Medical and forensic examinations - advice
The advice provides additional information regarding the considerations and procedures to be followed when a medical or forensic medical examination is required for the assessment of risk of harm.
Document ID number 2421, version 2, 1 March 2016.
See procedure Medical and forensic examinations for tasks that must be undertaken.
Consultation and consent
Wherever possible, parents will be informed, consulted and appropriately involved in any medical examination or treatment planned for their child. Usual practice will involve seeking parental consent for examination and treatment regardless of whether the legislation requires consent or not. In the event medical attention is required for the child and the parent's consent is not forthcoming or they are unable to be contacted, practitioners must act in accordance with the powers contained under s. 597 of the CYFA and in consultation with a qualified medical practitioner.
Section 597 relates to children under a:
- family reunification order
- care by Secretary order
- long term care order
- a therapeutic treatment order,
and for children:
- in the legal custody of the Secretary as provided for by s. 483 (in detention)
- placed out of parental care as a result of an interim accommodation order, or
- in emergency care as a result of a protection application or other application.
These provisions do not relate to children who remain in the care of their parents. Where children remain at home with parents, parental consent is required unless there is a court order in existence permitting examination.
Young people with sufficient maturity and comprehension of their medical situation and the proposed treatment are able to request or refuse treatment without the endorsement of their parent or a person who holds parental responsibility. The powers of the Secretary under s. 597 do not override this ability. However, practitioners should encourage the young person to involve their parents and others who hold parental responsibility as appropriate. Legal advice should be sought when in doubt.
A forensic or medical examination may be required at any time during the investigation phase, the protective intervention phase or protection order phase for the purpose of:
- investigating current injuries, undetermined illnesses, unusual or obscure symptoms, or where the cause of the injury or condition or illness is undetermined, suspicious or vague, and to explore believed harms
- investigating new allegations of recent or past injuries
- conducting an in-depth health check including blood tests, bone scans and x-rays (where indicated as necessary)
- medical comment on the adequateness of the parents' explanation of any physical injuries or illness
- medical report on the likelihood of injuries or illness being non-accidental and exploration of possible causes particularly where differing medical opinions exist
- assessment of paediatric development
- documentation of injuries or illness and symptoms
- provision of a report and evidence (including, photographic) for court
- providing treatment for injury or illness as well as providing recommendations for further medical treatment.
Medical examinations need not only take place for forensic purposes (gathering information, evidence and assignment of a likely cause), but even more importantly, may be necessary to identify any physical trauma or condition requiring medical attention and reassure the child and parent or carers that the child is physically undamaged and unhurt or any injuries have been identified and treated.
Child protection practitioners should be clear about the purpose of all medical assessments and clearly convey the purpose to the medical practitioners. That is, in the initial discussion with the medical practitioner, child protection practitioners should clearly indicate the purpose of the assessment being requested, explain the need for a report and the potential for the medical practitioner being required to appear in court as a witness.
Physical abuse and neglect allegations
A forensic medical examination of a child, who has been or is suspected of being physically abused, should be undertaken unless the child, who has been assessed as having sufficient understanding and capacity to make decisions, does not consent to the medical examination.
Protective intervention reports relating to physical abuse and neglect require the practitioner to see the child to assist in the decision of substantiation and to assess the need for any immediate medical attention. Practitioners should not conduct any physical examination of the child. However, should the visual examination indicate non-accidental injury, issues of serious neglect or any injury or illness requiring medical attention, the practitioner should consult with their supervisor and the child's parents before proceeding to a medical examination.
Sexual abuse allegations
A forensic medical examination of a child, who has been or is suspected of being sexually abused, should be undertaken unless the child, who has been assessed as having sufficient understanding and capacity to make decisions, does not consent to the medical examination.
Medical examinations are often important, however the absence of medical evidence alone cannot be relied upon to prove that a child has not been abused. Forensic medical examinations can be a means of collecting corroborating evidence. A medical examination does not only focus on forensic evidence. It can assist the child to understand what has happened to them and their body and may alleviate any concerns they may have in relation to the alleged abuse that has occurred.
Priority must be given to the child's immediate health and wellbeing. Where it is evident that a child needs immediate medical treatment, this must take priority over the forensic aspect.
Temporary assessment orders
A temporary assessment order may be sought if there is a reasonable suspicion that a child is, or is likely to be in need of protection, further investigation and assessment of the matter is warranted and the investigation and assessment cannot properly proceed without a temporary assessment order. A temporary assessment order may provide for a medical examination to be undertaken on a child. However, if a registered medical practitioner or registered psychologist by whom the child is to be examined is of the opinion that the child has sufficient understanding to give or refuse consent to the examination and the child refuses, the assessment must not proceed.
Practitioners should refer to and act in accordance with the protocol between the department and Victoria Police where police are involved in forensic examinations.
In cases where criminal concerns are apparent (sexual and physical abuse, serious neglect) practitioners and the police must liaise regarding the arrangements for the forensic examination. Reports are to be made available to both Victoria Police and the department.
A medical examination is a potentially traumatic experience for the child and therefore adequate planning and preparation (where possible) are vital to minimise the potential trauma.
Practitioners should consider involving a support person for the child who can be present throughout the examination. This could be a non-offending parent if they are supportive of the child.
Child protection practitioner's presence
Where a forensic medical examination is required, the child protection practitioner investigating the allegations must attend the examination to ensure relevant information is provided to the medical practitioner and immediate feedback can be obtained.
It is generally not necessary or appropriate for the child protection practitioner to be present in the room whilst the examination is undertaken.
Obtaining an initial provisional opinion report
In cases where an urgent forensic medical examination is being undertaken, the practitioner should request, in writing, prior to the commencement of the examination, that the examining medical practitioner provide an initial provisional opinion report and any clinical photographs on completion of the examination. If the child is subject to an application by emergency care, this medical information will assist practitioners in negotiations at court and will assist the court in decision making on the first mention date. A final reviewed report will need to be available for further hearings.
Timing of the examination depends on the presence or possibility of physical injuries and evidence, the level of value to the investigation and the availability of medical specialists. In the event the child appears to need urgent medical attention this must be addressed as soon as possible and the forensic aspect dealt with in due course. If the child has already had a medical examination, the request for a forensic examination must be discussed with the forensic medical team.
The procedures for consent for medical examinations and treatment are listed in procedure Consent for medical examination and treatment.
Arranging the forensic or medical examination
If it is determined that a forensic medical examination of a child is required, the child protection practitioner or the police need to contact the Victorian Forensic Paediatric Medical Service (VFPMS) to discuss the reason for the forensic paediatric medical examination and to arrange the appointment.
The process for administering requests for forensic photographs has been centralised so that there is a single contact point and all requests are coordinated from this point. Following phone contact all requests for documentation should also be made in written form. This process will ensure appropriate release of sensitive photo documentation, create an audit trail and assist in the prompt processing of requests.
Triage and intake
The initial response to a phone call to the service is to assess the level of urgency for the child to determine the most appropriate immediate response. Trained clinical staff, in consultation with others such as child protection, Victoria Police or other clinical staff will make this decision.
Access to triage is available 24 hours a day, seven days per week. Out of business hours, this may be provided in collaboration with staff located within emergency departments or centres against sexual assault. The after hours service of the VFPMS will organise for the on-call medical practitioner to contact the child protection practitioner directly. The child protection practitioner will discuss the referral with the medical practitioner and be advised as to which hospital to attend with the child for the forensic examination.
When preliminary screening suggests that a child may have been abused, the VFPMS will carry out a comprehensive forensic medical assessment. If the abuse is sexual then the centre against sexual assault (CASA) counselling staff will be included at the time of the assessment. In other cases counselling or other mental health services may be included as part of referrals for other health needs.
This is usually done at a VFPMS site, but outreach assessment is available for a child under particular circumstances such as serious illness. As an outreach assessment involves significant additional time and costs it is used only where a child is considered to be at significant risk and when it would not otherwise be possible to do the assessment.
Assessment may include a physical examination and talking to the child as well as parents or carers to:
- identify symptoms and signs of sexual, physical or emotional abuse or neglect
- assess the child's developmental status and its relevance to the presenting problems
- determine appropriate referral pathway
- collect evidence, including clinical photographs for court.
A full forensic paediatric assessment, diagnosis and initial treatment planning generally takes about one and a half hours.
Regional and rural public hospitals
Forensic paediatric medical services available across the state vary considerably. The direct supervisor and other experienced child protection practitioners will be able to assist the child protection practitioner with details of the relevant service provider in the area and procedure to access a forensic paediatric examination. Many rural areas have protocols with their local hospitals. Practitioners should refer to these protocols (where they exist) for guidance.
The child protection practitioner can phone 1300 66 11 42 for assistance.
Additional medical opinions
Following a forensic or other medical examination, it may be necessary for additional medical assessments or opinions to be sought. For example, a child may need to see an orthopaedic surgeon or ophthalmologist. The child protection practitioner must be clear about the purpose of such assessments and clearly outline details of the information required to the medical practitioner. Child protection practitioners should also make enquiries about who is the most suitably qualified person to undertake the assessment and make enquiries regarding their availability to undertake this task through the public system.
Mental health or substance use
Where concerns exist about a child's mental health or substance use, refer to the respective advice in this manual for information about obtaining assessment and treatment as required.
Considerations for good practice
Forensic medical examinations can be a means of collecting corroborative evidence, obtaining expert opinion on the aetiology (assignment of a cause) of an injury, providing information about the overall health and development of a child, comment on the plausibility of parental explanations and recommending any further assessment and treatment.
As previously identified, where a child or young person has an apparent non-accidental injury or an undetermined and suspicious illness, a forensic medical examination must be undertaken unless exceptional circumstances exist, for example where a child or young person of sufficient maturity refuses to be examined, or where the best interests of the child or young person are not served by proceeding.
The timing of a medical examination is an important issue. If a child is presenting with an injury or apparently in need of immediate medical attention a medical examination should occur at the earliest possible time. In the case of a developmental assessment or in cases involving alleged sexual abuse, a more planned approach should be taken to reduce any possible distress to the child and family, unless the need for urgent assessment and treatment is indicated.
Where possible, include a parent in the process of the medical assessment. It is always desirable for the assessment to be undertaken with the child supported by the parent unless this would place the child at risk or jeopardise the integrity of the assessment in some way. The medical examination should be planned in consultation with the medical and hospital social work staff.
In arranging a forensic medical examination practitioners should consider a broad range of issues including:
- early contact with the relevant hospital staff to arrange the assessment
- issues of who’s consent is required before the assessment can occur
- obtaining an initial provisional opinion report from the examining medical practitioner, if it is likely that legal intervention may be initiated
- obtaining the final reviewed report at a later stage
- issues of gender, culture and consistency of medical practitioner, where possible.