G88(P) Improving the quality of child protection medical reports: Guidance on opinions and risk analysis

Abstract

ObjectiveEvaluate the quality of the medical opinion and risk analysis in reports of child protection medicals undertaken by paediatricians.MethodsAll child protection medical reports for examinations undertaken (Acute admissions and NAI Clinic), between 1st Jan and 31st Mar 2015, were reviewed (n=86) and assessed against the following quality criterion: Does the report conclude whether it is thought that the injury is accidental or non-accidental?Is there a clear conclusion with a clear statement of the level of concern regarding the risk to the child/young person?Are the presence/absence of additional concerns documented clearly?Was the report subject to peer review? Outcomes11% of the initial proformas did not make a judgment as to whether the injury was felt to be accidental, non-accidental or unclear. A further 29% were recorded as unclear. In the final written reports, 8% did not give a clear conclusion and 10% did not document clearly the presence/absence of additional concerns. 21% of reports were subject to peer review within 2 weeks and 33% within 3 weeks.ConclusionThis quality improvement audit shows that in more than a third of cases the initial conclusion of a child protection medical report is unclear or not documented. There was great clarity in the final written reports however standards regarding peer review and documentation of additional concerns were not met. It is important when writing child protection medical reports that they give a clear conclusion as to whether on balance of probability, the injury is more likely to be accidental or non accidental. Additional concerns should be documented and a risk analysis formulated. Subsequently, a new guideline has been developed on best practice for child protection medical reports, with specific guidance on terminology, impact statements and formulating a risk analysis.

What is Said and What is Understood? The Readability and Language of Child Protection Medical Reports

“…Unfortunately, a quarter of disseminated reports that were examined had spelling errors and 27 per cent were felt to have no clear opinion. Previous research has also found that up to a third of reports have no clear opinion (Aucott et al ., ; Klepacka et al ., ). This absence of an opinion ‐ even one of being ‘unsure’ ‐ can be unhelpful in moving forward for children and families, as well as leaving the report open to interpretation.…”