Responses to concerns about child maltreatment: a qualitative study of GPs in England.

OBJECTIVES: To provide a rich description of current responses to concerns related to child maltreatment among a sample of English general practitioners (GPs). DESIGN: In-depth, face-to-face interviews (November 2010 to September 2011). Participants selected and discussed families who had prompted 'maltreatment-related concerns'. Thematic analysis of data. SETTING: 4 general practices in England. PARTICIPANTS: 14 GPs, 2 practice nurses and 2 health visitors from practices with at least 1 'expert' GP (expertise in child safeguarding/protection). RESULTS: The concerns about neglect and emotional abuse dominated the interviews. GPs described intense and long-term involvement with families with multiple social and medical problems. Narratives were distilled into seven possible actions that GPs took in response to maltreatment-related concerns. These were orientated towards whole families (monitoring and advocating), the parents (coaching) and children (opportune healthcare), and included referral to or working with other services and recording concerns. Facilitators of the seven actions were: trusting relationships between GPs and parents, good working relationships with health visitors and framing the problem/response as 'medical'. Narratives indicated significant time and energy spent building facilitating relationships with parents with the aim of improving the child's well-being. CONCLUSIONS: These GPs used core general practice skills for on-going management of families who prompted concerns about neglect and emotional abuse. Policy and research focus should be broadened to include strategies for direct intervention and on-going involvement by GPs, such as using their core skills during consultations and practice systems for monitoring families and encouraging presentation to general practice. Exemplars of current practice, such as those identified in our study, should be evaluated for feasibility and acceptability in representative general practice settings as well as tested for efficacy, safety and cost. The seven actions could form the basis for the 'lead professional' role in general practice as proposed in the 2013 version of 'Working Together 'guidance.

Fatal child maltreatment in England, 2005-2009.

OBJECTIVE: This paper presents comprehensive and up-to-date data covering 4 years of Serious Case Reviews into fatal child maltreatment in England. METHODS: Information on all notified cases of fatal maltreatment between April 2005 and March 2009 was examined to obtain case characteristics related to a systemic classification of 5 broad groups of maltreatment deaths (severe physical assaults; covert homicide/infanticide; overt homicide; extreme neglect/deprivational abuse; deaths related to but not directly caused by maltreatment). RESULTS: A total of 276 cases were recorded giving an incidence of 0.63 cases per 100,000 children (0-17) per year. 246 cases could be classified based on the data available. Of these the commonest specific group was those children who died as a result of severe physical assaults. Apparently deliberate overt and covert homicide was less common, while deaths as a direct consequence of neglect were rare. In contrast, some evidence of neglect was found in at least 40% of all cases, though not the direct cause of death. CONCLUSIONS: Class characteristics differ between the different categories of death and may suggest the need for different strategies for prevention.

Healthcare use by children fatally or seriously harmed by child maltreatment: analysis of a national case series 2005-2007.

AIM: To determine antecedent patterns of healthcare use by children fatally or seriously harmed by maltreatment. METHODS: The authors analysed recorded healthcare use for children who were the subject of a serious case review (SCR) in England in 2005-2007. The SCRs were initiated when a child under 18 years old died or was seriously harmed, maltreatment (abuse or neglect) was a factor, and there were lessons for interagency working. The authors analysed a purposive sample (N=40), similar in key demographics to all 189 SCRs in England in 2005-2007. RESULTS: Children had extensive recorded contact with universal (N=34/40; 85%) and secondary (N=26/40; 65%) healthcare services and children's social care (N=21/40; 53%). Thirty-one children (78%) had recorded health visitor and/or school nurse contact. Fourteen children (35%) had missed appointments. Almost three-quarters (N=29) had complex family problems recorded (parental domestic violence, alcohol/drug and/or mental health problems). Data quality regarding healthcare use was poor, and the extent and type of 'missing data' varied by age. CONCLUSIONS: Complex paediatric and family problems and a high level of contact with services preceded serious adverse events. Universal health services are likely to be well placed for giving ongoing and family-orientated support to vulnerable families. The absence of standardised data collection and any control group limits how far the Biennial Analyses of SCRs can meet their stated objective of identifying national trends and patterns. Linking SCRs to healthcare databases would provide a control group, improve understanding of the population context and diminish demands for data from professionals delivering care.

Variation in recording of child maltreatment in administrative records of hospital admissions for injury in England, 1997-2009.

BACKGROUND: Information on variation in the recording of child maltreatment in administrative healthcare data can help to improve recognition and ensure that services are able to respond appropriately. OBJECTIVE: To examine variation in the recording of child maltreatment and related diagnoses. DESIGN: Cross-sectional analyses of administrative healthcare records (Hospital Episode Statistics). SETTING AND PARTICIPANTS: Acute injury admissions to the National Health Service in England of children under 5 years of age (1997-2009). Outcome measure Annual incidence of admission for injury recorded by International Classifications of Diseases 10 codes for maltreatment syndrome (child abuse or neglect) or maltreatment-related features (assault, undetermined cause or adverse social circumstances). Proportion of all admissions for injury coded for maltreatment syndrome or maltreatment-related features. RESULTS: From 1997 to 2009, the annual incidence of injury admissions coded for maltreatment syndrome declined in infants and in 1-3-year-old children while admissions coded for maltreatment-related features increased in all age groups. The combined incidence of these categories remained stable. Overall, 2.6% of injury admissions in infants, and 0.4-0.6% in older age groups, had maltreatment syndrome recorded. This prevalence more than doubled when maltreatment-related codes were added (6.4% in infants, 1.5-2.1% in older age groups). CONCLUSION: Despite a shift from maltreatment syndrome to codes for maltreatment-related features, the overall burden has remained stable. In combination, the cluster of codes related to maltreatment identify children likely to meet thresholds for suspecting or considering maltreatment and taking further action, as recommended in recent National Institute of Health and Clinical Excellence guidance, and indicate a considerable burden to which hospitals should respond.