The Forensic Medical Examination

Dr Rosalyn Proops
Royal College of Paediatrics
and Child Health
Norfolk and Norwich Hospital

11th March 2008

Toby 18 months
Seen in the Children's Assessment Unit with mother with
bruising inside of thigh and pain passing urine.
Left with the babysitter ( male friend of the family )
Extended and immediate family known to Local Authority
Difficult to examine, unhappy and irritable
Bruising on penile shaft and glans.
Examination under anaesthetic with paediatrician,
paediatric surgeon and Forensic Physician
Evidence of significant trauma to foreskin, glans and
penile shaft
No adequate explanation
Full care order
No prosecution
2

Lauren 13 years
Lauren is brought to out-patients by mother and
stepfather to review her cerebral palsy. Step dad is
concerned about Lauren's difficult behaviour and
mother tells the doctor they want to see an
orthopaedic surgeon to help her walking.
What the doctor doesn’t know and what Lauren
would tell him if she trusted him is that she is deeply
distressed because her step father has been having
sex with her for the last 7 months and she is
convinced that she is pregnant. She is also worried
about more painful surgery as she finds using her
wheel chair gives her more freedom, mobility and
self respect.
The consultation ends with the doctor prescribing
medicine to calm her down
3

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 Child Protection IS everyone's business
• Awareness within the wider health team

• Consider the whole child

• Concurrent abuse and co-morbidities

• The child with a disability

• The family history and relationships

• Children’s Rights ( of protection participation and provision)

• Child advocacy
4

The burden
of child maltreatment to the individual and to
society

Cost to the Individual Cost to the state

Mortality and Morbidity The Public Health
problem
Physical
Developmental What £ cost?
Emotional Health and Social care
Mental health
Crime and Justice

The next generation

5

The Forensic Medical Examination

• Clinical history
• General examination
• Examination relevant to the abuse
• Detailed contemporaneous documentation
(including line drawings)
• Photo documentation
• Forensic sampling
• Arranging after care
• Writing a report
• Attending court

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 Pathways and Networks
prevention identification assessment intervention
long term support

• What needs to be done, based on best evidence

• Who needs to do it based on competencies
• Where it needs to be delivered based on safety
convenience…
• With which additional resource/ support

• And common ground between commissioners,

providers and regulators
– clarity of purpose, underpinning values
– leadership
– commitment to innovation and learning

What are the indications for a paediatric

forensic medical examination?
• Allegation (direct or indirect) of sexual abuse/ rape /
assault
• Sexually transmitted infection or pregnancy in a child
• Problems such as recurrent vaginal discharge genital
bleeding secondary enuresis AND relevant history of
concern
• Concerning genital injury
• Behavioural disturbance e.g. self harm cruelty
to children or animals AND relevant history of concern
• Contact with sex offender
• Sibling or close friend of index child

Paediatric Forensic Examination

When?
• Whenever a child has made a disclosure of
recent sexual abuse, sexual abuse has been
witnessed or when a referring agency strongly
suspects abuse has occurred

Timing depends on:

• Medical care required
• Likelihood of physical signs and / or positive
DNA sampling
• STI cultures ( repeat cultures in 2 weeks and samples
for blood born infection after 3 and 6 months)
• Legal requirement
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 Where should the assessment take place?
• What do the children want ?

• Sexual abuse in children is (usually) part of the bigger story of

significant harm

• Paediatric out patients with dedicated suite ( forensic standards)

– Hospital based - with all health support facilities
– Community based - with LA / police

• Sexual assault referral centres for all age

providing services for children and young people ( paediatric
standards)
- Hospital based
- Community based

• Young people over 14 years

• Young people with (learning) disabilities
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Who ?
One or two doctors?
• It depends… a single doctor examination may take place
if he/ she has the full complement of knowledge skills and
experience, or two doctors with complementary skills

• Most general paediatricians will not have the forensic

competencies

• Most forensic physicians will not have the paediatric

competencies

• Children presenting with concerns about physical abuse

neglect or emotional harm should also be fully examined
as part of the assessment

• May need other specialists

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Medical findings as diagnostic of sexual

abuse
• What can be the determining factor…?
Exceedingly rarely can this be a medical finding
alone
• History
• Medical findings- USA and UK
– Clinical diagnosis
– Laboratory diagnosis

• Common standards and a common language

• Peer review
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 UK
The Physical Signs of Sexual Abuse:
An evidence based review and guidance
for best practice

• First guidance issued 1991 RCP, reviewed 1997

• 4 years in the making. Publication April 2008
• Led by RCPCH with multiple stakeholders
• Aims
– Review evidence in relation to ano genital signs of
sexual abuse in girls and boys <18yrs
– Agree good practice in relation to assessment and
examination of children where there are concerns
about sexual abuse 13

USA
Approach to the Interpretation of Medical
and Laboratory Findings in Suspected Child
Sexual Abuse: A 2005 revision
Joyce A. Adams

• Working group of the American Academy

of Paediatrics and Helfer society to
determine evidence –based criteria and
reach consensus

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Children in the USA are no different

from UK children
• Physical signs are uncommon certainly less
than 10% , probably less than 5 (3)% and
decreasing (photodocumentation, more information about range
of normality)
• Certain physical signs are indicative of blunt
force trauma
– Laceration of hymen
– Bruising of hymen
– Perianal lacerations
– Hymenal transection between 3-9 o’clock
– Missing segment of hymenal tissue in posterior half
15

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 The language of grading and
association
• USA • UK
• Diagnostic of trauma • Diagnostic of ..
and/or sexual abuse • Good quality
• Indicative of ..blunt force evidence ..showing
trauma association with
• Indeterminate • Limited
findings: insufficient or • Non-discriminatory
conflicting data from research
studies • Insufficient
• Conflicting
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Summary
• Sexual assault in children and young people is a
relatively common problem

• Physical findings are not so common

• Developmental and behavioural indictors are important

and frequent

• Most children are not heard and most do not get to

court

• The doctor has an overriding duty to the court and to

the child to maintain an impartial high standard of
clinical and professional practice 17

GMC
0-18 years: guidance for all doctors 2007

Assessing best interests

Communication

Making decisions

Confidentiality

Access to records by parents

and children

Child Protection
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 except in an emergency, where the patient has
the capacity to give consent you should obtain
written consent in cases where providing clinical
care is not the primary purpose of the
examination or investigation and / or where there
may be significant consequences for the patients
..social or personal life

General Medical Council

Seeking patients’ consent: the ethical considerations.
1998
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Consent and assessing capacity to

consent
Can the young person understand the nature purpose
and possible consequences of the investigation?

– Understand the information relevant to the decision

– Retain that information
– Use and weigh the information as part of the process
of making the decision
– Communicate their decision whether by talking, using
sign language or any other means

Must provide and discuss all relevant information before

deciding if the young person has the capacity to
consent
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• Capacity to consent depends more on

ability to understand and weigh up options
than on age
– At 16 years can presume consent
– Under 16 years may have the capacity
depending upon their maturity and ability to
understand what is involved and upon the
complexity and importance of the decision

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 Consent
• We assume parental consent as a proxy for the
best interests of the child

• If the parents are not acting in the child’s best

interests, may need the intervention of the court

• Parental Responsibility is shared with the LA

under an order ( EPO, ICO , CO but LA is the senior partner)

• Must obtain consent for examination, forensic

sampling and photo documentation

• Failure to obtain consent may constitute assault 22

Competent and confident with:

• Examination
- general paediatric
- developmental
- specific examination
• Forensic sampling
• Photo documentation
• Evidence base
• Note keeping contemporaneous notes reports
• Communication with other agencies, within and
outside of health
• Presenting evidence in court
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Do you have ?
• Access to training
• The right kit
• Support at the time of the examinations
• Supervision of practice
• Peer review of cases
• Supportive clinical team
• Supportive management / employer team
• Links with audit and research
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• Can you deliver a safe clinical service in
your area?

• Is it safe for the child

• And safe for you ?

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Very Useful Reading

• GMC 0-18 years: guidance for doctors

2007

• Child Protection Companion

RCPCH 2006

• The Physical Signs of Child Sexual Abuse: An evidence- based

review and guidance for best practice
March 2008 RCPCH in collaboration with RCP FFLM

• Paediatric forensic examinations in relation to possible sexual abuse

RCPCH and RCP FFLM 2007

• Recommendations of best practice in the management of intimate

images that may become evidence on court
RCPCH and RCP FFLM 2007

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Forensic samples and their collection

• For up to date information

http://www.forensic.gov.uk

• Guidelines for the Collection of Specimens

http://www.fflm.ac.uk

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 Joint RCPCH and FFLM Guidelines April
2007
• It is essential that high quality photo
documentation be obtained, if not document the
reasons

• A single doctor can conduct a paediatric forensic

exam provide he/ she has all the necessary
skills ( complementary skills)

• The examining doctor must ensure they are

familiar with the evidence- based guidance
regarding the interpretation of signs

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Department of Children Families and

Schools 2007
the Government's view is that where
professionals are undertaking child
protection work, their first duty is to the
children concerned. As far as the
children's parents are concerned,
professionals must simply act in good
faith, exercising reasonable skill and care.

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Forensic samples
• Sampling techniques and forensic requirements are specific and a
competent practitioner needs both the theoretical and practical
training

• Evidential samples
- Semen blood saliva or other body fluids containing
cellular material
- Loose hairs fibres debris particles
- Blood urine hair for toxicological analysis
- Unwashed clothing bedding items used in the assault

• Control samples for comparison purposes

• Persistence of cellular material for up to 7 days
• Labels must show signature of first person and all others( chain of
evidence)
• Retain a list of samples and identification numbers

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