Emergency health care services

Children or young people may be taken or present themselves at accident and emergency departments. In some instances, abuse or neglect may be suspected, so in addition to care and treatment, local procedures for raising child protection concerns must be followed. Local guidance must be in place to respond to refusal of treatment, or premature removal of a child from the emergency department. If health staff suspect that a child or young person has experienced or is at risk of abuse or neglect, they must provide any immediate medical care required, gather information from the child or young person's medical records, and contact social work standby services. They must examine the child for evidence of injuries (remembering that these may be concealed under clothing), document carefully all clinical findings including skin condition, bruising, scars, weight and height, and ensure that senior practitioners are involved in any decision-making process. They must follow local child protection procedures, including ensuring concerns are raised immediately with social work services.

Children may attend a primary care or general practice unscheduled care service for medical care. In some instances, abuse or neglect may be suspected. In addition to care and treatment, local procedures for raising child protection concerns should be followed. Local guidance should be in place to support response to refusal of treatment, or premature termination of the appointment. If health staff suspect that a child or young person attending an unscheduled care service has experienced or is at risk of abuse or neglect, practitioners should provide any immediate medical care required. They should examine the child for evidence of injuries, remembering that these may be concealed under clothing, document carefully all clinical findings including skin condition, bruising, scars, weight and height, and follow local child protection procedures. They must share concerns about risk of abuse or neglect without delay with social work out of hours services. This will ensure the local child protection register is checked. If there is immediate risk of harm the police should be contacted.

The Scottish Ambulance Service covers the whole of Scotland and has a duty of care to protect the public, including the care and protection of children. Ambulance crews attend emergency and urgent calls across the whole of the country and may be the first to identify that a child is at risk or may have been harmed, at which point local policy for raising their concerns will be followed.

NHS 24 delivers a range of urgent and unscheduled care services connecting people to the care they need and is Scotland's National Telehealth and Telecare Service. It provides access to clinical assessment, healthcare advice and information 24 hours per day. The aim is to provide service users with a timely response in relation to any assistance or advice required to meet their health needs, including additional support that requires onward referral to alternative professional services. Most calls are received via the 111 service when GP surgeries and other services are closed.

NHS 24 plays a crucial role in the recognition and timely response to public protection concerns, which include the unborn baby, children and young people. This is to ensure relevant and proportionate information regarding protection needs is shared with appropriate professionals, including social work and/or Police Scotland.

If social work services contact emergency medical services or NHS 24 due to concerns about a child or young person's injuries or illness, the health staff professional should:

• arrange appropriate clinical care
• establish whether social work and/or the police have discussed the case with the local NHS child protection service, confirming that social work are in contact with the on-call child protection paediatrician
• establish whether a joint investigation has been undertaken or planned
• consult previous medical records to check any previous attendance for analysis of the information to be shared
• share any relevant information, where it is proportionate to do so, with health staff involved in the child or young person's care

Community pharmacists, pharmacy technicians and pharmacy support staff regularly support the healthcare needs of children and parents or carers, including those in 'at risk' groups, such as children of parents with drug problems. As such, they have an important role to play in identifying and raising concerns when a child is thought to be at risk of or experiencing significant harm or abuse.

Dental care practitioners will often come into contact with vulnerable children and are in a position to identify possible child abuse or neglect from routine examinations, or presentation of injuries or poor oral hygiene. The dental team must have knowledge and skills to identify these concerns and raise concerns in line with local policy.

All mental health staff in child and adolescent services and within adult services must be competent to identify concerns about children and young people. Mental health services are largely community based, with some inpatient facilities, and delivered by multi-disciplinary teams including social workers. They may become aware of children and young people who have experienced, or are at risk of, abuse and/or neglect, and should raise concerns in line with local policy. Within adult services, consideration should then be given to the impact of the mental ill health of a significant person in the child's world. If they are concerned that a person's mental health could put children at risk of immediate or significant harm, they must take action in line with local child protection procedures.

Mental health practitioners should take account of any wider factors that may affect the family's ability to manage and parent effectively, including strengths within the family in relation to the child's needs. For further information, see the section on parental mental health problems. Mental health practitioners have a potential key role in both adult and child support and protection, because they engage with vulnerable people. They play an important role in reducing any risks arising from adult mental health difficulties identified within the child's plan.

In some cases, adults and older young people may disclose abuse experienced some time ago. Even if they are no longer in the abusive situation, a crime may still have been committed and other children may still be at risk. Advice should be sought from professional advisors within their health boards.

Addiction services, whether based within health or social work or delivered by a community-based joint addiction team, have an important role to play in the protection of children. Practitioners from addiction services have a critical role in the on-going assessment of adult service users who have caring responsibilities for children. Where risks are identified, practitioners must share information and participate in relevant Core Groups and planning meetings. All addiction practitioners should identify where children are living in the same household as, and/or are being cared for, by adults with alcohol and/or drug use problems. Consideration should then be given to how the problematic alcohol and/or drug use of the parent or carer impacts on the child, in conjunction with children and family services. (For further information, see Part 4 of this Guidance on Parental alcohol and substance use.)

All health staff providing services to adults have a duty of care to children and young people and must work to consider and identify their needs. Providers of adult health services must be able to identify when a child is or at risk of significant harm, and must raise their concerns in line with local policy.

All health staff working in the NHS or Highland Council may identify child protection concerns. Child protection concerns must be raised in line with local policy. NHS Highland and Highland Council have specialist staff who can advise and support staff in relation to child protection.

1. GMC guidance (2018) Protecting children and young people: The responsibilities of all doctors
2. GMC Ethical Guidance (2018) https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors
3. NMC The Code (2015)
4. Nice Clinical Guidance (2017) Child maltreatment: when to suspect maltreatment in under 18s https://www.nice.org.uk/guidance/cg89
5. Nursing and Midwifery Council (2019) Standards of Proficiency for Midwives
6. RCGP Safeguarding Toolkit (2018) https://www.rcgp.org.uk/clinical-and-research/resources/toolkits/child-safeguarding-toolkit.aspx
7. RCPCH Child Protection Companion 2nd Edition https://www.rcpch.ac.uk/resources/child-protection-companion-about
8. Scottish Government (2017) The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland. https://www.gov.scot/publications/best-start-five-year-forward-plan-maternity-neonatal-care-scotland-9781786527646/
9. Scottish Government/Scottish Executive Nurse Directors (2018) Transforming Nursing, Midwifery and Health Professions' (NMaHP) Roles: Pushing the boundaries to meet health and social care needs in Scotland. Paper 4: The school nursing role in integrated community nursing teams. https://www.gov.scot/publications/school-nursing-role-integrated-community-nursing-teams/