Launceston General Hospital

SDMS ID P2010/2159-001 LGH Policy 9.4-11WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Paediatric Forensic Medical Examination New policy Paediatric Forensic Medical Examination Sexual assault forensic nurse examiners and medical officers, LGH Sexual assault forensic evidence, paediatric examination Sexual Assault Services : LGH Policy 9.1-11WACS Emergency Contraception and Chlamydia Prophylaxis following Sexual Assault WACSClinProc 9.3/10 DHHS Policy for Request & Consent to Medical Procedures & Treatment

Introduction: The Launceston General Hospital is committed to providing both a safe and high standard of care when performing paediatric forensic medical examinations. The principle which underlies this protocol is that the interests of the child are paramount. Paediatric examination is conducted on a pre-pubescent child or on most females under age of 14yrs. Over 14yrs of age (if post-pubertal female), the Nurse Examiner may complete the forensic and medical examination and may use clinical judgement regarding involving a medical review. The best interests of the child include obtaining evidence in ways that do not require multiple examinations (including, but not limited to, using colposcopy and performing any screening tests in ways that have the highest probability of returning a true result). In general, genital examinations for the purpose of determining whether or not abuse has occurred in children will only be performed by appropriately trained and experienced medical staff. All forensic/medical examinations will be conducted in the SAFE room with a SAFE nurse examiner acting as chaperone and support for the DNA collection and assistance with the use of colposcopy and photographic recording. It is preferable that the examination not be performed after 2400 hours even if within the acute time frame (<72 hours), except in the following circumstances: - Allegation of oral ejaculation. - Allegation of anal ejaculation. - Violent injuries. - History of abduction. - 72 hours has almost run out. Historic cases (> 72 hours) to be seen in day time hours.

Paediatric Forensic Medical Examination

LGH 9.4/11 WACS

Aim of a Paediatric Forensic Medical Assessment : The aim is to provide medical care as a priority and obtain forensic information that is acceptable to the child. The goal of a forensic paediatric medical examination is to formulate a diagnosis optimal for legal purposes. Origins of suspected sexual molestation can be from: Allegation Direct Older child makes spontaneous allegation to another person. Indirect Child has genital symptoms questions directed by another (often parent) and allegation emerges. o Child manifests sexualised behaviour questions directed by another (may be a parent) and an allegation emerges. Medical symptoms Medical consultation, directed suspicion leads to allegation. Genital Injury Sexual molestation suspected because of characteristics of and/or an unexplained injury.

Recommendations: A Paediatric Forensic Medical Examination should not be performed unless a comprehensive history of the events of alleged abuse has been provided to the examiner and the attending trained medical officer feels that proceeding with the examination is both warranted and will not be detrimental to the child. Interviewing and the obtaining of a history of young children (<5 years) should be performed by an appropriately trained and experienced psychologist and should not be done in the context of a forensic medical examination. Incidental conversations disclosing relevant information should be record in I said/(s)he said format.

Prior to Examination: The incident/allegation must be reported to child protection as per mandatory reporting. It must be established that necessary consent has been obtained. Children 16 years and above are deemed medically competent and able to consent. Consent to a medical examination must be informed consent. The capacity for a person under the age of 16 years to give consent is governed by Marions Case. The capacity of a child to give informed consent to medical treatment depends on the rate of development of each individual. Consent is required to conduct the examination and the recording of the examination. If the child does not give permission, the examination does not occur unless in circumstances where there are serious concerns re the childs health e.g. haemorrhage from acute genital trauma.
Paediatric Forensic Medical Examination LGH 9.4/11 WACS

It is important to assess: - The current safety of the child. - The urgency of the examination. - General issues such as any concerns that the child may have about the gender of the Doctor. - The nature of the complaint made by the child/parent. - Whether there have been previous notifications or investigations. Ensure examination room is prepared. Discuss if appropriate with a Psychologist, the order in which to proceed ie interview child/parent alone or together, before or after the medical examination.

Medical History General: - Birth history. - Developmental milestones. - Past medical history including injuries. - Circumstances leading up to the reason for medical assessment. - Detailed explanation of injury(ies) including time frames, fall heights, forces involved. - Names of any witnesses. - Family court orders/access arrangements/alternative carers of child and when they had recent contact. Specific to sexual assault: - Specific allegations in regard to sexual abuse/assault. - Any information about perpetrators risk of STI. - Genital symptoms pain, dysuria, discharge, bleeding, constipation - Immunisations, including Hepatitis B. - Previous genital injury. - Previous genital symptoms/infections. - Age at first menstruation if has occurred. - Contraception use/concerns about pregnancy if relevant.

Medical Examination Explain to the child the outline of the examination process and obtain the childs permission verbally or by their co-operation. Maintain childs privacy throughout the examination with careful draping of body parts and minimal exposure. Photograph and document injuries on the body chart, making note of their relationship to underlying bony prominences or any swelling or tenderness. Note any explanations the child may provide in I said/(s)he said format. Photograph using right angle rulers for bite marks and consider wet and dry swabs. Measure injuries and photograph with scale if it is likely to be important in relation to injury mechanism. Document relevant developmental capabilities. Measure growth parameters in infants and specific lengths relevant to injury mechanism ie sitting height, arm reach etc.
LGH 9.4/11 WACS

Paediatric Forensic Medical Examination

After the examination download digital photos to computer, label each photo with name and hospital number and burn disc and arrange for CD labelling before inserting into file. Save second copy of photos to external hard drive.

Colposcopic Examination Colposcopy that includes imaging is considered the gold standard of recording a forensic/medical paediatric examination. Colposcopy also allows for peer review which is vital for medical training in this area, helps resolve disputes and allows the accused to have their own expert review the information. Explain the purpose of video recording the examination to the parent/carer and patient. Before any intimate images are taken of the child, informed consent of the child and/or person/authority who holds parental responsibility for the child will be obtained and recorded. In obtaining consent the child and/or person acting on their behalf must be advised that the images are diagnostic and forensic tools, and consequently, they might be shown to other medical experts including experts instructed on behalf of a defendant. Exceptionally, they may be shown to a Court. If the child or person acting on their behalf refuses permission for intimate images to be obtained this must be respected and recorded in the notes. Specific consent should be obtained for the images to be used for medical education, training and the peer review process. All the images obtained will be coded, cross referenced in the forensic record and all care taken that the individual can never be recognised. Images of faces must never be included. The forensic record is stored separately to the medical record within the WACS department. Software images are securely stored on the colposcopy software Document any visible external injury prior to magnification and consider photographic documentation for visible external injury. Ensure adequate recording of any abnormal finding. Consider prone examination if possible healed injury to the posterior rim of the hymen. Undertake repeat examination if injury is found, to maximise visualisation of injury and document healing and/or changes noted in a minor injury over time. Consider swabs based on the history for forensic purposes.

Ensure colposcope is cleaned thoroughly at the completion of the examination using sodium hypochlorite and methylated spirits.

Forensic Medical Examination Explain the procedure, including the taking of forensic specimens and their analysis by forensic science for use in Court. Ensure the necessary permission for examination and recording of the examination has been obtained. Consider the issue of intoxication in gaining consent, as well as considering examination without recording. The range of specimens which may need collecting include: - Buccal swab.
Paediatric Forensic Medical Examination LGH 9.4/11 WACS

Fingernail scrapings. Pubic hair combings if indicated (rarely performed). Wet and dry skin swabs as indicated overlying tissue injuries (e.g. bites, suction bruises or sites of possible ejaculation). Vestibular, low and high vaginal swabs collected, labelled and plated on labelled slides. Consider request/indications for drug screening. If >12 hours since alleged assault and indicated, collect urine sample. Collect appropriate clothing/underwear as indicated by the history.

Information to be included within the SAIK is: - Date and time of examination. - Date and time of alleged assault/abuse. - Types of abuse/assault alleged. - Examination findings. - Samples collected. - Indications for urine drug testing. Complete SAIK and contact Police for collection of the kit ensuring the chain of evidence is maintained throughout the process. The attached SAIK label is signed, along with the attending police officer, who will also be informed that a report will be sent to them within two weeks, including the opinion following peer review. Sign, along with the attending police officer, the attached label on the SAIK and inform that same officer that a report will be sent to them within two weeks, including your opinion, after it has been peer reviewed.

Medical Procedures: Consider the need for emergency contraception (up to 5 days 120 hours) and discuss efficacy (>97% if taken within the first 24 hours), side effects (nausea, changes to menstrual cycle) and provide written information. If there is a concern re possibility of recent pregnancy then perform a pregnancy test first. Refer to Emergency Contraception and Chlamydia Prophylaxis following Sexual Assault WACS policy 9.3/10

Consider the need for STI screening and any prophylactic STI treatment (refer to the Emergency Contraception and Chlamydia Prophylaxis following Sexual Assault WACS policy 9.3/10. Child may be referred to sexual health (if appropriate) for screening or: Ascertain if the child is immunised against Hepatitis B. If unsure of immunisation status consider option to: - Give immunisation anyway. - Determine if this information can be readily obtained from another source, or - Obtain serology sample and ensure results are checked and followed up the following day.

Where indicated, obtain a PCR sample for Chlamydia and Gonorrhoea. Best results are afforded in the case of females by the insertion of a PCR swab into the posterior fornix (this is not for a forensic purpose and often be done by the girl/woman herself. In males, a first pass urine sample is optimal. Indications for this test include: - Abuse/assault involved genital to genital contact > 5 days prior to the examination.
Paediatric Forensic Medical Examination LGH 9.4/11 WACS

If genital symptoms or observed genital erythema or discharge (and collect relevant swabs for STI testing). Consider need for baseline STI status (urine and/or serology). Please note the sample needs to be taken directly to the lab or refrigerated.

Arrange for follow up STI screening by GP or Sexual Health (if appropriate) if genital to genital contact occurred <5 days prior to the examination. Assess risk of HIV transmission and provide information regarding HIV prophylaxis (if less than 72 hours since exposure). Recommend HIV, Hepatitis C serology in 6 weeks (high risk) or 3 months (lower risk).

Psychosocial Issues Ensure psychosocial issues have been addressed, including: - Assessment of verbal skills and address issue of suitability to be interviewed. - Urgent psychosocial issues. - Willingness to engage in a therapeutic service. - Referral to the most appropriate therapeutic service.

Feedback Following completion of the forensic medical assessment/examination, feedback is to be provided to: - The child. - Parent/carer. - Requesting agency, which here in Tasmania is the Police in the manner of a report including an informed opinion.

Follow up If a repeat medical examination is required, make an appointment at the completion of the assessment and record. A repeat examination may be indicated for the following reasons: - To discuss whether any further relevant information available. - Check that the Hepatitis immunisation is completed. - To obtain history of symptoms subsequent to the first examination. - Document injury healing. - To obtain samples for STI screening if symptomatic repeat the examination and obtain relevant samples and first pass urine for chlamydia and gonorrhoea PCR. If not symptomatic and there is no previous injury it may only be necessary to collect urine for PCR. - Further assessment of psychosocial issues.

PREPARE REPORT AS SOON AS PRACTICABLE FOLLOWING THE EXAMINATION, BEARING IN MIND THE REQUIREMENT FOR PEER REVIEW. All Staff Positions accountable for
Paediatric Forensic Medical Examination LGH 9.4/11 WACS

a) compliance with the policy: medical officers and sexual assault forensic nurse examiners. b) monitoring and evaluation of the policy: LGH sexual assault service c) development and revision of the policy: LGH sexual assault service Attachments
Attachment 1 Paediatric Forensic Medical Examination Report template

References: Royal Australasian College of Physicians (RACP): Genital Examinations in girls and young women: A Clinical Practice Guideline, (2009) Royal College of Paediatrics and Child Health: Guidelines on Paediatric Forensic Examinations in Relation to Possible Child Sexual Abuse (Oct 2007) Royal College of Paediatrics and Child Health/ Association of Chief Police Officers: Guidance for best practice for the management of intimate images that may become evidence in court (Jun 2010) Victorian Forensic Paediatric Medical Service (VFPMS) Medical Reports South Australia Health Practice Guidelines (chapter on Medical Assessment) (undated) (received Sep 2010)

Performance Indicators: Paediatric forensic medical examination will be provided in a timely manner to all clients who present to the sexual assault service at the LGH. Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years by the LGH Sexual Assault Service. Developed By: Medical officers and sexual assault forensic nurse examiners, LGH Sexual Assault Service Medical officers and sexual assault forensic nurse examiners, LGH Sexual Assault Service

Stakeholders:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

Paediatric Forensic Medical Examination

LGH 9.4/11 WACS