3 February 2006
Children’s Commissioner’s Report on Child Safety in Hospitals Released
Children’s Commissioner, Dr Cindy Kiro, has released a report on an investigation carried out by her Office following
incidents where two young children were hospitalised with suspected non-accidental injuries in 2004. These children were
then further abused while in hospital. In both cases, parents were convicted of assault against the child.
“The investigation determined what protocols were in place between key agencies at the time of the incidents at the
hospitals involved. We also looked at those in other District Health Boards nationally and hospitals internationally. We
needed to see what changes were necessary to keep children admitted to hospital with suspected non-accidental injury
where the perpetrator is not known, safe while in hospital.
It is important to have the opportunity to improve procedures and we appreciate the co-operation of all those involved
in the investigation,” said Dr Kiro.
“The ultimate aim was to put forward a model for implementation in all District Health Boards to safeguard these
children in hospital.”
The investigation found that in both incidents, the hospital and CYFS staff did not have clear guidelines or procedures
to follow in those circumstances and that there is a need for a robust inter-agency protocol to respond to situations of
children presenting at hospitals with suspected non-accidental injury where the perpetrator is unknown. The Police, CYFS
and the District Health Boards involved have subsequently made significant changes to improve interagency collaboration.
In addition, the Ministry of Health has reviewed policies and procedures around the security and safety of children in
all District Health Boards. They found that key safety and security arrangements are either in place or are in the
process of being implemented.
“The findings and recommendations of this report are relevant and useful internationally as the investigation found that
there are few international guidelines for keeping a child safe from abuse while in hospital,” said Dr Kiro.
As a result of the investigation, the Children’s Commissioner has made a number of recommendations. These include:
1. That in every instance of admission for a non-accidental injury, the hospital notifies CYFS and the Police.
2. That in all cases where a child is hospitalised as a result of suspected non-accidental injury and there is no clear
indication as to who the perpetrator is, a Place of Safety Warrant is obtained by CYFS.
3. That the child is kept physically safe in the hospital through security measures that protect the child 24 hours a
day every day from unscheduled or unsupervised access.
4. That there is a formal meeting within 24 hours between CYFS, the District Health Board and the Police to discuss the
situation, share information and clarify roles and tasks.
5. That there is a liaison social worker appointed in CYFS whose role is to liaise between CYFS, the hospital and the
Police.
6. That there is on-going training of staff in all key agencies to up-skill staff on the recognition and management of
child abuse.
7. That the National Office of CYFS, the Police and the Ministry of Health formulate Memoranda of Understanding which
clearly establishes the responsibilities, processes and procedures in every hospital.
8. That whenever a child is further injured while in hospital, there shall be an investigation conducted by external
reviewers to consider practice issues, identify any problem areas and, if necessary, formulate protocols and guidelines
to address these problem areas.
9. That any such investigation shall be reported to the Children’s Commissioner both at the start and at the conclusion
of the investigation process.
“It is not intended that children will be separated from parents or caregivers but that in these particular
circumstances, it will be a matter of supervised contact to ensure the safety of the child,” said Dr Kiro.
“Since these incidents, considerable progress has been made to ensure the safety of children in hospitals. The agencies
involved have taken steps to improve interagency collaboration as well as the policies and procedures around children’s
security and safety. Of course, my Office will continue to keep a watching brief on the situation.”
ENDS