In addition, every Health Authority or Board appoints a Designated Doctor and Designated Nurse in child protection, who are available for advice.

Local guidelines should be readily available to all staff working with children: they identify key personnel together with relevant telephone numbers including those of the local Social Services and the Police Child Protection offices.

Suspecting Abuse or Neglect

Many forms of child abuse may involve the eye and they may coexist. The Ophthalmologist mainly encounters physical abuse (indirect trauma, shaking, smothering and direct eye trauma), and occasionally induced illness (Munchausen Syndrome by proxy), sexual abuse, neglect, and emotional abuse.

What To Do If You Suspect Child Abuse or Neglect

Professionals should not intervene on their own and all suspicions should be discussed with the hospital social worker and ND. When child abuse is felt to be occurring there is a responsibility to inform the social services office

1. If a trainee suspects abuse or neglect, there should be immediate consultation with a senior colleague, the senior nurse of the ward or department, and the consultant Ophthalmologist in charge of the case to confirm suspicions of abuse.

2. There should be early consultation with the Named Doctor and Nurse, who will frequently be responsible for the further investigation and general medical management. In Trusts where there is no Named Doctor, the consultant Ophthalmologist or the Paediatrician in charge of the case should decide the lines of responsibility and discuss the case with the Designated Doctor.

3. Admission may be necessary if the named doctor is not readily able to see the child or if there are grave injuries or serious suspicions about the immediate risks to the child. A full history must be taken and an examination of the patient made, including non-ocular areas of the body if the Paediatrician has not yet become involved. There must be full documentation of the history, including what is said by all parties, and the physical findings must be noted, with annotated drawings and photography where possible. Early involvement of a paediatrician is advisable.

4. If, after consultation, abuse or neglect is still considered a possibility, a referral will be made by the Named Doctor to the Social Service Department, via the hospital's social worker, if there is one, or directly if there isn't. The responsibility for investigating suspected child abuse lies with the Local Authority Social Services department and the Police Child Protection team.

 

LOCAL TELEPHONE CONTACTS
Named Doctor:	________________________
Named Nurse:	________________________
Paediatrician:	________________________
Designated Doctor:	________________________
Local Social Service Office:	________________________
Police Child Protection Team:	________________________

Enter the telephone numbers of the above in the spaces provided

Presentations, Injuries or Behavioural States Which Should Alert the Clinician

• Children at risk
• Premature, handicapped, and crying babies,
• Siblings of abused children,
• Children of previously abused parents.

Worrying factors in the presentation

• The account of how the injuries occurred is inconsistent with their appearance.
• The apparent age of injuries is inconsistent with the account given, or a delay in presentation.
• Unexplained injuries.
• Injuries blamed on siblings
• Multiple attendances at A&E departments.
• An unusual lack of parental concern at the severity or extent of the injuries.

Eye signs suggestive of abuse

• Retinal haemorrhages
• Periocular bruising, lid lacerations
• Unexplained lens dislocation or cataract
• Unexplained conjunctival or corneal injuries, especially in the lower half of the eye

Other signs of abuse

• Head or face injuries in infants or non-mobile children
• Subdural or subarachnoid haemorrhages.
• Bite marks, scalds or fingertip bruising.
• Cigarette burns, especially if multiple.
• Unusual injuries in inaccessible sites, e.g. neck, armpit, groin etc.

Neglect

When a child presents dirty and unkempt or where there is worrying, e.g. aggressive, hyperactive behaviour, this should be discussed with the hospital social worker and consideration given to discussing this further with the GP or Health Visitor. Similar procedures should be observed when parents behave aggressively towards their children, or show unusual behaviour towards hospital staff. This particularly applies if drug or alcohol abuse is suspected.

Principles

Informed Consent

to medical examination should be obtained from an adult with parental responsibility for the child, and from the child, in a manner appropriate for age and level of understanding. Medical examination can be carried out with only the child's consent when, in the opinion of the doctor, the child has sufficient understanding

Refusal to give consent

If the carer or the child refuse to give consent or to co-operate with admission or treatment, the doctor should inform the Consultant in charge or the Named Doctor immediately: it may be necessary to consider emergency legal action, initiated by the Social Services Department or the Police.

Children's Rights

Children have a right to know what is going on. They should not be made promises that cannot be kept, and their views and wishes should be taken into consideration. They should be given the opportunity to explain what has happened to them, but probing and confrontational 'disclosure' interviews should not be carried out. Physical examinations should be few, and carried out in a suitable environment by appropriately trained staff and in the presence of a trusted adult.

Parents' or Carers' Rights

Carers are entitled to know what is going on and to be helped to understand the steps being taken, but the child's welfare is paramount. If the child is under a Child Protection Order or accommodated by the Local Authority, arrangements for contact with the family should be clarified with Social Services.

Evidence

Therapeutic needs take precedence over evidential requirements. Accurate and unbiased records are essential for case conferences, and legal proceedings which may be the ophthalmologists duty to take part in.

References

1). Working together to safeguard children, 1999 (Child Protection: Medical Responsibilities, Child Protection: Arrangements between the NHS and other agencies, are addenda to the above)

2). Child abuse and the eye. report of the British Ophthalmology child abuse working party. Eye 1999; 13: 3-10

3). Duhaime A-C et. al. Non-Accidental Injury in Infants, N E J Med 1998;338 1822-1829

4). "Handle with Care" NSPCC document for parents, National Centre, Curtain Road London EC23NH

This document was prepared by the Ophthalmology Child Abuse Working Party(ref.2), 4.3.1999 in discussion with The Royal College of Paediatrics and Child Health Standing Committee on Child Protection.