Introduction
The Victorian Forensic Paediatric Medical Service (VFPMS) is a 24 hour, state-wide coordinated medical service providing assessments and care for children and young people who have been abused, assaulted and neglected. The service is provided by a network of doctors and other health professionals, operating throughout Victoria, governed by a consortium of service providers and funding agencies.
The service providers are:
- the Monash Medical Centre
- the Victorian Institute of Forensic Medicine (VIFM)
- the Royal Children's Hospital.
The target group is all children referred by child protection or Victoria Police who are subject to protective involvement requiring a comprehensive forensic paediatric medical examination for assessment of harm, general health and wellbeing.
Access to the VFPMS is via referrals from child protection or Victoria Police.
Appointments can be arranged by calling the VFPMS 24 hour contact number 1300 66 11 42.
If you are not successful in gaining access to the above telephone number, you can call directly to the Royal Children's Hospital – 9345 4299 or Monash Medical Centre – 9594 2155.
The VFPMS website provides information regarding the referral process - http://www.rch.org.au/vfpms/.
There is a difference between a forensic paediatric examination and a medical paediatric examination. The former is performed to gather information and evidence for criminal proceedings or Children's Court proceedings, whilst the latter is performed to identify and meet the medical requirements of the child. In cases where criminal concerns are apparent (such as alleged physical or sexual abuse of a child), the police are responsible for arranging the forensic paediatric examination, though this may be negotiated with the child protection practitioner.
Triage and intake
The initial response to a phone call to the service is to assess the level of urgency for the child or young person 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, 7 days per week. Out of business hours, this may be provided in collaboration with staff located within emergency departments, centres against sexual assault (CASA) or counselling. During out of business hours, the after hours service of the VFPMS will organise for the on-call medical practitioner to contact the child protection practitioner directly. The 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.
Assessment
When preliminary screening suggests that a child or young person 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.
At times clinical photographs of the child's injury may also be taken and provided to child protection practitioners (following a written request) for use as evidence in court.
The assessment is usually conducted at a VFPMS site, but outreach assessment is available for a child under particular circumstances such as serious illness. As 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.
A forensic paediatric assessment can:
- address specific unexplained injuries and explore believed harms
- conduct an in depth health check including blood tests, bone scans and x-rays (where indicated as necessary)
- comment on the adequateness of the parents’ explanation of any physical injuries
- comment on the likelihood of injuries being non accidental and possible causes
- document any injuries for the client file
- if necessary provide a report and evidence for court
- measure height and weight with reference to standardised measures of physical development
- include the taking of photos of the physical injuries.
The assessment may include a physical examination and talking to the child, as well as parents or carer 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 for court.
A full forensic paediatric assessment, diagnosis and initial treatment planning generally will take about one and a half hours.
Some children may require further specialist assessment of their psychological and neuropsychological status; cognitive, speech and language function; developmental stage; educational attainment; and/or capacity in social relationships.
Family assessment may also be needed to understand the interaction between a child’s difficulties and those of their parents, and provide appropriate support and advice.
After the assessment the child and their family or carer may be given information and advice, and may be referred to other departments or organisation. See Medical and forensic examinations.
Medical report
If it is likely that legal intervention may be initiated the practitioner should request from the examining medical practitioner an initial provisional opinion report (sometimes called an 'interim report') prior to the commencement of the paediatric evaluation. If the child is subject to a protection application by emergency care, this medical information will assist in the negotiations at the court hearing and will assist the Court in decision making on the first mention date. A final reviewed report will be available for further hearings.
Non genital photographs taken as part of the medical assessment will also be provided to the child protection practitioner following a written request.
Specialist medical expertise is required to interpret clinical photographs obtained from a sexual abuse medical assessment. Therefore, clinical photographs of genitalia will not be provided to child protection practitioners. If, however, after consultation with senior management, it is believed that these photographs are critical evidence in this case, and verbal information from the medical practitioner, in relation to the photographic information, will not suffice, the photographs can be requested via subpoena.
Under s. 208 of the CYFA, the giving of information to a child protection practitioner during the course of the investigation of a report does not breach the Health Services Act or Mental Health Act nor constitute unprofessional or unethical behaviour. If the medical examination is to be conducted by court order, the child protection practitioner should obtain a condition regarding the release of information to the department.
Witnesses
If a medical practitioner is required to give evidence in court, child protection will issue a subpoena. The child protection practitioner should inform medical practitioners that a decision has been made to issue a subpoena that will require them to appear in court. This allows for the professional’s release from duties and removes the onus of choice from the professional in giving evidence. The use of a subpoena can be helpful in maintaining the relationship between the medical practitioner, the client and the family.
Child protection will make every attempt to provide reasonable notice for medical staff that they must attend court to provide evidence. Child protection will aim to ensure at least three clear days notice in advance of the scheduled hearing date is provided, unless there is an urgent listing of a matter or other circumstances, which require more immediate attendance. Where possible the child protection practitioner should negotiate the medical practitioners’ availability. See Children’s Court witness summons.
Consent
It is department's policy to always obtain a parent’s consent to a medical examination to the extent that this is in the child’s best interest. In addition, consistent with the protection of human rights of children and young people and, in particular, the right of children and young people not to be subjected to medical treatment unwillingly, if a child is of an appropriate age and level of development, and has the capacity to provide consent, they must be informed about, and involved in, any decision to receive medical treatment.
Child protection is required to act in the best interests of the child and may authorise medical examinations and treatment even where a parent(s) and child object. See Consent for medical examination and treatment.
Regional and rural areas
Forensic paediatric medical services available across the state vary considerably. In the larger regional areas, the local base hospital will generally provide an on-call service. In most instances this will be accessed via the emergency department. In smaller rural areas, practitioners may be required to travel to either Melbourne or the larger regional service provider.
Considerations for good practice
Medical examinations can be a means of collecting corroborating evidence, obtaining expert opinion on the aetiology (assignment of a cause) of an injury, provide information about the overall health and development of a child, comment on the plausibility of parental explanations,and recommend further assessment and treatment.
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 best if the assessment is 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 social work staff.