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Any visible Bruises/Burns/Scalds in non-mobile infant – Complete following in ALL cases:

1. Senior ED Review:To establish level of risk/concern
2. Refer to  Children’s Social Services: This should be done for all irrespective of risk or concern [As social services can monitor attendances across all trusts]. But also information on home circumstances, and siblings can be gathered to better judge the safety of discharge.
3. Refer to Paeds Consultant:This should be done by the reviewing senior in ED [The Paeds Con will arrange admission for assessment & safeguarding medical]

Parent Information Leaflet

Child and Adolescent Mental Health services (CAMHS)

CAMHS will come and assess all individuals under the age of 18 who present with a mental health illness i.e. self-harm, suicidal thoughts, personality disorders, etc. From Monday to Friday 9-5pm they can be contacted through switch board and a response is expected during the working day. After 5pm the adult service RAID will assess all 16 and 17 year olds on behalf of CAMHS and make an assessment re admission or further CAMHS review. There is a self-harm pathway and protocol that must be followed and can be found under protocols on EDIS and on the paediatric guidelines page on the intranet under CAMHS.

A mental health assessment must be performed in the ED before if medically fit for assessment before the referral is made.

Those aged under 16 requiring medical treatment, sobriety or observation are admitted to ward 3 at CRH under paediatrics. Those aged over 16 are admitted to the A&E CDU or MAU on the appropriate site until fit for assessment.

MARAC – Multi Agency Risk Assessment Conference – Domestic Abuse

This agency includes the probation service, West Yorkshire Police, Housing agencies, social and educational services.

In order to identify, and provide appropriate care for victims of domestic abuse, clinicians in the emergency department should:

• Ask all persons who present with injuries resulting from a history of ‘assault’ if they know who the perpetrator is and whether they live at the same address, if they are an intimate partner, or someone close to the family.
• Consider domestic abuse in any patient for whom injuries do not match the history given or in whom there are injuries without adequate explanation.
• Consider domestic abuse in any patient with multiple attendances to the emergency department with injuries that could have been the result of assault.
• Have due regard for privacy and dignity when questioning patients about (potential) domestic abuse.
• Follow the domestic abuse pathway when domestic abuse is disclosed or is an alert on EDIS.
• Consider safeguarding needs of any children in families where domestic abuse has occurred and follow appropriate policy.

If you have serious concerns re: a presentation with suspected or identified Domestic Violence please look at the MARAC checklist to see if a referral is required. This can be found on the intranet under adult safeguarding. Consent will need to be given by the patient for a MARAC referral however if the patient does NOT consent this needs to be documented and explained that the information may still be shared confidentially amongst the concerned agencies because there is such a high level of concern for the individual’s safety.

CHFT Domestic Abuse Pack

Female Genital Mutilation (FGM)

This is defined as “any procedure that injures the female genital organs for non-medical reasons”. There are huge pressures on some families and communities to ensure daughters have FGM. Young girls may present in shock, severe pain, with infections such as tetanus, HIV, Hep B or C, inability to pass urine, difficulty walking or damage to other organs e.g. bowel. They may not want any form of examination. Please note the majority of cases occur aged 5-8 years.

If you suspect this, you must contact the safeguarding team immediately once the patient has been stabilised. During working hours contact the safeguarding team on 01422 224570.

Out of hours if aged less than 16 years of age contact the on-call consultant for safeguarding via switchboard for advice. It is mandatory that all Trusts report such cases to the D of H. The Emergency Social work team should be contacted in all suspected cases who will inform the Police.

Child Sexual Exploitation

There have been a number of cases locally where young people have been repeatedly sexually exploited and abused. It is very important you know what to look for and what to do if you have any suspicions. Likely victims may include:

• Individuals that have been reported missing – they may be from out of our catchment area with no parent accompanying them.
• Regularly missing school
• Boyfriend or Girlfriend that looks significantly older
• Suffering from a STI
• Drug and alcohol misuse.
• Inappropriately dressed
• Appearing with unexplained gifts or new possessions.
• Inappropriate sexualized behaviour for the age of the patient. If you suspect such a case it is important to be aware of the law:
• A child under the age of 13 is not legally capable of consenting to sex or any other type of sexual touching – this is rape!
• Sexual activity with a child under 16 is also an offence.
• Non-consensual sex is rape whatever the age of the victim.
• Child sexual exploitation is potentially a child protection issue for all children under the age of 18.

On suspicion of such a case you must discuss with the senior doctor on duty and discuss with the Safeguarding team. If it is out of hours contact the duty Social work team immediately for further discussion or the on-call Consultant for Safeguarding.

Human Trafficking

This is essentially modern-day slavery. It can affect adults and children and a case has recently been highlighted locally. It is the recruitment, transportation and harbouring of an individual/s under threat or force or for financial gains to exploit the person e.g. for domestic duties, slavery, prostitution and in severe cases for organ donation. Be aware of individuals who look malnourished, scared of the person with them, may confess to being a sex worker of present with STD’s, PID etc.

For more information see Hope for Justice Website

Restraint

 Acute Behavioural Disturbance Guidance

There are different definitions as to what constraint entails:

• Restrictive Physical Intervention – is direct physical contact between 2 persons where a reasonable force is applied against resistance to restrict movement or prevent harmful behaviour towards the patient or others. It should only be used to prevent harm and for the minimal time necessary.

• Therapeutic Holding – immobilization of a person or part of a person by splinting or limited force. This is commonly used to restrict movement during uncomfortable painful or unpleasant procedures.

• Containing – use of physical barriers or restraint to prevent a child leaving, harming themselves or others or causing serious damage to property.

In all cases the procedure should be explained by the practitioner to the child and guardian. Therapeutic distraction resources/techniques should be used where applicable. If the investigation is for an emergency or life-threatening situation then the procedure must be undertaken with or without consent from the child or guardian.

The Trust Restraint Policy can be found on the Intranet under Paediatric Policies

Capacity and Consent

 When deciding whether a young person has understood the nature, purpose or possible consequences of not having a treatment or investigation one must assess their capacity. Only if they:

• Understand;
• Retain;
• Use and weigh up this information;
• Communicate their decision to others.

Can they be deemed to have capacity? At 16 years of age a young person is presumed to have capacity. Under this age it depends on the maturity and the ability to understand.

•  If a child lacks capacity to consent then the parent’s consent can be obtained. One parent is sufficient. If the parents cannot agree seek legal advice.
• If the young person is aged 16-17 years parents can still consent to investigations and treatment if the individual lacks capacity. It can also occur without the parent’s consent.
• If a young person refuses treatment and has capacity you must respect the young person’s view. Parents cannot override a competent young person with capacity. In this case seek advice from the legal team.
• The Trust legal team can be contacted via switchboard or advice sought through your defence union. Also look at the GMC guidance on 0-18 years guidance for all doctors.

Gillick Competency and Fraser Guidelines are often mentioned. These are not interchangeable they are different:

1. Gillick Competency = The ‘Gillick Test’ helps clinicians to identify children aged under 16 who have the legal capacity to consent to medical examination and treatment. They must be able to demonstrate sufficient maturity and intelligence to understand the nature and implications of the proposed treatment, including the risks and alternative courses of actions.
2. Fraser Guidelines = Lord Fraser specifically addressed the dilemma of providing contraceptive advice to girls without the knowledge of their parents. Fraser guidelines are narrower than Gillick competencies and relate specifically contraception. You can find the guidelines on the internet.

Drugs & Alcohol

The Base – This is a Huddersfield based service which is free and entirely confidential and available to give drug and alcohol advice to patients up to the age of 25 years.

Branching out via Lifeline – This is the equivalent service for young people up to the age of 21 years.

Leaflets for the referral process and for parents and carers can be found in the orange drawers in the central area at CRH and outside the seated room at HRI A&E.