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EDITORIALS: David Hall Child protectionlessons from Victoria Climbié BMJ 2003; 326: 293-294 [Full text]

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General Practitioner Training for Child Protection

Clare Goodhart, N16 9DP   (11 February 2003)

GP's not attending case conferences

Penny A Mellor   (13 February 2003)

Best Practice in A&E Departments improves detection of Child Abuse

Graham E Jay   (13 February 2003)

Victoria Climbié — can we get the lessons right?

Ruth E Freeman, Mary Russell, Anne Lazenbatt, Wagner, Marcenes   (25 February 2003)

General Practitioner Training for Child Protection 11 February 2003
Clare Goodhart, General Practitioner Statham Grove Surgery, Stoke Newington, Hackney, N16 9DP Send response to journal: Re: General Practitioner Training for Child Protection	EDITOR – Lord Laming’s proposal for regular revalidation in child protection for all general practitioners (1) is valid but will need careful development. What form should such training take? In 1990, I conducted a questionnaire survey asking Hackney general practitioners about their training needs, and found that they wanted to learn more about child protection in practical terms (2). In response to this we developed a training package for use at practice-based workshops (3). The seminars were held at the invitation of individual practices and reached 60% of all local GPs. The aims of the training programme were to inform GPs about their medical and legal obligations, to ensure they knew the referral pathways they should use and that they were aware what support was available to them. We set out to promote multi-professional collaboration. A key component of our approach was discussion of actual cases the practices had encountered. It was perhaps because of this experiential learning that the sessions were well received, with 90% of GPs rating them as good or excellent and 94% wanting further sessions. While training programmes could be standardised, they need to build on what doctors already know, rather than rely on didactic approaches. GPs should be trained jointly with other members of their primary care team, to help teams develop common approaches. It is also good to have input from social services and the locally-designated doctor for child protection. In Hackney, our programme lapsed because of lack of resources, a reminder that effective training will need adequate funding. However as David Hall points out, providing this would probably cost less than a further public inquiry into a child’s death (4). Reference List 1. Lord Laming. Inquiry into the Death of Victoria Climbie. 2003. London, Stationary Office. www.victoria-climbie-inquiry.org.uk (accessed 10 Feb 2003). 2. Goodhart C. General practitioner's training needs for child health surveillance. Arch Dis Child 1991;66:728-30. 3. Weir A, Lynch E, Hodes D, Goodhart C. The Role of the General Practitioner in Child Protection and Family Support: A Collaborative Training Model. Child Abuse Review 1997;6:65-9. 4. Hall D. Child-Lessons from Victoria Climbie. BMJ 2003;326:293-4. Competing interests:   None declared
GP's not attending case conferences 13 February 2003
Penny A Mellor, Advocate Home 6 Coven Mill Close Coven WV9 5HX Send response to journal: Re: GP's not attending case conferences	I have sat in on numerous child protection case conferences as a support to a child's carer. Without exception in all the case conferences I have attended, the GP has failed to turn up and over 50% of the people attending had never met the child or the family and theoretically should not be there at all. If GP's are to have any say in these matters, not only do they need the training which should include not being brow beaten into changing their opinions based on their dealings with the family by somebody more senior in the NHS but they also have to be given the time off to attend these first vital steps towards establishing whether or not a child is being abused or at risk of harm. GP's, health visitors, school nurses and teachers could all assist in drawing up an overall picture of what may be happening to a child, it is vital that they attend case conferences and it should be made a statutary requirement as part of their jobs. The police, I know from experience, do not like case conferences, so quite often don't attend either. Case conferences are minuted only, with many ommissions when they are typed up and in cases that are pursued to either the family or criminal courts, there are always disputes as to who said what, making these minutes an unreliable source of information. A very senior member of CID in Staffordshire told me whilst in conversation about the failure of the police to turn up at one particular case conference, that there are implications in law for both the police and the child/children's carers insofar as should a carer make admissions in case conference that could lead to criminal proceedings, not only have their rights in law been violated, but there would be difficulties prosecuting the case as the procedures used to gain such an admission are inadmissable. The simple solution would be that all parties invited attend and that all such case conferences are taped and the carers have legal representation present. Social services, no doubt will say that this makes case conferences confrontational, something they claim they are not, my experience has shown me that they are indeed already confrontational, with many of the participants having never met the carers or the children and submitting opinions about people they know nothing about, this leads to the carers going on the rear guard and becoming very defensive. Certainly none of this helps the children. I hope for every child's sake, that in the future thorough investigations into allegations of child abuse are conducted, with hard evidence to support any allegation that is made and that ALL the professionals who are involved with any child make it a priority to attend any meetings called to protect children. Competing interests:   Gave evidence to Griffiths Inquiry relating to Professor Southall's work in child protection
Best Practice in A&E Departments improves detection of Child Abuse 13 February 2003
Graham E Jay, Specialist registrar in emergency medicine Kingston Hospital Send response to journal: Re: Best Practice in A&E Departments improves detection of Child Abuse	Editor - Hall's editorial on lessons from Lord Laming's inquiry noted that prevention of child abuse is the responsibility of all who work with children. This is especially true of Accident and Emergency departments. A&E departments have a critical role in the recognition of children intentionally harmed. One in six visits to paediatric A&E is as a result of injury. Therefore, staff seeing this group must be aware that non accidental injury is a possibility. This awareness can be improved by the following ways: better record keeping; regular training, updated protocols and good communication between emergency and paediatric staff (1); easier access to the child protection register by electronic means (2); and, inclusion of reminder flowcharts measuring delays in seeking medical help, inconsistent histories, unexplained injuries and inappropriate interaction and behaviour of children (3). These measures are being incorporated into practice in our centre, because, there is the evidence to support changes in practice which can improve detection of child abuse. We must never see another "missed" Victoria. (1) Sidebotham PD, Pearce AV. Audit of child protection procedures in accident and emergency department to identify children at risk of abuse. BMJ 1997;315:855-856 (2) Quin G, Evans R. Accident and emergency department access to the child protection register: a questionnaire survey. Emerg Med J 2002;19:136 -137 (3) Benger RB, Pearce AV. Simple intervention to improve detection of child abuse in emergency departments. BMJ 2002;324:780-782 Competing interests:   None declared
Victoria Climbié — can we get the lessons right? 25 February 2003
Ruth E Freeman, Professor of Dental Public Health Queen's University, Belfast, BT12 6BP, Mary Russell, Anne Lazenbatt, Wagner, Marcenes Send response to journal: Re: Victoria Climbié — can we get the lessons right?	EDITOR - Child abuse and domestic violence since Victoria Climbié has taken centre stage and as rightly identified by Hall1 is set to dominate the medical and political horizon as a public health issue. Knowledge of the roles key professionals can play in child protection, are now clearly defined, however as health professionals do we recognise the new and serious challenges we are facing? What is our understanding of the complexities surrounding identifying and reporting child abuse cases, and preventing further abuse? It was with these questions in mind that a survey of general medical and dental practitioners and community nurses was conducted. In Northern Ireland (NI), more women, are killed by their husbands or partners than anywhere else in the UK. Figures suggest that this crime is perpetrated in at least one house in every street in NI2. For children, exposed to domestic violence there is a 1-in-2 chance that they will be physically abused3. This upsurge in domestic violence has coincided with the cessation of political conflict and this provided the backdrop to the survey. Although anonymity was assured the response rate4 was disappointing (41%). This may indicate that child abuse was a subject not worthy of response. For those that did respond (n=276) only 54.3% had recognised at least one suspicious case in their professional lives (Mean number 3.82, SE 0.52) and 74.3% of those had reported at least one case (Mean number 2.03, SE 0.33) of child abuse. Among all participants, the major anxiety in reporting suspicious cases was fear of misdiagnosis (73.4%). In addition, 30.8% stated that they did not know how to report suspicious cases. Therefore the wish for undergraduate and postgraduate education and multi-disciplinary working to protect ‘at-risk’ children was stated as highly desirable (78.7%). Nearly all (95.3%) of the sample reported that it should be part of vocational training courses. Thus, we congratulate Lord Laming for insisting on ‘A balance between theoretical teaching and practical training [to] be guaranteed on all training courses’ and the urgent need for a computerised database5. However, the recommendations for policy, in our view and in agreement with Hall1, do not go far enough. They do not acknowledge that domestic violence and child protection are closely entwined nor do they address the anxieties experienced by those who suspect child abuse1. Our survey has also identified that a climate of secrecy prevailed fed not only by fears of misdiagnosis, but isolation, stigmatisation and a lack of confidence in the social services, i.e.: the repercussions ‘too awful to contemplate’. The acquisition of professional knowledge, which ignores people’s fears and anxieties, is unlikely to result in the desired improvements in child protection. Even in the heightened atmosphere of the Victoria Climbié case, the NI health professionals seemed “apathetic” however it may be postulated that this reflected, first their lack of appropriate knowledge and secondly, their fears. This sends a clear message for policy makers - the issue of fear within professional groups must also be addressed. Staff must be confident in asking questions and giving information rather than advice. It is by acknowledging the culture of secrecy fuelled by anxieties and fears1 within the professions that Lord Laming’s5 recommendations can be implemented and the protection of children achieved. Mary Russell, Research Associate , School of N&M, Queen’s University, Belfast, 50 Elmwood Avenue, Belfast BT7 1NN. Ruth Freeman, Professor of Dental Public Health, School of Dentistry, Queen’s University, Belfast, RGH, Grosvenor Road, Belfast BT12 6BP Anne Lazenbatt, Reader in Health Sciences, School of N&M, Queen’s University, Belfast, 50 Elmwood Avenue, Belfast BT7 1NN. Wagner Marcenes, Professor of Oral Epidemiology, Center for Oral Biometrics, Barts and The London, QMUL. References 1.Hall D. Child protection – lessons from Victoria Climbé. Br Med J 2003: 326: 293-296. 2.Dornan, C. Secrets and Lies, Northern Woman, Belfast: Greer Publications:, 2001 3.Mooney, J. The hidden figure: domestic violence in north London—the findings of a survey conducted on domestic violence in the north London Borough of Islington. London: London Centre for Criminology, Middlesex University, 1993 4.Sjostrom, D., Holst D., Lind, S.V. Validity of a questionnaire survey: the role of non-response and incorrect answers. Acta Odontol Scand 1999; 57: 242-246 5.Lord Laming. Inquiry into the death of Victoria Climbié. London: Stationery Office, 2003. www.victoria-climbie-inquiry.org.uk Competing interests:   None declared