Date published: 21 August, 2023
Date last updated: 21 August, 2023
Children and young people, Health and justice, Workforce

Paediatric forensic healthcare practitioner capabilities framework for child sexual abuse assessment

Introduction and background

Ensuring an appropriately trained workforce and introducing consistent quality standards, are two of the core priorities identified within the national strategy – Strategic direction for sexual assault and abuse services; Lifelong care for sexual assault and abuse services; Lifelong care for victims and survivors: 2018-2023.

It is essential that an appropriately trained workforce with the required knowledge, skills and behaviours is available to support and improve the health outcomes of children and young people who are survivors of sexual assault at any point along the pathway.  In-depth knowledge should include child development, social vulnerabilities and adverse childhood events that affect neurodevelopment. This is critical to ensuring that they receive the same standard of care as any child or young person would obtain within the NHS, including timely access to the services and support they and their families/carers need.

This capabilities framework identifies and describes the professional knowledge, skills and behaviours required by Forensic Healthcare Practitioners to deliver a high-quality, patient-centred service. In addition, the framework will inform the standards of education and training and continuing professional development which includes peer review and supervision of the workforce undertaking forensic and clinical assessments of children and young people from 0 and up to the age of 18 years.

The Forensic Science Regulator expects relevant legal entities that provide forensic services to comply with applicable standards and requirements and to seek and obtain accreditation from the United Kingdom Accreditation Service (UKAS). UKAS is also the body that is recognised by government, to assess against internationally agreed standards. They have been appointed to oversee the accreditation of sexual assault referral centre (SARC) forensic services and have mandated that all SARC services nationally should be accredited by October 2025. Essentially, the accreditation will seek assurance for quality management systems, staff competency and forensic processes and integrity, which includes premises. This capability framework should be seen as supporting UKAS accreditation. However, SARC providers will still be required to ensure that all applicable standards to meet accreditation by UKAS are also met. In addition, the capabilities set out in this framework are aligned with the Faculty of Forensic and Legal Medicine  (FFLM)/Royal College of Paediatrics and Child Health (RCPCH) Quality Standards to articulate the knowledge, skills, behaviours and qualifications required for paediatric forensic practice.

A nationally agreed capabilities framework will not only enable consistency in the training required and quality of forensic and clinical assessments undertaken by forensic healthcare practitioners, irrespective of professional background, but it will also help to support the sustainability of the workforce. Workforce sustainability is particularly critical given some of the challenges resulting from the national shortage of the workforce in this area, and the impact that this can have on providing timely and essential care for children and young people from 0 to 18 years of age who have been sexually abused.

About capabilities

For the purposes of this framework, the following definition of capabilities is being used:

Capabilities are the attributes (skills, knowledge and behaviours) which individuals bring to the workplace.  This includes the ability to be competent with the additional abilities, to:

  • manage change.
  • be flexible.
  • deal with situations which may be complex, sensitive or unpredictable and,
  • continue to improve performance.

Therefore, ‘capability’ can be more than ‘competence’. To be competent is to consistently perform to defined standards required in the workplace – usually focused on the outputs of work and observable performance. Competence tends to describe practice in stable environments with familiar problems. Whereas ‘capabilities’ describe the ability to be competent, and beyond this, to work effectively in situations which may be complex and require flexibility and creativity.

In practice, the terms ‘capability’ and ‘competence’ are both widely used in educational and workforce development literature, and they have often been used interchangeably, with little clear distinction between the two. Both capability and competence:

  • are about ‘what people can do’.
  • describe knowledge, skills and behaviours.
  • can be the outcome of education, training or experience.

However, for the purposes of this framework the term ‘capabilities’ is being used as this describes the ability to be competent, and beyond this, to work effectively in situations which may be complex, sensitive or unpredictable and require flexibility and creativity.

Who is this framework for?

Regulators

The framework can support the work of regulators, for example:

  • the Care Quality Commission, in their role in monitoring the quality of service provision, in relation to their understanding of the levels of training required by staff delivering services
  • the United Kingdom Accreditation Service (UKAS), in relation to the proposed accreditation of sexual assault referral Centres by the Forensic Science Regulator.    

Service commissioners

The framework can support commissioners of services to specify minimum standards for clinical employment; it sets out clear expectations about what forensic healthcare practitioners need to do.

The capabilities support the development and planning of the workforce to meet local population need and support a common understanding and expectation of staff undertaking forensic and clinical assessments of children and young people.

Employers

The framework enables employers and managers to benchmark the forensic healthcare practitioners they employ and/or manage, ensuring they meet the capabilities, or have developmental plans in place along with the necessary supervision to ensure the safety of the child/young person and their forensic, medical and immediate psychological needs are met.

Employers should note that this framework applies in its entirety to all practitioners who see children and young people without direct immediate supervision. Where there is reference within the framework to practitioners working within the scope of their practice, this does not imply the capability statement may be omitted as it is deemed necessary to a patient-centred approach. Employers should ensure they employ practitioners who can meet all the requirements of children and young people using the service. Development plans should be in place for those practitioners who may not currently meet all the capabilities.    

This framework underpins and supports the requirement of professional and regulatory bodies for the continuing professional development of forensic healthcare practitioners. It ensures their practice is, safe, effective, remains up-to-date and supports the process of quality assurance for the safety and effectiveness of the services they deliver.

Education and training providers

Educational institutions can use the framework to inform the design of their curricula and the delivery of education, training, and development programmes, including identifying learning outcomes. This will ensure that their learning and development provision contributes to the full range of knowledge to support the capabilities required for forensic healthcare practitioners to practise safely and effectively.

Supervisors

The framework will assist supervisors at all levels by providing a clear structure to assess against.

Current and future staff

The framework sets out clear expectations for forensic healthcare practitioners about the requirements for effective and safe practice.

It can be used to conduct formal or informal appraisal, alongside a training needs analysis, comparing current skills and knowledge with required skills and knowledge. It can also be used to support revalidation requirements and will assist forensic healthcare practitioners in the development of a portfolio of evidence of capability.

Scope of the framework

This framework is patient-centred in its approach. Whilst it is recognised that there will be a varying number of roles involved in providing interventions, it specifies a range of core capabilities expected of the forensic healthcare practitioner working with infants, children and young people from 0 to 18 years, where there is a report or suspicion of rape or sexual assault. This includes the ability to triage, take a history, undertake a clinical and forensic assessment as necessary, synthesise information and use clinical reasoning to diagnose, treat and formulate a shared management/personalised care plan and on-going support for children and young people, their families and carers.

It is acknowledged that all capabilities may not be applicable to all settings and forensic healthcare practitioners will work in accordance with their scope of practice.

The forensic healthcare practitioner must:

  • Work within the scope of their role and professional competences, agreed and documented by their employer, recognising where there may be a deficit between own scope of practice and the requirements of the child or young person, and address gaps in a timely manner.
  • Adhere to the articles of the UN Convention on the Rights of the Child, in particular:
  • Ensure the best interests of the child are the top priority in all decisions and actions that affect children (Article 3).
  • Recognise and work to ensure that every child has the right to express their views, feelings and wishes in all matters affecting them, and their views are considered and taken seriously. This right applies at all times, for example, during immigration proceedings, housing decisions or the child’s day-to-day home life (Article 12).
  • Work to ensure that children are protected from all forms of violence, abuse, neglect and ill treatment by their parents or anyone else who looks after them (Article 19).
  • Work to ensure that every child has access to the best possible healthcare, including access to clean water, nutritious food and a clean environment, and education on health and well-being in so that children stay healthy. (Article 24).
  • Work to ensure children are protected from all forms of sexual abuse and exploitation (Article 34).
  • Work to ensure that children who have experienced neglect, abuse, exploitation, torture, or who are victims of war, receive special support to help them recover their health, dignity, self-respect and social life (Article 39)
  • Adopt a trauma-informed approach to care and act in a manner that is appropriate to the age and developmental stage of the child/young person.
  • Work collaboratively as a member of the multi-agency team to ensure the optimal safeguarding and welfare of children and young people. Working within the statutory safeguarding frameworks, including participation in strategy and case conferences as needed, to achieve shared decision making, personalised care and support planning for the child, young person, their families and/or carer(s).
  • Support the criminal and family justice process through the collection of samples, interpretation of findings, and information sharing. This includes clear safeguarding reports, court statements and being a professional witness when required.
  • Ensure adequate, appropriate and timely sharing of information.
  • Deliver a safe service that reflects the same standard of care a child/young person would receive within the NHS following any other serious incident/child protection issue.
  • Provide continuity of care, where appropriate and possible, in collaboration with the child, young person, their families and/or carer(s), considering all their physical, mental and psychosocial challenges.
  • Participate in case management activities, including governance oversight, ensuring the safety and quality of care for each child/young person.

Professional values and behaviours

The following values and behaviours underpin all the capabilities in this framework and focus on the core competencies that children, young people, their families and carers can expect of those providing them with care, treatment and support.

The forensic healthcare practitioner must:

  1. Adhere to appropriate codes of conduct, work within scope of practice/limits of competence, and act with professional integrity in their own day to day clinical and professional practice.
  2. Take responsibility for own continuing personal and professional learning including proactively seeking training and development opportunities including engaging in regular peer review and supervision.
  3. Demonstrate critical thinking and decision-making skills. Recognise ethical considerations in assessing and managing children and young people, including understanding unconscious bias. Take a child and young person-centred approach at all times.
  4. Comply with relevant legislation, policies, procedures, protocols and guidelines, and interact appropriately with the criminal justice system.
  5. Recognise the potential personal impact of working within a safeguarding and child protection focused environment and actively engage in safeguarding supervision activities.
  6. Critically reflect on how own values, attitudes and beliefs might influence own professional behaviour and the behaviour of colleagues.
  7. Identify and act appropriately when own or others’ behaviour undermines equality, diversity and human rights.
  8. React promptly and impartially when there are concerns about self, colleagues, services or service users. Take advice from appropriate people and, if necessary, engage in a referral procedure.
  9. Participate in a range of governance activities, seeking and reflecting on feedback from service users and partners, whenever possible.

Structure of the framework

The framework is presented in four domains:

  • Domain A. Child and young person-centred collaborative working
  • Domain B. Assessment, investigations, clinical and forensic procedures, diagnosis and record keeping
  • Domain C.  Case management, condition management, ongoing referral, strategies for managing risk
  • Domain D. Leadership and management, governance, education and research

Within the domains are a total of 12 capabilities. The capabilities are numbered for ease of reference – this does not indicate a prescribed pathway, process or hierarchy.

Domain A – child and young person-centred collaborative working

Introduction

Forensic healthcare practitioners have highly developed interpersonal and communication skills in order to engage effectively in often complex interactions with children, young people, their families and carers, and other relevant professionals. They have advanced skills in listening and information-processing, alongside empathetic skills to ascertain, understand and respond to the complex needs and concerns of the child and young person. They need to be impartial and objective, whilst adopting a person-centred approach.

Forensic healthcare practitioners are able to utilise strategies such as play, distraction and grounding techniques to prevent re-traumatisation. They recognise the development specific needs of children and young people and the significant differing needs of pre-pubertal and post-pubertal children, as well as the skills required when working with children and young people of differing developmental needs. They uphold and safeguard the interests of children and young people and are sensitive to individual preferences and needs.

Forensic healthcare practitioners adhere to all relevant legislation. They follow national and local safeguarding policies and professional guidelines when implementing recommendations, and when planning and delivering services for infants, children and young people, in any setting.

This level of practice will include initiating and/or contributing to ‘conversations with a range of health and social care professionals. This includes professionals working within the criminal justice system to collaboratively manage ‘highest complexity and significant risk’ i.e. Step 3 of the Person-centred approaches framework: Person-centred approaches (Health Education England and Skills for Health 2017).

Capability 1. Communication and consultation skills

The forensic healthcare practitioner must:

a. Critically appraise communication strategies and be able to optimise communication approaches appropriately whilst minimising re-traumatisation. They should use skills such as active listening, for example frequent clarifying, paraphrasing and picking up verbal cues such as pace, pauses and voice intonation, reframing techniques and other strategies.

b. Consider the impact of own communication style, reflect on communication strategies and skilfully adapt those employed to ensure communication strategies proactively seek the ‘voice’ of the child/young person.

c. Adapt communication styles in ways that are empathetic and responsive to the communication and language needs, preferences and abilities of children/ young people, including picking up on subtle or behavioural cues that indicate a child may be trying to communicate. Give immediate feedback in a developmentally appropriate way.

d. Communicate effectively and engage with children, young people, families and/or carers, including those with additional needs, recognising that the agenda of children/young people and their families/carers may be different, particularly where there are children/young people or families in conflict.

e. Recognise and seek assistance from, for example, a professional interpreter or person with sign language expertise, where the child, young person, their family or carers needs support to understand communication.

f. Communicate complex and sensitive information clearly, in ways that avoid jargon and assumptions. Respond appropriately to questions and concerns to promote understanding, including use of verbal, written and digital information.

g. Understand court proceedings and communicate effectively when required to give verbal testimony/professional opinion at court. Recognise the differences between child protection, which has a threshold of ‘on the balance of probabilities’ and the criminal justice system which is related to a specific offence and is ‘beyond all reasonable doubt’.

h. Understand open and leading questions and the impact on the criminal justice system.

i. Understand and apply multi-agency safeguarding processes and communicate effectively when required to give professional opinion at strategy meetings, case conferences and other multi-agency meetings.

j. Communicate effectively with other healthcare professionals and other team members, for example, police, social workers, crisis workers, designated and named safeguarding leads, GPs, paediatricians, sexual health clinicians, mental health teams, health visitors, Childrens/Independent Sexual Violence Advocates (CH/ISVAs).

k. Write and maintain accurate reports for child protection processes, including:

  • child protection reports on all children seen aged up to 18 years.
  • police statements
  • medical reports for social services and court
  • written reports for multi-agency strategy meeting and child protection conferences

to ensure medical, forensic and safeguarding needs are met, and information is shared appropriately.

l. Evaluate and remedy situations, circumstances or places which make it difficult to communicate effectively for example the impact of alcohol/drugs on the ability to understand and react or noisy and distressing environments which may occur in emergency situations. Have strategies in place to overcome these barriers.

m. Enable effective communication approaches in non-face to face situations, for example phone, video, email or remote consultation.

n. Communicate in ways that build and sustain relationships. Seek gather, and share information appropriately, efficiently and effectively to expedite and integrate the care of children and young people.

Capability 2. Practising holistically, to personalise care and promote the health of the child and young person

The forensic healthcare practitioner must:

a. Determine how the preferences and experience of the child, young person, their families and carers, including:

  • cultural and religious background
  • gender
  • race
  • sexuality
  • adverse childhood experiences
  • exposure to previous abuse of any type
  • domestic abuse

and can offer insight into their neurodevelopment, wellbeing, impact upon them, and on the assessment of risk and management of the care plan and concerns.

b. Adopt a trauma-informed approach and engage the child/young person to allow participation in decisions affecting them as appropriate to their age and developmental ability by:

  1. supporting them to express their own ideas, concerns and expectations and encourage them to ask questions.
  2. explaining, in non-technical language, all available options (including doing nothing).
  3. exploring with them the risks and benefits of each available option, discussing the implications, how it relates to them, and promoting their understanding as much as possible.
  4. supporting them to decide, as appropriate, on their preferred way forward, and communicate their decision.
  5. supporting the empowerment of the child, young person.
  6. undertaking a robust assessment of self-harm, mental health, sexual health, suicide and safeguarding issues, and act appropriately on findings.c.

c. Co-produce and promote shared management/personalised care/on-going support plans for the child/young person to meet their needs in partnership with other health and social care providers and with carers/family members and voluntary organisations where applicable.

d. Work collaboratively across agencies and boundaries to improve health outcomes and reduce health inequalities, participating in the progression of criminal justice outcomes, where appropriate.

e. Understand and apply national and local safeguarding policies and procedures in relation to children and young people. Work collaboratively with other agencies to ensure the safeguarding and wellbeing of children and young people and provide advice about safeguarding/child protection policy and legal frameworks.

f. Consider the role of the parent in the consent process and be aware of the role of parental responsibility. Understand the process for obtaining consent for under 13 and for under 16-year-olds. Have knowledge of the issues that young people face in the care of the local authority.

g. Demonstrate, the application of the relevant legislation for informed consent and shared decision making (for example, mental capacity legislation, Gillick Competency and Fraser Guidelines in relation to contraception).

h. Undertake a mental health risk assessment on children of all ages, being aware of the increased risk to the older adolescent. Advise on and refer the child/young person to psychological therapies and counselling services, in line with their needs and wishes, and those of the families and/or carer(s), as appropriate, taking account of local service provision.

i. Contribute to child and young person-centred approaches in the management and development of services.

Capability 3. Working with colleagues, teams and agencies

The forensic healthcare practitioner must:

a. Ensure their work is within professional and personal scope of practice and to access advice when appropriate.

b. Utilise the expertise and contribution to the care and treatment of children and young people of other health, social care and criminal justice professionals. Work collaboratively within the multi-agency team to ensure services meet the needs of children and young people, their family and carers and are provided in a coordinated way.

c. Have a deep and systematic understanding of safeguarding systems, the ‘whole system’ within sexual violence settings, and the roles of other professionals and agencies within safeguarding, as well as other agencies, from whom expert advice can be sought, as appropriate.

d. Make decisions, provide expert opinion as required, communicate effectively when there are professional differences of opinion, and manage, including escalation, where required.

e. Demonstrate receptiveness to challenge and preparedness to constructively challenge others, escalating concerns that affect people, families, carers, communities, colleagues’ and own safety and well-being, when necessary.

f. Promote and maintain effective communication and working relationships within and across multi-agency teams, managing any complexity of transition from one team to another, and determine any relevant parties with whom information is to be shared.

g. Initiate effective multi-agency/multidisciplinary team activity as a lead member and understand the importance of effective team dynamics. This may include but is not limited to the following:

  • service delivery processes
  • audit
  • quality improvement
  • significant event review
  • shared learning
  • development and research.

h. Take responsibility for one’s own well-being and promote the well-being of the team, escalating any causes for concern appropriately.

Domain B – assessment, investigations, clinical and forensic procedures, diagnosis and record keeping

Introduction

Forensic healthcare practitioners must demonstrate safe, effective, autonomous and reflective practice, informed by available evidence and established best practice. They work at an advanced level within their agreed scope of practice, work effectively as part of a multi-professional team, either as a leader or as a team member. They contribute to multi-agency/multi-disciplinary teamworking to optimise the quality of service and clinical outcomes delivered to children and young people.

They undertake forensic medical assessments, which include being impartial and objective, identifying appropriate strategies to promote effective evidence gathering and minimise miscarriages of justice due to contamination and poor technique.

Forensic healthcare practitioners undertake forensic and clinical assessments and develop effective management plans and referrals, if needed, relevant to the diagnosis. They demonstrate skills in problem-solving, critical thinking and evaluating the impact and outcomes of their interventions, as well as analysing and synthesising information, particularly where information may be incomplete or contradictory.

Capability 4. Planning for arrival

The forensic healthcare practitioner must:

a. Hear the voice of the child/young person in the planning, preparation and pathway chosen.

b. Understand the legislative framework for child protection, the key participants in strategy meetings, section 17 and 47 (Children’s Act), alongside other key legislation.

c. Triage cases effectively and decide on the extent and timeliness of the clinical and forensic examination. They must manage competing priorities and seek assistance from other clinicians as appropriate.

d. Ensure the child/young person is medically and psychologically fit for the examination.

e. Attend, where possible, strategy meetings to ensure all available information is considered prior to assessment. This includes ensuring safeguarding concerns are clearly understood, a risk assessment is undertaken to ensure the safety of the forensic team as well as the individual, and that all individuals, including those required for consent and wider needs, such as interpreters, are organised prior to attendance.

f. Consider the assessment and management of others that may be at risk, including familial sexual abuse and exploitation.

g. Prepare the examination/assessment environment prior to attendance or where off-site medicals are undertaken. Consider the most appropriate forensic and clinical strategy.

h. Identify, using evidence-based resources, where, when, and by whom a child should be seen, including consideration of wider child protection resources, or alternative clinical pathways, where appropriate.

i. Consider medication and other needs prior to attendance, including acute injury and illness, which would require an emergency department pathway.

j. Determine whether the child/young person is under the influence of any intoxicants and what medical care is required. Understand its effect on capacity and consent to medical intervention and to sexual activity, and what safeguarding strategy threshold has been met.

k. Be able to facilitate a self-referral pathway, ensuring safety and effective risk management, where appropriate. 

Capability 5. Information gathering and interpretation

The forensic healthcare practitioner must:

a. Take into account 16 and 17 year-olds who have the capacity to consent to medical intervention and parental responsibility. They must also consider Gillick competence when assessing capacity and obtaining consent, whilst maintaining the child/young person’s confidentiality, in accordance with legal guidance for example Mental Capacity Act 2005, local and national policy. They must take into account all factors relevant to assessing capacity and obtaining consent for 16- and 17-year-olds, including Gillick competence, parental responsibility, Mental Capacity Act (2005), and local and national policy, whilst maintaining confidentiality.

Undertake an accurate, holistic, developmentally appropriate systematic review of:

  • current health
  • birth history
  • past medical history
  • developmental history
  • sexual health history
  • menstrual and contraceptive history (where relevant)
  • allergies and medicines
  • social and family history

They must recognise where information is lacking, and actively seek the information needed to make a holistic assessment and draw appropriate conclusions.

b. Undertake a developmental assessment and a mental health assessment appropriate to the age of the child/young person from 0-18 years.  

c. Be able to understand the history of the incident, relating any medical signs and symptoms to the history of the incident and take a medical history in relation to the differential diagnosis. Where appropriate, they will need to include a sexual health assessment, which will include decisions about baseline screening for sexually transmitted infections and recommending follow up tests based on incubation periods and risk assessment. Be able to understand and complete laboratory forms and chain of evidence.

d. Formulate a forensic strategy, prepare the room, minimising contamination, utilising personal protective equipment and evidence-based techniques to retrieve the full range of evidence following chain of evidence processes.

e. Understand what assessment is required in the clinical examination, for example, non-recent versus acute sexual abuse, forensic sampling opportunities versus injury assessment, or ongoing health needs where the child/young person declines assessment.

f. Synthesise and incorporate information from other appropriate sources (for example previous histories and investigations, information from a GP) and interpret the history and examination findings, utilising evidence and diagnostic reasoning.

g. Critically appraise complex, incomplete, ambiguous and conflicting information gathered from history taking and clinical assessment and examination. Distil and synthesise key factors from the appraisal and identify those elements that may need further investigation.

h. Deliver a diagnosis and interpret investigation results sensitively and appropriately. Use a range of mediums including spoken word and diagrams to ensure the child, young person, family and/or carers has an understanding about what has been communicated.

i. Make detailed accurate, comprehensive and contemporaneous notes. Document and communicate all pertinent information gathered, including safeguarding concerns, concisely and accurately for clinical management and medico-legal purposes. Documentation must comply with local guidance, legal and professional requirements for confidentiality, data protection and information governance.

j. Interpret and provide preliminary findings for police and social services directly after the assessment to ensure appropriate safeguarding of the child/young person and criminal justice standards are met.

k. Ensure safety through sharing information appropriately, including the analysis of risk, and provide advice to others on appropriate information sharing according to Caldicott principles.

l. Hold others to account and challenge the views or opinions of other professionals when required.

m. Understand how to manage uncertainty, the need to seek further opinion, and the mitigation of risk in these circumstances. 

Capability 6. Clinical examination and procedural skills

The forensic healthcare practitioner must:

1. Undertake immediate or paediatric intermediate life support, as appropriate.

2. Provide any immediate healthcare needs, for example, pain relief.

3. Identify signs of medical illness, psychological illness, non-fatal strangulation and other physical injuries, and determine whether the examination may need to be deferred. Be aware of concerns regarding occult injuries in children, particular those under the age of 2.

4. Ensure the child/young person, family and carers, and other professionals, understand the purpose of the forensic and clinical assessment, physical examination, and/or mental health assessment and sexual health assessment. Describe what will happen, and the role of the chaperone, where applicable.

5. Determine capacity and obtain consent, clearly record if and how consent has been obtained.

6. Arrange the place of examination to give the child/young person privacy and to respect their dignity (and comfort as far as practicable).

7. Adapt the forensic and clinical assessment to meet the needs of infants, children and young people, including those with particular needs (such as neurodevelopmental conditions, cognitive impairment, sensory impairment or learning disability). Recognise where a flexible approach is needed for the examination, particularly in young children, in order to maximise cooperation. Work with chaperones, play specialists etc to support those needs.

8. Apply a range of forensic and clinical assessment and physical examination techniques appropriate to the needs of the child/young person, systematically and effectively. This will include general physical examination and ano-genital examination, using appropriate equipment, for example:

  • Stethoscope
  • Opthalmoscope
  • Auroscope
  • Patella hammer
  • Cuscos speculum of appropriate size
  • Foley catheter
  • Proctoscope
  • Use of camera systems to document bodily and ano-genital injuries.
  • Know when not to use equipment.i

9. Understand normal ano-genital anatomy and undertake an ano-genital examination of pre-pubertal and peri-pubertal male and female children (including Tanner Staging). Use positions and techniques appropriate to the examination of pre-pubertal girls, such as labial traction, flooding the hymen, use of on-lap semi-supine knee chest in very young children, and prone positioning.

10. Undertake an ano-genital examination of post-pubertal males and females. Use appropriate positions and techniques including:

  • modified lithotomy.
  • left lateral and knee chest positions.
  • moistened swab.
  • foley catheters etc.

Understand the range of normal findings, including anal mucosa, midline defects, oestrogenised hymen etc.

11. Understand anatomical variation and recognise and identify abnormalities, for example, female genital mutilation, or other harmful cultural practices, and refer on as appropriate.

12. Be able to undertake a top-to-toe forensic assessment and document injuries, including important negative findings and stages of healing.

13. Undertake a physical examination, utilising equipment where appropriate (to include height, weight and BMI to identify failure to thrive, eating disorders and obesity).

14. Be able to utilise body maps/anatomical diagrams and photo-documentation.

15. Be able to undertake phlebotomy in all ages or facilitate this when required.

16. Be able to conduct a speculum, foley and proctoscope assessment, and use techniques for examining the pre-pubertal hymen such as vaisa manoeuvres, and flooding of the hymen.

17. Apply Locard’s Principles in formulating forensic strategy, utilising personal protective equipment and evidence-based techniques to retrieve the full range of potential evidence, including the evidence base for forensic opportunities.

18. Undertake the collection, handling, storage and maintenance of relevant forensic samples, with regard to chain of evidence and admissibility of evidence.

19. Recognise the need for a systematic approach to clinical examination, identify and accurately interpret signs and absence of signs of child sexual abuse.

20. Identify other categories of abuse, for example:

  • child exploitation.
  • physical, neglect.
  • emotional abuse.
  • perplexing presentations/fabricated or induced illness.

Recognise that concerns such as perplexing presentations/fabricated or induced illness are difficult to assess in a single assessment, and the need for a factual report describing the presentation features of the child/young person.

21. Provide a comprehensive holistic health assessment, and identify and address, where necessary, unmet physical and mental health needs, including developmental delay and other neurodevelopmental conditions.

22. Assess the mental health of the child/young person, including risk assessing for imminent self-harm/suicide risk, recognise physical manifestations of mental health concerns, and determine subsequent appropriate action.

23. Identify the symptoms and signs of alcohol and/or drug intoxication, withdrawal, or overdose. Assess any risk, manage symptoms and take action as appropriate, including the need for the emergency department. Ensure the child/young person remains safe.

24. Be cognisant of the role that drugs and alcohol play in the offence and include in the safeguarding referral. Recognise drug facilitated sexual assault and identify a management plan for those dependent on drugs and alcohol. Utilise relevant assessment tools, for example, Comprehensive Health Assessment for Teens (CHAT) substance misuse assessment or Drug and Alcohol Screening Tool (DUST), as appropriate.

25. Undertake an assessment for the risk of sexually transmitted infections (STI). Consider the time since possible exposure and determine whether an STI screen should be undertaken at the time of the forensic clinical assessment. Utilise a chain of evidence, or arrange for future screening.

26. Undertake screening investigations for blood borne viruses, for example, hepatitis B and hepatitis C, human immunodeficiency virus (HIV), and manage results, liaising with specialist teams. Recommend/prescribe/administer Hepatitis B vaccination courses. Appropriately prescribe HIV post-exposure prophylaxis.

27. Identify pregnancy, assess and discuss options and risk, and appropriately prescribe emergency contraception where necessary (all forms).

28. Be able to manage a new pregnancy diagnosis, understand impact, discuss options including forensic implications and support requirements.

29. Undertake an assessment in a pregnant young person.

30. Provide health promotion that is timely and appropriate to the circumstance.

31. Adhere to statutory and local requirements in relation to the management of medicines.

32. Safely administer, dispense and prescribe medications and treatments relevant to scope of practice, liaising with pharmacy services, as required, including patient group directives (PGDs).

33. Maintain accurate, legible and contemporaneous records of medication prescribed and/or administered and advice given in relation to medicine.

34. Provide relevant feedback and tailored reassurance to the child, young person, their family/carers on conclusion of the examination, and provide feedback in relation to any future management plan made and with consideration given to the wishes of the child/young person.

35. Comprehensively and accurately record all information gathered through assessments, for clinical management and medico-legal evidence, and in compliance with local guidance, legal and professional requirements for confidentiality, data protection and information governance.

36. Accurately document and communicate all additional safeguarding concerns, taking responsibility for ensuring these are communicated or formally referred, according to local policy.

Capability 7. Formulate and communicate a clinical opinion

The forensic healthcare practitioner must:

a. Apply clinical and diagnostic reasoning and utilise knowledge of the evidence base in safeguarding and sexual offences medicine to recognise and interpret signs (including behavioural signs) and absence of signs, of child sexual abuse to aid decision making. Use knowledge of what constitutes normal anatomy, anatomical variants and pathology that may mimic traumatic injury.

b. Apply clinical and diagnostic reasoning to recognise and interpret signs of other aspects of abuse, including physical abuse, neglect, emotional abuse, sexual and/or criminal exploitation.

c. Apply the evidence-base to form professional opinion and explain that evidence base (and limitations) clearly to others such as police, social workers or courts in verbal or written forms.

d. Target further investigations appropriately and efficiently following due process, with an understanding of respective validity, reliability, specificity and sensitivity, and the implications of these limitations.

e. Understand the importance and implications of results and take appropriate action. This may be urgent referral/escalation as in acute, emergency, life threatening situations, or further investigation, treatment or referral.

f. Utilise the expertise of multi-agency, multidisciplinary and multi professional teams to aid in diagnosis where needed, recognising the forensic science regulator guidance to develop a preliminary findings statement at the end of the examination. Arrange a further review if required, to ensure valid conclusion.

g. Formulate a differential diagnosis of presentation, including medical and mental health conditions, as well as forensic considerations.

h. Exercise clinical judgement and select the most likely diagnosis in relation to all information obtained. This may include the use of time as a diagnostic tool where appropriate.

i. Revise hypotheses in the light of additional information and think flexibly around problems, generating functional and safe solutions.

j. Recognise when information/data may be incomplete and take mitigating actions to manage risk appropriately.

k. Be confident in and take responsibility for own decisions whilst being able to recognise when a clinical situation is beyond own capability or competence and escalate appropriately.

l. Be able to utilise a domestic abuse stalking harassment and honour based violence (DASH) risk assessment. Interpret the findings, and refer to the Multi-Agency Risk Assessment Conference (MARAC)

m. Communicate the clinical opinion in a timely and appropriate manner to children, young people, families/carers and other professionals.

Domain C – case management, case review, on-going referral and strategies for managing risk

Introduction

Forensic healthcare practitioners work in collaboration with health, social care and criminal justice colleagues and voluntary organisations. They advise on interventions and formulate and enable the development and implementation of shared management/personalised care/support plans.

Capability 8. Case review and ongoing referral

The forensic healthcare practitioner must:

a. Work collaboratively with other professionals and agencies. Work with children, young people and their families and/or carers when there are safeguarding concerns, physical, psychological, educational and additional needs. Utilise inter-agency and relevant assessment frameworks and child protection assessment processes.

b.Undertake an immediate assessment, including assessment of risk of self-harm and suicide, and provide a management plan, safety plan, onward referral or urgent treatment to children, young people, their families/carers and other professionals, followed by a comprehensive safeguarding report.

c. Be aware of and identify features of exploitation, for example,

  • criminal exploitation.
  • forced labour.
  • sexual exploitation.
  • so-called honour-based violence.

Take appropriate action, for example, a safeguarding referral or notifying the police of immediate danger.

d. Identify and comment on possible physical abuse if injuries are seen. Identify the signs of domestic abuse, understand the impact on the child/young person and undertake a risk assessment as appropriate, taking into account the principles of trauma-informed care. Take action as appropriate.

e. Work as part of a multi-agency/multidisciplinary team to contribute to and formulate appropriately, implemented care management plans to ensure continuity of care and the voice of the child is heard. Make relevant referrals in response to the needs identified by an initial assessment, such as onward referral to specialist services, for example, psychological/therapeutic support for children, young people, their siblings, non-abusing parents, and/or carers.

f. Participate in case reviews, contribute to professional oversight, ensuring the safe and effective management of children, young people and their families/carers. Consider safeguarding and professional curiosity along with the management of non-attenders, those with high risk and complex needs, and where referrals have been declined.

g. Contribute to the management of referrals and queries, and where the child/young person does not attend their ongoing referral appointments, participate in a safeguarding plan.

h. Participate in the management of investigation results, particularly in relation to sexual health. Ensure negative results are communicated as per the consent, and where positive results receive treatment ongoing follow-up is organised. Adhere to local policies and processes in relation to case closure and any follow-up activities in accordance with the commissioned service.

i. Participate in peer review according to local policies and procedures, recognising the Forensic science regulator guidance to quality assure reports.

j. Make direct referrals in a timely manner as indicated by the needs of children and young people with regard to referral criteria.   

Capability 9. Managing clinical complexity and additional risk

The forensic healthcare practitioner must:

a. Apply knowledge of normal developmental milestones for speech/language, gross and fine motor skills, cognition, social development etc. when assessing children/young people with additional needs.

b. Apply knowledge of the processes and legislation for looked after children/young people, children/young people as carers and children/young people with additional needs. Understand the possible impact of a learning disability, or other additional needs on attainment of immediate, medium or longer- term positive outcomes for children and young people.

c. Liaise with other people and agencies involved in the care of children and young people, to determine the most effective and appropriate communication strategies and a shared approach across agencies.

d. Understand the impact of childhood adversity and other social risk factors on children and young people’s neurodevelopment, behaviour and experience of abuse. Work with the multi-agency team to determine how these might be mitigated.

e. Manage all situations where immediate care is needed in and out of hours. Understand how to enable the necessary arrangements for care, make referrals, and construct a safe management plan.

f. Participate in care planning for repeat attenders.

g. Participate in supporting police and social care to develop a strategy to prevent harmful sexual behaviours, particularly where there is a history of sexual abuse.

h. Participate in strategy meetings and court processes, where high risk individuals present to the service, according to commissioning arrangements.

i. Consider utilising specific screening tools, which include screening for post-traumatic stress disorder.  

Domain D – leadership and management, governance, education and research

Introduction

The capabilities for leadership and management, education and research apply to a range of professionals, and are presented in the following Domain D.  

Capability 10. Leadership, management and governance

The forensic healthcare practitioner must:

a. Be able to prioritise appropriately and be well organised with due consideration for colleagues. Be able to carry out both clinical and non-clinical aspects of work and demonstrate effective time management within time constraints.

b. Adhere to organisational policies and processes in relation to information governance, health and safety, including infection control and Forensic Science Regulator guidance. Recognise the highly sensitive nature of the service and the specialist skills required to quality assure.

c. Respond positively, including when services are under pressure, acting in a responsible and considered way to ensure safe practice.

d. Proactively initiate and develop effective relationships, fostering clarity of roles (particularly crisis workers, administrators, and ongoing services) within teams, to encourage productive working.

e. Evaluate own practice and participate in multi-disciplinary service and team evaluation (including audit).

f. Apply knowledge of models of effective clinical supervision and peer support, as appropriate.

g. Actively engage in safeguarding supervision to ensure understanding and keep up to date with the safeguarding environment.

h. Actively engage in regular peer reviews to inform own and other’s practice. Formulate and implement strategies to act on learning and make improvements.

i. Actively seek and be positively responsive to feedback and involvement from children, young people, families, carers, colleagues and other professionals in the co-production of service improvements.

j. Contribute to, where appropriate, new practice and service redesign solutions with others in response to feedback, evaluation, data analysis and service need, working across professional boundaries and broadening sphere of influence.

k. Critically and strategically apply advanced clinical and forensic expertise across professional and service boundaries to enhance quality, reduce unwarranted variation and promote the sharing and adoption of best practice.

l. Demonstrate leadership, as appropriate, resilience and determination, managing situations that are unfamiliar, complex or unpredictable, and seek to inspire confidence.

m. Actively participate in serious incident investigation, safeguarding practice reviews and other reviews, and apply and share the learning.

n. Adhere to the complaints procedure, including the freedom to speak up and the duty of candour.

Capability 11. Education and development

The forensic healthcare practitioner must:

a. Maintain own revalidation and participate in appraisal processes. Critically assess and address own learning needs through the engagement in self-directed learning and participatory sessions. Formulate a personal development plan that reflects the breadth of required on-going professional development.

b. Critically reflect on practice to maximise advanced clinical and forensic skills and knowledge, as well as own potential to lead and develop care and services for children and young people, their families and carers.

c. Actively seek and be open to challenge and feedback on own practice to promote on-going development, including from service users.

d. Regularly promote and utilise clinical supervision for self and others to support and facilitate advanced professional development.

e.  Contribute to a culture of organisational learning, including mandatory and statutory training (to include Level 3 Safeguarding, as a minimum, and PREVENT).

f. Facilitate collaboration of the wider team, actively participate in and support peer review processes to identify individual and team learning and support them to address these, where appropriate.

g. Act as a role model, seeking to instil and develop the confidence of others and actively facilitate their development. Contribute to an environment of growth, learning and, where appropriate, openness.

h. Actively seek to share best practice, knowledge and skills with other members of the team, for example through educational sessions and presentations at meetings.

i. Understand the Human Rights Act in relation to children and young people, be aware of the Sexual Offences Act (2003) (and other emergent legislation, for example Domestic Abuse Act 2021) and understand how to manage disclosure and the specialist interview techniques for children.

j. Understand the measures in the criminal justice system including, video evidence, use of advocates and wider systems for inclusion. 

Capability 12. Quality improvement, research and evidence-based practice

The forensic healthcare practitioner must:

a. Evaluate and audit own and others’ clinical and forensic practice by selecting and applying valid, reliable methods. They must act on the findings by critically appraising and synthesising the outcome and use the results to underpin own practice and to inform that of others.

b. Understand and utilise the evidence of best practice to inform own practice.

c. Be aware of the importance of robust governance systems and contribute to the development and implementation of them, as appropriate.

d. Contribute to and participate in quality improvement initiatives/projects – sharing outcomes and leading change.

e. Disseminate Forensic Science Regulator guidance, including the FFLM 6 monthly update on forensic sampling, best practice research findings and quality improvement projects through appropriate media and forums (for example presentations and peer review research publications).

f. Facilitate collaborative links between clinical and forensic practice. Undertake research through proactive engagement, working as part of multi-agency teams, and networking with academic, clinical and other active researchers.

g. Take a critical approach to identify gaps in the evidence base and its application to practice, alerting appropriate individuals and organisations to these gaps and how they might be addressed in a safe and pragmatic way. This may involve acting as an educator, leader, innovator and contributor to research activity and/or seeking out and applying for research funding.

h. Critically engage in research/quality improvement activity, adhering to good, ethical research practice guidance, so that evidence-based strategies are developed and applied to enhance quality, safety, productivity and value for money.

i. Participate in embedding patient safety in accordance with the Patient Safety Strategy.

Acknowledgements

This framework was commissioned by NHS England and supported by:

  • Kate Davies CBE, Director of Health and Justice, Armed Forces and Sexual Assault Services Commissioning
  • Angelique Whitfield, Performance and Assurance Lead
  • Esther Silva, Sexual Assault and Abuse Programme Lead
  • Rupi Bhandal, Interim Sexual Assault and Abuse Programme Lead

A project steering group, chaired in turn by Esther Silva, Dr Alison Steele, Officer for Child Protection, The Royal College of Paediatrics and Child Health, Dr Cath White, Sexual Offences Lead, Faculty of Forensic and Legal Medicine and Rupi Bhandal, guided the development of the framework. Project management support was provided by Rosemarie Simpson and Colin Wright, senior consultants at Skills for Health.

We are extremely grateful to members of the project steering group for providing their guidance, expertise and support.  Key stakeholder representation on the steering group included the following organisations:

  • Centre of Expertise on Child Sexual Abuse (CSA Centre)
  • NHS England
  • Royal College of Paediatrics and Child Health (RCPCH)
  • Royal College of Nursing (RCN)
  • Skills for Health
  • The Faculty of Forensic and Legal Medicine (FFLM)
  • The Havens Sexual Assault Reference Centre, London
  • The UK Association of Forensic Nurses and Paramedics (UKAFN)

In addition, we wish to thank the 67 respondents to the online consultation survey.

Further detail of how the framework was developed is presented in Appendix 2.

Appendix 1. Education, training and quality standards

Education and training

Educational institutions can use the framework to inform the design of their curricula and the delivery of education, training, and development programmes, including identifying learning outcomes. This will ensure that their learning and development provision contributes to the full range of knowledge to support the capabilities required to ensure forensic healthcare practitioners are safe and effective.

Education and training providers and employers will need to work together to ensure education programme learning outcomes are aligned to identified capabilities within the framework. Learning outcomes must be measurable and objective to ensure learners can demonstrate identified capabilities.

The framework will inform those who design and deliver training and development opportunities to focus on the key capabilities that forensic healthcare practitioners need to achieve and maintain. This in turn, will guide the content to be included and the use of appropriate learning and teaching strategies.

In addition to the capabilities set out in this framework, the training and competency requirements set out in the Forensic Science Regulators ‘Guidance for the assessment, collection and recording of forensic science related evidence in sexual assault examinations’ also apply to the role of a forensic healthcare practitioner who conducts forensic medical examinations in a SARC or custody facility.  The requirements include holding and maintaining records of all training and to undergo competence assessments at defined intervals to ensure that competency has been maintained and is up to date. Further guidance on the assessment and maintenance of ongoing competency is provided in ‘Forensic Science Regulator guidance -The control and avoidance of contamination in forensic medical examinations FSR-G-207’.

Quality standards

The ‘FFLM and RCPCH quality standards for clinicians undertaking paediatric sexual offence medicine (PSOM)’ provide guidelines and recommendations for clinicians undertaking paediatric sexual offence medicine.

“It is essential to have competent clinicians in terms of knowledge, skills and attitudes to understand the needs of the child and to provide safe care for child complainants of alleged sexual abuse, assault and exploitation or where sexual abuse is suspected but no allegations have been made…

Clinicians in PSOM training may come from different backgrounds, so it is essential that the exact period and content of training should be tailored to meet the needs and requirements of the individual clinician with overall outcome: a competent paediatric forensic practitioner.”

The capabilities set out in this framework are aligned with the quality standards to articulate the knowledge, skills, behaviours and qualifications required for paediatric forensic practice.

In addition, the FFLM/RCPCH quality standards provide guidance for:

  • recruitment, for example minimum recommended relevant experience prior to PSOM training
  • initial training
  • workplace-based supervision
  • continuing professional development.

The FFLM quality standards for clinicians undertaking paediatric sexual offence medicine (PSOM) is regularly updated and should be referred to.

Appendix 2. How the framework was developed

Development of the framework was guided by a project steering group representing key stakeholders including forensic healthcare practitioners, Royal Colleges and professional bodies.

A wider stakeholder list was also established to include a more diverse range of organisations and individuals that wished to be updated on the development of the framework and to provide comments or feedback as part of the consultation process.  Individuals were able to register their interest on a project web page.

Initial desk research was undertaken to identify key references, resources and significant themes or issues for consideration – further references and resources continued to be identified during the project (see Appendix 3. Bibliography).

Initial iterations of the framework were developed based on the findings of the desk research and consultation with the project steering group. Subsequently, in September and October 2021 a wider online consultation survey was conducted with a total of 67 respondents. Based on analysis of these survey outcomes further amendments and refinements were undertaken, leading to a final meeting of the project steering group on 15 December 2021.

Appendix 3. Bibliography

Publication reference: PR00160

Date published: 21 August, 2023
Date last updated: 21 August, 2023