A tough call

It had been a busy morning as duty doc, with three house calls and a full emergency surgery, when a message flashed on my screen. ‘Please call Mrs Jones, social worker, asap. She wants to discuss medical information about Lilly R (21/5/2009), child protection matter.’ I know that information sharing is really important in child protection but what about confidentiality? What should I tell this social worker? I decide to ask my trainer before making the call.

CHILD protection is a very difficult area of practice that can involve making decisions with far reaching consequences in emotionally charged situations, sometimes against parents’ wishes. One high-profile example of this happened in Orkney in 1991 when nine children were removed from their homes following allegations of child abuse. The children denied anything had occurred and medical examinations produced no evidence of abuse. The charges were eventually dismissed by a judge but the media attention had a huge impact on those involved.

In contrast, reviews into the tragic abuse of Victoria Climbié in 2000 and Baby P in August 2007 concluded that a lack of preventative action and information sharing between organisations were key factors in the failure to prevent the children’s deaths.

Knowing when it is appropriate to act can be a difficult judgement call for any healthcare professional to make. It is essential that all patients, including young people, can be confident that the information they share with their doctor remains confidential. But, equally, it is vital that all doctors have the confidence to act without fear of reprisal if they believe a child or young person may be the victim of abuse or neglect.

New GMC guidance Protecting children and young people the responsibilities of all doctors, which has recently come into effect, seeks to clarify this issue. It states that “taking action will be justified, even if it turns out that the child or young person is not at risk of, or suffering, abuse or neglect, as long as the concerns are honestly held and reasonable and the doctor takes action through appropriate channels.”

The guidance makes clear that child abuse covers not only physical or sexual abuse but also emotional neglect, including fabricated or induced illness.

Justification

Doctors who make decisions in line with the eight principles set out in the GMC guidance will be able to justify their actions if they are called into question.

The principles are as follows:

1. All children and young people have a right to be protected from abuse and neglect – all doctors have a duty to act on any concerns they have about the safety or welfare of a child or young person.

2. All doctors must consider the needs and wellbeing of children and young people – this applies even where the child is not your patient, i.e. if you are treating an adult relative.

3. Children and young people are individuals with rights – doctors must not unfairly discriminate against a child or young person for any reason.

4. Children and young people have a right to be involved in their own care – this includes the right to receive information that is appropriate to their maturity and understanding, the right to be heard and the right to be involved in major decisions about them in line with their developing capacity.

5. Decisions made about children and young people must be made in their best interests - see appendix 2 of the guidance for factors to be considered when assessing best interest.

6. Children, young people and their families have a right to receive confidential medical care and advice – but this must not prevent doctors from sharing information if this is necessary to protect children and young people from abuse or neglect.

7. Decisions about child protection are best made with others – consulting with colleagues and other agencies with appropriate expertise is encouraged.

8. Doctors must be competent and work within their competence to deal with child protection issues – doctors must keep up-to-date with best practice through training appropriate to their role. If they are unsure how to meet their responsibilities to children and young people, doctors must get advice from a named or designated professional, a lead clinician or, if they are not available, an experienced colleague.

It is advisable to read the guidance for more in-depth information.

Making the call

Back to our trainee doctor’s scenario which relates to issues of confidentiality and information sharing.

Bear in mind that confidentiality is not an absolute duty and can be breached in certain circumstances, for example in response to a court order or when the breach can be justified in the public interest. This can occur when the benefits to the child/young person of sharing the information outweigh both the public and the individual’s interest in keeping the information confidential.

Before deciding whether to share information it’s important to have sufficient details. The doctor in our scenario does not yet have enough information and rightly spoke to her trainer who advised she contact the child’s social worker for more details. In particular he suggested finding out what degree of risk the social worker believed Lilly to be facing.

Consent

It is good practice to ask for consent before sharing confidential information unless there is a compelling reason for not doing so. Such reasons include an increased risk of harm to the child should there be a delay in seeking consent.

When seeking consent, it is important to approach the correct person. Where a child lacks the capacity to decide for themselves, you should approach the person with parental responsibility. By law, a mother always has parental responsibility for her child but not all fathers do. In relation to children born after December 1, 2003 (England and Wales), April 15, 2002 (Northern Ireland) and May 4, 2006 (Scotland), both biological parents have parental responsibility if they are registered on a child’s birth certificate. It’s important to always check if a father does have parental responsibility.

Adoptive parents have responsibility, as does a person appointed as a child’s special guardian and local authorities can also possess parental responsibility if there is a care order relating to a child. Married step-parents and registered civil partners can apply to the courts for a parental responsibility order. (Find out more in the MDDUS Essential Guide to Consent)

When seeking consent, be sure to explain why you want to share the information and how it will benefit the child. You should also explain what information you will share and with whom, as well as where they can go for independent advice. Record the details of your discussion in the medical record including the name of the person who gave consent.

If consent is refused you must weigh the harm that is likely to arise from not sharing the information against the possible harm both to the patient and to the overall trust between doctor and patients of all ages arising from divulging that information. If a child or young person is at risk of or is suffering abuse or neglect it is usually in their best interests to share information with the appropriate agency. It is extremely unlikely that a doctor would be criticised for this unless they are acting maliciously.

It is very important to inform a parent or guardian of your decision to breach confidentiality unless you think this will put the child at further risk. It is also important to record the reason for your decision to breach and any steps you took to try to obtain consent prior to breaching.

If you remain unsure about whether to disclose information, seek advice from your local child protection unit or, alternatively, contact an MDDUS adviser.

Dr Susan Gibson-Smith is a medical adviser at MDDUS