Wednesday, 4 March 2015

Mandatory reporting etc - some initial thoughts and questions

This post attempts to capture merely initiial thoughts.

In this case questions and concerns about mandatory reporting of suspected child abuse and related issues. This post represents some random thoughts, concerns and questions which occur to me at this moment. They don't represent any form of final position or comprehensive list of aspects of debate with respect to this important issue.

The post is, in part, stimulated by a discussion on Twitter yesterday with Jonathan West ( and Professor Liz Kelly ( )

There is, I think, no great distance between our positions but it's possible that this post may begin to highlight some differences.

Disclaimer: I write as a retired doctor and that will, I suspect, explain parts of my viewpoint, the issues that come immediately to mind and, in all likelihood, some of my points of "bias" or ignorance.

Need to protect children

I think (and hope) that we're in total agreement that children who have been abused need to be protected and that it is not possible to protect them if "the system" hasn't been informed of any evidence of abuse.

I hope we're further agreed that "the system" to which reports of suspected abuse are made must work effectively.

What are the aims of mandatory reporting?

What are the aims of mandatory reporting?

Identification of actual abusers? I assume so.

Avoidance of harm to the innocent? I think that should also be an aim.

If others agree that those are the aims, then how are the two aims to be balanced?

What constitutes "suspicion"?

As I understand proposed mandatory reporting (at least in some versions) any suspicion of child abuse must be reported within 10 days or a criminal offence has been committed.

It seems to me that what constitutes "suspicion" is a fundamental question.

Scenario: Accident & Emergency Department. Child with suspected fracture and possibly old bruises presents. Among the differential diagnoses is child abuse. Sometimes that will be merely one possibility on a tick list. That shades into "I wonder if this could just possibly be child abuse" to "This looks like it might be child abuse" to "I'm deeply suspicious this is child abuse". 

If, for example, the presence of abuse on a differential diagnosis list is reported then any system will become very quickly overloaded and, worse, overloaded with likely false positives.

So for me there is question of what level of "suspicion" is necessary for reporting to be mandatory?

If the test is "reasonable suspicion" what does that mean? It's not immediately obvious to me what it means.

Suspected current abuse or suspected past abuse?

Is ongoing suspected abuse to be reported? I assume yes.

If abuse is in the past, how "historic" does the abuse have to be for the mandatory reporting requirement to be waived, if ever?

Who reports about whom?

I'm unclear if there is agreement about who is to be obliged to report.

Schools? Teachers? Care workers? It seems so.

Doctors? Other health professionals? If not, they should be. As indicated above the question of differential diagnoses and when they shade into "reasonable suspicion" (or similar phrase) is not, to my mind, an easy question.

Family members? I understand that is not currently proposed. 

Who are reports to be made to?

Maybe this is obvious to others, but it isn't to me. I assume Police and/or Social Services. Both? Or either?

Are reports to be rated?

Are reports to ask for rating?

In other words are professionals to be asked to rate reports as "very likely" on some scale to "slight suspicion"? If not, how is "the system" to prioritise its response to a report?

Reporting isn't the only failure

The Oxfordshire case demonstrates, in my view, that "the system" didn't respond appropriately to reports of suspected child abuse.

Therefore it seems to me that any process of mandatory reporting etc must feed into a system that works.

It further seems to me that mandatory reporting without appropriate improvements in other parts of the system is potentially merely "problem shifting".

If too low a threshold of suspicion is implemented there are dangers that "the system" will be overloaded and that serious cases of abuse will be lost or delayed due to possible large numbers of more tenuous suspicions.

In a setting of budgets under pressure it seems to me that there are very real dangers of "the system" not being able to cope.

What happens to suspected abuser?

If, say, a professional is suspected of abuse what is to be the process?

Scenario: Allegation of abuse by a teacher.

Is the accused teacher suspended immediately a report of suspected abuse is made?

What is made public about an allegation? When?

If a teacher is suspended for suspected abuse what is the effect on service delivery? What is the effect on that person's reputation and future? Some who are suspected will be totally innocent.

When might "10 day" rule not apply?

Scenario: Adult psychiatrist/therapist. No evidence of ongoing abuse. It's in the past.

Should the 10 day rule apply? Or not?

Should the 10 day rule (or whatever period) apply only if suspected (or acknowledged) abuse is ongoing?

Should the 10 day rule be waived only when the abuser is dead and therefore poses no future risk to anyone else?

Abuse isn't the only potential harm

Scenario: Psychiatrist/psychotherapist sees patient (child or adult). Screening tests indicate possible abuse.

Is reporting to be mandatory at that stage? If so, likely large volume of false positive reports will flood the system.

Scenario: Adolescent/adult is deeply distressed by initial exploration of past abuse.

Is he/she to be thrown into a possible Police investigation by Law when, in the applicable clinical judgement, he/she could be seriously damaged by forcing the pace of the process of coming to terms with past abuse?

Scenario: Falsely accused / mistakenly accused / "exonerated" professional who has been suspended.

Possibility of "no smoke without fire" response. Can the professional continue in post? What effect on any marriage/relationship? What effects on children of a marriage after, say, marital breakup? It isn't only abused children who can be damaged by an allegation/suspicion of abuse.

Is abusee consent required? When if at all?

It seems to me that the question of abusee consent arises in some settings.

Scenario: Adult/adolescent seeing psychiatrist/psychotherapist

The patient doesn't want the matter reported to the Police. Is the professional to be required by Law to report?

If so, will (some) patients share anything / fully about past / ongoing abuse?

In other scenrios consent is likely irrelevant e.g. young child with signs of abuse.

If there is to be a Law, how if at all is the threshhold for consent to be expressed? What age, for example?

Many more scenarios possible

The foregoing merely illustrates some example scenarios which cause me potential concern.

It's a topic for very careful thought in my view.

Other may already have given issues such as those raised above much more detailed thought than I have. I'd like to be reassured that the whole process.

"Mandatory reporting" and the system that responds to it  must, in view, reflect a carefully considered process of "joined up thinking".

1 comment:

  1. WONT apply in nonceland Scotland where the Hollie Greig cover up continues