Intended for healthcare professionals

Education And Debate

Ethical debate: child sexual abuse: when a doctor's duty to report abuse conflicts with a duty of confidentiality to the victim

BMJ 1998; 316 doi: (Published 03 January 1998) Cite this as: BMJ 1998;316:55

The woman who wanted to see her paediatric hospital records

  1. T J David, professora
  1. a University Department of Child Health, Booth Hall Children's Hospital, Manchester M9 7AA

    A 21 year old woman asked to see her medical records from a children's hospital, and because I had been the paediatrician in charge of her case I was approached by the hospital administration. The case was one of possible non-accidental injury. Because of the risk of misunderstanding what had been written in the notes, not to mention their poor legibility, I met the woman and went through the medical records with her. I also gave her a full photocopied set to keep.

    The woman had been our patient 15 years before. At 6 years of age she had been admitted to hospital for a few days' observation because she had a large number of bruises for which there was no adequate explanation. Screening tests gave no evidence of a coagulation disorder and a skeletal survey showed no fractures.

    Careful inquiries were made of social services, the National Society for the Prevention of Cruelty to Children, the health visitor, the child's general practitioner, and her school. All reports were favourable. The girl came from a good family, there were no concerns, and there was nothing in her background to suggest that this was a case of non-accidental injury. As a result, social services decided not to hold a case conference and the child was discharged. We notified all the above agencies about the bruising and it was suggested that any further episodes of bruising should be reported immediately to social services. The child was never seen again with injuries.

    When I saw the woman I had no idea why she wanted to look at her records. I was concerned that the family might have been disrupted because of our earlier inquiries into possible child abuse or that we had failed to detect abuse and she had been injured further.

    After I had gone through her hospital notes, the woman explained that the bruises we had seen had been inflicted deliberately, and that she had wanted to see from her medical notes if we had known about the sexual abuse that she had experienced. She had been sexually abused by a male babysitter over a period of weeks, and had been beaten up by this man whenever she had shown an unwillingness to cooperate. He had threatened to harm her if she ever reported him; she did not report him.

    The woman said that this man still lived in the same neighbourhood and now had a young daughter of his own. We discussed at length what action she might take. She was unwilling to report the matter to the police or social services, and she repeatedly said that I should not under any circumstances share this information with anyone else. She told me that she had had bulimia for some years. This she attributed to her childhood experiences, and she feared that bringing the subject out into the open now would make her distressed and depressed.

    The woman's request to maintain confidentiality placed me in a difficult position. Her story, if true, suggested that other children might have been harmed or might still be at risk, and I saw little reason to doubt her. The question was whether I had a duty to report the matter that outweighed respect for the woman's demand that I tell no one.

    View Abstract