st mary’s children’s sarc the manchester experience

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 FormTo 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%AdultsChildren

Age of Children Seenlast 5 years

57%

43%13-17 yearsUnder 13 years

87%

13%

GirlsBoys

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 casesBrotherDadGrandfatherStep grandfatherUncleFriend of FamilyCousinNeighbourMum's boyfriendStepfatherAcqaintanceBaby sitterBoyfriendSisterFriend

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

Dr Catherine White 41

THANKYOU

0161 276 6515www.stmaryscentre.org

Stmarys.sarc@cmmc.nhs.ukCatherine.white2@nhs.net