Section 1 - Types of abuse and indicators - should I be worried about this child, young person or family?

This section of the toolkit will help frontline practitioners identify different types of abuse and historical, parental, familial and/or environment factors which may be of concern.

Child maltreatment

Child maltreatment (abuse and neglect) is recognised to be a major contemporary public health issue. 

Any child can be at risk of abuse, however there are a number of factors that can increase a child’s vulnerability to abuse and neglect (NICE, 2017)

  • Socioeconomic factors such as poverty, poor housing and deprivation
  • Child factors: disabled children are more vulnerable to abuse or neglect
  • Family factors such as parental/carer substance misuse problems, parental/carer mental health problems and domestic abuse. These factors may be compounded if the parent/carer lacks support from family or friends (social isolation).
  • Vulnerability factors for recurring or persistent child abuse and neglect (be aware that neglect and emotional abuse may be more likely to recur or persist than other forms of abuse):
    • The parent or carer does not engage with services.
    • There have been one or more previous episodes of child abuse or neglect.
    • The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
    • There is chronic parental stress.
    • The parent or carer experienced abuse or neglect as a child.

    Other important risk factors include:

    • A family history of maltreatment
    • Being in care (looked-after child)
    • A history of offending (parent or child)

Prevention and early identification of child maltreatment, which is key, may depend on the early recognition of risk factors and warning signs, including those related to parents and the environment. 

Preventing abuse requires promoting family well-being and resilience and fostering strong, stable relationships between parents and child. Planning positive intervention involves assessing and addressing parental risk factors, preferably before a child is conceived, and certainly in early pregnancy. Practitioners need to retain awareness that most parents in families with risk factors do not maltreat their children, and some parents in families with no identified risk factors do maltreat their children.

How common is child maltreatment?

A UK-wide survey of young people, carried out in 2009, found that almost one in five young people aged 11-17 years reported experiencing high levels of maltreatment during their childhoods (Radford et al., 2011).

More recent statistics point to a year on year increase in the numbers of children who are referred to statutory services and those subject to child protection proceedings (e.g. child protection plans). This may, in part, reflect greater professional and public awareness and response to child maltreatment, but there is a continuing need to be vigilant and responsive to concerns.  

The NSPCC How Safe are our Children? Annual Conference and report provides a useful analysis of various sources of child protection data from across the UK. The research and resources site links to the How Safe initiative and provides links to UK government child protection returns on numbers of children subject to statutory intervention, for example being subject to a child protection plan.

Types of child maltreatment

Abuse is a form of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Children may be abused in a family or in an institutional or community setting by those known to them or, more rarely, by others. Abuse can take place wholly online, or technology may be used to facilitate offline abuse. Children may be abused by an adult or adults, or another child or children.

(Working Together To Safeguard Children 2018)

Statutory guidance across the four countries of the UK describes four main categories of abuse, and these definitions will normally be reflected in local organisations’ policies and procedures. The four categories are; physical abuse, emotional abuse, sexual abuse and neglect (definitions of abuse taken from Working Together 2018).

Reference to one (or sometimes more than one) category of abuse is made for the purposes of child protection planning. Government statistical returns show that the most common reason for child protection intervention reflects concerns about neglect, closely followed by concerns about emotional abuse. Physical abuse and sexual abuse feature in significantly fewer cases subject to statutory intervention, however, it should be noted that in most local authorities, only one category can be ticked on a child protection plan. So, while physical abuse and sexual abuse might be ‘ticked’ less often, that doesn’t mean they don’t feature in the plans.

Presentation of child maltreatment can take many forms. A child may present with physical or behavioural signs of abuse and/or neglect, which are incidental to the reason for attendance at the GP practice. Alternatively, they may attend with mental health or behavioural issues as a result of abuse/neglect.

Children and young people may disclose maltreatment, although disclosure to professionals is rarely a sudden or one-off event. Young people describe it as going on a journey, with trust and confidence in the process growing over time.

Abuse and neglect should always be considered when seeing children and young people of any age for any presentation. If practitioners don’t consider it, they may not ask about it and may not see the signs. It is important that abuse is asked about directly in age appropriate language, bearing in mind that children and young people may not recognise that they are victims of abuse.

Practitioners should be very clear with children and young people about confidentiality and its limits.

Concerns that a child may be at risk of, or may be suffering, abuse or neglect may arise from consultations with adults rather than with the children. In these situations, it is equally important that practitioners are very clear with the adult about confidentiality and its limits, and also their professional duty to safeguard children and young people. Professional curiosity is also very important (refer to the Introduction section of the toolkit for a further explanation).

Other types of child maltreatment and contextual safeguarding

In addition to the four main categories of abuse, which generally reflect harm from family members, or those known to the child or young person, there are other forms of child maltreatment that GPs and their practice staff should be alert to. These threats which have been referenced as contextual safeguarding, can also arise from within the family but might arise at school, from within peer groups, or more widely from within the local community. It may include threats ranging from online safety, exploitation, honour-based violence, forced marriage, criminal gangs and organised crime groups to the influences of extremism leading to radicalisation and trafficking.

More details can be found in the sections below and on the NHS England safeguarding pages

Where concerns are raised about presentations that are indicative of contextual or specialised forms of abuse, it is likely that the practitioner will want to seek additional advice, for example from local safeguarding and child protection leads. National helplines, such as those provided by the NSPCC, include dedicated helplines for specialised forms of abuse. 

More details of contextual forms of abuse can be found on the NSPCC website

Physical, emotional, sexual abuse and neglect

Physical abuse

A form of abuse which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child.

Injuries to non-independently mobile children *

(*Non-independently mobile children includes not only babies, but older children with physical disabilities who are not independently mobile). 

The likelihood of children sustaining accidental injuries increases with increasing mobility. However, Serious Case Reviews (SCR) have identified that professionals sometimes fail to recognise the highly predictive value, for child abuse, or the presence of injuries to non-independently mobile children.

Infants under 12 months are at increased risk of non-accidental injury (NAI). When examining a child who is non-independently mobile, it is important to remember 'those who can't cruise rarely bruise'. A small apparently insignificant bruise in a baby might be a marker for a serious life-threatening injury. Children under 12 months are consistently over-represented in Serious Case Reviews (SCR), almost exclusively because of severe injury or death as a result of physical abuse.

Bruising is the most common presentation in children who have been physically abused although other injuries can include burns, fractures or unexplained bleeding. This short video is a useful resource. 

Any injury to a child who is independently mobile should be treated with concern. Physical abuse must be considered. 

When faced with an injury or potential injury in a non-independently mobile child, practitioners should: 

  • Seek an explanation from the parent or carer 
  • Consider if the injury is feasible given the child's age and developmental stage (bearing in mind that developmental age is not always related to chronological age). 
  • Consider if there has been a delay in presentation
  • Consider whether there are any other safeguarding concerns regarding the child's presentation, for example, indicators of neglect
  • Consider adult behaviours which may affect the safety of their child such as domestic abuse, mental health issues, learning disability or substance misuse
  • Consider if there is any information available regarding the child or family history which would raise concerns, for example, child or children subject to previous child protection plans. 
  • Seek further information about who is in the child's life, for example, new partner of the parent or the hidden male (see Introduction section for further information). 

Children should, where possible, be asked to contribute to the history taking and have an opportunity to be seen alone during a consultation if age-appropriate. Young or pre-verbal children presenting with physical indicators of harm should be fully examined.

It is important to note that even in the absence of other known safeguarding concerns such as those listed above, an injury to a non-independently mobile child must still be taken seriously – this may be the first indication that a child is suffering maltreatment or neglect. 

If physical abuse is suspected, a safeguarding referral must be made immediately to Children's Social Care. Processes will vary across the nations, but in many places it is the responsibility of Children’s Social Care to arrange an urgent medical assessment by a Consultant Paediatrician. However, if the child is in need of urgent medical attention, you should arrange immediate medical assessment either through the Emergency Department or Paediatrics as well as making the immediate safeguarding referral to Children's Social Care. 

It's important to make yourself aware of your local pathways of referral. 

For more information on bruising and patterns of bruising in child abuse, please visit the Forensic Medicine for Medical Students website.

Tool to aid practitioners when faced with a possible injury in a non-mobile baby:

ICON Abusive Head Trauma prevention programme – GP six-week postnatal check intervention

Coping with a crying baby can be very stressful for parents. Serious Case Reviews show that crying is the main trigger for babies being shaken. Research has shown that public health campaigns educating new parents and caregivers in coping with their baby's crying can reduce rates of abusive head trauma by up to 75%. This poster from the Hampshire CCGs provides advice that health professionals can give parents to help them cope with their baby crying and also a suggested template for the 6-week postnatal check.
 
The six week postnatal check is the ideal time to enquire with parents and carers about their babies crying as infant crying hits a peak at 6-8 weeks of age. The ICON webpage offers advice and support to both parents and carers and professionals. This includes leaflets, posters, coping with crying plans and information about the research behind the programme and can be accessed via this link: www.iconcope.org 

Fabricated or induced illness

Fabricated or induced illness (FII) is when a parent or carer fakes, or creates, the symptoms of an illness in their child.

In fabricated illness the perpetrator does not directly harm the child but reports a clinical story to doctors which is eventually established to be fabricated.

In induced illness the perpetrator inflicts direct (hands-on) harm on the child.

FII is a spectrum of presentations rather than a single entity. At one end of the spectrum, less severe presentations may include a genuine belief that the child is ill or exaggeration by carers of the child's existing symptoms. At the other end of the spectrum, the behaviour of carers includes them deliberately inducing symptoms in the child.

A key professional task is to distinguish between the very anxious carer who may be responding in a reasonable way to a very sick child and those who exhibit abnormal behaviour.

The following behaviours by carers can be associated with fabricating or inducing illness in a child:

  • deliberately inducing symptoms in children such as giving medication or other substances, intentionally causing transient obstruction of airways or by interfering with the child’s body so as to cause physical signs;
  • interfering with treatments by over dosing with medication, not administering them or interfering with medical equipment such as infusion lines;
  • claiming the child has symptoms which cannot be verified unless observed directly, such as pain, frequency of passing urine, vomiting or fits. These claims result in unnecessary investigations and treatments which may cause secondary physical problems;
  • exaggerating symptoms which cannot be verified unless observed directly, causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and therefore are harmful and possibly dangerous;
  • obtaining specialist treatments or equipment for children who do not require them;
  • alleging psychological illness in a child.

What is the impact of FII on the child?

In addition to the consequences noted above, the impact of FII on a child can be catastrophic – some of these children will die due to this abuse. Many will suffer long term consequences such as significant emotional problems in adulthood, post-traumatic stress and inappropriate health-seeking behaviours. 

FII comes under the category of physical abuse but it can also be neglectful and cause significant emotional harm. 

Warning Signs of FII 

Warning signs of fabricated or induced illness

In cases of suspected FII, the GP is likely to have had a higher level of involvement and knowledge of the child and family than other health professionals. GPs involvement and contribution to the management of FII concerns is essential to ensure that all key information with regard to the child is shared. GPs will also be aware about parental health issues – including both physical and mental health – and these should be taken into consideration as part of any assessment and information sharing.

Working with adults

Concerns about the welfare of a child may arise from a practitioner's involvement with a parent or carer. These concerns may increase if a parent/carer is known to fabricate or induce illness in themselves. 

Good practice points

  • The child's needs are paramount in this situation.
  • As with any other forms of abuse, GPs have a duty to share any relevant and proportionate information that may impact on the welfare of a child. This includes sharing relevant information about parents and carers as well as the child. 
  • Good documentation is essential. As the primary record keeper of all health records, primary care can play a key role in recognising patterns or worrying behaviour from multiple presentations at different settings. When recording concerns about FII, GPs should ensure that these concerns are recorded within the child's clinical record but that the entry is not visible on online access, as parental awareness of the concern may escalate the risk to the child.
  • Good communication between health professionals is essential. 
  • If there are concerns about FII and the child is not known to a Consultant, they should be referred to a Paediatrician, Consultant Child Psychiatrist or Consultant Clinical Psychologist (dependent upon the presenting issues) with expertise in symptoms and signs that are being presented. Concerns about possible FII should be in the referral letter.
  • Chronologies can be helpful in these situations. 

If you are in a situation where you are starting to consider Fabricated or Induced Illness in a child, it is vital that you seek further advice and guidance from experienced safeguarding colleagues. These are complex situations which should not be managed by any practitioner alone.

Where there are sufficient concerns that a child may be suffering or is likely to suffer significant harm resulting from a parent or carer's persistent attempt to fabricate, induce or exaggerate an illness, a referral should be made to Children's Social Care as soon as possible in line with local multi-agency safeguarding procedures. 

At the point of referral to Children's Social Care, advice should be sought from the organisational safeguarding lead regarding whether or not parents should be made aware of the referral, since doing so may increase the risk for the child/ children.

References: 

Emotional abuse

Emotional abuse is the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child's emotional development. It may involve conveying to a child that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them, or 'making fun' of what they say or how they communicate. It can include ignoring a child. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child's developmental capability, as well as over-protection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyber bullying), causing children to frequently feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.

Presentation of emotional abuse in general practice is dependent on the child's age and developmental stage and may be difficult to identify. Alerting features include failure to thrive at any age, physical, mental, emotional developmental delay and the following age-related concerns:

  • Babies: feeding difficulties, irritability.
  • Toddler: sleep refusal, food refusal, behavioural difficulties, communication delay.
  • School age: low self-esteem, withdrawn or shy, difficulty making friends, secondary enuresis, encopresis, hiding or scavenging food, unexplained change in emotional or behavioural state, school refusal; precocious or coercive sexualised behaviour, self-harm, somatisation – aches, pains.
  • Adolescent: self-harming/mutilation, extremes of emotion, aggression or passivity, drug and/or solvent abuse, risk taking, sexual experimentation, homelessness, for example due to family conflict, running away.

Emotional abuse is the second most common reason for children needing protection from abuse in the UK

For further information on emotional abuse visit the NSPCC website. 

Sexual Abuse

Involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, or whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example, rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse. Sexual abuse can take place online, and technology can be used to facilitate offline abuse. Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.

Asking about sexual abuse

Asking about sexual abuse can be very difficult. There is very little practical guidance available on how to ask children about sexual abuse (there are plenty of resources for older children and young people in context of Child Sexual Exploitation – CSE – see this section for further details). 

The following questions are examples provided by the authors and reviewers of this toolkit – these are phrases that they use in everyday practice.

  • "I need to ask you about your privates. You won't get in trouble" (perhaps draw a line drawing of a child to help)
  • "Has anyone done anything to you that makes you feel uncomfortable?"
  • "Has anyone asked you to keep a secret?"

If a child discloses, listen to the child and let them explain what happened in his or her own words. Don't stop the child in the middle of the story to go and get someone or do something else. The following questions can be useful. 

  • What happened?
  • When did it happen?
  • Where did it happen?
  • Who did it?
  • How do you know them? (If the relationship of the abuser is unclear).

It is also really important to ask the parent or guardian about any concerns they might have about the child. Changes in behaviour can be an important indicator of sexual abuse. Questions to ask parents or guardian:

  • Who looks after your child in the day and at night other than you/ who is involved in the looking after of your child on a daily basis? 
  • Do you have any concerns about the care your child has?
  • Have you noticed any change in your child's behaviour?
  • Does your child seem to be afraid of anyone or not wanting to spend time with a particular person?
  • Is your child having any problems at school? Have the school noticed any changes in your child's behaviour?
  • Are you worried about the behaviour of anyone in your child's life?
  • Is there anything else that worries you?

This NHS website has excellent information on sexual abuse – what it is, how to spot a child who may be being sexually abused, which children are more at risk and what the effects are of sexual abuse. 

The Seen and Heard website and resources are also very useful:

The Seen and Heard RADAR code:

Respect. Value all young people – remember how hard it can be for them to disclose abuse or exploitation

Approach. Show warmth from the start - give young people a chance to build a relationship with you

Discover. Be pro-active – stay alert and on the lookout for potential signs of abuse

Ask. Be 'professionally curious' - ask questions and take young people's answers seriously

Respond. Follow safeguarding procedures - keep the young person informed and supported

For further information on Child Sexual Exploitation (CSE) see the separate section on this. 

Neglect

The persistent failure to meet a child's basic physical and/or psychological needs, is likely to result in the serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:

  1. provide adequate food, clothing and shelter (including exclusion from home or abandonment)
  2. protect a child from physical and emotional harm or danger
  3. ensure adequate supervision (including the use of inadequate care-givers)
  4. ensure access to appropriate medical care or treatment

It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.

Action for Children have worked with the University of Stirling, and other partners, to develop resources for professionals who work with neglected children:

'Was Not Brought'

Children not being brought to health appointments can be a sign of neglect or other abuse. There are, of course, many simple reasons why a child may not be brought to a health appointment e.g. parent forgot the appointment, the child is now better, parent got the wrong appointment time/date. Generally, in most cases, a one-off missed appointment would not be a concern. However, patterns and context are very important. For example, a child who is on a child protection plan for neglect who is not brought to one health appointment should raise the practitioner's level of concern and prompt action to ensure the welfare of the child. Practices should consider having a practice procedure or policy relating to children not being brought to appointments. 

Children not brought to appointments should be coded 'was not brought' rather than 'did not attend'. 

Every time a child is not brought to a health appointment, the practitioner should consider what the impact on the welfare of the child could be, whether there are any other concerns within the family and take action if necessary. A checklist of issues to consider when a child is not brought to an appointment: (practices may consider doing this with the admin/reception team to aid the clinician)

  • What was the purpose of the appointment (may not be known)? If the purpose is known, what could the potential impact of the missed appointment be on the child's welfare?
  • Does the child have any ongoing physical or mental health problems?
  • Are there other health appointments that the child has not been brought to? Is there a pattern of missed appointments?
  • Are there a high volume of Emergency Department and GP Out of Hours attendances?
  • Is the child on a child protection plan or a Looked After Child?
  • Are there any safeguarding concerns documented in the child's records?
  • Are there any siblings and if so, is there a pattern of health appointments that the children have not been brought to?
  • Are there any concerns about the parent/carer that could impact on their ability to bring the children to health appointments, for example physical or mental health problems, drug and alcohol issues, domestic abuse, safeguarding concerns. 

If there is any concern about the child following the completion of the checklist, action needs to be taken proportionate to the level of concern. This could include: 

  • asking the reception staff to contact the parents to arrange another appointment 
  • contacting the parent/child yourself to discuss why the child has not been brought and make a further assessment
  • contacting other health professionals such as a health visitor, to share information and concerns to aid further decisions 
  • contacting Children's Social Care 

In all cases, it is important to document your actions and reasons for them. 

Video: Rethinking Did Not Attend

Child Sexual Exploitation (CSE)

Awareness of child sexual exploitation (CSE) is essential for GPs and their staff especially in the provision of contraception and sexual health services to young people who may be victims of this form of abuse. Co-existence with substance misuse is often a feature, as is an increased risk to those who have a history of adverse experiences in childhood, including interfamilial maltreatment and being in care.

The NSPCC defines CSE as:

"Child sexual exploitation (CSE) is a type of sexual abuse. Children in exploitative situations and relationships receive something such as gifts, money or affection as a result of performing sexual activities or others performing sexual activities on them."

"Children or young people may be tricked into believing they''e in a loving, consensual relationship. They might be invited to parties and given drugs and alcohol. They may also be groomed and exploited online.

"Some children and young people are trafficked into or within the UK for the purpose of sexual exploitation. Sexual exploitation can also happen to young people in gangs. 

"Child sexual exploitation is a hidden crime. Young people often trust their abuser and don'' understand that they''e being abused. They may depend on their abuser or be too scared to tell anyone what'' happening.

"It can involve violent, humiliating and degrading sexual assaults, including oral and anal rape. In some cases, young people are persuaded or forced into exchanging sexual activity for money, drugs, gifts, affection or status. Child sexual exploitation doesn't always involve physical contact and can happen online.
It is vital to acknowledge that a groomed child is not consenting to sexual activity."

It is vital to acknowledge that a groomed child is not consenting to sexual activity. 

Summary of 'Spotting the Signs' – a framework to help professionals detect CSE

  • Department of Health, BASHH, Brook

CSE is an abuse of power and can take many forms such as:

  • Peer-on-peer abuse
  • Older adults exploiting younger children
  • Online grooming

Factors that put young people at risk of CSE:

  • Sexual health and behaviour, for example sexually transmitted infections, pregnancy, terminations, inappropriate sexualised behaviour
  • Absent from school or repeatedly running away
  • Familial abuse and/or problems at home
  • Emotional and physical condition, for example poor mental health, learning disability
  • Gangs, older age group and involvement in crime
  • Use of technology and sexual bullying
  • Alcohol and drug misuse
  • Receipt of unexplained gifts or money
  • Distrust of authority figures

Potential risk factors:

Migrant, refugee or asylum seeker • Financially unsupported • Changes in behaviour • Death, loss or illness of a significant person • Staying out overnight with no explanation • Substance misuse by parents, carers or child • Experiencing homophobia • Being groomed on the internet • Disappearing from the 'system' with no contact or support • Being taken to clubs and hotels by adults and engaging in sexual activity • Disclosure of serious sexual assault and then withdrawal of statement • Being moved around for sexual activity • Abduction and forced imprisonment

**********

Although in the UK the age of consent is 16, a 16 or 17-year-old can still be sexually exploited. Irrespective of age, a person's ability to give consent may be affected by a range of other factors, including alcohol, drugs, threats of violence, grooming or an imbalance of power between perpetrator and victim.

Asking about CSE

  • Is there someone who they feel they can talk to?
  • How are things at home?
  • Do they often miss days or parts of the school day?
  • Do they have any contact with other professionals e.g. GP, Social worker, mental health services
  • What do they understand 'sexual contact' to be?
  • Do they understand what consent is?
  • Do they feel they could say "no" to sex?

Have they ever: 

  • Felt uncomfortable or forced to send or receive sexual messages/images?
  • Been intimidated?
  • Pushed into doing something sexual?
  • Offered gifts, alcohol, drugs or protection for sex?
  • Tried to hurt themselves?

If they're having sexual contact: 

  • Where and how did they meet the person they have sex with?
  • Do their friends or family know and/or like their sexual partner?
  • Where do they spend time together? Where do they have sex?
  • How old is their sexual partner?
  • Do they often drink alcohol / take drugs before sex?
  • Have they had a sexually transmitted infection?
  • Is anyone else there when they have sex (or any other form of sexual contact)?
 

This Child Sexual Exploitation Risk Questionnaire (CSERQ) is a useful tool for practitioners working with young people. 

Prescribing contraception 

One of the challenges for primary care is that clinicians may lawfully prescribe contraception for sexually active children under the Fraser guidance. It should be remembered that this was intended to give advice on consenting children who were sexually active. In CSE, the child is not consenting due to the fact they are being groomed or coerced.

Professionals working with children need to consider how to balance children's rights and wishes with their responsibility to keep children safe from harm.

Resources for identifying CSE

County Lines

'County Lines' is a national issue involving the use of mobile phone ‘lines’ by groups to extend their drug dealing business into new locations outside of their home areas. A 'county lines' enterprise almost always involves exploitation of vulnerable persons; this can involve both children and adults who require safeguarding.1 The National Crime Agency (NCA) provides further useful information. 

'Cuckooing' is a form of crime in which drug dealers take over the home of a vulnerable person to use it as a base for drug dealing.

65% of Police forces reported the exploitation of children in ‘County Lines’ situations. This exploitation includes drug running, sexual exploitation and human trafficking. Vulnerable young people aged 13 to 18 years are being recruited to be drug runners or dealers. 

Several children used are vulnerable, not only because of their age. Many have also been identified as having broader mental health issues, coming from broken homes, experienced chaotic or traumatic lives, or have been reported as missing. They may also be drug users.

Most of these young people have accrued drug debts and the networks are using fear tactics, threatening them with violence in order to force them into working for the line. Sexual exploitation is a significant risk factor associated to county lines

Fearless.org has further information and also tips on how to spot a child who might be involved.

Reference

Child Trafficking

Child trafficking occurs when a child is recruited, moved or transported and then exploited, forced to work or sold. Many children are trafficked into the UK from abroad, but children can also be trafficked from one part of the UK to another. Further information can be found on the NSPCC website.

UNICEF UK Report: Identify. Protect. Repeat. How to lead the world in supporting child victims of trafficking:

  • In 2016, almost 50 million children globally were on the move, including 10 million child refugees, 1 million child asylum-seekers and an estimated 17 million children displaced within their own countries.
  • In 2014, children comprised 28 percent of all detected victims of trafficking.
  • Children, especially children travelling alone, are most vulnerable to trafficking and exploitation.
  • The risks of not identifying a child victim of trafficking at the earliest opportunity are significant. As the main purpose of trafficking is exploitation, non-identification results in the exploitation or continued exploitation of children and the trauma and harm that it brings.
  • Children who are not identified may also be punished or criminalised for illegal activities they have been forced to carry out by their traffickers.

Further resources

Domestic abuse

"Domestic abuse can seriously harm children and young people. Witnessing domestic abuse is child abuse, and teenagers can suffer domestic abuse in their relationships."

One in four women and one in six men will experience domestic abuse in their lifetime. 

Anyone can be a victim of domestic abuse, regardless of gender, age, ethnicity, socio-economic status, sexuality or background.

For detailed and specific guidance on recording domestic abuse information (including MARAC – Multi Agency Risk Assessment Conference) in the patient record, go to Section 3 of this toolkit. 

Responding to domestic abuse: a resource for health professionals

This is an excellent resource for all health professionals. We advocate that all GPs/GP trainees consult this document directly for learning and guidance. The relevant pages in this document are:

  • Pages 6 -12: How to use the resource. This sets out the prevalence, context, cost and legal aspects of domestic abuse
  • Pages 28 - 46: Practitioners responding to victims. This sets out Health Professionals' responsibilities; early identification of domestic abuse; sensitive enquiry and asking about domestic abuse; multi agency assessment; how to respond well to particular groups, for example, children, older adults; interventions; gathering and recording information; confidentiality and information sharing
  • Pages 51 – 54: Health Professionals responding to perpetrators of domestic abuse
  • Pages 25 - 26: Supporting staff who experience domestic abuse

Abuse in teenage relationships 

Domestic abuse is not limited to adults; there is an increasing awareness of domestic violence within teen relationships.

A 2009 study by NSPCC found that up to three-quarters of teenage girls and up to half of teenage boys reported emotional, physical and/or sexual violence in their intimate partner relationships, with girls experiencing more severe violence.1 

Further information can be accessed from the hideout website created by Women's Aid for children and young people who are experiencing domestic abuse:

  • A study showed that 32% of students in one secondary school were currently experiencing some form of domestic abuse (Alexander et al., 2005)
  • A US study showed that 7 out of 10 teenagers have experienced abusive/controlling behaviour from a partner (Teen Dating Relationships Survey, 2008)
  • The same study said that 11% of the teenagers studied had experienced physical abuse in a relationship (Teen Dating Relationships Survey, 2008)
  • What do young people think about abusive behaviour in relationships?
  • 36% of boys think that they might personally hit a woman or force her to have sex (Burton et al., 1998)
  • 78% of men and 53% of women think that women and girls are 'often' or 'sometimes' to blame for the violence perpetrated against them (Burton et al,. 1998)
  • One in two boys and one in three girls think there are some circumstances when it is ok to hit a woman or force her to have sex (Burton et al., 1998)
  • 19% of young women and 34% of young men do not think that being forced to have sex is rape (Regan & Kelly, 2001)

Technology and unhealthy teenage relationships

Young people's lives can be consumed by mobile phones, social media, sharing information online, lack of privacy or increased surveillance by peers or partners and it's easy to see how the abusive use of technology could become normalised.

Mobile technology is increasingly a part of young people's lives and it's important that adults must understand how young people use it and how it could be a medium for abuse. Further information and resources can be found on the NSPCC website.

MARAC (Multi-agency Risk Assessment Conference)

A Marac is a regular local meeting to discuss how to help victims at high risk of murder or serious harm. A domestic abuse specialist (Idva), police, children's social services, health and other relevant agencies all sit around the same table. They discuss safety measures and ways to help the victim. The meeting is confidential.

Together, the meeting writes an action plan for each victim. They work best when everyone involved understands their roles and the right processes to follow. 

For further information visit SafeLives

Groups of victims of domestic abuse who may be 'hidden' from services or who may face additional barriers to accessing services

SafeLives have a series of Spotlights on groups of domestic abuse victims who may be 'hidden' from services or who may face additional barriers to services:

  • Domestic abuse and mental health
  • LGBT+ people and domestic abuse
  • Homelessness and domestic abuse
  • 'Honour'-based violence and forced marriage
  • Young people and domestic abuse
  • Disabled people and domestic abuse
  • Older people and domestic abuse

Adolescent to Parent Violence

Child on Parent Violence (CPV) or Adolescent to Parent Violence and Abuse (APVA) is any behaviour used by a young person to control, dominate or coerce parents. It is intended to threaten and intimidate and puts family safety at risk. Whilst it is normal for adolescents to demonstrate healthy anger, conflict and frustration during their transition from childhood to adulthood, anger should not be confused with violence. Violence is about a range of behaviours including non-physical acts aimed at achieving ongoing control over another person by instilling fear. 

Most abused parents have difficulty admitting even to themselves that their child is abusive. They feel ashamed, disappointed and humiliated and blame themselves for the situation, which has led to this imbalance of power. There is also an element of denial where parents convince themselves that their son or daughter's behaviour is part of normal adolescent conduct.

Taken from Reducing the Risk of Domestic Violence: Child on parent violence 

This website also has a booklet for parents. 

If a parent discloses violence towards them by their child, it is important to examine and document any injuries. Parents should be signposted to local domestic abuse services for support for themselves.

These situations are complex and challenging. It is important that a young person using abusive behaviour towards a parent receives a safeguarding response. A child who is displaying violence towards their parent may also be victims of abuse themselves. 

For further information

Information Guide: Adolescent to parent violence and abuse (APVA), Home Office 2015

Reference
1. Responding to Domestic Abuse. A resource for health professionals. Department of Health 

 

Honour Based Violence and Forced Marriage

'Honour' based violence (HBV) is a form of domestic abuse which is perpetrated in the name of so called 'honour'. The honour code which it refers to is set at the discretion of male relatives and women who do not abide by the 'rules' are then punished for bringing shame on the family. Infringements may include a woman having a boyfriend; rejecting a forced marriage; pregnancy outside of marriage; interfaith relationships; seeking divorce, inappropriate dress or make-up and even kissing in a public place.

HBV can exist in any culture or community where males are in position to establish and enforce women's conduct, examples include: Turkish; Kurdish; Afghani; South Asian; African; Middle Eastern; South and Eastern European; Gypsy and the travelling community (this is not an exhaustive list).

Males can also be victims, sometimes because of a relationship which is deemed to be inappropriate, if they are gay, have a disability or if they have assisted a victim.

In addition, the Forced Marriage Unit have issued guidance on Forced Marriage and vulnerable adults due to an emerging trend of cases where such marriages involving people with learning difficulties.

This is not a crime which is perpetrated by men only, sometimes female relatives will support, incite or assist. It is also not unusual for younger relatives to be selected to undertake the abuse as a way to protect senior members of the family. Sometimes contract killers and bounty hunters will also be employed.

Further information can be found on:

 

Female Genital Mutilation

Female genital mutilation (FGM) is illegal in the UK and should be viewed and responded to as a form of physical child abuse. Health professionals in England and Wales now have a mandatory duty to report cases of FGM to the police if:

  • they are informed by a child under the age of 18 that they have undergone FGM.
  • they observe physical signs that an act of FGM may have been carried out on a child under the age of 18 (Section 74 Serious Crime Act 2015).

More information

Radicalisation and Extremism

Radicalisation is a psychological process where vulnerable or susceptible individuals are groomed to engage in criminal, terrorist activity.

It can be hard to know when extreme views become dangerous.

Radicalisation can be difficult to spot. Signs that may indicate a child is being radicalised include:

  • isolating themselves from family and friends
  • talking as if from a scripted speech
  • unwillingness or inability to discuss their views
  • a sudden disrespectful attitude towards others
  • increased levels of anger
  • increased secretiveness, especially around internet use

Children who are at risk of radicalisation may have low self-esteem or be victims of bullying or discrimination. Extremists might target them and tell them they can be part of something special, later brainwashing them into cutting themselves off from their friends and family.

However, these signs don't necessarily mean a child is being radicalised – it may be normal teenage behaviour or a sign that something else is wrong.

(NSPCC, Protecting Children from Radicalisation)

Prevent Duty

Prevent is part of the Government's counter-terrorism strategy, CONTEST, to reduce the threat to the UK from terrorism by stopping people becoming terrorists or supporting terrorism.

Prevent focuses on all forms of terrorism and operates in a 'pre-criminal' space'. The Prevent strategy is focused on providing support and re-direction to individuals at risk of, or in the process of being groomed or radicalised into terrorist activity before any crime is committed. Radicalisation is comparable to other forms of exploitation; it is a safeguarding issue that staff working in the health sector must be aware of.

Radicalisation is a process by which an individual or group adopts increasingly extreme political, social, or religious ideals and aspirations that reject or undermine the status quo or undermine contemporary ideas and expressions of freedom of choice.

The Prevent Programme is designed to safeguard people in a similar way to safeguarding processes to protect people from gang activity, drug abuse, and physical and sexual abuse.

Tailored support for any individual identified as being vulnerable to being drawn into terrorism is offered through the voluntary Channel panel. This is a Local Authority led multi-agency panel, which decides on what the most appropriate support package for that person will be. On this panel, like many others, the health sector plays a pivotal role in providing appropriate health services for an individual's needs, whether that be through primary care, mental health services or wider support services.

In 2015, the Prevent Statutory Duty under Section 26 of the Counter-Terrorism and Security Act 2015 was made a statutory responsibility for the health sector. The Duty stated that the health sector needed to demonstrate “due regard to the need to prevent people from being drawn into terrorism”.

NHSE Prevent Training and Competencies Framework states:

'Staff must be able to recognise key signs of radicalisation and be confident in referring individuals to their organisational safeguarding lead or the police thus enabling them to receive the support and intervention they require.'

For more information visit:

Recognition of child maltreatment in general practice

Presentations of child maltreatment in general practice are seldom, clear-cut and well-defined, and different types of abuse can overlap in the same child. The context for concerns is often more important than the identification of an 'incident'. Child protection work has been likened to a patchwork or jigsaw puzzle. Often, it is when individuals and agencies share information together that the picture is complete. This involves effective record keeping, information-sharing and communication, both internally and between agencies.  

Liaising with other universal health services providers (for example, midwives, health visitors and school nurses) is invaluable as they may be the first health professionals to recognise when a child, young person or family member is in difficulty and can help to build a more complete picture. The value of universal service provision is that GPs and their staff see a multitude of presentations and behaviours in children and young people, the majority of whom will not require action to be taken to ensure their welfare. Thus, when there is a situation that 'does not feel quite right' practitioners'intuition and clinical acumen are, in our experience, usually well-founded.   

Multi-disciplinary working

It is advised that every GP practice has a system that enables the GP lead for safeguarding, as well as other relevant staff, to meet with the midwife, health visitor and school nurse in a safeguarding Multi-Disciplinary Team (MDT) meeting. These meetings are invaluable for sharing information, identifying children and families who may be at risk and for discussing children who are already known to be at risk and are on child protection plans for example. These meetings could be incorporated into regular practice meetings e.g. Significant Event meetings. The suggested frequency would be to have these meetings once per month. Sometimes practitioners involved in the MDT meetings can raise concerns about a child or a family together as a group, which can be very powerful.
 
This template [PDF] can be used or adapted for these MDT meetings. 

Some pitfalls and potential barriers

The RCGP has previously highlighted pitfalls and potential barriers to recognition and response to child maltreatment in general practice. It is helpful to revisit some of these, as they help to illustrate the challenges in safeguarding; even where practitioners' knowledge of clinical indicators is sound.   

'Not seeing the child' reflects the reality that the needs of the child can easily be over shadowed by those of the parents, the needs of the child should always come first. It can be helpful to consider 'what is the daily lived experience of this child?' and act accordingly. When working with adults, it is always important to consider whether there might be any children who could be at risk of abuse or neglect as a result of the adult's health, behaviour or circumstances – see the child behind the adult. It is important to remember that the children who may be at risk may not always be within the family and may not be living locally or even in the UK.  

'Not seeing the adult' - It is important to establish who is in the child's life. Practitioners need to bear in mind that there may be new adults in the child's life such as new partners of their parents or friends/family members who may be staying within the household who may pose a risk to the child – 'see the adult behind the child'.

'Not looking' reflects the fact that child maltreatment is upsetting, as well as challenging. Ignoring the problem, or seeking other, more comfortable explanations for observations, especially when, for example, feeling compassionate towards parents of a disabled child. Personal experience of abuse or neglect, including domestic violence, can also affect practitioners' ability to get involved.

'Not knowing what to do next' - Although much progress has been made, there remain gaps in procedural knowledge and contacts. Each practice should make their procedures and details of local contacts available to all staff, including non-clinical staff and locum staff, together with guidance on how to discuss and communicate concerns. If there are concerns about a child, doing nothing is never an option. Speaking to a senior colleague and/or the practice safeguarding lead or deputy can help practitioners to take forward their concerns. Advice may also be sought from Named or Designated professionals.

'Cultural relativism' - This concept describes practitioners' acceptance of different childcare practices as normal and acceptable to the culture of the family and this may influence a decision not to intervene. Culture, ethnicity, religion or any other diversity issue should not prevent action being taken to safeguard a child.

Liverpool Safeguarding Children Board - Practice Guidance: Cultural Awareness, Cultural Sensitivity & Safeguarding 

The Hidden Male - From the analysis of Serious Case Reviews, the NSPCC identified two categories of 'hidden men':

  • men who posed a risk to the child which resulted in them suffering harm
  • men, for example, estranged fathers who were capable of protecting and nurturing the child but were overlooked by professionals.

This NSPCC briefing highlights the risk factors for hidden men in serious case reviews and learning for improved practice: 

  • Lack of information sharing between adults' and children's services
  • Relying too much on mothers for essential information
  • Not wishing to appear judgmental about parents' personal relationships
  • Overlooking the ability of estranged fathers to provide safe care for their children

Learning for improved practice:

  • Identifying the men in the child's life
  • Involving fathers
  • Seeing men as potential protectors

Disguised compliance - This involves parents giving the appearance of co-operating with child welfare agencies to avoid raising suspicions and allay concerns. Learning from case reviews highlights that professionals need to establish the facts and gather evidence about what is actually happening, rather than accepting parent's presenting behaviour and assertions [see box below]. 

Practitioners should seek to establish trusting and compassionate relationships, but also remain curious, demonstrating 'respectful uncertainty' (Laming, 2003) about family life and issues that raise concern. Where families are failing to engage with services, the GPs interest will relate to the child/children's health and well-being. Clinicians must consider if health concerns have been fully and clearly explained, considering issues of language, culture, learning difficulties, disability, expectations of service provision and that parents or carers fully understand the concerns and risks of non-compliance.  

It is important to remember that, for some families, services may be difficult to access and/or engage with. In these situations, it is important that health professionals consider how their service can improve access for these families.

Disguised Compliance

Adapted from Disguised Compliance: learning from case reviews. NSPCC March 2014

Risk factors for disguised compliance:

  • Missing opportunities to make interventions: Professionals reducing/downgrading a concern can allow cases to drift, leading to lost opportunities to make timely interventions.
  • Removes focus from children: Disguised compliance can lead to a focus on adults and their engagement with services rather than on achieving safer outcomes for children.
  • Over optimism about progress: Professionals can become over optimistic about progress being achieved, again delaying timely interventions.

Recognising disguised compliance:

  • Parents deflecting attention: Parents focus on engaging well with one set of professionals, for example in education, to deflect attention from their lack of engagement with other services.
  • Criticising professionals: Parents criticise other professionals to divert attention away from their own behaviour.
  • Pre-arranged home visits: Pre-arranged home visits present the home as clean and tidy with no evidence of any other adults living there.
  • Failure to engage with services: Parents promise to take up services offered but then fail to attend.
  • Avoiding contact with professionals: Parents promise to change their behaviour and then avoid contact with professionals.

Learning for improved practice:

  • Establish facts and gather evidence: Don't accept presenting behaviour, excuses or parental assertions and reassurances that they have changed or will change their behaviour. Establish the facts and gather evidence about what is actually occurring or has been achieved. 
  • Build chronologies: Chronologies can be used to provide evidence of past parenting experience, including possible former instances of disguised compliance, and to analyse parenting history. The information can then be considered in relation to current parenting capacity and to gain a fully documented picture of the family environment. 
  • Record the children's perspective and situation: The focus should be on recording the children's perspective and situation rather than just the adult's participation and parenting capacity. This helps to retain the focus on the child and ensure that important information does not become lost when shared between multiple agencies.
  • Identify outcomes: Focus on outcomes rather than process, so that attention cannot be deflected by good intent or an appearance of participation. 
  • Use of staff supervision to challenge beliefs: Professionals can become overly optimistic about change that has occurred. Supervision needs to challenge professionals' beliefs about apparent changes and to seek evidence of actual progress. 

Learning from Serious Case Reviews

A serious case review (SCR) is a local enquiry carried out where a child has died or been seriously harmed and abuse or neglect are known or suspected, and there is cause for concern about professionals working together. The aim of the study is to provide evidence of key issues and challenges for agencies working individually and together in these cases.

Key findings

What do SCRs tell us about the child protection system?

  • There has been an increase in the number of SCRs carried out since 2012, but this has been against a backdrop of a steady year-on-year increase in child protection activity. There has been no change in the number of child deaths linked directly to maltreatment and, if anything, a reduction in the fatality rates for all but the older adolescent age group.
  • Only a small minority of children at the centre of a SCR (12%) had a current child protection plan at the time of their death or serious harm. This is at a time when nationally numbers of children with a child protection plan have been rising dramatically. 
  • While fewer than half of SCRs revealed current involvement with children’s social care, almost two thirds of the children had at some point been involved with Children’s Social Care at least to the level of child in need. It is apparent that many of these children’s cases had either been closed too soon or lacked the ongoing support services and monitoring that the children and families needed.
  • While these most recent SCRs suggest there may be a good awareness of risk factors among staff across universal, early help and specialist services, they also suggest that practitioners are not always rigorous in assessing and following through on all identified risks including domestic abuse. Where the threshold for children’s social care involvement is not met, there may be little analysis of risks of harm. 
  • Throughout the review there were examples of creative and effective child safeguarding. For many of the children, the harms they suffered occurred in spite of all the work that professionals were doing to support and protect them.
  • The review’s authors suggest an approach that steers away from trying to pronounce on whether a death or serious harm could have been predicted or prevented, to acknowledging that there is always room for learning and improvement in our systems. It is important to identify those lessons, disseminate the learning, and implement appropriate actions for improvement.
  • The report suggests an approach that recognises that children are harmed within contexts of risk and vulnerability and that there are many opportunities for prevention and protection, even without being able to accurately predict which children may be harmed, when or in what manner.

The Triennial Review suggests that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals:

  • Effective communication is central to all safeguarding practice.
  • All national guidance and legislation on confidentiality and data protection supports sharing information to safeguard children and vulnerable people.
  • The Data Protection Act 1998 and Human Rights Act 1998 are not barriers to justified information sharing, but provide a framework to ensure that personal information about living individuals is shared appropriately. (It should be noted that since this Triennial Review, there has been new GDPR and Data Protection Legislation – however, the new Information Sharing: Advice for practitioners providing safeguarding services 2018 legislation confirms this statement)
  • Child protection agencies must feedback promptly to referrers and others participating in safeguarding. 
  • Information must be triangulated and verified. This involves seeking independent confirmation of parents’ accounts and triangulating information between professionals.
  • Practitioner forums may provide opportunities for professionals to discuss cases and share information in a safe environment.

The NSPCC produces thematic briefings highlighting the learning from case reviews. The briefings focus on different topics or learning for different professional groups such as GPs and primary healthcare teams.

 Not Seen, Not Heard

The Care Quality Commission (CQC) in England also inspect regions to assess how the safeguarding services work together to protect children. Their July 2016 report Not Seen, Not Heard reflects the lessons from 50 inspections and finds that children have a variable experience of services. 

The report recommendations were:

    • children and young people must be actively engaged in their care
    • services must ensure their focus is on outcomes
    • more is done to identify children at risk of harm
    • children and young people must have access to the emotional and mental health support they need

Developments in Safeguarding Arrangements

Developments in Safeguarding in England

This section is relevant to England only. Named GPs and other safeguarding professionals may find the following summary helpful.

The Wood Review

In December 2015, the Department for Education (DfE) asked Alan Wood CBE to lead a review of the role and functions of the Local Safeguarding Children Boards (LSCBs) in England. As part of the review he also looked at serious case reviews and Child Death Overview Panels. The Wood Review was published along with the government response to the review. The Wood Review argued that a new system of local freedom is needed to allow local decision making and local accountability. The government plan to introduce a new statutory framework which will set out clear requirements, but give local partners the freedom to decide how they operate to improve outcomes for children. 

Working Together to Safeguard Children 2018

Working Together to Safeguard Children 2018 was published in July 2018 and is the statutory framework produced by the government in response to the Wood Review. This replaces ‘Working Together to Safeguard Children 2015’. This statutory framework only applies in England. 

Key implications for CCGs

  1. Multi-agency safeguarding arrangements 

‘To achieve the best possible outcomes, children and families should receive targeted services that meet their needs in a coordinated way.’

‘The responsibility for this join-up locally rests with the three safeguarding partners who have a shared and equal duty to make arrangements to work together to safeguard and promote the welfare of all children in a local area.’

The three safeguarding partners:

  • The local authority (Chief Executive) 
  • Clinical Commissioning Groups (CCGs) for any part of an area which falls within the local authority area (CCG Accountable Officer)
  • The chief officer of police for any part of an area which falls within the local authority area (Chief Constable)

The role of the safeguarding partners:

  • To set out and publish how they will work together and with any relevant agencies (as they consider appropriate) to coordinate safeguarding services. Plans should include how independent scrutiny of arrangements is to be implemented.
  • Act as a strategic leadership group in supporting and engaging others.
  • Implement local and national learning including from serious safeguarding incidents.
  • Agree contributions with relevant agencies, including funding, accommodation, services and any resources connected with the arrangements.
  • Be clear how they will assure that relevant agencies have policies and procedures in place and understand how they will share information. 
  • Communicate regularly with relevant agencies and others they expect to work with them.
  • Agreeing clear links with other strategic partnerships (Health and Wellbeing Boards, Local Safeguarding Adult Boards, Channel Panel, Family Justice Board, MAPPA). 

Information Requests

Organisations and agencies within a strong multi-agency system should have confidence that information is shared effectively, amongst and between them, to improve outcomes for children and their families. Safeguarding partners may require any person, organisation or agency to provide a relevant agency for the area, a reviewer or another person or organisation or agency, with specified information. This must be information which enables and assists the safeguarding partners to perform their functions to safeguard and promote the welfare of children in their area, including related local and national child safeguarding practice reviews.

The person or organisation to whom a request is made must comply with such a request and if they do not do so, the safeguarding partners may take legal action against them.

As public authorities, safeguarding partners should be aware of their own responsibilities under the relevant information law and have regard to guidance provided by the Information Commissioner’s Office when issuing and responding to requests for information.

Timescales:

  • 29 June 2019 – safeguarding partners must have published local arrangements and had these agreed by Secretary of State for Education.
  • 29 September 2019 – all new local arrangements must have been implemented.
  1. Child Death Reviews 

Establishment of ‘Child Death Review Partners’:

  • Local authority
  • CCGs operating in the local authority area

Child death review partners for two or more local authority areas may combine and agree that areas may be treated as single area (should cover a child population such that partners review at least 60 deaths per year). 

Role of Child Death Review Partners:

  • Establish a structure and process to review all deaths of children normally resident in the local area. The purpose of child death reviews is to identify any matters relating to the death which are relevant to the welfare of children in the area or to public health and safety and to consider any necessary action.
  • Agree core representation on panel or structure set up to review deaths. Must include Designated Doctor for Child Deaths.
  • Funding arrangements to be agreed.
  • Analyse information from all deaths reviewed.
  • Publish agreed local arrangements.
  • Prepare and publish reports.

Timescales:

  • 29 June 2019 – child death review partners must have published local arrangements and notified NHS England when they have done so.
  • 29 January 2020 – all outstanding child death reviews (i.e. commenced prior to 29 June 2019) must have been completed
  1. Child Safeguarding Practice Reviews 
  • A new national Child Safeguarding Practice Review Panel has been established and commenced operating on 29 June 2018.
  • The Panel may commission and publish national reviews of serious child safeguarding cases which they consider are complex or of national importance.
  • Serious child safeguarding cases are those in which:
    • Abuse or neglect of a child is known or suspected and
    • The child has died or been seriously harmed
  • Local Authorities are required to notify the Panel of any serious incident within five working days.
  • Safeguarding partners (or Local Safeguarding Children Boards where the new partnership arrangements are not yet in place) to undertake a rapid review into all serious child safeguarding cases promptly and complete this within fifteen working days of becoming aware of the incident.
  • Copy of rapid review to be forwarded to the Panel, including whether partners intend to undertake a Child Safeguarding Practice Review.
  • Any national child safeguarding practice reviews undertaken by the Panel are to be funded centrally. Other reviews will continue to be funded by local partnerships.
  • Panel will advise regarding initiation and/or publication of Child Safeguarding Practice Reviews.

Timescales:

  • Following establishment of local safeguarding partner arrangements - ‘grace period’ of 12 months to complete and publish any outstanding SCRs.
  • Learning from SCRs must be passed on to safeguarding partners to consider follow up actions as appropriate.

So what are the challenges for CCGs going forward?

  • CCG representation on new partnership arrangements?
  • What will new arrangements look like?
  • Who are ‘relevant partners’ from the health economy and how do we engage partners who may not have direct representation in new arrangements?
  • How are new child death reviews to be undertaken?
  • Funding?
  • Making the most of new opportunities as an equal partner with police and local authorities.

Developments in Safeguarding in Wales

Social Services and Well-being (Wales) Act 2014

This section is relevant for practitioners working in Wales. 

The Social Services and Well-being (Wales) Act 2014 came into effect in April 2016. It sets out what must and should be done to safeguard children and adults. The intention of the Act is to strengthen and build on existing practice. It is important that health professionals and workers are aware of the law, guidance and regulations that apply to their role. 

Overarching Principles and Duties

The Act aims to change the way people’s care and support needs are met. The vision of care and support under the Act is one where individuals have a voice in and control over reaching the goals that matter to them and to help them achieve wellbeing.

Central to the Act is the well-being duty. People have a responsibility for their own well-being supported by their families, friends and communities. However, they may also need support from practitioners to ensure that they achieve well-being. A person exercising functions under the Act must seek to promote the well-being of people who need care and support, and carers who need support. This overarching duty applies to health organisations and their practitioners.

The Act attempts to rebalance the focus of care and support to prevention and earlier intervention, increasing preventative services within the community to minimise the escalation of needs to a critical level.

Collaboration, strong partnership working between organisations and co-production with people needing care and/or support is a key focus of the Act.
Other overarching duties when exercising functions under the Act. Practitioners have to: 

  • ascertain and have regard to the individual’s views, wishes and feelings (and for under 16s, those with parental responsibility, if practical and consistent with the child’s well-being);
  • support them to participate in decisions and to communicate; 
  • promote and respect their dignity; 
  • have regard to the characteristics, culture and beliefs of the individual;
  • supporting people to participate includes considering whether advocacy support is necessary.

For adults specifically, there is also the duty to:

  • begin with the presumption that an adult is best placed to judge their own well-being and;
  • to have regard to the importance of promoting their independence where possible.
  • for children specifically there is also the duty to promote the upbringing of the child by the child’s family, in so far as doing so is consistent with the well-being of the child.

In the Act, protection from abuse and neglect is one of the aspects of well-being. In relation to a child, well-being also includes their physical, intellectual, emotional, social and behavioural development as well as their welfare and ensuring that they are kept safe from harm. Safeguarding is part of helping people to live life to the full, not just stopping abuse, neglect and harm.

Other Legislation 

Under the Act, you need to have regard to the following:

  • United Nations Principles for Older Persons. 
    This includes respect for older people’s dignity, beliefs, needs and privacy and for the right to make decisions about their care and the quality of their lives. 
  • United Nations Convention on the Rights of the Child.
    This includes the right to life, survival and development, and protection from violence, abuse and neglect. 
  • United Nations Convention on the Rights of Disabled People (UNCRDP).
    The code of practice for Part 2 of the Act also points out that public authorities must not act in a way that is incompatible with rights under the European Convention on Human Rights. This includes the right not to be subjected to inhuman or degrading treatment and the right to liberty and security. 

Safeguarding 

Part 7 of the Act (sections 126-142) deals with safeguarding and is underpinned by the overarching duties of the Act. It reiterates that safeguarding is everyone’s business and that practitioners in all agencies need to recognise and act when they identify children and adults at risk. It also confirms that safeguarding is much broader than protection from abuse, neglect or harm and how to help people to keep themselves safe should be something that is always considered. 

Other parts of the Act link to the duty to protect people from abuse and neglect, and to protect children from harm are:

  •  Part 2 links prevention, information and advice to safeguarding;
  • Part 3 links assessment to safeguarding;
  • Part 4 links meeting needs to safeguarding;
  • Part 6, Section 78 says that a local authority looking after any child must safeguard and promote the child’s well-being;
  • Part 9 says that a local authority must make arrangements to promote co-operation between itself and partners with a view to protecting adults with needs for care and support, or children, who are experiencing, or are at risk of, abuse or neglect;
  • Part 10 says that local authorities must arrange, where necessary, for an independent advocate to support and represent an individual in safeguarding processes. 

Children and Young People Under 18 

There is a new definition of a ‘Child at Risk’. The old term of ‘Child in Need’ as under section 17 of the Children Act 1989 is removed. 

There is a new duty for relevant partners of a local authority to report children at risk (Section 130). If a partner has reasonable cause to suspect a child is at risk, it must inform the local authority of that fact. Again, the decision to act does not require actual abuse or neglect to have taken place.

When a child has been reported under Section 130 of the Act, the local authority shall make enquiries to enable them to decide whether they should act to safeguard or promote the child’s welfare under section 47 of the Children Act 1989.

This means that practitioners will still need to use the Children Act 1989 section 47 and the All Wales Child Protection Procedures in the same way as they do now when responding to child protection referrals.

Developments in Safeguarding in Scotland

This section is relevant for practitioners working in Scotland.

National Guidance

The key guidance for anyone working with children in Scotland is the National Guidance for Child Protection in Scotland (Scottish Government, 2014).

GIRFEC

The national approach to improving outcomes for children and young people in Scotland is ‘Getting it right for every child (GIRFEC)’ (Scottish Government 2015). GIRFEC is based on children’s rights and its principles reflect the United Nations Convention on the Rights of the Child (UNCRC). It provides a framework for those working with children and their families to provide the right support at the right time.

  • Its principles help shape all policy, practice and legislation that affects children and their families.
  • It provides a consistent way for people to support and work with all children and young people in Scotland.
  • It aims to improve outcomes for children and make sure that agencies work together to take action when a child is at risk or needs support.
  • Is underpinned by prevention, recognising that: early intervention and partnership working is the best protection, that child wellbeing and protection is a collective responsibility

The Children and Young People (Scotland) Act 2014

The Children and Young People (Scotland) Act 2014  was passed by the Scottish Parliament in  March 2014. This legislation is a key part of the Scottish Government's strategy for making Scotland the best place in the world for children to grow up. By facilitating a shift in public services towards the early years of a child's life, and towards early intervention whenever a family or young person needs help, the legislation encourages preventative measures, rather than crises' responses.

Underpinned by the Scottish Government's commitment to the United Nations Convention on the Rights of the Child 1989 ( UNCRC), and the national approach, GIRFEC, the 2014 Act also establishes a new legal framework within which services are to work together in support of children, young people and families.

The Children and Young People (Scotland) Act:

  • Part 3 of the Act places requirements on local authorities and health boards to prepare ‘children’s services plans' for each local authority area, reporting on this each year.
  • Establishes a 'Child’s Plan' (Part 5) for every child that is deemed to need one, to be prepared by the health board for pre-school children and the local authority for school-aged children.
  • Establishes a 'Named Person'(Part 4) for every child up to age 18, to be provided by the health board for pre-school children and the local authority for school-aged children.
  • Places a definition of 'wellbeing' on a statutory footing, referring to the SHANARRI indicators.
  • Makes looked after children a priority for a host of publicly funded bodies by naming them as Corporate Parents, tackling issues important to looked after children and young people, such as poverty, early school leaving, poor health and exclusion. 

The Children and Young People (Information Sharing) (Scotland) Bill

Organisations must handle, store, process and share personal information in line with existing laws and guidance. People working with children, young people and their families must work in partnership with them when considering and sharing information necessary to promote, support or safeguard a child or young person's wellbeing.

This Bill was introduced in June 2017. It aims to bring clarity and consistency to sharing information for the named person service and child’s plan.

The Bill's objective is to give families, practitioners and the wider public greater confidence in how the safeguards to information sharing will operate in relation to the named person service and provision of a child’s plan, for example  human rights, data protection and confidentiality.

The Bill responds to a Supreme Court ruling in 2016. The Supreme Court found that providing a named person for every child to promote and safeguard their wellbeing was ‘unquestionably legitimate and benign’. It ruled that changes are required to the information sharing provisions in Part 4 of the Act to make those provisions compatible with Article 8 of the European Convention of Human Rights. 

Information sharing: code of practice

The Bill requires Scottish Ministers to issue a code of practice that will apply when sharing information by or with the named person service and in relation to a child’s plan.

The code will require the services that support children and young people and their families, such as the NHS, local authorities and the third sector, to follow the code helping them to ensure that relevant safeguards are considered and applied when sharing information in relation to the named person service and child’s plan.

Child Protection Improvement Programme (CPIP)

In February 2016, the Scottish Government announced it would be undertaking a Child Protection Improvement Programme (CPIP). The core objective was to identify where recommendations for sustainable improvement could be made, building upon the observable improvements in practice that have already taken place in recent years and seeking to further embed Scotland's unique approach to child wellbeing: GIRFEC.

The CPIP report sets out a number of actions, including:

  • taking action to tackle and prevent child neglect
  • taking action to tackle and prevent child sexual exploitation
  • working with partners to implement the children's actions outlined in the Human Trafficking and Exploitation Strategy, which is being overseen by the Child Trafficking Strategy Group
  • supporting children affected by parental substance misuse
  • working with partners to keep children safe online

Human Trafficking and Exploitation (Scotland) Act

Human Trafficking and Exploitation (Scotland) Act was introduced in October 2015. The Act introduced a range of provisions, including a new single offence of trafficking for all forms of exploitation for both adults and children and those who seek to exploit others.

The Act also increases the maximum penalty for offenders to life imprisonment, commits ministers to publishing and updating a human trafficking strategy, and places a duty on ministers to ensure there is a guardian service available for both child victims and children who are at risk of and vulnerable to becoming victims.

In October 2016, the Scottish Government launched a consultation on Scotland’s first Human Trafficking and Exploitation Strategy. The consultation set out the Scottish Government’s plans to tackle trafficking. A guide to what the Act does and a small number of case studies to illustrate some of the facets of trafficking and exploitation in Scotland were also published.

Limitation (Childhood Abuse) (Scotland) Bill

The Limitation (Childhood Abuse) (Scotland) Bill was introduced by the Scottish Government in November 2016. It will remove the three-year time limit on bringing civil cases to court, also known as a time-bar, and remove the limitation period for actions of damages in respect of personal injuries resulting from childhood abuse.

Child Death Review System

In 2014 the Scottish Government accepted the recommendation of the Child Death Reviews Working Group that Scotland should introduce a national Child Death Review System. Recommendations include: 

  • Systematically review each death in a multi-agency forum. Any local learning would be implemented amongst relevant professionals and services. These reviews should be timely, appropriate and sensitive to the needs of bereaved families.
  • Collate a uniform data-set relevant to each child death for national analysis to inform national multi-agency learning and aid the development of national policy and
  • Identify factors which may reduce preventable childhood deaths. 

National Guidance for Child Protection Committees for Conducting a Significant Case Review

Introduced in 2015 and replaces previous guidance (2007). Significant Case Review is a multi-agency process for establishing the facts of, and learning lessons from, a situation where a child has died or been significantly harmed. Significant Case Reviews should be seen in the context of a culture of continuous improvement and should focus on learning and reflection on day-to-day practices, and the systems within which those practices operate. Wherever possible, staff should be involved in reviews and should get feedback when the review is finished.

All reviews are now shared with the Care Inspectorate The primary role for the Care Inspectorate is to support continual improvement in the quality of services for children and young people, including child protection services. They will conduct a biennial review of all SCRs completed in Scotland, reporting nationally on the key learning points for the benefit of relevant services across Scotland and the Scottish Government.

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