The Forensic Medical Examination, Dr Rosalyn Proops

The Forensic Medical Examination

Dr Rosalyn Proops Royal College of Paediatrics and Child Health Norfolk and Norwich Hospital 11th March 2008

1

Toby 18 months Seen in the Children's Assessment Unit with mother with bruising inside of thigh and pain passing urine. Left with the babysitter ( male friend of the family ) Extended and immediate family known to Local Authority Difficult to examine, unhappy and irritable Bruising on penile shaft and glans. Examination under anaesthetic with paediatrician, paediatric surgeon and Forensic Physician Evidence of significant trauma to foreskin, glans and penile shaft No adequate explanation Full care order No prosecution 2

Lauren 13 years Lauren is brought to out-patients by mother and stepfather to review her cerebral palsy. Step dad is concerned about Lauren's difficult behaviour and mother tells the doctor they want to see an orthopaedic surgeon to help her walking. What the doctor doesn’t know and what Lauren would tell him if she trusted him is that she is deeply distressed because her step father has been having sex with her for the last 7 months and she is convinced that she is pregnant. She is also worried about more painful surgery as she finds using her wheel chair gives her more freedom, mobility and self respect. The consultation ends with the doctor prescribing medicine to calm her down 3

1

Child Protection IS everyone's business • Awareness within the wider health team • Consider the whole child • Concurrent abuse and co-morbidities • The child with a disability • The family history and relationships • Children’s Rights ( of protection participation and provision) • Child advocacy 4

The burden of child maltreatment to the individual and to society Cost to the Individual Mortality and Morbidity Physical Developmental Emotional Mental health

Cost to the state The Public Health problem What £ cost? Health and Social care Crime and Justice

The next generation 5

The Forensic Medical Examination • • • • • • • • •

Clinical history General examination Examination relevant to the abuse Detailed contemporaneous documentation (including line drawings) Photo documentation Forensic sampling Arranging after care Writing a report Attending court 6

2

Pathways and Networks prevention identification assessment intervention long term support

• What needs to be done, based on best evidence • Who needs to do it based on competencies • Where it needs to be delivered based on safety convenience… • With which additional resource/ support • And common ground between commissioners, providers and regulators – clarity of purpose, underpinning values – leadership – commitment to innovation and learning 7

What are the indications for a paediatric forensic medical examination? • Allegation (direct or indirect) of sexual abuse/ rape / assault • Sexually transmitted infection or pregnancy in a child • Problems such as recurrent vaginal discharge genital bleeding secondary enuresis AND relevant history of concern • Concerning genital injury • Behavioural disturbance e.g. self harm cruelty to children or animals AND relevant history of concern • Contact with sex offender • Sibling or close friend of index child 8

Paediatric Forensic Examination When? •

Whenever a child has made a disclosure of recent sexual abuse, sexual abuse has been witnessed or when a referring agency strongly suspects abuse has occurred

Timing depends on: • Medical care required • Likelihood of physical signs and / or positive DNA sampling • STI cultures ( repeat cultures in 2 weeks and samples for blood born infection after 3 and 6 months)

• Legal requirement 9

3

Where should the assessment take place? •

What do the children want ?

•

Sexual abuse in children is (usually) part of the bigger story of significant harm

•

Paediatric out patients with dedicated suite ( forensic standards) – Hospital based - with all health support facilities – Community based - with LA / police

•

Sexual assault referral centres for all age providing services for children and young people ( paediatric standards) - Hospital based - Community based

• •

Young people over 14 years Young people with (learning) disabilities 10

Who ? One or two doctors? • It depends… a single doctor examination may take place if he/ she has the full complement of knowledge skills and experience, or two doctors with complementary skills •

Most general paediatricians will not have the forensic competencies

• Most forensic physicians will not have the paediatric competencies •

Children presenting with concerns about physical abuse neglect or emotional harm should also be fully examined as part of the assessment

• May need other specialists

11

Medical findings as diagnostic of sexual abuse • What can be the determining factor…? Exceedingly rarely can this be a medical finding alone • History • Medical findings- USA and UK – Clinical diagnosis – Laboratory diagnosis

• Common standards and a common language • Peer review 12

4

UK The Physical Signs of Sexual Abuse: An evidence based review and guidance for best practice • • • •

First guidance issued 1991 RCP, reviewed 1997 4 years in the making. Publication April 2008 Led by RCPCH with multiple stakeholders Aims – Review evidence in relation to ano genital signs of sexual abuse in girls and boys <18yrs – Agree good practice in relation to assessment and examination of children where there are concerns about sexual abuse

13

USA Approach to the Interpretation of Medical and Laboratory Findings in Suspected Child Sexual Abuse: A 2005 revision Joyce A. Adams • Working group of the American Academy of Paediatrics and Helfer society to determine evidence –based criteria and reach consensus 14

Children in the USA are no different from UK children • Physical signs are uncommon certainly less than 10% , probably less than 5 (3)% and decreasing (photodocumentation, more information about range of normality)

• Certain physical signs are indicative of blunt force trauma – – – – –

Laceration of hymen Bruising of hymen Perianal lacerations Hymenal transection between 3-9 o’clock Missing segment of hymenal tissue in posterior half 15

5

The language of grading and association • USA

• UK

• Diagnostic of trauma

• Diagnostic of .. • Good quality evidence ..showing

and/or sexual abuse

• Indicative of ..blunt force trauma

association with

• Indeterminate findings: insufficient or conflicting data from research studies

• • • •

Limited Non-discriminatory Insufficient Conflicting 16

Summary • Sexual assault in children and young people is a relatively common problem • Physical findings are not so common • Developmental and behavioural indictors are important and frequent • Most children are not heard and most do not get to court • The doctor has an overriding duty to the court and to the child to maintain an impartial high standard of clinical and professional practice

17

GMC 0-18 years: guidance for all doctors 2007 Assessing best interests Communication Making decisions Confidentiality Access to records by parents and children Child Protection 18

6

except in an emergency, where the patient has the capacity to give consent you should obtain written consent in cases where providing clinical care is not the primary purpose of the examination or investigation and / or where there may be significant consequences for the patients ..social or personal life General Medical Council Seeking patients’ consent: the ethical considerations. 1998 19

Consent and assessing capacity to consent Can the young person understand the nature purpose and possible consequences of the investigation? – Understand the information relevant to the decision – Retain that information – Use and weigh the information as part of the process of making the decision – Communicate their decision whether by talking, using sign language or any other means

Must provide and discuss all relevant information before deciding if the young person has the capacity to consent 20

• Capacity to consent depends more on ability to understand and weigh up options than on age – At 16 years can presume consent – Under 16 years may have the capacity depending upon their maturity and ability to understand what is involved and upon the complexity and importance of the decision 21

7

Consent • We assume parental consent as a proxy for the best interests of the child • If the parents are not acting in the child’s best interests, may need the intervention of the court • Parental Responsibility is shared with the LA under an order ( EPO, ICO , CO but LA is the senior partner) • Must obtain consent for examination, forensic sampling and photo documentation • Failure to obtain consent may constitute assault

22

Competent and confident with: • Examination - general paediatric - developmental - specific examination

• • • • •

Forensic sampling Photo documentation Evidence base Note keeping contemporaneous notes reports Communication with other agencies, within and outside of health • Presenting evidence in court 23

Do you have ? • • • • • • • •

Access to training The right kit Support at the time of the examinations Supervision of practice Peer review of cases Supportive clinical team Supportive management / employer team Links with audit and research 24

8

• Can you deliver a safe clinical service in your area? • Is it safe for the child • And safe for you ?

25

Very Useful Reading •

GMC 0-18 years: guidance for doctors

•

Child Protection Companion

•

The Physical Signs of Child Sexual Abuse: An evidence- based review and guidance for best practice

2007

RCPCH 2006

March 2008 RCPCH in collaboration with RCP FFLM

•

Paediatric forensic examinations in relation to possible sexual abuse RCPCH and RCP FFLM 2007

•

Recommendations of best practice in the management of intimate images that may become evidence on court RCPCH and RCP FFLM 2007 26

Forensic samples and their collection • For up to date information http://www.forensic.gov.uk • Guidelines for the Collection of Specimens http://www.fflm.ac.uk

27

9

Joint RCPCH and FFLM Guidelines April 2007 • It is essential that high quality photo documentation be obtained, if not document the reasons • A single doctor can conduct a paediatric forensic exam provide he/ she has all the necessary skills ( complementary skills) • The examining doctor must ensure they are familiar with the evidence- based guidance regarding the interpretation of signs 28

Department of Children Families and Schools 2007 the Government's view is that where professionals are undertaking child protection work, their first duty is to the children concerned. As far as the children's parents are concerned, professionals must simply act in good faith, exercising reasonable skill and care.

29

Forensic samples •

Sampling techniques and forensic requirements are specific and a competent practitioner needs both the theoretical and practical training

•

Evidential samples - Semen blood saliva or other body fluids containing cellular material - Loose hairs fibres debris particles - Blood urine hair for toxicological analysis - Unwashed clothing bedding items used in the assault

• • •

Control samples for comparison purposes Persistence of cellular material for up to 7 days Labels must show signature of first person and all others( chain of evidence) Retain a list of samples and identification numbers

•

30

10