Child protection—lessons from Victoria Climbié
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7384.293 (Published 08 February 2003) Cite this as: BMJ 2003;326:293
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests