NHS Trust hospitals that deal with children should have a Named Doctor
(ND) and Named Nurse (NN) with particular expertise in child protection.
They have responsibility for providing appropriate training and dissemination
of local child protection guidelines. The ND is usually a consultant paediatrician,
but in an Eye Hospital the ND may be an Ophthalmologist who will need to
have links with the Named Doctor (Paediatrician) in a neighbouring trust.
addition, every Health Authority or Board appoints a Designated Doctor
and Designated Nurse in child protection, who are available for advice.
guidelines should be readily available to all staff working with children:
they identify key personnel together with relevant telephone numbers including
those of the local Social Services and the Police Child Protection offices.
Abuse or Neglect
forms of child abuse may involve the eye and they may coexist. The Ophthalmologist
mainly encounters physical abuse (indirect trauma, shaking, smothering
and direct eye trauma), and occasionally induced illness (Munchausen Syndrome
by proxy), sexual abuse, neglect, and emotional abuse.
To Do If You Suspect Child Abuse or Neglect
should not intervene on their own and all suspicions should be discussed
with the hospital social worker and ND. When child abuse is felt to be
occurring there is a responsibility to inform the social services office
If a trainee suspects abuse or neglect, there should be immediate consultation
with a senior colleague, the senior nurse of the ward or department, and
the consultant Ophthalmologist in charge of the case to confirm suspicions
There should be early consultation with the Named Doctor and Nurse, who
will frequently be responsible for the further investigation and general
medical management. In Trusts where there is no Named Doctor, the consultant
Ophthalmologist or the Paediatrician in charge of the case should decide
the lines of responsibility and discuss the case with the Designated Doctor.
Admission may be necessary if the named doctor is not readily able to see
the child or if there are grave injuries or serious suspicions about the
immediate risks to the child. A full history must be taken and an examination
of the patient made, including non-ocular areas of the body if the Paediatrician
has not yet become involved. There must be full documentation of the history,
including what is said by all parties, and the physical findings must be
noted, with annotated drawings and photography where possible. Early involvement
of a paediatrician is advisable.
If, after consultation, abuse or neglect is still considered a possibility,
a referral will be made by the Named Doctor to the Social Service Department,
via the hospital's social worker, if there is one, or directly if there
isn't. The responsibility for investigating suspected child abuse lies
with the Local Authority Social Services department and the Police Child
|LOCAL TELEPHONE CONTACTS
|Local Social Service Office:
|Police Child Protection Team:
the telephone numbers of the above in the spaces provided
Injuries or Behavioural States Which Should Alert the Clinician
factors in the presentation
handicapped, and crying babies,
of abused children,
of previously abused parents.
signs suggestive of abuse
of how the injuries occurred is inconsistent with their appearance.
age of injuries is inconsistent with the account given, or a delay in presentation.
blamed on siblings
attendances at A&E departments.
lack of parental concern at the severity or extent of the injuries.
signs of abuse
bruising, lid lacerations
lens dislocation or cataract
conjunctival or corneal injuries, especially in the lower half of the eye
face injuries in infants or non-mobile children
or subarachnoid haemorrhages.
scalds or fingertip bruising.
burns, especially if multiple.
injuries in inaccessible sites, e.g. neck, armpit, groin etc.
a child presents dirty and unkempt or where there is worrying, e.g. aggressive,
hyperactive behaviour, this should be discussed with the hospital social
worker and consideration given to discussing this further with the GP or
Health Visitor. Similar procedures should be observed when parents behave
aggressively towards their children, or show unusual behaviour towards
hospital staff. This particularly applies if drug or alcohol abuse is suspected.
medical examination should be obtained from an adult with parental responsibility
for the child, and from the child, in a manner appropriate for age and
level of understanding. Medical examination can be carried out with only
the child's consent when, in the opinion of the doctor, the child has sufficient
to give consent
the carer or the child refuse to give consent or to co-operate with admission
or treatment, the doctor should inform the Consultant in charge or the
Named Doctor immediately: it may be necessary to consider emergency legal
action, initiated by the Social Services Department or the Police.
have a right to know what is going on. They should not be made promises
that cannot be kept, and their views and wishes should be taken into consideration.
They should be given the opportunity to explain what has happened to them,
but probing and confrontational 'disclosure' interviews should not be carried
out. Physical examinations should be few, and carried out in a suitable
environment by appropriately trained staff and in the presence of a trusted
or Carers' Rights
are entitled to know what is going on and to be helped to understand the
steps being taken, but the child's welfare is paramount. If the child is
under a Child Protection Order or accommodated by the Local Authority,
arrangements for contact with the family should be clarified with Social
needs take precedence over evidential requirements. Accurate and unbiased
records are essential for case conferences, and legal proceedings which
may be the ophthalmologists duty to take part in.
Working together to safeguard children, 1999 (Child Protection: Medical
Responsibilities, Child Protection: Arrangements between the NHS and other
agencies, are addenda to the above)
Child abuse and the eye. report of the British Ophthalmology child abuse
working party. Eye 1999; 13: 3-10
Duhaime A-C et. al. Non-Accidental Injury in Infants, N E J Med 1998;338
"Handle with Care" NSPCC document for parents, National Centre, Curtain
Road London EC23NH
document was prepared by the Ophthalmology Child Abuse Working Party(ref.2),
4.3.1999 in discussion with The Royal College of Paediatrics and Child
Health Standing Committee on Child Protection.
Royal College of Ophthalmologists