Management of ‘Was Not Brought’ for Children and Young People’ (unseen child)

Was not Brought (WNB) applies to children and young people (who require the presence or support of a parent or carer to attend appointments) who did not attend a planned appointment and had not cancelled the appointment.

It is recommended that this term replaces the use of ‘did not attend’ (DNA) and more accurately reflects the fact that children and young people rely on their parents/carers to attend appointments. It allows professionals to consider the impact of the WNB on the child and plan what support they may need, including consideration of child protection processes.

Did not attend (DNA) Following an assessment of the non-attendance and exploring vulnerabilities and any factors impacting on attendance, can be applied to adolescents & young people, (who are old enough to attend appointments without a parent or carer) or to the parents/carers of children who did not attend a planned appointment and had not cancelled the appointment.

Unable to attend Applies to children and young people and/or their parents/carers who cancel appointments. Repeated cancelled and rescheduled appointments should also be treated with professional curiosity and may occasionally indicate potential harm.

Professionals are required to recognise this and challenge non-compliance/disguised compliance

Non-Engagement/Non-Compliance Resistance and disguised compliance, usually meaning disguised non- compliance or non-effective compliance, are the terms often used when services find it hard to engage with families (National Guidance for Child Protection 2021).

Within Child Protection,’ resistance’ is broadly acknowledged as ‘non- engagement and/or non-compliance from one or both parents/carer(s) and can describe a range of behaviours and attitudes, such as;

• Failure to enable necessary contact (for example missing appointments) or refusing to allow access to the child or to the home.
• Active non-compliance with the actions set out in the Child’s Plan (or Child Protection Plan). Such as, cancelling/missing appointments and/or meetings and not engaging in programmes of work.
• Disguised compliance, where the parent/carer appears to co-operate without actually carrying out actions or enabling them to be effective.
• Threats of violence or other intimidation towards practitioners.

Neglect of health needs

• Neglect is the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development (National Guidance Child Protection 2021).
• Medical neglect involves carers minimising or ignoring children’s illness or health (including oral health) needs, failing to seek medical attention or not administrating medication and complying with treatments.
• This is equally relevant to pregnant mothers who fail to prepare appropriately for the child’s birth, fail to seek ante-natal care, and/or engage in behaviours that place the baby at risk through, for example harmful substance use.
• Parents/carers may also fail to bring children to essential follow-up appointments, child health promotion or surveillance programmes.

Unseen child/Young Person/Unborn Child may result from the following:

• Address unknown
• Unable to gain access to the child/YP/pregnant mother/family
• There is a pattern of a child/YP was not brought to or not attending health appointments and/or not being seen by any other professional, including GP. Include pregnant mother not attending antenatal care.
• Refusal of a service
• Resistance and disguised compliance
• Mobile or travelling families
• No access visits Examples:
  • When a health professional has been invited into the home, but the child/YP/pregnant woman is not physically seen (child is said to be asleep and not to be disturbed, or in the care of others, not in the house)
  • Denied access visits – when the door is opened by the carer in charge and the professional is refused access
  • No access visit – when a visit is arranged but no one is at home

• All NHS Borders staff have a responsibility to recognise when a child/YP/unborn is experiencing or at risk of harm and be familiar with the Scottish Borders Child Protection Procedures and process for reporting & referring concerns.
• All Health professionals have a responsibility to act in the best interests of the child/YP.
• Professionals should aim to have an understanding of the child / young person’s needs within the context of the family and when referring children to services should ensure adequate information is available to allow robust assessments should children be unseen or not be brought to appointments.
• Practitioners have a responsibility to provide families and other professionals with information on the services they provide, and the impact on the child if their child is not brought to or supported to attend appointments.
• Health Professionals must liaise and work with other professionals or services involved in a family’s care to avoid extra or unnecessary appointments, and where possible, ensure coordination of appointments.
• Health Professionals should seek to support attendance and understand reasons why children/YP and their parent/carer might not be engaging with services and work together to resolve difficulties.
• Individual services have a responsibility to identify how this policy will be implemented within their own clinical areas. Services also have a responsibility to make best use of patient information systems.
• It is important for professionals to demonstrate that they are seeking opportunities to work in partnership with parents in order to achieve good outcomes for the child.

Any NHSB staff involved with a child/young person/pregnant mother (unborn child) where there is a pattern of non-attendance for health appointments or they cannot gain access to the home to see the child/young person/family should take the following actions:

1 Administration

• If a child or young person WNB for their appointment, check family address and contact details and that they correspond with referrer’s details.
• Liaise with Child Health Dept who can support checks of contact details.
• Contact details of GP, HV, Family Nurse (FN), SW (if appropriate) and lead health professional (LHP) (if appropriate) should be noted in the child’s EMIS record including school contact details for older children.
• Arrange another appointment for the child/YP or with the pregnant mother via appropriate communications (e.g. letters, cards, texts, e-mail).

2 Actions to Support Assessment of Risk

Following a WNB/non-access visit episode, the responsibility for this and the assessment of risk remains with the professional to whom the child or young person has been referred to and in certain cases, in conjunction with the referrer and/or key/lead professional.

A missed health appointment for a child or young person on its own may be of no concern or it may be very significant. Each non-attendance or non-access visit should be assessed on an individual basis to ascertain whether there is a need for further action (professional judgement should be applied).

•  Review relevant health records / electronic systems as appropriate to establish if there is any information that would suggest increased vulnerability /
• Contact the referrer directly to discuss any concerns. You may also contact other key professionals involved as appropriate.
• For children/unborn on the Child Protection Register, contact the child’s social worker to inform and confirm actions required with the Social Worker. If the child’s social worker is unavailable, ask to speak to the Social Work Team Leader. Ensure communication and agreed actions are documented in the child/YP/pregnant woman’s
• Work in collaboration with the family, other health professionals and partner agencies within the GIRFEC principles to promote their health and wellbeing.
• Decide on a reasonable and safe timescale in which the child/YP should be seen/offered appointment.
• In circumstances where children are repeatedly denied access to routine health services designed to promote their health and development, ensure that parents/carers have sufficient information about the importance of the appointments/treatments to their child, outlining alternative means of provision and enabling them to make informed choices.
• Identify whether further action is required to secure child’s health and wellbeing including information sharing with key identified professionals or taking advice from the NHS Borders Protection Team to support decision making (01896 664580)
• Where Child Protection Concerns are identified a Child Protection Referral should be made to Children and Families Duty Social Work as per Scottish Borders Child Protection Procedures.
• If there is an immediate concern/risk to the child/ren, contact the Police 999.

Points to consider include (list not exclusive):

• Have there been previous WBNs?
• If so, how many and is this significant?
• Is there a pattern of non-engagement or cancelled appointments (disguised compliance)?
• Is child know to SW and/or on the Child Protection Register?
• Does child or young person have a disability and/or complex health needs? (see section 8)
• Is child or young person LAC/care experienced?
• Are there any factors that may be preventing access/engagement (e.g. is the time and place mutually convenient, is the location acceptable to the child, young person, pregnant woman or family, financial hardship, domestic abuse)?
• Are there any known difficulties regarding literacy, language or communication?
• Remember that WNB or disengagement may be a risk factor and may be an indication that something harmful is happening.
• Be mindful that parental issues such as mental health or substance use may impact on parent/carer’s ability to bring their child to a health appointment and consider the impact this behaviour is having on the child or young person.
• Does the parent/carer fully understand the requirement for the appointment and consequences of not attending.
• Would a Meeting Around the Child/Family be support co-ordination of support and care planning?
• Consider if this meets criteria for a missing family and follow NHSB missing family
• Prior to raising a Missing Family Alert (MFA)/risk of flight for pregnant woman, discuss with NHSB Public Protection Team who will agree the appropriateness of raising a NHS Scotland Missing Family Alert Form (MFA1)

Consider the GIRFEC questions:

• What is getting in the way of this child/young person/unborn’s well-being?
• Do I have all the information I need to help this child/young person/unborn?
• What can I do now that is needed and appropriate to help this child/young person/unborn?
• What can my agency do to help this child/young person/unborn?
• What additional help, if any, may be needed from others?

3 Communication and Record Keeping

It is important to have written documentation to evidence that you have attempted to gain co-operation with parents/carers in the routine delivery of services.

If there are no concerns, then follow clinical service’s Did Not Attend (DNA)/Child Was Not Brought procedure.

The following information should be documented:

• Follow your clinical service arrangements for contacting/sending letter to parent/carer and/or YP re non-attended appointment/no access visit including notifying referrer and key professional (as appropriate).
• Letters should include information on further appointments or offers, clear reasons as to why the child needs to be seen, potential impact on child if not seen and any further information sharing relating to the WNB/non-access episode.
• Where appropriate information should be shared via letter with GP and HV/Family Nurse, allocated Social Worker or any other key professionals identified.
• Risk assessment and decision to re-appointment or not should be documented fully in the child’s record. Including any discussion with parent/carer and other involved professionals regarding episode (if recording on EMIS, send task to referrer/ health professionals involved to share information as appropriate.).
• Record WNB/non-access/cancelled appointments/phone call on child/YP chronology.
• For all No Access visits leave written communication stating you have called as arranged, with contact details and record action in child/YP/pregnant mother’s case
• Monitor the situation by regular liaison with other professionals who are in contact with the child/YP/pregnant woman/family (e.g. General Practitioner, Playgroup, Nursery, Family Centre, School, School Nurse, Health Visitor, FNP, mental health and mental services) to establish the child/YP/pregnant woman has been seen recently and if there are any current concerns.
• Where there are child protection concerns and a referral has been raised with C& F duty SW this should be recorded in the child’s chronology and record.

• Children/YP subject to child protection processes including being on the CPR should be clearly visible and identified when referrals are made about their health needs.
• Where known, referrals should include contact details for the child/young persons named person (HV/FN) or lead professionals such as named social worker or lead health professional.
• Robust initial information sharing will support risk assessments and decisions if a child is not brought to an appointment or there are no-access visits.
• Children on CPR or subject to CP processes or who are Looked After/Care Experienced will be flagged through appropriate use of alerts on EMIS and Trac.

It is important to acknowledge that health professionals do not have a legal right of entry into a house. If, however, a practitioner discovers that a child appears to be unsupervised and/or alone in the house or is concerned for the immediate welfare of a child/young person, they should contact the police (dial 999) for advice and ensure the child does not remain alone whilst waiting for the police to arrive.

If a child is not available to be seen at home for a pre-arranged visit, contact should be made with the family and a further appointment made. If there are identified vulnerabilities (clinical or social concerns or active social work involvement) the relevant GP, HV/FN/School Nurse, LHP and SW should also be informed of the no access visit.

If the child is not available to be seen at a second pre-arranged home visit consider a wider assessment of the child, consider discussing in supervision and/or consideration of further multi-agency action such as Meeting Around Child and or requirement for Welfare or CP referral.

All no access visits should be appropriately recorded within the child’s record.

Children with complex health needs Should Not be discharged from a service for WNB without discussion with the lead health professional and a risk assessment undertaken. If appropriate this information should also be shared with the allocated social worker.

For children with complex health needs, which may require them to attend multiple appointments, consideration should be given to co-ordination of appointments and ensure effective communication across specialties. Barriers to attending appointments should be explored, including parental risk factors or vulnerabilities, transport and financial challenges.

If child protection concerns are subsequently identified due to WNB staff should follow Scottish Borders child protection procedures

The principles in this document also apply to young people between the ages of 16-18yrs (or older if care experienced or with complex health needs) who are attending our services.

Like adults, most young people above the age of 16 are presumed to have capacity to consent to referrals and treatment. They can however require parental or carer support to attend appointments- this can include financial and emotional support.

When a young person does not engage with an appointment it is important to understand any wider vulnerabilities or concerns before recording a ‘DNA’ where in fact the principles of WNB apply.

Every child has the right to the best possible health (Article 29, UNRC).

Under the Age of Legal Capacity Act 1991, those under 16 may consent to medical treatment if, in the health professional’s opinion, they are capable of understanding the nature and possible health consequences of the procedure or treatment. Equally children and young people may have capacity to withhold/withdraw consent even if their parents want them to. See the NHS Borders Consent to Treatment Policy for further information.

In circumstances where parents/cares decline health services for their children, health professionals should assess all available information. It is advised that professionals consider each individual child’s circumstances and the likely implications of the failure to receive appropriate services. (NOTE: Babies and very young children are particularly vulnerable).

Professionals should take steps to ensure that parents are able to make informed choices and be flexible in negotiating alternative means of offering services.

Where parents, the child/YP or others refuse or fail to co-operate with prescribed medical, dental or therapeutic treatment such that a child suffers, or is likely to suffer significant harm, or neglect, a Referral should be made immediately to the Children & Families Duty Social Work Team as per the Scottish Borders Child Protection Procedures (01896 662787).

Attempts may be made to justify the above neglect on some basis, for example:

• The religion of the child/parent/carer
• Cultural expectations
• Disability of the child including learning difficulties

These attempts may be misguidedly believed to be in the child’s best interests. Such information and reasons do not change the legal duties of all agencies to protect the child’s best interests, which may result in NHS Borders or Scottish Borders Council taking legal advice.

For further information refer to the Scottish Borders Child Protection Procedures.

All health staff can access advice and support from the NHS Borders Public Protection Team on 01896 664580.

Management of the unseen child/YP/unborn flow chart (PDF)