The jigsaw of child protection
Authors: Heather Payne
Journal: Journal of the Royal Society of Medicine (2008)

Child protection work is demanding, sensitive and often difficult, and generates much anxiety for all concerned - children, parents and professionals, including paediatricians.

If, like me, you deal with child protection matters on a daily basis, you probably spend a fair bit of time reflecting on how the process works, and whether it does what it says on the tin. It's not protecting children to remove them from non-abusive parents. Neither is it protecting them to leave them with abusive ones. There are always many things we know we don't know, like the exact significance of fingertip bruising, or of a simple skull fracture attributed to a fall.

The truth is that some of these injuries will be accidental, and some will be non-accidental injuries (NAI). It is extremely difficult to get it right in every case. Err in one direction, and a baby goes home to further risk of abuse and may come back dead. Err in the other direction, and enormous distress is caused by unnecessary hospitalization of the child or removal to foster care.

Until recently, I had confidence that the child protection process (based on many years of ‘Working Together’1 with social services, police and other colleagues highly skilled in this field) would protect both me and the children it was put in place to serve. The deal, reinforced by the Laming Report,2 is this: when you see a child who may have suffered NAI, but you are not sure, then use the child protection procedures to involve other eyes and ears, share information and come to a collective decision about the risk to the child. I felt that there was safety in numbers (decisions taken with professional colleagues), and that this appropriate use of the ‘medical model’ would mean I could express concerns and get answers to tough questions like: ‘Is it safe for this bruised child to be in this household tonight or should they be moved to a safer place?’

But my illusion of safe practice has been shattered by two recent GMC decisions3 about professional practice relating to the paediatrician Dr David Southall. In direct opposition to the Laming recommendations, the GMC have adjudged that David Southall was wrong to share his concerns about a high profile child abuse case when he did not have the full information. But this is precisely what we are obliged to do under all child protection procedures, which use words to the effect that ‘if you have concerns that a child may be suffering abuse you must refer.’ This reflects the reality, often called the ‘jigsaw of child protection’, whereby no individual has all the pieces, but requires the help of others to get the full picture.

When there is concern about abuse, it is vital to assess the risk to the child of remaining at home. This is especially the case when a child has died and there is therefore a risk to any other children of the household. High stakes and high pressure assessments are the name of this game. However hard I try to maintain professional calm, and however carefully I choose my words, it's not unusual for stressed parents to construe my precise but neutral questions about how the child came by their injury as ‘an accusation that they have battered their child’. I had always thought that the presence of a social work colleague would protect me from this becoming a substantiated complaint, but the GMC have now discounted the stories of David Southall and a senior social worker who took contemporaneous notes, instead believing a parent's accusation that David Southall had accused her of murder. He has been struck off, and the protection I thought I had - protection which allowed me to do this difficult work as well and conscientiously as I could, without the worry of losing my job - is no longer there.

Nobody wants to get it wrong in child protection. Children's lives and happiness are at stake in the short term. But in the longer term, the average paediatrician is already walking away4 from work in areas where they feel they are a target for those who would shoot the messenger. Courts' delays in child care cases due to the lack of paediatricians willing to provide expert witness reports are already directly affecting the lives of children and their families.

The rock of child protection work and the hard place of these GMC decisions5 have led to this situation. The rock will not go away, so the hard place needs to examine itself and see whether its decisions are justified and really serve children, or whether the GMC has fallen into the first trap of child protection that we warn trainees about - always listen to what the child is telling you rather than just listening to the parent.