Initial Management of children 8-18yrs presenting in situations of near drowning, apparent self-harm or strangulation and consideration of the possibility of child maltreatment in LTHT

Publication: 01/08/2018  
Next review: 17/02/2024  
Standard Operating Procedure
CURRENT 
ID: 5676 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Initial Management of children 8-18yrs presenting in situations of near drowning, apparent self-harm or strangulation and consideration of the possibility of child maltreatment in LTHT

Aims

  • Framework for considering the possibility of child maltreatment in children 8-18 presenting in situations of near drowning, apparent self-harm, or strangulation to LTHT

Background and indications for standard operating procedure

Patients, their carers and families, receiving care and treatment for presentations of near drowning, apparent self-harm or strangulation receive holistic treatment in LTHT.

Self-harm and suicide are major health concerns in young persons, and increasingly in younger children. They reflect a complex interplay of genetic, biological, psychiatric, psychological, social and cultural factors; including having been subject to physical or sexual abuse.

Equally those presenting with near drowning or poisoning may also have been subject to physical or sexual abuse.

The association between child maltreatment and such presentations is neither direct, nor common; but is recognised.

One can readily appreciate how distressed the individual and their carers might be, particularly in situations where the individual with such a presentation is critically ill.

Professionals manage these situations with sensitivity, but also have a statutory obligation to identify child maltreatment. Resolving these two elements can be extremely challenging.

This document is produced as a framework, articulating the context of safeguarding concerns in such cases, and suggesting means to apply this knowledge to the case in hand.

Clinical Contexts.

Aspects within such presentations that raise concern as to the possibility of child maltreatment.

  • Safeguarding concern expressed by professionals attending the patient (Police, Ambulance, secondary care- including Emergency departments/ A&E).
  • Safeguarding concern expressed by professionals (social care) or non-professionals involved with the patient.
  • Family factors;
    • parent/ carer drug/alcohol misuse
    • parent/ carer mental health concerns
    • domestic abuse
    • previous child maltreatment concerns
  • Patient factors
    • Pre-existing disability in patient
    • Links to gangs
    • History of run away
    • School exclusion
    • Looked after by local authority
    • Privately fostered
    • Previous child maltreatment (including sexual abuse) concerns

The attending Health Professional must make an opinion based upon the information available, either documented, or following professional dialogue concerning these considerations. If there is no documentation of professional dialogue with the relevant Children’s Social work Service to permit such an opinion, then the attending health professional should contact the relevant Children’s Social Work Service for such dialogue.

This opinion must be documented by the responsible Consultant for the case in the notes.

  • In cases where there are safeguarding concerns, then the features which support this opinion should be included within this documentation. The case should be referred to the On Call Paediatric Medicine Consultant, who will attend, conduct a safeguarding assessment (history and examination with consent) and hold responsibility for the safeguarding aspects of the case.
  • In cases where there are no safeguarding concerns, this should be documented.

The case should then be considered by the responsible Consultant for the prognosis. Expanding upon this, in situations where the event is sudden and unexpected- yet the prognosis is poor despite initial resuscitation, the Police may secure the scene, but will not be able to do so indefinitely. These cases should be discussed with the responsible SUDIC team, for consideration of enacting a SUDIC investigation, while the child remains alive; as important information might be found that can assist the treating team and police; this is a change in practice suggested by the recent inter-collegiate review of the SUDIC process by Baroness Kennedy in 2016.

Such prognoses might well hinge upon further investigations or the response of the child to treatments; it may well be that it is not possible to make such a decision. In these situations the responsible Consultant should consider discussing the case with responsible SUDIC team (or on call Consultant Paediatrician) covering the child’s place of residence- explaining the uncertainty. In these situations the prognosis, and need for SUDIC involvement should be regularly reviewed.

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Procedure method (step by step)

  1. Health professionals to a patient under the age of 18, who attends LTHT with a presentation of near drowning, strangulation or self harm should be aware of the possibility of safeguarding concerns underlying this presentation.
  2. Health professionals should consider this possibility in such cases, making their opinion upon dialogue, or documentation accompanying the patient recognising:-
    1. The presence or absence of a safeguarding concern being articulated by professionals (Ambulance, Police) attending the patient at the scene.
    2. The presence or absence of a safeguarding concern being articulated subsequently by professionals (Ambulance, Police, secondary care- including Emergency Departments/ A&E, Transport service).
    3. Safeguarding concern articulated by professionals (social care) or non-professionals involved with the patient.
    4. Family factors
      • parent/ carer drug/alcohol misuse
      • parent/ carer mental health concerns
      • domestic abuse
      • previous child maltreatment concerns
    5. Patient factors
      • Pre-existing disability in patient
      • Links to gangs
      • History of run away
      • School exclusion
      • Looked after by local authority
      • Privately fostered
      • Previous child maltreatment (including sexual abuse) concerns
  3. The admitting team for this patient hold the responsibility to make this opinion, this may well require dialogue with the responsible children’s social work service if there is no documentation that this has already been sought and answered.
  4. This opinion should be clearly written in the notes, by the Consultant responsible for the patient, in accordance with Trust standards for documentation.
    1. If this opinion is that there are safeguarding concerns, the features of the case suggesting this opinion should be documented and the case referred to the on call Paediatric Medicine Consultant, defining these concerns.
    2. If this opinion is that there are no safeguarding concerns. This should be documented.
  5. The Consultant responsible for the patient should consider the prognosis of the child, recognising instances where despite initially successful resuscitation, the child subsequently dies, sometimes days or weeks later (please see Background and indication above). In cases where the prognosis is felt to be poor, then the presentation should be discussed with the responsible SUDIC team (or on call Paediatric Consultant) covering the child’s place of residence, even whilst the child remains alive.
  6. This consideration should be reviewed on a regular basis whilst the child is critically ill.

Provenance

Record: 5676
Objective:
Clinical condition:

Situations of near drowning, apparent self-harm or strangulation

Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Adapted from:

Evidence base

References

National Institute of Health & Clinical Excellence Clinical Guideline 89; ‘Child Maltreatment: when to suspect in under 18s’. London current (2009-2016)

National Institute of Health & Clinical Excellence Clinical Guideline 16; ‘Self-harm in over 8s: short-term management and prevention of recurrence’. London current (2004-2011)

Sudden Unexpected death in infancy and childhood (2nd edition). Multi-agency guidelines for care and investigation. The report of the working group convened by the Royal College of Pathologists and The Royal College of Paediatrics and Child Health (November 2016)

Self Harm and suicide in adolescents; Hawton ,K et al; Lancet 2012; 379: 2372-82)

Management of children with an injury concerning for the possibility of sexual assault in Leeds; Leeds Local Safeguarding Children’s Board (LSCB) 2016

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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