Aftercare Following Sexual Assault in Under 13 Year Olds in East London

1. Aftercare Following Sexual Assault in Under 13 Year Olds in East London Dr Jessica Burton (Registrar GUM/HIV) Dr Anna Riddell (Consultant Paediatrician) Annual Scientific Meeting British Association of Community Child Health 9th October 2012

2. Introduction Currently all children under the age of 13 years who have been assessed at Haven SARCs in London are followed up in their Borough of residence by a Community paediatrician. There is clear RCPCH and FFLM guidance regarding how these services should be delivered. This audit assessed service delivery across the Boroughs of East London and looked at the individual follow up of all cases between 2009 and 2011 against these national standards.

3. Existing Guidelines Service Specification for the Clinical Evaluation of Children & Young People who may have been sexually abused 2009 (RCPCH) ‘Purple Book’: The Physical Signs of Child Sexual Abuse. An Evidence Based Review and Guidance for Best Practice March 2008 (RCPCH/FFLM) Guidelines on Paediatric Forensic Examinations in Relation to Possible Child Sexual Abuse 2007 (RCPCH/FFLM)

4. Service Specification for the Clinical Evaluation of Children & Young People who may have been sexually abused 2009 (RCPCH) • Page 8: 2.3.3Follow-up Arrangements • Children will be offered follow up by the service either at the specialist centreor more local to their home dependent on the service provision although good practice would be for the follow-up examination to be performed by the same examiner. The follow-up may comprise of: • Review of the healing process • STI screening/treatment/Hepatitis B vaccination • HIV counselling • Exclusion of pregnancy where emergency contraception inappropriate due to time lapse post assault • Psychological support

5. Methodology of Audit Participants: • Children <13 years of age resident in the London Boroughs of Tower Hamlets, City and Hackney, Newham, Barking and Dagenham, Havering, Redbridge, Waltham Forest, Enfield and Haringey who had Forensic Medical Examinations at The Haven Whitechapel between 1st April 2009 and 31st March 2011. Method of data collection: • Retrospective case notes analysis of children and young people aged < 13 years attending Haven Whitechapel for a Forensic Examination • Survey of Paediatricians accepting referrals • Survey 1: What services are available in their Borough? • Survey 2: What services were offered to the individual index cases?

6. Results • We collected data on all children <13 years of age, resident in Boroughs covered by Haven Whitechapel, who had Forensic Medical Examinations at The Haven between 1st April 2009 and 31st March 2011. • 45 children fitted the above criteria. • Children seen by Borough • Barking & Dagenham: 7 • City & Hackney: 8 • Enfield: 2 • Haringey: 7 • Havering: 2 • Newham: 7 • Redbridge: 2 • Tower Hamlets: 7 • Waltham Forest: 3

7. What services could the Boroughs offer? • A general survey was sent to the designated doctor in each Borough with the aim to determining what services they could offer. 8/9 (89%) of the Boroughs responded. • 7/8 (88%) could offer medical assessment including genital examination • 7/8 (88%) could offer photo-documentation • 6/8 (75%) could offer STI screening • 4/8 (50%) could offer pregnancy testing • 3/8 (28%) could offer chain of evidence • 5/8 (63%) could offer Hepatitis B vaccination • 2/8 (25%) could offer follow-up of PEP • 8/8 (100%) could offer psychology services/referral to CAMHS • 1/8 (13%) could offer/refer to 3rd sector

8. Results of Survey 2: What services were offered to the individual index cases? • We did not receive information back regarding 5 children. We therefore only have information regarding follow-up of 40 children. • Was the child seen for follow-up by Community Paediatrics? • According to the information we received, 11/40 (27.5%) children were seen by Community Paediatrics for follow-up.

9. If child wasn’t seen, what was the reason? • 14/29 (48%) There was no record of the child or the referral was not received • 5/29 (17%) DNA’d appointments • 2/29 (7%) Declined appointments • 7/29 (24%) Other reason for not being seen were stated (see below) • Informed that the child will be seen in a different Borough • Child referred to another service • Felt that follow-up wasn’t appropriate • Unable to trace family • Appointment cancelled and family then left the area • Haven summary indicated ‘No action needed. For information only’ • Young person attended another sexual health service – already known to that service

10. What happened to the 11 children seen?

11. Children seen for follow-up • Of the 11 children seen for follow-up • 4 allegations of vaginal rape • 4 allegations of anal rape/attempted anal rape • 1 allegation of digital penetration of vagina • 1 sexual assault/1 allegation not known • 5 had genital injuries at the time of the forensic examination • Would be expected that all children would have a physical/genital examination with photo-documentation at follow-up • Would be expected that any child where the allegation was of vaginal/anal rape or digital penetration of vagina would have an STI screen • PEP/Hep B vaccination/pregnancy testing would depend on individual cases

12. Conclusions • Need to ensure a pathway is in place to complement the guidelines. • There appears to be variable achievement of service delivery against RCPCH Service Specifications across the Boroughs of East London, with some Boroughs able to offer a full range of services and some able to offer very few. • The numbers of children seen in each Borough is very small. This raises the question as to whether it is possible for each Borough to offer a high quality service with access to full set of required resources when the activity is so low.