View Working Together View Working Together
 
  View Hertfordshire Safeguarding Children Board website

3.9 Hospital Appointments, A&E Attendance and Discharge Procedures

SCOPE OF THIS CHAPTER

These procedures apply if:

  • Child protection concerns are raised when a child is presented at an A & E department;
  • Child protection concerns are raised about a child admitted to hospital;
  • For a maternity unit and midwifery service, if there has been a pre-birth assessment or subsequent child protection concerns;
  • A child is to be discharged to parents / carers with learning disabilities, substance or serious mental health problems;
  • A child deemed to be at risk has failed to attend out-patient or other health appointments.

See Health Trust policy for detailed guidance.


Contents

  1. Child Presented at Hospital
  2. Referral to Children's Services
  3. Strategy Discussion
  4. Pre-discharge Planning Meetings / Reconvened Strategy Meetings
  5. At Discharge
  6. Maternity Unit and Midwifery
  7. Discharging a Child into Care of Parents with Learning Disabilities / Substance Misuse or Serious Mental Health Problems
  8. Outpatient or Other Health Appointments


1. Child Presented at Hospital

If any staff members (of whatever profession and however junior) have concerns about the welfare of a child they must inform their manager or the child's consultant or the named doctor or nurse and record the discussion / consultation.

Whenever medical or nursing staff see a child at A & E or on the ward with possible signs of abuse or neglect they must alert the consultant paediatrician or named nurse.

If abuse or neglect is suspected the child must at a minimum be examined by a specialist registrar in paediatrics, who must discuss the case with the consultant paediatrician.

No child who is thought to have been abused or neglected should be sent home without being examined by a senior paediatrician or with the permission of, a consultant paediatrician:

If the child is presented in the night and admitted, it is possible to delay the consultation until the next day. In these circumstances, consideration must be given to potential safety issues of any siblings.

A senior paediatrician must see all children brought to hospital by Police, Children's Services staff or staff of another public agency.


2. Referral to Children's Services

Once a concern is raised at the hospital, Children's Services must be informed without delay on its dedicated number and confirming on the Single Service Request Form, which must be faxed within twenty four hours.

If a parent wishes to discharge the child from hospital against medical advice and there are concerns for the welfare of the child, Children's Services must be contacted urgently. Hospital staff cannot prevent the parent from leaving the ward with her/his child, but Police and Children's Services must be contacted immediately.

(See Referrals Procedure)


3. Strategy Discussions

A Strategy Discussion must be held whenever a professional or agency has raised child protection concerns about a child admitted to hospital, and this includes:

  • Concerns relating to incidents or circumstances that may have arisen either prior to or during the hospital stay (including pre-birth concerns);
  • Circumstances in which differing opinions are held between professionals about the origin of an injury or the risks to the child.

The participants should include the consultant in charge of the child (or suitable delegated health professional), Children's Services, Police Joint Child Protection Investigation Team (JCPIT) and other relevant agencies and health professionals.

The meetings should be held at a location, which facilitates the attendance of key participants e.g. the hospital.

The Strategy Discussion should consider (in addition to the normal Strategy Discussion agenda)

The above should be read in conjunction with the Strategy Discussion and Meetings Procedure

Consultation with Designated/Named Doctor/Nurse

If it is unclear whether an injury has a non-accidental cause, or there is a difference of opinion within the medical team, the consultant in charge of the child's care should seek a second opinion either from the designated / named child protection doctor or from a specialist consultant.

If achievable the second opinion should be available to the Strategy Discussion.

Other agencies particularly Children's Services need to be made aware that a second opinion has been requested and the consultant in charge of the child's care should advise on the anticipated timescale.

Even if there is no clear diagnosis of non accidental injury in the medical report, an assessment of need and risk, including the likelihood of the child suffering significant harm in the future, should be made.


4. Pre-discharge Planning Meetings / Reconvened Strategy Meetings

If the Strategy Discussion did not cover the pre-discharge planning, a meeting must be arranged sufficiently early to ensure that a pre-discharge plan is in place before the child becomes medically fit for discharge.

The discussions and outcome of pre-discharge planning must be recorded in the child's health record at the earliest opportunity and before going off duty that day by the senior doctor attending.

The purpose of the pre-discharge planning is to:

  • Consider the medical and social reports about the cause of concern;
  • Consider the social work / multi-agency assessment(s) of the risks to and the needs of the child, including 'home safety' informed (wherever practicable) by a home visit by a social worker;
  • Consider the needs / risks in relation to other children in the family;
  • Clarify on-going medical care;
  • Ensure the child is registered with a GP;
  • Identify support needed for those caring for the child once discharged;
  • Formulate a multi-agency plan on discharge from hospital that address's the risks / concerns raised in respect of the child;
  • Identify a Lead Professional;
  • Agree contingency plans should the child fail to attend planned follow up health appointments;
  • Agree timescale for discharge, once the child is medically fit.

Chair of Pre-Discharge Meeting

The social work Team Manager or the consultant / senior paediatrician should chair these meeting and may give guidance on which health professionals need attend.

Possible Attendance of Pre-Discharge Meeting

The potential members of a pre-discharge planning meeting are:

  • Consultant (or designated deputy);
  • Social worker(s);
  • Social work Team Manager or assistant Team Manager;
  • Police officer Joint Child Protection Investigation Team (JCPIT);
  • Ward staff;
  • Paediatric liaison health visitor / health visitor and midwife (if child is new born);
  • Staff from any specialist units to be involved post discharge e.g. burns unit;
  • School nurse;
  • GP;
  • Designated/named nurse;
  • Any other professional with information to assist with decision making.

Though parent(s) would not normally attend the pre-discharge meeting they will need to be informed, by the chair (or other agreed professional) of any decisions made at it.

Quoracy

To be quorate, the meeting must be attended by representatives from the Primary Care / Health provider, Children's Services and hospital medical and nursing staff.

Records of Meeting

The Chair should ensure there is a brief record of the discussion and 'agreed plan'. This record must be provided to all those attending within one working day.

It is the responsibility of the agencies present to ensure appropriate onward communications; e.g. the health agency must share its record with the GP, health visitor, school health advisor, named nurse and (if the child is looked after) notify the designated nurse for looked after children.

The Chair of the meeting must ensure that a handwritten copy of the decisions agreed at a pre-discharge planning meeting are placed on the child's medical notes directly after the meeting and this must be left at the hospital.

If an incident number has been raised with the Police, this should also be recorded.

The social worker should ensure the decisions of the meeting are recorded on the database immediately and consider raising an EDT alert if database recording is not immediately possible.

Timescales for Pre-Discharge Planning Meetings

As soon as medical staff are able to predict the child's fitness for discharge, they should convene the pre-discharge meeting and thus provide an opportunity for professionals to undertake checks, read files and attend the meeting.

Because an assessment of risk must be concluded before the child is ready for discharge, a pre-discharge planning meeting will normally be convened within twenty four hours of it being called. This narrow time-frame requires a high level of flexibility and co-operation between professionals.

GP Registration

No child about whom there are concerns about abuse or neglect should be discharged from hospital without an identified GP.

The Nurse in charge must ensure that the hospital Consultant Paediatrician knows if a child is not registered with a GP. Arrangements have been agreed with the Practitioner Services Unit as follows:

  • General enquiries (to obtain the name of a GP) 01707 390855 (Charter House Switchboard[MB1]);
  • Specific request for GP to be allocated:
    • Registration Manager: 01707 361275;
    • Secure Fax: 01707 361302;
    • Mobile: 07789 935584.

Parental Support

The 'pre-discharge planning meeting' should clarify how the parents will be supported and who will undertake this role.


5. At Discharge

It is the responsibility of the nurse in charge at the time of discharge to ensure that follow up arrangements have been clearly documented.

It is the responsibility of the child's consultant to ensure that junior doctors write discharge summaries, which include any concerns:

  • About the child's welfare, including child protection;
  • As well as medical issues.

Follow up arrangements must include clear and specific documentation about what to do if the child fails to attend out patient appointments or any other health appointments.

The senior nurse must ensure that a discharge checklist is completed and filed in the child's health record. The checklist should include (example and not exhaustive):

  • Action plan completed and by whom;
  • Address and details of parent / carer where the child is being discharged to;
  • Next out patient appointment;
  • Who to inform if the child fails to attend;
  • Other follow up arrangements;
  • CP advisor /named nurse/ named doctor informed;
  • Health visitor notified;
  • Social worker notified;
  • Community children's nurse notified;
  • Liaison health visitor informed;
  • School nurse informed;
  • GP letter;
  • Discharge summary;
  • Medication dispensed;
  • Parent held record completed.

Following Discharge

Within two working days of discharge the GP for the child must be sent:

  • A typed discharge letter;
  • A copy of the hospital's referral form to Children's Services.

The health visitor or school nurse (depending on the age of the child) must be provided with a copy of this correspondence.


6. Maternity Unit and Midwifery

Whenever there have been any child protection concerns about a new born baby (including concerns pre-birth), the ward should liaise with the Named Midwife for Child Protection and lead Midwife as part of discharge planning to ensure provision of appropriate postnatal care.

Discharge planning from the neonatal unit should include liaising with the senior neonatal nurse, GP, health visitor and Children's Services so that appropriate follow up support is provided.

A discharge planning meeting (as described above) should be convened at the hospital before the baby is discharged if:

  • Children's Services has undertaken a pre-birth assessment (irrespective of outcome);
  • Any child protection concerns have arisen before, during or subsequent to the birth.

Maternity hand-held records should be returned as soon as possible to maternity records as per normal practice.


7. Discharging a Child Into Care of Parents with Learning Disabilities/ Substance Misuse or Serious Mental Health Problems

If a child is to be discharged to parents / carers with learning disabilities, substance misuse or serious mental health problems a multi-agency / professional pre-birth assessment should have been undertaken. If not, it should be undertaken prior to discharge. See Chapter 10.4 Joint HSCB Protocol for Children and Families Living with Substance Misuse.

A multi professional pre-discharge meeting must also take place to ensure a comprehensive plan is in place to support the parents / carers.

It is the responsibility of the nurse in charge of the ward to liaise with Children's Services to arrange this meeting and include ACS / CAMHS / CDAT etc

If a nurse or other health professional is still concerned about a parent's competence, (s)he must record any concerns and inform the senior nurse and child's consultant.


8. Outpatient or Other Health Appointments

When it is known that a child is subject to a Child Protection Plan, Children's Services should be informed, in writing, of any failed health appointments. It is the responsibility of the clinician who the child is due to see in the outpatient department to ensure this is done.

For other children who fail to attend health appointments, where the clinician has/ is aware of concerns about their welfare (s)he must discuss this with their supervisor or named/designated doctor or nurse to decide on further action. Any discussion about the child must be fully documented in the child's health record.

Any child who has been identified as vulnerable and who fails to attend an outpatient appointment must have their notes reviewed by the consultant paediatrician who will determine any necessary further action.

End