Who wears the crown?

Alex Dobson investigates the tendency of staff
in health and social work to defer to the judgements of those who
are seen as higher up the professional ladder, sometimes
unbalancing child protection systems.

The child protection system is only as strong
as its weakest link, as witnessed by many inquiries into children’s
deaths.

In
almost all child protection cases, more than one agency holds vital
information. Unfortunately, any failure to share information,
particularly in a climate where professional relationships are not
based on trust and empathy, can result in tragic
consequences.

During
the Victoria Climbie Inquiry, for example, it became apparent that
the lines of communication between health and social services had
been far from clear, with discussions between professionals over
crucial issues appearing to obscure rather than clarify
issues.

An
early medical diagnosis by a senior paediatrician that Victoria
Climbie had scabies was to have profound implications for the way
that the case was subsequently handled. Junior doctors and nurses
also came into contact with Victoria during her admissions to
hospital, but although they identified child protection concerns,
their influence on subsequent events seems to have been
marginal.

Janet
Foulds is unit manager in the child protection abuse unit of Derby
Council and vice chairperson of British Association of Social
Workers. She argues that staff from both health and social care
need to understand how other professionals arrive at their
assessments. Without that understanding, Foulds says that the
ability to question and challenge those decisions is
lost.

“It is
vital to work on trust and communication which in turn works to
protect children,” she says. “Where you have that trust you don’t
get the imbalance of power that can sometimes happen, where there
are workers who are lacking in confidence and who may defer to
someone else because they are from a certain discipline.

“What
is important is to work on relationships to the point where
everyone has an equal ownership of the duty to protect and an equal
ownership of the duty to communicate,” Foulds adds. “Practitioners
from whatever setting and in whatever job they have, be it ward
staff in a hospital or a junior member of social services, must
have their views taken into account and given equal
weight.”

Her
own experience working in Derby has been positive, with a
successful partnership between health and social services that has
worked to protect vulnerable children. She says that good practice
means working together but it also involves having the confidence
to challenge decisions even when they come from senior
practitioners.

“It
may mean going to a paediatrician and saying that the decision that
he or she has made may not be the right one and then having the
confidence to sit down and talk about it. Senior managers and
training staff have a responsibility to promote a culture so that
new workers or inexperienced workers have the confidence to go and
talk with people from other agencies. So that they can say ‘I don’t
agree’. It is far better to lose face in an argument than allow a
child to become injured,” she adds.

When
health professionals first came into contact with Victoria she was
diagnosed as suffering from scabies by an experienced
paediatrician, Ruby Schwartz. That diagnosis was to be highly
influential in the classification of her as a child in need rather
than a child at risk, but the contact that she had with other
health professionals seems to have either been lost through poor
communication or simply not given sufficient weight.

During
the time that Victoria spent on the Rainbow Ward of North Middlesex
hospital, nurses had the opportunity to spend time with a child who
was displaying behaviour consistent with abuse. They noted that she
was poorly dressed in stark contrast to Kouao and that at times a
master-servant relationship appeared to exist between the two, with
Victoria standing rigidly by her bed when her aunt was
there.

The
child had a voracious appetite, she wet the bed, and although she
had been admitted because of the burns to her head, it was observed
during bath-times that she had unexplained marks on her body, one
of which looked like it had been caused by the buckle of a
belt.

The
extent to which this crucial information was passed to social
services is a matter of debate, but what is striking is that the
suspicions of nurses – several of whom were highly experienced –
were not taken into account in a way that might have helped to
prevent the unfolding tragedy.

Fiona
Smith, adviser on paediatric nursing at the Royal College of
Nursing, says that paediatricians are by no means the only medical
staff that are involved in the assessment of child protection
cases. She says that the key issue is one of training in child
protection awareness and the setting up of support structures so
that staff who may be concerned can take that concern forward and
be given a proper hearing.

“Where
the practitioner believes that there is a child protection issue
involved, then the nurse has a duty to make a referral and that is
why it is so important to have a named nurse or designated nurses
to support junior nurses. But this can also apply to junior doctors
who sometimes need access to a designated doctor for child
protection because they may have been the one who assessed the
child,” says Smith.

She
continues: “Junior practitioners need to have access to key
individuals both within acute trusts and primary care trusts, to
discuss particular cases and to be assisted to follow through the
referral process.”

According to Smith there are also
issues surrounding effective communication between different
agencies, as well as ensuring that messages of concern are properly
documented and understood by all sides.

She
says that health terminology is sometimes unclear in meaning to
social services staff. Likewise health professionals occasionally
misunderstand what social workers are saying.

In
order to counter what can be basic but crucial misunderstandings,
she says that some organisations have implemented procedures
designed to clarify and simplify discussions between
agencies.

Rhian
Stone, child protection policy adviser for the NSPCC, says that
there are problems of hierarchy and status within the health
profession as there are in most professions, and points out that
the decisions and judgements of paediatricians hold considerable
weight.

“Often
that deference can be the right thing as those professionals do
have a particular expertise and social services are often reliant
on their medical diagnosis of non-accidental injury if they are to
have the grounds to pursue an investigation. In the Victoria
Climbie case the paediatrician’s opinion held a great deal of
weight because of the absence of other information,” she
says.

She
adds that the proposals that the NSPCC has put forward to the
inquiry include developing a model that would improve collaborative
working by putting together teams that would include a health
representative. This would have the effect of improving the
dialogue and collaboration between social services and
health.

She
says that the area child protection committee could provide an
independent point of consultation and advice for professionals who
are concerned about a child. This would allow more junior staff to
have access to help and advice, she suggests.

What
has emerged from the Victoria Climbie Inquiry is a story of
misunderstandings that led to a failure to protect a vulnerable
child. But what has also emerged is the importance of giving due
weight to the opinions of all those professionals that come into
with a child at risk.

Everyone in the team needs to
have the ability and confidence to question the decisions of
others, whoever they are, consultant or nurse, social worker or
junior doctor. It is, after all, far better to lose face than to
lose a child.