Our duty of care

Health care professionals have an obligation to be aware of signs of child abuse, record findings and refer if necessary, says Desrin Dionne Conteh EDT.

Following recent tragedies such as Victoria Climbié and ‘Baby P’, child neglect and child abuse have really been in the media spotlight. It is becoming increasingly common to hear of such stories. As healthcare professionals, we have an obligation to be aware of signs of child abuse, record any findings, and refer if necessary.

This article aims to explore signs of potential child abuse which may present in general dental practice; define what our duty of care is in relation to child abuse; and provide correct protocol where child abuse is suspected.

Safeguarding

Safeguarding is a broader term than ‘child protection’ as it also includes prevention. Safeguarding includes:

• The Children Act 1989¹ which gave every child the right to protection from abuse and exploitation and the right to have inquiries made to safeguard their welfare. Enforced in England and Wales in 1991²

• The Children Act 2004³ which places a responsibility on child practitioners to work together to help a child to reach five outcomes:

  • 1 Be healthy

  • 2 Stay safe

  • 3 Enjoy and achieve

  • 4 Make a positive contribution

  • 5 Achieve economic wellbeing.⁴

• All agencies working with children, young people and their families taking all reasonable measures to ensure that the risks of harm to children's welfare are minimised

• All agencies taking appropriate action where concerns are raised about a child's safety/wellbeing. Working together to agreed policies and procedures.⁵

The Independent Safeguarding Agency (ISA) has been halted by the Coalition Government, and is no longer a requirement for those working with children/vulnerable groups. An enhanced CRB check is sufficient.⁶

Statistics

• There are around 12 million dependent children in the UK (figures vary between sources)

• It is estimated that one in every ten children is abused in the UK⁷

• Fifty percent of child abuse cases involve orofacial trauma, meaning dental professionals are in a good position to spot such injuries⁸

• 46,705 children in the UK were on a child protection plan in March 2010, but child maltreatment is under reported and under recorded, so the actual figure of children at risk from abuse is believed to be much higher⁹

• There were 547,000 referrals to social services departments in the year ending 31 March 2009. Of those referrals, 23% were repeat referrals within 12 months of a previous referral¹⁰

• One child per week is killed (murder, manslaughter or infanticide) on average in England and Wales. In 56% of homicide cases the parent is the primary suspect.¹¹

Child protection policy

This is a statement of intent that demonstrates a commitment to safeguard children involved with a charity from harm. The essential inclusions for a child protection policy are outlined below:

• The welfare of the child is paramount

• All children have the right to protection from abuse regardless of gender, ethnicity, disability, sexuality or beliefs

• The policy is approved and endorsed by the board of trustees

• The policy applies to all staff and volunteers

• 

  Children and parents are informed of the policy and procedures as appropriate. Child protection policies should be displayed

• All concerns and allegations of abuse will be taken seriously by all staff and volunteers and responded to appropriately. This may require a referral to children's services and in emergencies, the police

• A commitment to safe recruitment, selection and vetting (ie reference and CRB checks)

• Reference to principles, legislation and guidance that underpin the policy

• Arrangements for policy and procedures review

• Reference to all associated policies and procedures (health and safety) which promote children's safety and welfare.⁵

An example of a child protection policy is included as Appendix 1.

Signs of child abuse

Trust your judgement and discuss any concerns with a colleague

Forms of child abuse may include physical abuse, emotional abuse, neglect and child sexual abuse, bullying and domestic violence.

The majority of child abuse cases involve a family member. Below are a few pointers to look out for. In some cases, signs may have an acceptable explanation. Other things which are not listed may worry you. Trust your judgement and discuss any concerns with a colleague.

• The parent putting down, swearing or humiliating the child

• The parent and child rarely looking at/touching each other

• Domestic violence/drug or alcohol abuse present in the family home

• The child is very unclean

• The child lacks clothing which is suitable for the weather (eg no winter footwear or coat)

• Frequent injuries/bruising

• Slap/pinch marks

• Cigarette burns

• 

  Bite marks (may require urgent referral to paediatrician for DNA swabs and photography)

• Labial fraenum injury/other intraoral trauma

• Parents may delay medical/dental treatment. Record when and how the patient/parent says the injuries were received

• Untreated dental caries, failure to access services, failure to complete courses of treatment, multiple extractions despite advising parents on oral health, fluoride and diet.

There are further useful resources available online.^8,12

Dental neglect is defined as:

‘The wilful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.’ ⁸

Consider neglect when a child's parent persistently fails to access available services to treat their child's dental caries.¹³

Example:

‘An 11-year-old child returned for the second time as an emergency, presenting with pain and swelling due to severe dental infection. The patient failed to attend numerous filling appointments six months ago, and also failed a hospital appointment for extractions three months ago. New caries has been noted at each appointment, but the patient failed to attend appointments or respond to letters sent to make further appointments. The records show that toothbrushing, diet and fluoride advice has been given to the mother at each appointment attended.’

This is a cause for concern, as the needs of the child are not being addressed by the parent. The parent has failed to respond to a significant dental problem which has resulted in the child experiencing severe pain over a long period of time.

Record keeping

• Record who the child is accompanied by

• Summarise discussions with the parent (eg oral health, diet and fluoride advice)

• Record any injuries, even if there are no concerns. Include precise descriptions and diagrams if possible

• Good record keeping can help when the child sees different clinicians. A pattern may emerge of frequent injuries. Abusers may avoid detection by taking the child to different practitioners on different occasions

• Record non-attendance and cancellations with reasons.

Duty of care

As a dental practice working with young and vulnerable people, we must have policies in place to help keep children safe. We have a moral obligation to report suspected child abuse.⁸

A safe staff recruitment policy is very important. This includes checking references and carrying out Enhanced Criminal Record Bureau (CRB) checks for potential staff. The CRB provides a disclosure service, which offers access to records held by the police, together with information from the following lists: Protection of Children Act 1999 (POCA), Protection of Vulnerable Adults (POVA) and List 99. However, these are limited. The CRB will check UK convictions, but they cannot access foreign criminal records.¹⁴

The GDC expects all registrants to follow the practice policy where this is suspicion of neglect or possible abuse.

The much publicised story of Vanessa George, a daycare assistant (with children of her own) convicted of child abuse, is a stark reminder that there are no stereotypes for child abusers.

The General Dental Council (GDC) expects all registrants to be aware of the protection of children and vulnerable adults, and to follow the practice policy when there is suspicion of neglect or possible abuse of a child/vulnerable adult. Child protection is a recommended CPD topic.

Child protection policy

The procedures and systems should include:

• Local Safeguarding Children Board (LSCB) procedures folder accessible to all staff

• Safe staff recruitment, selection and vetting procedures

• A named person – the Safeguarding Practice Lead (and deputy) – with a clearly defined role, ie updating child protection policies and ensuring staff are aware of their duty of care

• A child protection policy adapted to the practice, details on how to respond to concerns, and relevant contact details for children's services should be readily available. A flowchart can be downloaded from the web⁸ and adapted to your practice

• Follow best practice with record keeping

• Undertake regular team training.

Referring a child

• Each county has its own procedure for child protection and referrals available online. The telephone numbers for the local social service department, named nurses and named doctors for the local area are available online

• If you believe a child to be in immediate danger, contact the police or the out of hours social services department

• These telephone numbers should be included in the practice policy and be readily available. Telephone referrals must be followed up with a referral form within 48 hours

• Non-urgent referrals can be made by fax or by post; online forms are available

• The named doctors and named nurses can be contacted for advice if you have concerns and are unsure of what to do

• You can telephone the NSPCC (National Society for Prevention of Cruelty to Children) Helpline on 0808 800 5000

• As dental professionals we cannot make anonymous referrals to social services and must provide our professional role and contact details in a referral.¹⁵ The parent will be told that we have raised a concern. So, it is best practice to involve the parent from the beginning, and explain that we have a responsibility to make a referral, because we want to help find support for them.

Summary

• All staff need to be aware of child protection issues, and a Safeguarding Practice Lead appointed

• Good record keeping is important to establish patterns

• The dental team are not responsible for making a diagnosis of child neglect/abuse, only to share any concerns with other members of the dental team, and other agencies.

Box 1: Appendix 1

CHILD PROTECTION POLICY STATEMENT

SMALLTHORNE FAMILY DENTAL PRACTICE

We are committed to protect children from harm. Every member of the dental team accept and recognise our responsibilities to develop awareness of the issues which cause children harm.

We will endeavour to safeguard children by:

• Adopting child protection guidelines through procedures and code of conduct for all the dental team

• Making staff and patients aware that we will take child protection seriously and respond to concerns about the welfare of children

• Sharing information about concerns with agencies who need to know, and involving parents appropriately

• Have a plan of what to do if we have concerns about a child

• Following procedures for staff recruitment (ie CRB, ISA)

• Provide effective management for staff by ensuring access to supervision, support and training.

We are also committed to reviewing our policy at regular intervals, and amending if necessary to keep up to date with best practice.

Safeguarding Practice Lead (SPL)

Deputy SPL

Date policy adopted

Due date for review (12 months)

Local Contacts

Children's Specialist Services Office

Named Nurse (enter name)

Named Doctor (enter name)

Out of Hours Services

NSPCC helpline: 0808 800 5000