The death of Victoria Climbie highlighted serious failings in the child protection system. Jenny Fraser discusses the need for midwives to be aware of possible child abuse and how to react if they think a child may be at risk.
Midwives magazine: March 2005
All children should be safe in our world, loved and cared for by those charged with this responsibility, which should ideally be their parents. Sadly some children are particularly unsafe - those for whom scavenging on the streets is a daily occurrence, those orphaned through war, those forced into prostitution and the sex-trade, to name a few. These children will never know what normal life is, and unless something dramatically turns their lives around, will never be able to feel secure and safe.
While such shocking circumstances may not be so acute in the UK, there still remain many children in dire need of protection. According to the United Nations' Children's Fund, up to 80% of child abusers are the biological parents. The risk of death from maltreatment is approximately three times greater for those aged under one than for those aged one to four, who in turn face double the risk of those aged five to 14.
The statistics on child abuse in the UK are truly horrifying. At least one child dies every week as the result of an adult's cruelty and thousands more endure abuse and neglect. Yet these facts reveal only a fraction of the problem, because most cases of abuse go unreported, leaving children to suffer in silence (National Society for the Prevention of Cruelty to Children (NSPCC), 2002).
- Most abuse is committed by someone the child knows and trusts.
The abuse is often known about or suspected by another adult who could have done something to prevent it.
More than 30 000 children are on child protection registers because they are at risk of abuse, and over 600 children are added every week
Recent NSPCC research involving 2869 young adults revealed that one in ten of them had suffered serious abuse or neglect during childhood
The cost of child abuse to statutory and voluntary organisations is £1billion a year (NSPCC, 2002).
The abuse of a child is considered to be the omission of care,maltreatment or neglect, and can be intentional or unintentional. It may be part of a pattern of behaviour or a `one-off '. Usually adults cause this harm.
Child protection is governed by statute and this in itself often makes midwives fearful of the work. The relevant laws are the Children Act 1989 and the Children (Scotland) Act 1995. These documents are summarised in two publications ± for England and Wales,Working together to safeguard children: a guide to interagency working to safeguard and promote the welfare of children (1999), and for Scotland Protecting children ± a shared responsibility: guidance on interagency cooperation (1998). These publications lay out the professional's responsibility regarding child protection.
Midwives ought to make sure they are familiar with the appropriate publication and are urged to obtain a copy for themselves or their department. It is vital that midwives become used to the signs and symptoms of child abuse and have basic knowledge of the child protection process. This will then offset some of the fear and apprehension surrounding this issue that is inherent within the profession.
There are three main agencies involved in child protection:
- Health workers, such as midwives, health visitors, doctors and nurses
- Social workers
- The police
Any child protection work involves close communication and working practices between these three agencies. The two publications mentioned above set out clearly the responsibilities of each group and how they are expected to cooperate fully together. Midwives need to be particularly mindful of their clientele. Babies are immensely vulnerable as they are completely dependent on others and cannot survive without their basic needs being met.
Signs and symptoms of abuse
The midwife should be alert for possible abuse in any of the following situations:
Bruising or other injuries for which there is no adequate explanation
Burns, particularly cigarette burns in unusual areas, such as the soles of the feet in a non-mobile child
Any delay in seeking medical advice
Vague history that lacks detail and is inconsistent when repeated
History of shaking
Bites, either human or animal
Neglect of basic physical needs, such as hygiene or feeding
Where the parents are fabricating an illness in their baby or child, demanding that unnecessary medical tests are undertaken on the child
Unrealistic expectations or undermining of the baby or child.
Such comments will invariably continue as they grow older, unless successfully contested with adequate explanations that are understood and acted on by the parents (Fraser, 2004). These examples are not exclusive and if a midwife suspects that she may be witnessing a child at risk of harm, then it is vital that she takes action in order to protect the child. If the midwife is not sure that what she is seeing is abuse, then it is still important to get information from those responsible for child protection in the Trust. This is legitimate communication between professionals on a 'need-to-know' basis. It is important for midwives to know their role within child protection regarding confidentiality.
The NMC (2002) Code of professional conduct clearly sets out when it is acceptable to disclose confidential information:
It can be justified in the public interest (usually where disclosure is essential to protect the patient, client or someone else from the risk of significant harm)
It is required by law or an order of court.
Child protection is all about reducing the risk of significant harm and a midwife has a duty to do this. If this means that she has to disclose information, then this is what needs to happen. It is always good practice to share with the parents that this is a possibility, but their consent to disclose information is not mandatory in these circumstances.
The Code of professional conduct says: 'Where there is an issue of child protection, you must act at all times in accordance with national and local policies' (NMC, 2002). It is therefore crucial that the midwife makes herself aware of child protection policies and procedures, from the initial referral stage until the convening of a child protection conference, if necessary, and beyond.
All acute and primary care Trusts will have a designated doctor and nurse, who will usually have a health visitor qualification, for child protection. These are usually full-time strategic posts, taking the lead on child protection within Trusts. In addition to the designated people, there are named individuals who coordinate the smooth running of child protection. The named nurse within an acute Trust may or may not have undertaken midwifery training, but many Trusts, particularly large ones,may also have a named midwife. These individuals should have knowledge of local arrangements for safeguarding children and promoting their welfare. They are expected to provide a source of advice and expertise for fellow professionals and other agencies. They also play an important role in promoting good professional practice within the Trust, in order to protect children (Fraser, 2004).
The legal framework
The Children Act 1989 and the Children (Scotland) Act 1995 have a number of common themes. These include:
- Making children's welfare a priority
Recognising that children are best brought up within their families wherever possible
Requiring local authorities to provide services for children and families in need
Promoting partnership between children, parents and local authorities
Improving the way courts deal with children and families
Giving rights of appeal against court decisions
Preserving the rights of parents when children are being looked after by local authorities.
A court will only issue an order if it is satisfied that this will be of benefit to the child. Children subject to care proceedings through the courts will usually have an expert appointed to provide advice about their welfare.
Victoria Climbie was not detected by the child protection process. Lord Laming chaired a recent enquiry into her death and in his summing-up he was critical of the fact that she had managed to slip through the net. Victoria was known to three housing authorities, four social services departments, two child protection teams of the Metropolitan Police Service and a specialist centre managed by the NSPCC. She was twice admitted to two different hospitals prior to the third admission when she died of suspected deliberate harm.
No one could fail to be moved by the plight and unbelievable abuse suffered by Victoria. When she died on 25 February 2000, she had 128 separate injuries on her body. Dr Nathaniel Carey, who undertook the postmortem, said that there was no part of her body that had been spared.Victoria was eight years old when she died as a result of the most unspeakable abuse. Lord Laming has made 108 recommendations for changes to the child protection system in light of her death. It is likely that the child protection committees as recognised at present will not function in the same way.
Among Lord Laming's recommendations was to establish a ministerial children and families board. This has been done and is chaired by Margaret Hodge, the minister of state for children. Lord Laming wants a national agency for children and families that will report to the ministerial board. Among the agency's responsibilities are:
- Assessing and advising the board about the impact on children and families of proposed changes in policy
- Advising on the implementation of the United Nations' Convention on the Rights of the Child
- Advising on setting nationally-agreed outcomes for children and how they might best be achieved and monitored
- Ensuring that legislation and policy are implemented at a local level and monitored through its regional office network (The Victoria Climbie Inquiry, 2003).
This restructuring of the arrangements for child protection is just as pertinent to midwives as to agencies dealing with older children such as Victoria (Fraser, 2003).
It is vital that midwives keep their eyes and ears open at all times to the possibility of a baby or child being abused.
Midwives must remember that they have a duty to safeguard any such child by following the relevant child protection policies. It is also imperative that midwives identify their local named and designated professionals for child protection. Use them ± your actions could potentially save a child in the future from suffering the kind of torture experienced by Victoria.
Department of Health. (1999) Working together to safeguard children: a guide to interagency working to safeguard and promote the welfare of children. HMSO: London. Fraser J. (2003) Victoria's story. The Practising Midwife 6(8): 4-5. Fraser J, Nolan M. (2004) Child protection: a guide for midwives (second edition). Books for Midwives Press: Oxford. National Society for the Prevention of Cruelty to Children. (2002) Child abuse in Britain. See: www.nspcc.org.uk (accessed January 2005). NMC. (2002) Code of professional conduct. NMC: London. The Scottish Office. (1998) Protecting children ± a shared responsibility: guidance on interagency cooperation. The Stationery Office: Edinburgh. The Victoria Climbie Inquiry. (2003) The Victoria Climbie Inquiry: report of an inquiry by Lord Laming. See: www.victoria-climbieinquiry. org.uk (accessed January 2005).