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St Mary’s Children’s SARC The Manchester Experience Dr Catherine White March 2011
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St Mary’s Children’s SARCThe Manchester Experience
Dr Catherine WhiteMarch 2011
• Opened 1986
• Adult service
• Acute child cases
• 2.5 million in 2005
• 2.8 million in 2010
Dr Catherine White 4
• 1986• 15,000 clients• All ages• Male & female• Children’s SARC Feb
2006• 400 Children per year
Dr Catherine White 5
St. Mary’s CentreCore Services
• Forensic medical examination• Emotional and practical support• One-to-one counselling for clients and supporters• Post-coital contraception and pregnancy testing• Post exposure prophylaxis• Screening for STIs and HIV counselling• 24-hour telephone support and information • Support through criminal proceedings• Training and consultancy services• Children’s SARC
Problems
• Not a child friendly environment
• Increasing child numbers
• Lack of staff to deal with children– ISVAs– Counselling– Doctors
7
What is a child?
Operation Artemis
• Board established
• Current demand
• Agree pathways
• Identify site
• Secure funding
The examination suite
St Mary’s Child Cases
0
50
100
150
200
250
300
350
400
450
no of child cases 250 389 378 438 442 426
2005 2006 2007 2008 2009 2010
Child Cases 2009
0
20
40
60
80
100
120
140
160
180
200
no 78 85 98 181
0-4 5-9. 10-14. 15-17.
Dr Catherine White 15
The Team
• Crisis Workers x 11• Forensic Physicians x 26• Counsellors x 4• ISVA• Child Advocate x 2• Consultant Paediatrician• Centre Manager• Researcher• Police Liaison Officer• Clinical Director
The process
• Referral made to SARC• Examination• Review of notes next working day• Re-contact by Child Advocate• Support video interview• Counselling• STI screening
Dr Catherine White 17
Telephone referral to Social Care EDT*Fax completed MARF** to EDT (place copy of MARF in notes and
contact EDT to check receipt)
SARC SAFEGUARDING PATHWAY
Initial contact with SARC
Immediate action required
Risk assessment child protection/vulnerable adult
Letter to GP (Copy to Social care)
Case reviewed next working day
NO immediate action required
Referral to Trust Safeguarding TeamComplete MARF (copy in notes)
Letter to GP
Copy of MARF to Trust Safeguarding Team (next working day)
(copy of MARF in notes)
All children aged 17 years and under and vulnerable adults attending SARC will be referred to the Trust Safeguarding Team. Where there is concern for the patient’s (or child’s) safety the Emergency Duty Team (EDT), Children and Families should be contacted. This protocol should be considered in conjunction with Trust Safeguarding Policy. This is available on the Trust intranet link to Child protection all SARC staff should familiarise themselves with it.
*EDT Emergency Duty Team
** MARF Multiagency Referral Form
To be actioned immediately
To be actioned the next working day
Medical rota
• Day time clinics three days a week.
• Out of hours rota to cover child and adult cases.
• Single doctor examinations
Quality
• Feedback
• Dashboard
• Peer review
• Qualifications
Feedback forms
Domain Indicator Nov Dec Jan 92%
Benchmark
Quality and Safety
ISVA
Safeguarding
% attendance counselling supervision
100% 100% 100% 100%
Re contacting : 5 working days
98% 98% 86% 95%
% notes reviewed : 1 working day
100% 100% 100% 100%
% MARF : 1 working day 98% 94% 96% 100%
Medical Allergy documentation 97.5% 97% 95% 98%
Correct HIV PEP Script 100% 100% 100% 98%
Chain of custody 99% 100% 100% 98%
Gaps on <13 rota 7/38 (18%) 6/38 (16%) 7/41 (17%) <5%
Gaps on >13 rota 1/68 (1.5%) 1/68 (1.5%) 4/73 (5%) < 5%
Child service Working days to next appointment
4 3 2.5 <3
% pre pubertalColposcopic exam
100% 100% 100% > 95%
% marked of interest peer review
100% 100% 100% 100%
% DVD marked normal peer review
30% 30% 40% >10%
Training and Development
Corporate mandatory training
92% 92% 92% 100%
Clinical mandatory training
50% 50% 50% 100%
Domain Indicator Nov Dec Jan Benchmark
Centre Activity
Children
Total cases 92 79 98
Adults 52 (56%) 42 (53%) 54 (55%)
Children 40 (40%) 37 (47%) 44 (45%)
Children 0-12 22 (55%) 19 (51%) 15 (34%)
Children 0-17 18 (45%) 18 (49%) 29 (66%)
Acute child 22 (55%) 27 (73%) 26 (59%)
Non acute child 18 (45%) 10 (27%) 18 (41%)
All cases %Forensic Exam 80 (87%) 63 (80%) 80 (81%)
Client source %self referral 15.2% 21% 17% > 15%
% female 83 (90%) 74 (94%) 91 (93%) < 90%
% male 9 (10%) 5 (6%) 7 (7%) > 10%
% BME groups 23% 14% 8% 9%
%ethnic record 100% 97% 98% 98%
Police referrals % Police referrals 84.8% 79% 83%
% reported to police UK UK UK
Counselling New referrals 18 19 43
% police referral 44% (8/18) 10% (2/19) 11.5% (5/43)
Waiting list time 6 wks 4 weeks 6 wks < 8 wks
Active caseload 43 49 52
DNA rate 11.2% 15% 9% <15%
Peer Review
• Monthly process
• Not diagnosis by consensus
• Challenge v nurturing
• External peer review
Qualifications
• 26 female forensic physicians– 22 in place more than 12/12– 22 are either Consultants or GPs
• 50% have MFFLM• 100% FMERSA course• Additional payment for higher qualifications
• (FNEs for 9 years until 2009)
Children as a total of all cases 2006-2011
56%
44%Adults
Children
Age of Children Seenlast 5 years
57%
43%13-17 years
Under 13 years
87%
13%
Girls
Boys
Gender of Children Seen
Problems…
• Commissioning
• Capacity
• Resistance to refer
• Evolution
Reasons to refer….• Assessment and treatment of any possible injuries• Documentation of injuries• General health assessment• Reassurance • Recovery of trace evidence e.g. semen, DNA, lubricants etc• Screening and if necessary treatment of sexually transmitted infections.• Emergency contraception• Pregnancy testing• Post exposure prophylaxis for HIV and Hepatitis B• Psychological support for complainant and carers.• Practical support through the criminal justice process.
Dr Catherine White 31
Criminal Justice Issues
• Support through video interview• Pre trial visit• Witness and Victim Support Services• Pre trial therapy• Disclosure• Outcomes• Post court
Inter Agency WorkingDoes it work?
Are the health needs met?
Review of statement requests January 2006 - December 2010
Total numbers Statement cases %
All cases 4646 1008 22
Adults 2614 573 22%
Children 2032 435 21%
Females under 13 673 119 18%
Female children 13-17 1093 262 24%
Male under 13 203 42 21%
Male children 13-17 63 12 19%
Under 13sCases where statement is requested.
54%
46%
Acute Historic
The assailants of the Under 13s
• Male• Known to child
• Adults 60%• 95% either adult or at least 5 years age
difference
95 % were non stranger casesBrother
DadGrandfather
Step grandfather
Uncle
Friend of FamilyCousin
Neighbour
Mum's boyfriend
StepfatherAcqaintance
Baby sitter
Boyfriend
SisterFriend
Injuries varied from abrasions to lacerations requiring surgery.
The Future….• Adolescent suite
• Increase Child Advocate capacity
• Centres of excellence
• Social worker on site
• Increase psychological support
• Preventative work
