Infant at risk of abuse and neglect

Child FIRST (Family Information Referral and Support Team) is a partnership between the DHHS and local family service agencies in each region. It was established to:

• provide a central referral point into family services programs
• ensure that vulnerable children, young people and their families are linked with community services  and support
• build strong connections between agencies to assist with coordination and planning.

Referral can also be made antenatally so that a wellbeing report can be made and early engagement with families can occur with their consent.

Child FIRST referral criteria

Child FIRST referral criteria includes:

• significant parenting problems which impact on child development
• serious family conflict
• families under pressure
• young, isolated, unsupported families
• significant social or economic disadvantage that impacts on child development or care.

Significant family risk factors for child abuse or neglect include:

• previous protective services involvement with the family
• homelessness, or lack of stable accommodation
• domestic violence
• alcohol or drug abuse
• intellectual disability
• significant history of psychiatric illness
• very young parents.

Doctors and nurses should be aware that the following presenting circumstances may indicate that a baby or young child is being physically abused:

• repeated complaints of illness, for which no medical explanation can be found (Munchausen by proxy should be considered)
• the ‘accident prone’ toddler or child
• inconsistent or implausible history of injury
• sudden unexpected death of infant (SUDI) or ‘near miss’, especially if there is a history of similar episodes involving either the presenting child or other siblings.

Persistent parental concern about a baby's medical condition may be indicative of postnatal depression, therefore an assessment of the mother's emotional state must also be made.

Delay in seeking medical attention, or ‘failure to thrive’ may indicate that a baby is being neglected.

There are some circumstances where signs of suspected child abuse might be due to an underlying medical disorder.  Examples include:

• bruising - this might be secondary to a coagulation disorder or is sometimes confused with Mongolian blue spots
• bone fractures - these might be pathological (for example, underlying bone defect, disorder, tumor, Vitamin D deficiency)
• failure to thrive - there are many organic causes for 'failure to thrive'.

It is important to exclude possible medical conditions in suspected child abuse.

A hospital nurse, doctor or social worker who believes that a baby or toddler may have been physically or sexually abused should notify the paediatric registrar or consultant paediatrician on duty if available.

If you work at a health service without a paediatric registrar or consultant, contact the on-call Medical Officer to contact the Victorian Forensic Paediatric Medical Service (VFPMS) (24 hours 7 days a week) on 1300 661 142.

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 Medical officer needs to perform an initial examination and consult with the paediatrician on duty or the VFPMS to decide the appropriate medical management for the baby.

Ensure careful documentation

Careful documentation is required, and needs to include:

• a general medical history, including the presenting complaint and any explanation given, previous presentations, and a family history including pedigree
• detailed documentation of the injury, in writing and with a diagram
• photographs if possible, with consent as this is the best evidence
• particular features to note (on physical examination) are:
  • bruising or bite marks
  • scars such as cigarette burns
  • napkin dermatitis
  • anal or vaginal excoriation or injury
  • finger marks on arms or trunk, which may indicate a shaking injury
  • retinal haemorrhages
  • pain or reluctance to move a limb, which may indicate a fracture
  • apathy, lethargy
  • developmental delay
• weight, length and head circumference of the baby, which should be plotted.

For assistance in recording the information accurately you can call the Victorian Forensic Paediatric Medical Service (24 hours 7 days a week) on 1300 66 11 42 or go to the VFPMS guidelines for forensic evaluation of suspected child abuse.

Record notes from everyone present

Details of persons present, their relationship to the baby, and their account of what has occurred should be noted. Question everyone in an objective, non-judgmental manner.

Note which information was obtained from each person. Information collected from each informant should be recorded on a separate sheet of paper, in order to comply with the Health Records Act.

Names of staff members present must also be documented. The name of the person conducting the examination, and what action is to be taken, must be clearly documented.

Admitting the infant to hospital

Admission of the infant to the hospital is an important first step where serious concerns exist. This should allow some time and opportunity to establish a relationship with the family, and a more thorough assessment of the child's medical and family circumstances.

If transfer to a larger hospital or the Royal Children's Hospital, is considered necessary this should be by ambulance, or by taxi with a nurse escort. Full documentation should remain at the referring hospital, and a copy should accompany the baby.

Do not intervene if parents resist advice to admit

If parents refuse to comply with medical advice, including admission to hospital, or attempt to remove the baby against medical advice, it should be made clear that hospital security and, if necessary, the police will be called.

No attempt should be made to physically resist the removal of a baby. In this case, the police and Protective Services must be notified immediately.

At most hospitals, the social work department is responsible for the coordination of Protective notifications to DHHS including antenatal notification. In this case, the social work department should be advised if physical or sexual abuse is believed to have occurred, or if a baby is considered to be at risk of abuse or neglect.

This will result either in a notification being made, or the family agreeing to referral to an appropriate community support agency.

Reports may lead to a protection application

A report to DHHS may lead to a protection application being made to the Children's Court, and hospital staff members or the baby's medical file may be subpoenaed. As stated above, it is essential that careful case notes are made. They should be objective, documenting what is observed or seen. Information that is given by another person must be clearly reported as such, and subjective judgments should not be made.

Hospitals should have clear policies 

Hospitals should have clear policy and procedures documents in place relating to vulnerable children. They should establish multidisciplinary committees to regularly review practices and support staff, and communicate regularly with local Child Protection and Child FIRST services.

In accordance with the Children, Youth and Families Act (2005), which came into effect in April 2007:

• DHHS can now accept antenatal (unborn) reports. No statutory action can be taken until after the baby's birth, but planning can be commenced.
• Child FIRST teams can also work antenatally with families, with their consent. If in doubt as to whether an Unborn report to DHHS or a referral to Child FIRST is more appropriate, consultation with DHHS, Child FIRST or the hospital's social work department should be undertaken. (Child FIRST services are not crisis services and are open during business hours only.)
• The cultural identity and needs of Aboriginal children are protected and promoted under the Act (see also Dardee Boorai: Victorian Charter of Safety and Wellbeing for Aboriginal Children and Young People).
• Cumulative harm (the effects of patterns of harm over time that may impact on a child’s safety and development) is recognised under the Act. The effects of cumulative harm are specifically referred to as requiring consideration when determining decisions or actions to be taken in the child’s best interests.
• When out-of-home care is deemed to be necessary in a child’s best interests, Child Protection will formulate a stability plan to ensure maximum timeframes for assessing care needs. Wherever possible, Aboriginal children will be placed with extended family or community members.

In 2014, the Victorian Parliament passed legislation to stregthen Victroia's response to children and young people in out-of-home care.

Children, Youth and Families Amendment (Permanent Care and Other Matters) Act 2014  

Children, Youth and Families Amendment (Security Measures) Act 2014  

The amendments address key recommendations of the January 2012 Report of the Protecting Victoria’s Vulnerable Children’s Inquiry regarding the simplification of Children’s Court orders and identifying and removing barriers to achieving permanent placements for children.

Amendments include:

• the authorisation of carers to make decisions on specified issues about the children in their care
• increased penalties for offences relating to the protection and exploitation of children, including leaving children unattended and harbouring children
• amendments to the Commission for Children and Young People Act 2012 have commenced, addressing the focus of systemic inquiries and requirements to provide persons names in inquiries an opportunity to respond to adverse comment or opinion.

• Children, Youth and Families Act (2005)
• Child safe standards
• Child FIRST and Family services policy and practice advice
• DHS (2007) Vulnerable babies, children and young people at risk of harm: best practice framework for acute health services
• Risk and protective factors for child abuse and neglect
• DHHS Child protection
• Department of Health Adult specialist mental health services
• Mandatory reporting of child abuse and neglect
• Child abuse assessment
• How to make a referral to Child FIRST
• Vulnerable Children training package

Protective services (after hours) - 13 12 78

Victorian Forensic Paediatric Medical Service: 1300 661 142

Hospitals' priority number- (03) 9843 5422

Royal Children's Hospital Gatehouse Centre for the assessment and treatment of child abuse:

• 9345 6391 (business hours)
• 9345 5522 (after hours - RCH main switchboard)

Child and family services information, referral and support teams