The health assessment of a child for whom there are child protection concerns aims –

• to establish what immediate treatment the child may need
• to provide a specialist medical opinion on whether or not child abuse or neglect may be a likely or unlikely cause of the child’s presentation
• to support multi-agency planning and decision-making
• to establish if there are unmet health needs, and to secure any on-going health care (including mental health), investigations, monitoring and treatment that the child may require
• to listen to and to reassure the child
• listen to and reassure the family as far as possible in relation to longer-term health needs

The decision to carry out a medical assessment and the decision about the type of medical examination is made by a paediatrician informed by multi-agency discussion with police, social work and other relevant health staff. Through careful planning, the number of examinations will be kept to a minimum.

The decision to conduct a medical examination may -

• follow from an IRD and inter-agency agreement about the timing, type and purpose of assessment
• follow when a person presents to health services. This includes the possibility of self referral for victims of rape and sexual assault who are over 16 years old as described below

Examination by a paediatrician and a forensic physician. This is the usual type of examination for sexual assault and is often undertaken for physical abuse, particularly infants with injuries or older children with complex injuries.

These are sexual assault examinations undertaken for children and young people aged 13-16. In some areas/situations a JPFE would occur, and in all areas/situations JPFE should be considered.

This type of examination is often undertaken when there is concern about neglect and unmet health needs but may also be used for physical abuse and historical sexual abuse. Comprehensive medical assessment for chronic neglect can be arranged and planned within localities when all relevant information has been collated. However there may be extreme cases of neglect that require urgent discussion with the Child Protection Paediatrician.

All medical examinations/assessments are holistic, comprehensive assessments of the child/young person’s health and developmental needs. There may be variations in who undertakes medical examination, and the purpose of the examination must be clear prior to the examination (usually discussed at IRD or at time of referral for the examination) to allow for a clinician with the appropriate skill set to undertake the assessment.

In some parts of Scotland, where victims of rape or sexual assault are aged 16 and over, they are able to self-refer for a forensic medical examination without first making a report to police. Professional judgement is required as to whether following self-referral, a forensic medical examination is in the person’s best interests. This includes clinical and non-clinical considerations. Even when an FME is not provided, the need for healthcare support and treatment must be considered.

Specialist paediatric or Joint Paediatric Forensic Examination (JPFE) is appropriate when –

• the child requires a specialist assessment or treatment from another department (for example, multiple fractures, signs of abusive head trauma
• the account of the injuries provided by the carer does not provide an acceptable explanation of the child’s presentation
• the result of the initial assessment is inconclusive and a specialist’s opinion is needed to establish the diagnosis
• lack of corroboration, for example by way of a clear statement from another child or adult witness, indicates that forensic examination, including the taking of photographs, may be necessary to support criminal proceedings against a perpetrator, and legal processes to protect the child
• the child’s condition (for example, repeated episodes of unexplained bruising) requires further investigation
• child sexual abuse is suspected

A comprehensive medical examination for neglect can be arranged and planned for within localities when all relevant information has been collated. However, there may be extreme cases of neglect that require urgent discussion with the Child Protection Paediatrician.

Significant new information may arise from a medical examination that requires the reconvening of an IRD.

Wherever possible, the wishes of children who may have experienced sexual abuse, should be considered and supported in respect of choice of sex of examiner (Clinical Pathways NHS Scotland 2022).

As far as can be achieved in the circumstances, the examining doctor should have –

• all relevant information about the cause for concern
• information on previous concerns about abuse or neglect
• the inter-agency plan to meet the child’s needs at this stage
• relevant known background of the family or other relevant adults
• information from joint investigative interview if available
• preparatory discussion with the relevant social work and police officer
• preparatory meeting with parent or carer and child

It should be recorded what information is handed over/conveyed verbally to the examining doctor and by whom.

Social work services, the police and the examining doctor should ensure that the child and parent(s) (and/or any other trusted adult accompanying the child) have the opportunity to hear about what is happening, why and where so that they have an opportunity to ask questions and gain reassurance.

Consideration will be given to how the child may be examined in child-friendly surroundings, with the right support for their age, stage and understanding.

Consent must be obtained in one of the following ways –

• from a parent or carer with parental rights
• from a young person assessed to have capacity
• through a court order

The Age of Legal Capacity (Scotland) Act 1991 allows a child under the age of 16 to consent to any medical procedure or practice if in the opinion of the qualified medical practitioner the child is capable of understanding the nature and possible consequences of the proposed examination or procedure. Children who are assessed as having capacity to consent can withhold their consent to any part of the medical examination, for example, the taking of blood, or a video recording. Consent must be documented within medical notes and must reflect which parts of the process have been consented to and by whom. This includes consent to forensic medical examination.

In order to ensure that children and their families give properly informed consent to medical examinations, it is the role of the examining doctor, assisted if necessary by the social worker or police officer, to provide information about all aspects of the procedure and how the results may be used; and to ensure informed consent has been obtained. Where a medical examination is thought necessary for the purposes of obtaining evidence in criminal proceedings, but the parents/carers refuse their consent, the Procurator Fiscal may, in exceptional circumstances, consider obtaining a warrant for this purpose. However, where a child who has legal capacity to consent declines to do so, the Procurator Fiscal will not seek a warrant.

If the local authority believes that a medical examination is required to find out whether concerns about a child’s safety or welfare are justified, and parents refuse consent, the local authority may apply to a Sheriff for a child assessment order, or a child protection order with a condition of medical examination. This is still subject to child’s consent (under section 186 of the 2011 Act).

Timing of the medical examination is agreed jointly by the medical examiners and the other agencies involved.

Child protection assessments should be carried out, in the child’s interests, during the day, unless there is a forensic need or other clinical indication of urgency.

In some cases, when there is not a forensic urgency, it may be a priority that the child has had time to rest and prepare. This may also allow for more information to become available. The majority of cases arise in working hours, and a comprehensive medical assessment will be carried out locally and timeously.

In cases of suspected or reported non-recent sexual abuse, examinations should be planned during normal working hours.

Local arrangements must be in place for medical examinations out of hours, where these differ from daytime/weekday arrangements to ensure the opportunity to collect forensic trace evidence is not lost.

The Clinical Pathway for Children and Young People who have disclosed sexual abuse is relevant for children under 16 years of age (or up to 18 years of age for young people with vulnerabilities and additional support needs) (Scottish Government 2022).