In ear drum and a bruise behind his

In the PBL case of Sinead Tompkin and her son David, they
attended their GP when Sinead had a viral infection that she believed she’d
caught from David. David was quiet and withdrawn with a perforated ear drum and
a bruise behind his ear, with the GP questioning the injuries and how they were
sustained. While the concern in the Tompkin case was one of physical abuse,
abuse can present in many different forms such as, sexual, neglect and
emotional abuse.

Legal and Ethical Obligations

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As a medical practitioner, there are many  legal and ethical obligations to report cases
of suspected child abuse (HSE, 2017). National guidelines for the
protection and welfare of children were first published in 1999 and have been
updated a number of times since, with the latest published in 2017 (Department OF Children and Youth Affairs, 2017). These guidelines highlight
well-being and safety of children as priority and provide guidance on
identifying situations where are child may be being abused or neglected. The
Children First Act 2015, building on published Child First National Guidelines,
sets out statutory reporting obligations of “Mandated Persons”, a category into
which medical practitioners are classified (Dept of Children & Youth Affairs, 2015). Section 14 of this act
outlines the mandatory reporting in cases where the individual has reasonable
grounds to suspect that a child has been harmed, is currently being harmed or
is at risk of harm. Section 14 also outlines the need for reporting if a child
has made a disclosure, of abuse, or risk of harm, to a mandated person. This
act provides guidance on timing of reporting and outlines that reports should
be made “as soon as is practicable” (Department OF Children and Youth Affairs, 2017).

There are other key pieces of legislation that also have
implications for medical practitioners such as the Criminal Justice Act 2006
and 2012. The Criminal Justice (Withholding of Information on Offences against
Children and Vulnerable Persons) Act of 2012 states that it is a criminal
offence to withhold information about a serious offence that a person knows, or
suspects, was committed against a child (Government of Ireland, 2012). The Criminal Justice Act of
2006 made it an offence for any individual with responsibility for a child to
endanger the child by causing or permitting a child to be placed, or left, in a
situation of significant risk (Government of Ireland, 2006).

While there is multiple legislation stating the legal
obligations to report there is also legislation in place to protect persons if
they make reports in good faith and have reasonable grounds. Protection for Person Reporting Child Abuse Act 1998 provides
protection to persons if they report suspected child abuse in good faith, to
the HSE, Tusla or Garda (Ireland, 1998). The Child First Act 2015
also has an element of protection for the reporter; As a mandated person, the
reporter is protected from civil lability. There are also no criminal sanctions
on mandated person who do not report suspected child abuse but information the
failure to report may be sent to the National Vetting Bureau, effecting future
employment, or to the Fitness to Practice Committee where sanctions may be
imposed on the practitioner (Dept of Children & Youth Affairs, 2015).

In addition to statutory obligations, medical professionals
must also follow a professional and ethical code of conduct as laid out by the
in Ireland by the Medical Council. In the latest version, published in 2016,
Section 26 of the guide deals with ethical obligations of child protection and
welfare. It outlines that national guidelines and legislation should be
followed and reiterates the importance of reporting if there are reasonable
grounds for suspecting abuse or risk of abuse and that if reporting is carried
out under these circumstances, that it would be considered justifiable breach
of confidentiality (Medical Council, 2016).


Challenges Faced When Reporting Suspected Cases

One major challenge facing doctors is defining reasonable
grounds. Physical abuse could present as a onetime occurrence and can be hard
to distinguish from childhood bumps and bruises.  In the type of scenario faced by the Tompkins
GP, it is important to consider the possibility of child welfare issues and not
presume accidental injury. Child welfare and abuse concerns are not a rare
phenomenon and suspicions shouldn’t be disregarded without proper
investigation. This is backed up with Tulsa figures which showed, in 2015,
there were 43,596 child welfare and protection referrals made to the HSE and
Tusla, the Child and Family Agency, an increase from 40,187 in 2012 (Department of Children and Youth Affairs, 2016). In the case of GPs there is
likely a relationship with both the parents and children, like Sinead and her
GP, and it can be difficult to believe that parents could be capable of harm
which could cloud judgement. Even though the ethical guidelines state that
reporting child abuse is a justifiable breach of confidentiality, many doctors
could be concerned about the effects of breaching confidentiality and the
impact on local reputation if the investigation does not find any evidence of
child abuse. Reporting suspicions could irrevocably damage the patient doctor
relationship and this could cause the parent to withdraw from GP services,
potentially isolating the child from medical services in the future. If the
report of abuse was well founded, but the child remains in the parental care,
this service evasion could risk further abuse to the child and it not being
seen. There is a high likelihood of the child remaining in the care of the
parents even if the case of proven abuse. This is backed up by the experiences
of Gardaí while acting under Section 12 as shown in a Section 3 of a report
carried out by Dr Geoffrey Shannon (Shannon, 2017). This shows that the concerns
of doctors are not unfounded and is just one of the many challenges faced when
making the difficult decision to report suspected child abuse.