Forensic Paediatric Medicine Trainees Advice and Information

Victorian Forensic Paediatric Medical Service 2016 Manual

Forensic Paediatric Medicine Trainees’ Advice and Information

Medical Director, Anne Smith

Niro Kennedy:

#1461152 – Seen at RCH 27.10.15 – Dict #1029196 – seen at RCH 27.10.15 – Dict #1583700 – seen at MMC 21.11.15 #1583646 – seen at RCH 22.11.15 – Dict #0978504 – seen at RCH 26.11.15 – Not Dict Feb 2016

R C H a n d M o n a s h C h i l d r e n ’ s V F P M S C L I N I C S Manual for Advanced Trainees / Fellows in Forensic Paediatric Medicine 2016

Contents No table of contents entries found.

Anne Smith, Director VFPMS 2 Manual for Advanced Trainees / Fellows in Forensic Paediatric Medicine 2016

Forensic Paediatric Medicine Trainees Manual 2016

Training in Child Abuse Paediatrics: Tips for Good Clinical Practice

PRINCIPLES GUIDING PRACTICE

Most of the children seen by the VFPMS live in deprived circumstances with adults who are finding it very difficult to adequately provide for their children’s health, development and emotional needs. Contact with VFPMS should provide each child with a “one-stop-shop” comprehensive assessment of his/her needs and recommendations for change to improve the trajectory of the child’s life.

The philosophies underpinning the operation of the Victorian Forensic Paediatric Medical Service are clearly outlined on the website. In summary, the care we provide for children and their carers is all of the following:-  Holistic (Paediatric, forensic, psychosocial and beyond.)  Based on an awareness of the ecology of child abuse (an “eco-bio-developmental” perspective)  Integrated with all other services for children (don’t duplicate health services)  Specialist (using FPM specialist knowledge and skills)  Effective (proven to produce good outcomes)  Efficient (not wasteful of resources, including time and energy)  Accountable  Evidence-based good practice (using standardized practice / CPGs and protocols)  Continuously improving

AIMS and COMPETENCIES

The training program in forensic paediatric medicine and child abuse has been designed to meet the training needs set out in the framework of the RACP Division of Paediatrics and Child Health Advanced Training Curriculum in Community Child Health and General Medicine (Paediatrics) in Child Protection. It also provides training in developmental-behavioural paediatrics for General Paediatrics trainees. Log book I encourage you to keep a log of cases seen for your own records, to monitor your progress and inform you about the scope of work experienced. Your ‘log book’ will not be assessed by VFPMS but the possibility exists that someone from an SAC, or one of your supervisors, might want to view it at some time in the future.

The VFPMS Fellows’ training manual aims to provide you with information about how best you might acquire knowledge, skills and experience to increase your expertise in this field of medicine. Note that the VFPMS awards a Certificate of Competency to successful trainees who have completed the training program and demonstrated the requisite knowledge, skills, attitudes and behaviours. The VFPMS evaluation of competencies is modelled on the Royal College of Paediatrics and Child Health 1 categories of desired competencies for forensic physicians and paediatricians. It also reflects the required clinical competencies described by the RCPCH in the

1 Guidance on Paediatric Forensic Examinations in Relation to Possible Child Sexual Abuse Produced by The Royal College of Paediatrics and Child Health and The Association of Forensic Physicians September 2004

Anne Smith, Director VFPMS 3 Manual for Advanced Trainees / Fellows in Forensic Paediatric Medicine 2016 document “Service specification for the clinical evaluation of children and young people who may have been abused September 2015”2.

Our approach to supervision of clinical work undertaken during your advanced training with the VFPMS is in keeping with the philosophies underpinning the use of “Entrustable Professional Activities” (EPA). Over the course of your rotation with VFPMS you will progressively be entrusted to make decisions regarding clinical care, you will communicate directly with Child Protection practitioners and Police and you will probably present evidence in court. At the start of your rotation you will need to discuss each case and each decision with your supervisors. By the end of your rotation you are highly likely to be capable of performing most tasks with only minimal supervision and occasional advice.

2 Service specification for the clinical evaluation of children and young people who may have been abused September 2015. Royal College of Paediatrics and Child Health 2015

WHAT DO DOCTORS OF THE VFPMS DO?

The key work of the VFPMS is to provide assessments of children when child abuse is suspected and to make recommendations for intervention, aiming to improve the quality of children’s

Anne Smith, Director VFPMS 6 Manual for Advanced Trainees / Fellows in Forensic Paediatric Medicine 2016 lives. Many doctors consider the “one child at a time” approach to be deeply rewarding. This approach does not preclude a co-existing public health approach to working with populations of abused and vulnerable children and most, if not all, of you will work in both these fields of medicine during your professional lives

The format of the assessment of the individual child follows the usual “history / examination / investigations / opinion / medical report” sequential process although there are a few additional tasks that might be required for children who present with problems such as child sexual abuse.

VFPMS doctors also provide consultations and advice in person and via electronic media and telephone. We also provide case file reviews, forensic opinions in relation to the causes and timing of children’s injuries and advice for medical professionals about appearing in court.

VFPMS provides education and training (multidisciplinary) about child abuse, forensic paediatric medicine and information about appropriate responses to suspected child abuse.

You will be invited to sit in with a consultant for at least one sexual abuse assessment and to have a consultant sit in with you for your first sexual abuse assessment. For subsequent assessments you should conduct the assessment on your own (with advice as needed) and discuss each assessment with your supervisor. As the demand for medical services varies and we have no control over the types of presenting problems that greet us each day, we cannot guarantee when this will occur. We assume you will be able to conduct an assessment of a physically injured child (with VFPMS Senior Medical Staff supervision) from your first day.

All medical reports are subject to quality assurance. You will be expected to conduct an appropriate review of the literature about each case to ensure that your information and knowledge-base is current.

Please read (and utilize) the document titled “tips for writing medical reports” available on the VFPMS website together with the VFPMS proformas, diagrams and guidelines.

WHAT DOES THE VFPMS NURSE MANAGER DO? The nurse managers at RCH and MMC perform a key role in being the point of first contact for professionals who wish to use the VFPMS. The nurses triage incoming requests for VFPMS services, liaise with referring agencies and counselling services and coordinate service delivery within the VFPMS. The VFPMS nurses manage the operation of the VFPMS clinics at RCH and MMC and they co-ordinate the VFPMS service response regarding inpatients.

The bookings for appointments, data analysis and reporting are all completed primarily by the VFPMS nurse managers. They provide education and training, advice and assistance for clinical practice and they have a key role in policy development, improvements in clinical practice and in quality assurance.

The nurse managers are members of the VFPMS Executive Committee.

The Executive Committee (Medical Director, Clinical Lead MMC, a SMS representatives from RCH and one from MMC, Nurse Managers and Senior Exec Officer) meets monthly to review and manage the operation of the VFPMS.

WHAT DO SOCIAL WORKERS, GATEHOUSE & SECASA COUNSELLORS DO?

Social workers working within hospitals in Victoria are familiar with the needs of patients interacting with the health system. The field of “medical social work” is becoming highly

Anne Smith, Director VFPMS 7 Manual for Advanced Trainees / Fellows in Forensic Paediatric Medicine 2016 specialized. Social workers are trained to recognize children’s vulnerability to a range of harms and to intervene to better protect and support vulnerable children and their carers.

Some of their work involves collaboratively assessing injured children in collaboration with the clinical work of medical and nursing staff.

Assessments of sexual abuse allegations must occur as joint work with sexual assault counsellors. (Note that chaperones must always be present during children’s genital examinations).

Assessments of physical injuries, assessments of risk of harm and assessments of symptoms and signs that might or might not be caused by abuse can occur concurrently with social workers, preceding or subsequent to a social work assessment of a child’s psychosocial situation. (Note that Child Protection usually perform this task for children who are outpatients and CP practitioners have access to far more information than hospital based SW staff.) Concurrent assessments with hospital-based social workers rather than Child Protection practitioners are more likely to occur for children who are inpatients, have recently sustained injuries or who present to Emergency Departments after hours.

A VFPMS doctor may choose to conduct a joint interview/assessment with a hospital-based social worker or counsellor at any time. Alternatively, some doctors prefer to provide medical consultations first and encourage social workers and/or counsellors to perform their assessments subsequent to this. Some doctors may choose to perform joint interviews with Child Protection practitioners or police. Because the doctor-patient relationship should be safeguarded (and patients expect a relationship of confidence and privacy), the presence of additional people during the consultation should only occur with the patients’ consent and at the discretion of the doctor.

The counselling teams comprise professionals who trained as social workers or psychologists. Some have family therapy training. Some have additional training in different counselling techniques and styles. All are supervised according to guidelines established by their disciplines and managers. All of these professional groups provide teaching and liaison work.

None of the sexual assault counselling services provide direct access to psychiatrists and none are governed according to the frameworks set up for services providing mental health care for children. The CASAs operate independent of mental health services in Victoria but may work collaboratively with individuals and agencies providing mental health care in relation to individual children (and young people because CASAs other than Gatehouse provide services for adults). Some CASAs operate as departments within health services (eg Gatehouse and SECASA) while others operate as independent organisations with CEOs and Boards of Management, albeit with (at least partial) DHS funding.

Much of the counsellors’ work with children involves therapy for abused children and their families (this includes parents, carers and siblings). The counsellors provide individual therapy, group therapy, family therapy or a combination of these.

The Sexually Abusive Behaviours Treatment program (SABT) was designed for children aged 10 to 14 years who display sexually abusive behaviours. Centres Against Sexual Assault are one of the key service providers for this program (Gatehouse and SECASA demonstrate leadership in this field). Criteria for acceptance into these SABT programs is not strictly limited to 10 to 14 year olds. The children do not need to be on a Therapeutic Treatment Order to be eligible for a SABT service.

SECASA does not usually provide individual services to children aged less than 5 years. You are encouraged to consider referral of younger traumatized and emotionally distressed children to

CAMHS or other local mental health services. (See VFPMS website for links and an excellent resource that includes contact details of mental health service providers in Victoria).

Use your clinical experience and the advice of senior VFPMS staff / colleagues in order to refer children to the most suitable service to meet the child’s needs. Please consider the mental health needs of infants and young children. Be particularly mindful of the need to refer young physically abused children to Infant Mental Health teams

You may also consider the broad range of mental health services to meet the carers’ needs, particularly when carers are not the child’s biological parents.

You can refer children to local mental health services, including CAMHS and RCH-MHS and OryGen. Your clinical judgement about the child’s symptoms and their family situation should guide you to make a referral to the service best suited to meet the child’s particular needs and/or their carers’ needs.

ROLE OF THE TRAINEE/ FELLOW IN FORENSIC PAEDIATRIC MEDICINE

Almost all Trainees and Fellows in FPM are doctors completing advanced training in paediatric medicine.

Clinical work is supervised by VFPMS consultants who are working in the same VFPMS clinic. Fellows also have an allocated clinical supervisor with whom they should have a weekly one hour clinical supervision session. I recommend that you work closely with your clinical supervisor (who works with you to supervise your clinical work and who operates in addition to the RACP supervision of training – ie Anne Smith) who may also be available to assist when/if the ‘going gets tough’). NB: One hour of clinical supervision should occur each and every week unless something exceptional intervenes.

The VFPMS Medical Director is your RACP training supervisor who will meet with you quarterly and “sign off” the training paperwork and complete RACP evaluations and assessments. Your VFPMS clinical supervisor (a VFPMS senior medical consultant) is there to help you improve your clinical skills and clinical decision-making.

The Fellows’ role is twofold, firstly to perform medical evaluations of children in whom child abuse is suspected (a clinical service component) and secondly to increase the doctors’ personal knowledge and skills in relation to child abuse (and thus, their own clinical competencies) in order that the doctors will provide a great service to children throughout the remainder of their professional careers.

What does this mean for me? Clinical work will occupy a significant percentage of your time with VFPMS. Time must be set aside (and protected) for clinical supervision. Time for personal study will fit around the demand for your clinical services.

How do I ‘fit in’? The trainee/fellow in FPM functions as part of a multidisciplinary team, liaising with the counselling team, police, protective services workers and the courts. The trainee conducts child abuse assessments of children referred because of suspected child abuse or neglect. At all times, the trainee is expected to consult with his/her supervisor about any cases or issues of concern. The VFPMS Medical Director (or delegate) reviews all medical reports before reports are sent to Police or Child Protection workers.

As a general rule, trainees should initially sit in with consultants and observe medical evaluations for suspected physical and sexual child abuse. The trainee should then conduct his/her own

Anne Smith, Director VFPMS 9 Manual for Advanced Trainees / Fellows in Forensic Paediatric Medicine 2016 assessment whilst the consultant observes the process. The trainee should then be able to conduct the assessments using the consultant for advice and technical assistance for the first few genital assessments using the DVD-colposcope. All DVD recordings of genital examinations and all images of injuries should be reviewed and discussed with your clinical supervisor. If possible, the SMS in clinic should also see these physical injuries and discuss both the cause and timing of injuries with you.

The trainees have been rostered for times when consultants are available in clinics. (I accept that we don't always live in an ideal world and there are times when consultants are NOT on site with you because they are in court, attending case conferences, on holidays or unwell). Use the consultant often and please do not hesitate to ask for advice or assistance! Call me if there are ANY problems and let me know early if you are NOT able to access the help you need.

VFPMS Guidelines for Trainees’ Clinical Practice

See all sections on VFPMS WEBSITE re tools and templates, referral procedures and CPG.

ONCALL - RECALL Attitude from the outset: The aim of the VFPMS 24/7 telephone advice service is to promptly solve problems, minimise angst and increase diagnostic accuracy. We aim to be helpful. We go the extra mile. We work hard. We collaborate. We demonstrate integrity. As good team players we are mindful of everybody’s roles and responsibilities and we always work as respectful partners with other professionals. We advocate for the safety, wellbeing and health of children and adolescents that we treat and we will not be bullied into compromising the quality of their medical care.

The fellow will receive incoming telephone calls to VFPMS (24/7 telephone number 1300661142) as the “first on call”. The senior on-call for VFPMS will act as backup and “second on call” for advice and consultation to the fellow and, where necessary, may respond to the original caller. The Victorian Institute of Forensic Medicine (VIFM) provides the after hours call service, and confusion can arise in relation to the roster so feel free to contact me if/when difficulties arise. Telephone advice is provided to:-  Victoria Police

 Health professionals and

 Child Protection practitioners

All incoming calls must be discussed with the senior doctor on call as soon as possible (within minutes) after the telephone call. If any doubt exists about case management then the fellow will plan management in consultation with the VFPMS consultant prior to advice being offered to the caller. In some instances the senior doctor on call may “take over” the case and deal directly with the caller.

The afterhours telephone call-service : VIFM The afterhours VIFM answering service currently provides the afterhours call service for VFPMS. The VFPMS 1300661142 number is answered by VIFM after 5.30 pm and prior to 9am on weekends and for 24 hours on weekends and public holidays. The VIFM operator will call the oncall VFPMS doctor who must maintain contact and availability for advice whilst on call (telephone charged, on, and doctor able to respond). Calls received afterhours are usually received in relation to requests for an urgent (after hours face to face) consultation but may relate to information about more general in-hours VFPMS services, advice regarding injury interpretation, procedural guidelines or appointments for in- hours services.

The Medical Director, Anne Smith or a senior VFPMS consultant provide 24/7 oncall advice for occasions when there are service difficulties and/or complaints.

Sexual abuse VFPMS has sole responsibility of provision of forensic medical services to under-18 year olds who might have been sexually abused. This means that VFPMS is the service that collects forensic samples using the FMEK according to VIFM standards and all medico-legal reports regarding sexual abuse of under-18 year olds should be written using the VFPMS report format, including when children are examined in regional Victorian locations. VFPMS provides MEDICAL TRIAGE regarding concerns about sexual abuse of under 18 year olds. This means that VFPMS collects sufficient information from the caller about the caller’s concerns regarding the nature and timing of possible sexual abuse in order to make decisions about  Whether a face to face consultation with VFPMS might be required, and if so

o The best location

o The best time

o The best health professional to conduct the assessment

 When no VFPMS face to face consultation is required then decisions are made and (when required) planning occurs for counselling, mental health care, medical care and engagement with Child Protection and Police.

When children have symptoms and signs that might be associated with sexual assault, medical triage by VFPMS (for the purposes listed above) should occur prior to engagement with sexual assault counsellors in order for optimal health care to be arranged at the best location, best time and with appropriately skilled medical professionals. When children are seen face to face for urgent evaluations of sexual assault by VFPMS, these evaluations should occur as joint responses with counsellors (Gatehouse and SECASA).

Category 1. Allegation of sexual assault When children allege recent sexual assault joint responses by VFPMS and counsellors should always occur. This means that sexual assault counsellors must be promptly informed by telephone about under 18 year olds who might require urgent counselling (possibly because of recent “disclosures”), even when VFPMS deems that individual case-details indicate that urgent VFPMS evaluations are not required (and VFPMS plans in-hours evaluations). When children require urgent face to face evaluations for suspected sexual assault, both VFPMS and counsellors should attend. The presence of individuals other than the doctor and patient in the consultation room during “history taking” is at the discretion of the doctor and consent of the patient. A chaperone should be present whenever a genital examination occurs.

Note: Only essential persons enter DNA-cleaned rooms. A log must be maintained of all persons entering DNA-cleaned rooms.

VFPMS provides holistic health responses inclusive of a forensic component (which is forensic sample collection and provision of evidence for the legal system). VFPMS services are offered regardless of children’s or their guardians’ willingness to involve police (although the decision about police involvement might affect the time and location of the VFPMS service delivery. Sometimes, when forensic samples do not need to be collected after hours, VFPMS face to face evaluations can be delivered during working hours on the next business day). This means that

VFPMS offers a medical service to EVERY under 18 year old who is considered to be a possible victim of sexual assault. The collection of forensic samples is part of the service we provide but only a component; the other components of the service are documentation of history and examination finings with reports written for future legal action, general health care including preventive health care (eg prescription of Azithromycin to prevent STI), discussion of sexual health, contraception, mental health and other concerns, discussion of safety issues and consideration as to whether contact should be made with Child Protection. All of these components of VFPMS service should be offered to victims of sexual abuse/assault regardless of decisions to report to police.

Category 2. No allegation of sexual assault When no allegation of sexual assault has been made but children have symptoms and signs that might be associated with sexual abuse but alternatively might be caused by conditions other than sexual abuse (that is, there exists a differential diagnosis that includes but is not limited to sexual abuse), then careful medical evaluation is required. Accurate diagnosis is extremely important. An open mind regarding all possible diagnoses must be maintained during the evaluation process. Professionals working in this field must be aware of, and takes steps to minimize, confirmatory bias in relation to suspected sexual abuse.

In these situations it is not appropriate for a sexual assault counsellor to be engaged until there exists a “reasonable probability” or at the very least, a strong suspicion, that the child might have suffered sexual abuse. It is not appropriate to refer children to sexual abuse counsellors when, in the absence of other concerns, the children have conditions such as accidental fall-astride injuries, urinary tract infections, dermatitis in the genital area, vulvovaginitis, labial adhesions, normal behaviour and medical conditions confused with abuse.

Consider urgent reporting to Child Protection if further comprehensive protective evaluation is required because of the child’s psychosocial situation. Promptly report children to Child Protection when you believe the children to be at imminent risk of significant harm. This should be considered regardless of the child’s reason for referral to the VFPMS, just as you would for a child seen in any other professional /medical consultation.

Suicide risk When children are deemed to be at risk of serious self-inflicted harm (ie children express suicidal ideation and suicidal behaviours, excluding isolated non-suicidal self-injury) then the hospital based mental health service should be asked to assess the children or a CAT assessment might be urgently required. Ask about suicidal ideation and plans. Do not discharge from VFPMS a child when you hold serious concerns about the child’s current risk of suicide or self harm. Refer immediately to the crisis mental health team, document your concerns and the referral process.  Urgent mental health assessments may occur while the child is in the Emergency Department. This may require the child to be “transferred” from VFPMS to the Emergency Department in order for this to occur.

 Referral to outpatient CAMHS or alternative should be arranged prior to children leaving the hospital premises. The planned time, date, location and (if known) name of service provider should be recorded in the UR file-notes

 If children are deemed by the mental health care team to require an inpatient admission because of serious mental illness associated with significant risks to health and safety then the responsibility for arranging admission rests with the mental health clinicians and Emergency Department staff.

 If children are deemed to be safe for discharge from ED then the mental health team (in collaboration with ED staff) are responsible for arranging ongoing mental health care.

 When an urgent afterhours mental health assessment is required for a child’s parent or care-giver is required then arrangements for this should be made in collaboration with Child Protection.

Presentations to Emergency Departments Children present to hospital Emergency Departments because of a broad range of conditions, concerns, injuries, symptoms and signs. Amongst this group of children there exists a very broad range of situations and conditions that raise concerns about possible sexual assault/abuse. Situations and conditions that generate thoughts about possible sexual abuse range from clear statements (allegations) of sexual assault to vague and nonspecific thoughts about sexual abuse that might be ill-founded, based on misinformation or unreasonable suspicions. Children attending triage desks in Emergency Departments thus have “pretest probabilities” of a diagnosis of sexual abuse that range from a high likelihood (>95% probability) to an extremely low probability that sexual abuse has occurred.

There is no algorithm or formula that reliably predicts the probability of a diagnosis of sexual abuse based on presenting symptoms and signs. An unbiased, objective, impartial evaluation is required in all circumstances, including when allegations of sexual assault have been made. When sexual abuse is considered in the context of a number of differential diagnoses (that is, sexual abuse might or might not be the reason for the child’s symptoms or signs), then VFPMS will consult with ED staff about possible examination and investigation. Attendance by VFPMS for urgent face to face assessment is possible, but not the only management option. Sometimes VFPMS consultants might have sufficient expertise to exclude the diagnosis of sexual abuse with a reasonable degree of certainty and under such circumstances will recommend medical management in the absence of VFPMS face to face consultation and/or follow up.

When clear statements about alleged sexual assault exist, both VFPMS and counsellors should respond to a request from ED staff. VFPMS should perform medical triage to determine the requirement for an urgent face to face forensic evaluation or an in-hours consultation. Counsellors should be promptly informed in order to respond as they deem appropriate. They should be informed about the timing and location of the forensic medical service. On some occasions, for example because of psychological distress caused by a recent disclosure, urgent counselling may be provided (within hours) when a medical consultation has been arranged for later in the week (within days).

Emergency department staff will attend to the child urgent medical needs PRIOR to attendance of VFPMS. This Emergency Department assessment and treatment might include  Resuscitation

 Examination / Treatment of serious physical injury (assault or accident)

 Examination for signs of head injury, monitoring and treatment

 Examination and monitoring for signs of airways compromise if strangulation is suspected

 Treatment of effects of drugs /alcohol, including hypoglycaemia

 Prevention of complications of injury

 Stabilisation and treatment of pre-existing medical conditions (eg., diabetes)

 Monitoring of vital signs while effects of drugs and alcohol wear off

NOTE: It is absolutely contraindicated for children who allege recent sexual assault AND who have not had yet an assessment of their medical needs to wait in an out-of-the-way area of an Emergency Department unsupervised by ED staff or supervised by individuals who lack medical training (this includes social workers such as CASA staff). If after initial assessment by ED staff, counsellors assume sole responsibility for monitoring the physical wellbeing of children who allege recent sexual assault then this decision should be made in conjunction with senior ED staff who are aware of the risks posed.

Consent Consent for forensic medical examination must be obtained  by the doctor/nurse conducting the examination /forensic procedure

 from the right person

 after ensuring that this person has the capacity to consent

 for each specific aspect of the procedure

 after informing about all aspects of the procedures including risks of adverse outcomes that might eventuate if the patient proceeds and risks/consequences if the patient does not proceed

 and it must be freely given (and able to be retracted at any time during the procedure)

Note that consent for forensic medical procedures may be provided by mature minors in some circumstances and it is the duty of the doctor who discusses matters of consent with the minor to determine the minor’s capacity to consent or with-hold consent. Factors used by the doctor to determine a minor’s capacity to consent (or lack of capacity to consent) should be documented in the VFPMS file notes. (See RCH handbook version 9 for information about Dr’s assessments of mature minors’ capacity to consent. Use the VFPMS mature minor consent form)  Chaperones should be present during genital examinations.

 Support persons of the children’s choice should also be present if the children wish.

Assessments for sexual abuse of children in Regional Victoria VFPMS style consultations in regional Victoria are to be planned in consultation with the VFPMS NUMs or consultants. Services in regional Victoria are in a constant state of flux and the NUMS and consultants are likely to know of the current situation in each region on a month by month basis. Currently children from the Geelong / Barwon region and Traralgon (West Gippsland) regions who have recently been sexually assaulted and who urgently need samples collected must travel to Melbourne for VFPMS consultations. Other areas of Victoria are better serviced. The VFPMS website (regional service information under “How to refer” titled “VFPMS contacts in your Region” includes links to contact details of service providers in each Region. http://www.rch.org.au/vfpms/refer ) •Barwon South West •Gippsland •Grampians •Hume •Loddon Mallee •Peninsula

Goals for forensic paediatric medical service delivery in regional Victoria In general, aim to have the child seen in the closest site where a high standard of forensic medical care can be provided.

Do not compromise the quality of care or accept an inadequate medical service, a dangerous or risky option merely because it suits or is convenient for other professionals.

Regional services (large publically funded health services that employ paediatricians and child health professionals) are responsible for the medical care provided to children when child abuse and neglect is suspected. These health services employ the paediatricians and other doctors and nurses who provide health care. VFPMS provides these doctors and nurses with advice, tools to use when evaluating children in relation to suspected abuse, professional support and assistance for report writing and court appearances.

VFPMS is responsible for the advice offered to callers regarding the adequacy of a forensic service in regional Victoria and in recommending the use of local /available expertise. At times the combined services of a paediatrician (history, physical examination and medical report) and a forensic nurse examiner (collect swabs for forensic analysis and report) may be utilised. If in doubt, a child should travel to Melbourne in order to obtain forensic paediatric medical expertise.

When doctor or nurse who is oncall for a regional Victorian health service refuses to provide a child with a forensic medical service, local options (eg doctors in neighbouring regions) maybe considered or the child might need to travel to Melbourne.

Physical Abuse Most doctors and many nurses possess the knowledge and skills to assess injuries and wounds in order to determine appropriate treatment. Some of these professionals have also been trained to assess wounds and injuries in order to determine CAUSE. It is these medically-trained professionals who work in the broader health system who have the capacity to provide (at least a component of) forensic evaluations of children’s injuries and reports / testimony in court. These professionals might include doctors working in Emergency Departments, some General Practitioners, most paediatricians, most forensic physicians, some specialists and some forensically-trained nurses. VFPMS works in an integrated way with other medically trained professionals to provide a forensic medical service to physically assaulted/abused children. This is a shared skill and duty. After hours VFPMS provides a 24/7 telephone advice service in relation to suspected physical assault / abuse. Most children seen in Emergency Departments will be adequately managed by ED staff in relation to the evaluation of their injuries. This includes medical investigations and photography. A follow up appointment (for an in hours VFPMS clinic) maybe be arranged for some children who require a comprehensive holistic VFPMS-style assessment after their attendance at ED.

Photographs Photographs of injuries should be taken when there is a forensic component to the medical evaluation and treatment. This means that photographs should be taken whenever assault /abuse might have caused injury AND ALSO when injury might have been caused by parental /care-giver neglect.  At RCH there is a photographer on call 24/7. Authorisation from VFPMS is required in order for ED to call in the after hours photographer.

 At MMC there is a photographer on call during business hours and a camera (Canon SLR) in the VFPMS clinic. MMC ED doctors are almost certain to refuse to take photographs of injured children. VFPMS doctors are encouraged to photograph the physical injuries seen on children examined after hours.

 Photographic equipment (cameras) and doctors’ willingness to take photographs varies from site to site across Victoria. Encourage doctors to take photographs if facilities exist.

Inpatients referred to VFPMS Children admitted to hospital should be seen face to face by VFPMS within 24 hours of admission, preferable as soon as possible. A child who is medically unstable and / or who has a serious head injury should be seen promptly (within hours). Note that children requiring intensive care might deteriorate extremely rapidly particularly when hypoxic ischaemic brain injury has occurred. Attendances by VFPMS should be provided in collaboration (wherever possible as a joint response) with social workers. In hours it is usually sensible for the NUM to participate in the consultation on the ward and for her to remain actively involved in the child’s case during admission. She should maintain daily contact with Gen Med (or alternative) medical staff to ensure a daily two-way exchange of information. The family should be visited daily (on weekdays) by VFPMS staff. The VFPMS staff should discuss all forensic interpretations of results with the child’s parents/carers, the treating medical team (ideally the consultant) and with Police and Child Protection.

VFPMS consultants must oversee all VFPMS Fellows work in relation to inpatients.

Reports for inpatients should be completed promptly. The KPI is that reports should be finished and sent within two weeks of the consultation. A template exists for INTERIM reports when Child Protection need a written interim opinion from VFPMS for Court. (See website)

REPORT WRITING – FORENSIC OPINION SECTION

The key question to address is, “Has this child been assaulted/abused?”. The opinion section should enable the reader to clearly understand your thoughts about this, even if your answer is “maybe”, “the cause is undetermined” or “I don’t know”. Comments about probability are appropriate. Comments about someone’s guilt or lack of guilt are entirely inappropriate. Anne’s notes regarding formulation of forensic opinion and presentation of evidence should be read. You will each be given a copy at the start of your VFPMS term. NOTE The opinion section should answer the following questions:-  What is the story?

 Is the child injured?

 What are the injuries?

 What else (physical damage) might be injured? Harmed?

 How did it happen? (Mechanism)

 What forces were/might have been involved?

 When did it happen? (Timing of all injuries?)

 What consequences might result?

 How do the findings and the story “match up”?

 What are ALL the possible differential diagnoses, and how are they weighted?

 Overall probability of assault versus accident versus other cause for findings.(if you can)

Proformas are available for use. The VFPMS proformas are available on the website. Use them.

Diagrams – There are diagrams for three sizes of children; infants, children and adolescents. Print off relevant pages to document the injuries using body diagrams.

Detail your description of injuries according to :-  site (reference body landmarks, anatomical position of the body, cm from a joint)  size (use one measurement – either cm or mm and remain constant)  shape  surrounds  surface  edge (margins)  colour  contour  contents  pattern  swelling  blanch / stretch/ movement  tenderness / pain on movement  discharge / fluid / debris

Additional proformas are available for your use with children you assess for Child Neglect

Write, type or dictate a report for every child you assess (yes, every single one!) Take it to administration staff for typing. You may type reports yourself if you wish or use Dragon Dictate (I am happy to show you how if you have not used voice transcription software before).

All reports are checked by the Medical Director (or delegate).

Changes (edits to your reports) will be suggested but you MUST ensure that you do not alter the facts or veer away from the truth.

All editing of reports can only address matters of grammar, syntax, congruity between stated history and examination findings etc. I like to see photographs and the DVD genital exam findings particularly for complex cases and I also like to see the radiology findings and RetCam photos. However, YOU will have a MUCH stronger impression about the case than someone merely reading your report and you must ensure than your report remains accurate. After all, it is YOUR report with your signature at the bottom. You must be happy with it. Accuracy is paramount! At the end of the day it will be up to YOU to defend all the statements in it.

Do one report only (even if asked for different things by different professionals) as an initial approach. Occasionally an interim report is required prior to a final (comprehensive) report and then a third medical report might be required for the criminal justice system (this court report would have “hearsay” and sensitive psychosocial information removed). If in doubt talk to me.

Seek advice, seek advice, seek advice….. READ THE TIPS FOR REPORT WRITING ON THE VFPMS WEBSITE

There are folders of confidential medical reports available for you to view in order to see examples of other doctors’ work in this field. One folder is a compilation of various doctor’s reports.  One folder relates to inpatients  One is for head injured children  On line at the VFPMS website is a selection of recent reports based on real cases (somewhat de-identified)

Note that all these reports are from actual children’s files and the cases might still be active in the courts (and are therefore highly confidential!!!) Please do not discuss the contents with others working outside VFPMS for privacy and legal reasons.

SHOCK, HORROR AND TAKE NOTICE!!!! Note than you are discouraged from using the following words unless you are quoting someone, in which case the words should be included in parentheses.

BANNED WORDS AND PHRASES  Rape  Assault – always say “alleged assault”  Disclosure – use “allegation” or an alternative phrase Intercourse – refer to the actual penetration or attempted penetration, for example, “attempted penile-vaginal penetration” or “penetrated her vagina with his penis” (the second is simpler – it is good to say what went where)  Sex / Had sex – refer to actual penetration instead – this phrase means different things to different people eg many adolescents do not regard oro-genital contact as “real sex”.  Oral sex – specify precisely what went where, for example, penile-oral penetration or you could use the technical terms (fellatio, cunnilingus) if you wish  Belted (unless a belt WAS used), gave someone a beating – use other words whenever possible, or in your conclusion, refer to inflicted blunt force trauma  Note the need to use correct terminology for injuries (bruise, petechiae, abrasion, laceration, incised wound, puncture wound etc).

REFERRALS AND INVESTIGATIONS

Use the expertise available to you within the VFPMS team! Feel free to investigate and refer children you see in this centre as though you were functioning as a paediatrician in a general medical clinic or in the community. Use the paediatricians and other VFPMS consultants for advice if you wish to “run things by someone” first.

I would prefer that you initially sought advice from VFPMS senior medical staff rather than refer children directly to subspecialist consultants. The senior consultants in VFPMS have a wealth of experience in General Medicine, Community Medicine and many subspecialist areas of practice so it is appropriate to seek their advice before referring to Haematologists, Dermatologists, Gynaecologists and others.

VFPMS provides a holistic service. You might hear others imply that VFPMS is merely a service for initial evaluation of suspected child abuse. This is NOT the case. The medical evaluation of children with whom we have contact should be thorough and comprehensive and, of course, there should be a therapeutic component. I (and others) get a bit miffed when children’s problems are identified but doctors do nothing to intervene! Go the extra mile, do the developmental assessment, telephone staff at school (with permission) and communicate with others involved in their care. You may wish to bring some children back to VFPMS for review to monitor their wellbeing and ensure that intervention has been put in place as you recommended.

Please consider investigations and referrals to evaluate, monitor, intervene and safeguard children’s health, growth, developmental, emotional and psychological wellbeing. The quality of their relationships and each child’s self concept are also very important considerations.

Doctors are encouraged to review children to ensure that the children’s medical care is being managed appropriately and that measures are in place to ensure the children’s ongoing medical follow-up, safety and psychological treatment.

Please consider the child’s ongoing health needs and have a low threshold for referral to a General Practitioner or Paediatrician in the community. It is NOT enough to merely say that a referral is required. It is up to you to actually arrange the referral and ensure that the process is commenced to ensure that the child attends required appointments and has recommended investigations. Child Protection workers need your help to make this happen! Be explicit and arrange everything you can. Insert the time, date and location into the recommendations section in your medical reports or at a bare minimum refer to time frames such as “within the next three months” or “before the end of this year”. The name, address and telephone number of the contact as well as the date and time of the booked appointment is ideal.

CASE CONFERENCES Doctors are encouraged to attend case conferences in relation to children assessed by VFPMS.

We keep data about VFPMS attendances at case conferences (including SCAN meetings) so ensure the NUMs are aware so it can be included in your stats.

VFPMS will pay for your additional time if you need to attend case conferences in non-rostered time.

CONSENT

Aim for VALID written (informed and freely given) consent. Use the VFPMS consent forms to detail precisely what consent has been provided / withheld.

At times Child Protection workers and police might arrive with a signed ‘consent form’ that is not a VFPMS form. This is not a valid VFPMS consent form. Arguably, this is often not valid consent and even if it is, how can you be sure?

You are encouraged to discuss with a consultant each situation when you are asked to examine a child but you do not have valid consent from a guardian. These cases are complex and accurate documentation of the circumstances for the examination is essential. For mature minors, competency to consent may be obtained from the young person according to the Gillick principle.

Verbal consent is OK if you are not able to obtain written consent and you explicitly go through each step of the consent form with the appropriate person. Do not assume “implied” consent (ie they are here – therefore they must be consenting to everything!)

In an emergency, the wellbeing of the child must take priority over all other considerations but note that an examination of a child without adequate informed consent leaves the doctor open to an allegation that the doctor “did the wrong thing”.

Reference the Child Abuse chapter in the RCH Handbook Version 9. VFPMS information and RACP guidelines - genital examinations in girls and young women Note VFPMS information related to photo-documentation

Note the VFPMS Memorandum of Understanding with the Office of Public Prosecutions

CONFIDENTIALITY

In the child abuse field it may not be possible (or safe) to guarantee confidentiality, especially when it might jeopardise a child’s safety or the safety of another person.

As a general principle during most consultations between doctors and patients it is acceptable to offer confidentiality to children and adolescents (and their parents/guardians) provided that there are no concerns about the child’s safety or the safety of another child. In this line of work there are usually concerns about safety and it is NOT possible to offer confidentiality because the Mandatory Reporting requirements in the Children Youth and Families Act 2005.

Be cautious and sensible about sharing information in medico-legal reports. Sometimes people ask that personal information be NOT documented or NOT included in a report. If information is included in your notes but not in the final report then your notes should indicate this situation and the reasons for it. Your notes are legally discoverable, that means that whatever you write in your notes can be discovered in court.

COURT APPEARANCES Please discuss any and all concerns about court cases with your supervisor or a consultant.

Always discuss a subpoena with a VFPMS consultant. Always prepare for a court hearing by discussing case details with a consultant.

At times your comprehensive report will provide the information that Child Protection seek and you might not be required in court. On other occasions you will need to appear – either in person or via videolink.

The legal system operates under very different rules to the medical system but the legal system usually is respectful of doctors and attempts are made to minimise disruptions to doctors’ day to day work and responsibilities.

We might be able to have someone come to court with you for moral support but it is unlikely.

Please use any opportunity you can to accompany a consultant who is going to court to give evidence.

Please discuss with the consultant how you might be remunerated for your time in court. (Payment from the courts is appallingly meagre – don’t get your hopes up). VFPMS will pay you for your time in court at the usual hourly rate of each half day (3.5 hours) and also see the section re Time in lieu

TELEPHONE ADVICE

Do not give out advice about medical reports or comment on medical management by other practitioners. NOT EVER!!!!

Note that the VFPMS has a policy to providing advice on medical reports to police, protective services and the legal profession. We insist that this is performed as a professional service when (and only when) all available information has been offered, the conditions under which the report will be reviewed are detailed in writing and the informed consent of all parties has been obtained.

An ‘expert opinion’ should be offered only by those with the required knowledge and skills and with all the required ‘safeguards’ in place.

In general, opinion about another doctor’s clinical practice should be offered when all the facts are openly able to be assessed. We prefer that the other doctor is aware that an expert opinion has been sought and that they are aware of the evidence on which this opinion will be based.

See clinical practice guideline regarding provision of expert opinions based on case file reviews.

MEDICAL DEFENCE

Fellows must maintain their medical indemnity insurance. This is a condition of employment.

POLICE CHECKS

It is a condition of employment that police checks are conducted on employees prior to commencement of employment.

All VFPMS employees must have current Working with Children Card.

MEETINGS

You are expected to attend VFPMS Peer Review meetings When ….. 1 st Thursday of the month at 9.30 am - 11am. Where……HELP at RCH

These meetings are part of the peer review program and it is expected that ALL abnormal video- colposcopy /DVD-colposcopy findings and other interesting cases will be reviewed by the group. If you are unable to attend a meeting please provide clinical material to the VFPMS nurse to present for discussion by the group.

Minutes of the peer review meetings are emailed to the group.

STRONGLY ENCOURAGED At least once during your term you might like to attend the VIFM Thursday am meetings at 8.30. This is a clinico-pathology meeting. Additional social ‘meetings’ occur from time to time and all fellows and other team members are encouraged to attend.

Anne Smith, Director VFPMS 21