BMJ  2004;328:775 (27 March), doi:10.1136/bmj.328.7442.775


Parents as well as children need protection
It is now some decades since the growing awareness of the different types
of child abuse fundamentally changed the work of consultant paediatricians
and of social workers. The idea grew that the protection of the child
should take precedence over all other considerations, but this idea
presupposes a well functioning system in which authority figures such as
consultant paediatricians make few major mistakes.

The 1987 inquiry into the Cleveland sex abuse scandal, when dozens of
children were taken from their families, showed that opinion regarding
physical signs could be deeply divided, and the inquiry and subsequent
episodes emphasised the damage that could be caused to families through ill
considered opinion or action. In January 2003 Lord Laming, in the inquiry
into the Victoria Climbié case, made numerous recommendations. These
concerned health care and actions by professionals, but in the summary of
the inquiry that the Royal College of Paediatrics and Child Health produced
for paediatricians I saw no mention of safeguards for parents.

I saw no mention of safeguards for parents

From the legal point of view it is notable that the health authority or NHS
trust has no duty of care to the parents while their child is in its care.
This leaves the parents with little opportunity for redress. To the lay
person the proposal that the child may in due course bring a retrospective
action, but only for damage that the child may have suffered through
negligence, does not seem to be of immediate relevance.

Retirement and having become a grandfather seem to have changed my focus. I
find it difficult to accept that the only steps usually open to parents are
to make a complaint to the very organisation concerned (until the
organisation eventually agrees to allow an independent inquiry) or to try
to obtain a judicial review (which is beyond the means of many parents).
The only alternatives-appeal to the health ombudsman or complaint to the
General Medical Council-are somewhat remote. Parents have to answer serious
charges by a number of authority figures unaided, unrepresented, and in a
potentially frightening environment. Even if an accused parent or carer
were to have good answers to mistaken or unsupported charges by senior
figures, there would still be a likelihood that the social services would
retain a degree of suspicion or uncertainty. At the least this suspicion
might result in placement of the child on the at-risk register, possibly
with restriction of visiting or other orders. Does this matter?

A case involving a family I know well emphasises the power that
paediatricians have, compared with that of social services and parents,
irrespective of the merits of the parents' version of events. In this case
the nursing staff may well have found the care of the child quite
challenging: the child was still on a ventilator three years after a
catastrophic neonatal illness but was making developmental progress and
needed increasing mobilisation. The increased activity resulted in repeated
temporary disconnections from the ventilator, each of which had to be
reported and investigated.

For whatever reason, the paediatrician had formed the view that the
original illness-for which no cause had been found-may have been caused by
the parents and had set investigations in train. The repeated
disconnections were now regarded as attempts by the mother to harm her son,
despite the fact that the nursing and medical notes showed that on eight of
10 disconnections over a period of two months she was not present. Child
protection proceedings were triggered on the last occasion.

Social services had to act on the paediatrician's account of the
suspicions. Further observation, police investigation, and a forensic
psychiatrist's report found no evidence of actual or intended child abuse,
but not before the family had suffered severe stress, in fact just short of
tragedy. The parents' account was later vindicated by the withdrawal of a
nurse's accusatory report, as having been "mistaken."

The Royal College of Paediatrics and Child Health recently expressed its
concern that paediatricians are coming under stress from accusations linked
to child protection. This suggests to me that all may not be well in a
wider field, but it could be that not all the faults rest with the public.
Such proceedings are inevitably stressful, and professional training and
retraining would appear to be the best way forward, as Lord Laming and
others have recommended.

It would also be helpful if accused parents due to face powerful
professionals in a potentially intimidating environment had the right to
submit the relevant papers to an independent professional and that an
alternative view of the situation, if so held, could be presented. There
are few other circumstances where an accused person risks (for them) such a
serious outcome without representation.

I do not believe that such a measure would shield parents who abuse their
children, as the parents' representative would need to be an experienced
and independent professional in good standing, and it would help the
maintenance of best practice in child protection work. Professionals who
chair child protection conferences might welcome the opportunity to have
additional opinions available when they have to make a decision in the face
of uncertainty.