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Safeguarding children: every nurse's responsibility

Fiona Smith
RSCN RGN Dip Prof BA(Hons) MBA(Health)
Adviser in Children and Young People's Nursing
Royal College of Nursing

Victoria Climbié was just eight years old when she died in 2000, the victim of appalling and sustained abuse. The inquiry into her death revealed no fewer than 12 occasions when local services had the opportunity to protect her and failed to do so.(1) Reviews and inquiries into cases where children have been let down by services often identify similar concerns:

  • Poor communication and information sharing between professionals and agencies.
  • Inadequate training and support for staff.
  • A failure to listen to children.

Since the Laming report into the death of Victoria Climbié, safeguarding children has been high on the agenda of the government. Among other developments the report led to the new Children Act 2004, the "Every Child Matters: Change for Children" programme  in England and Wales, a child protection reform programme in Scotland, and a revision of The Children (Northern Ireland) Order 1995.(2,3)
Every Child Matters seeks to address a range of issues to achieve the following key outcomes identified as essential for children and young people's well-being:

  • Being healthy: enjoying good physical and mental health and living a healthy lifestyle.
  • Staying safe: being protected from harm and neglect and growing up able to look after themselves.
  • Enjoying and achieving: getting the most out of life and developing broad skills for adulthood.
  • Making a positive contribution: to the community and to society and not engaging in antisocial or offending behaviour.
  • Economic wellbeing: overcoming socioeconomic disadvantages to achieve their full potential in life.

Protecting a child and safeguarding them from harm is a central component of policy directives. Practice nurses need to ensure that they are up-to-date with safeguarding procedures to meet the needs of children and young people who attend the practice. A pre-school child attends their GP practice about six times every year and a school-aged child two or three times a year.(4,5) Practice nurses are therefore ideally placed to identify children at risk and to signpost parents to sources of support.

Statistics
Over the last 30 years, deaths from abuse and neglect have not decreased:(6)

  • Approximately one to two children are killed by parents/carers each week.
  • Parents were chief suspects in 76 of the 98 child homicides during 2000/1.
  • On average there are 100-200 serious case reviews each year about children who have either died or sustained serious injury as a result of abuse.

What is abuse and neglect?
There are four categories of abuse: physical; emotional; neglect; and sexual abuse (see box 1).

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Physical abuse is perhaps more easily recognisable due to the presence of obvious physical signs and symptoms. However, it can sometimes be difficult to distinguish between accidental injury and nonaccidental injury.

Recognising child abuse
There is no definitive sign, symptom or injury. Identifying child abuse involves piecing together many factors. Family or social factors, such as poverty, domestic violence, drug or alcohol abuse, and mental health problems may indicate that a child could be vulnerable. Young children, particularly infants or children who have language or learning difficulties or physical disabilities, are more vulnerable.
Common indicators include:

  • Physical signs, such as hand-slap marks, bruising in unusual areas, bruised eyes, bite marks.
  • Poor physical care and inadequate hygiene, inappropriate dress for the weather conditions or failure to seek appropriate healthcare in a timely manner.
  • Unrealistic parental expectations.
  • A child's behaviour. For example the child may show a fear of adults or certain adults when they approach, display aggressive behaviour or deliberate self-harm and substance abuse.
  • The history provided by an adult may be inconsistent with injuries or the child may have attended a number of healthcare organisations with different injuries over a short period of time.

Factors that may impact upon recognition
Research has highlighted that there are numerous factors that affect the identification of children at risk of abuse. These include:

  • A failure to listen to children.
  • Myths around who abuses children.
  • Views that children are the property of their parents and so one should not interfere.
  • Beliefs that abuse only occurs in deprived and poor families.
  • Viewing children only in the context of their family and not as individuals.

Working Together highlights that sound professional practice involves making judgments supported by evidence that has been derived from research about the nature of maltreatment, and how and when to intervene to improve outcomes for children.(7)

Your role and responsibilities
The Royal College of Nursing has produced a useful leaflet to guide practitioners entitled Child Protection - Every Nurse's Responsibility.(6) The guide clearly highlights that all nurses, whether they work directly with children and young people or with adults whose lives impact on children, must be able to identify children and young people at risk of possible child abuse. Nurses must act in the best interests of the child. This duty is enshrined in the Nursing and Midwifery Council (NMC) Code of Conduct.(8)

What does this mean?

  • You must know what to look out for.
  • You must know where to seek expert advice and support.
  • You must know what actions you should take.

This also means acting according to local policies if you have concerns about the behaviour of a colleague or a student.

Record-keeping and documentation
Lord Laming noted that although a single practitioner may only see a particular child once, their contact may generate some extremely pertinent information, which, if adequately recorded and reviewed at a subsequent visit, could help save a life. Good record-keeping is always factual, clear, accurate, accessible and comprehensive. Practitioners are advised to:

  • Write down all observations and discussions as they happen.
  • Record judgments, any actions and decisions taken.
  • Include details and outcomes of healthcare contacts and follow-up arrangements.

Information sharing
Knowing how and when to share information isn't always easy, but it is extremely important to get it right. Your organisation should have a system of support and advice to help you decide what to do. In addition, the government has produced guidance about information sharing to aid those working with children and young people across all settings and advice can also be obtained from professional and regulatory bodies like the Nursing and Midwifery Council and the Royal College of Nursing.(9)
Many practitioners feel that the Data Protection Act prevents them from sharing information. However, the Information Commissioner has stated that:
"The Data Protection Act is not a barrier to sharing information, but is in place to ensure that personal information is shared appropriately."(10)
In most cases information will be shared with others having first obtained consent; however, there may be circumstances when sharing information without consent is in the child's best interest. You need to consider the principles of information sharing:

  • Is there a legitimate purpose for you or your agency to share the information?
  • Does the information enable a person to be identified?
  • Is the information confidential?
  • If so, do you have consent to share?
  • Is there a statutory duty or court order to share the information?
  • If consent is refused, or there are good reasons not to seek consent, is there a sufficient public interest to share information?
  • If the decision is to share, are you sharing the right information in the right way?
  • Have you properly recorded your decision?(10)

There has been confusion recently in relation to young people who attend seeking sexual health advice, as under the Sexual Offences Act 2003, sexual activity with a child under 16 is an offence, and with someone under 13 a very serious offence and should be taken to indicate a risk of significant harm to the child. Working Together provides clarity on this issue, maintaining the situation whereby practitioners are not automatically required to inform social services or the police whenever a child or young person under the age of 16 independently seeks medical assistance.(6) The guidance, however, clearly states that where a person under the age of 16 seeks sexual health advice, a discussion must take place with a named or designated professional for child protection within the organisation.

What to expect from your employer
You should expect your employer to ensure that:

  • You have access to experts in child protection - a named and designated nurse or doctor.
  • Child protection procedures are in place and widely available.
  • You have a secure facility for storing records.
  • There are clearly defined policies in place on how to raise concerns about colleagues, manage sickness and absence, and review individual performance.
  • There are stringent screening processes in place as part of recruitment and selection, including for students and volunteers.
  • You have access to training and education about child protection on induction and annually as part of updating processes.

Conclusion
Safeguarding children and young people is an important issue for all practitioners wherever they work and whether their role focuses on children or on adults whose lives impact on children. What you see, how you record it and what you do about it can make a real difference to a child. No one can bring Victoria Climbié back, but we can try to ensure that other children do not suffer a similar fate. You should remember that:
"No inquiry into a child's death or serious injury has ever questioned why information was shared. It has always asked the opposite." Georgina Nunney, solicitor, Lewisham.(10)

References

  1. Lord Laming. The Victoria Climbié Inquiry: report of an inquiry. London: The Stationery Office; 2003.
  2. Department for Education and Skills. Every child matters: change for children. London: DfES; 2004.
  3. Department of Health, Social Services and Public Safety. Co-operating to safeguard children. Belfast: DHSSPS; 2003.
  4. Department of Health. Getting the right start. The National Service Framework for Children, Young People and Maternity Services - emerging findings. London: DH; 2003.
  5. Department of Health. The National Service Framework for Children, Young People and Maternity Services. London: DH; 2004.
  6. Royal College of Nursing. Child protection - every nurse's responsibility. London: RCN; 2004.
  7. Department for Education and Skills. Working together to safeguard children. London: DfES; 2006.
  8. Nursing and Midwifery Council. Code of conduct. London: NMC; 2004.
  9. Department for Education and Skills. Information sharing: practitioners' guide. London: DfES; 2006.
  10. Department for Education and Skills. Making it happen - working together for children, young people and families. London: DfES; 2006. Available from: http://www.ecm.gov.uk