.  It is often mistaken for thrush and antifungal treatment should normally be avoided in younger girls. Bland emollients or barrier creams may reduce irritation and discomfort. 

c) Vaginal bleeding

Genital bleeding in prepubertal girls often presents as blood in the child’s underwear. It is essential that a complete history is taken to determine the source of blood.  Bleeding reported as vaginal may be genital, or from the skin, urinary tract or anus.

While CSA must be considered, other common causes include: lichen sclerosis, infections, vaginal foreign bodies, constipation and rarely tumours and anatomical abnormalities.  

d) Rectal bleeding

Differential diagnosis would include: constipation, anal fissures, inflammatory bowel disease, accidental trauma and rarely anatomical difficulties. It is essential that a history and examination is undertaken to exclude such causes in the absence of any direct disclosure of CSA or any other concerning features.

Neglect is the persistent failure to meet a child’s physical or psychological needs that is likely to result in serious impairment of the child’s health or development.  It is the most prevalent form of maltreatment in the UK.

There are different forms of neglect:  emotional, medical, nutritional, educational, physical and failure to provide adequate supervision and guidance.  GP practices may identify children affected by neglect from a variety of presentations: the physical appearance or lack of provision for a child, the engagement pattern some families have with the practice or risk factors that may make a child more at risk of neglect - e.g. parental problematic substance use, parental mental health problems and social and environmental factors such as poverty and social isolation.

It is important to recognise that children and young people with a disability are more likely to be neglected or harmed than their peers although often under recognised and under reported.

Medical Neglect

This is parents/carers disregarding or minimising their child’s health need, failing to seek medical attention or administer required medicines or treatments.  This may be for an acute ill health episode or for a child with a long term condition.

Children may also not be brought for essential appointments or screening opportunities. Generally a one off missed appointment would not be a concern however a pattern of not being brought and the context of these missed appointment can be a sign of neglect.  When children are not brought to an appointment the practitioner should code this event and consider the impact on the child. 

Neglect is rarely a one off event and GP practices should have effective communication processes to ensure concerns are shared with HVs and others working with children and young people who may be affected by neglect.

Response to concerns about neglect

1. In all cases where GPs are concerned about neglect advice can be sought from the Child Protection Service on 0141 451 6605 (Mon-Fri 09:00-17:00)
2. Good record keeping is essential in order to identify patterns of engagement or behaviours from multiple presentations that may indicate neglect.
3. Rarely after an isolated presentation that indicates acute neglect (young baby with significant weight faltering) or following an accumulation of concerns about neglect a notification of concern should be submitted to the local SW service.
4. In cases where there is evidence of medical neglect/unmet health needs a child protection assessment may be required via the Vulnerability Service.

Communication and Interpreting Needs

In all cases communication or interpreting needs of the child or young person should be considered and appropriately addressed. A parent or family member should not interpret or speak for the child.

Social Work Area Teams Numbers:

Typically SW offices are open:-

• Monday to Thursday inclusive: 08:45 - 16:45
• Friday: 08:45 – 15:55

Out with these times staff should contact Glasgow and Partners Emergency Social Work Service (Standby) on 0300-343-1505

Notification of Concern Form

http://www.staffnet.ggc.scot.nhs.uk/Corporate%20Services/Child%20Protection/Pages/ElectronicTemplateForms-CP.aspx [Staffnet link - you must be connected to the NHSGGC Network to access this link]

The form is also available electronically via Clinical Portal- while in patient record click on Forms and Pathways along top bar -> Add new form -> Notification of Concern (child protection)

Secure email addresses for Children and Families SW teams can be obtained after calling social work.