Children and Young people (YP) have the right to be protected from abuse, neglect and maltreatment by their parents or anyone else who looks after them (Article29, UNRC).

If staff have concerns that a child/YP/pregnant woman is unseen they have a responsibility to take action until they are satisfied that the child/YP/Unborn is not at risk of significant harm.

This policy has been developed to assist practitioners in determining the most appropriate course of action to take in situations where the child/YP/pregnant woman is ‘unseen’.

This document is intended to be used in conjunction with the Scottish Borders Child Protection Procedures.

1 The unseen child/Young Person/Unborn Child may result from the following:

• Address unknown
• Staff cannot gain access to the child/YP/pregnant woman/family
• There is a pattern of a child/YP/ante-natal mother not being brought to or not attending health appointments and/or not being seen by any other professional, including GP
• Refusal of a service
• Resistance and disguised compliance
• Mobile or travelling families
• No access visits
  Examples:
  • When a health professional has been invited into the home, but the child/YP/pregnant woman is not physically seen (child is said to be asleep and not to be disturbed, or in the care of others, not in the house)
  • Denied access visits – when the door is opened by the carer in charge and the professional is refused access
  • No access visit – when a visit is arranged but no one is at home

2 Non-Engagement/Non-Compliance
Resistance and disguised compliance, usually meaning disguised non-compliance or non-effective compliance, are the terms often used when services find it hard to engage with families (National Guidance for Child Protection 2021).

Within Child Protection,’ resistance’ is broadly acknowledged as ‘non-engagement and/or non-compliance from one or both parents/carer(s) and can describe a range of behaviours and attitudes, such as:

• Failure to enable necessary contact (for example missing appointments) or refusing to allow access to the child or to the home.
• Active non-compliance with the actions set out in the Child’s Plan (or Child Protection Plan). Such as, cancelling/missing appointments and/or meetings and not engaging in programmes of work.
  • Disguised compliance, where the parent/carer appears to co-operate without actually carrying out actions or enabling them to be effective.
  • Threats of violence or other intimidation towards practitioners.

Understanding the resistant behaviour and what underlies this, is important as this will contribute to the assessment of risk for the child/YP/Unborn and ultimately will support in addressing this resistant behaviour with the family. It may be a result of a number of influencing factors, including background; experiences; fear; lack of trust; confidence and parenting capabilities.

3 Concerns about children and young people
According to the Children (Scotland) Act 1995, Section 93, a child is in need if he or she is in need of care and attention because:

1. He or she is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development unless the local authority provides services for him under Part II or the Act.
2. His or her health or development is likely significantly to be impaired, unless such services are so provided
3. He or she is disabled.
4. He or she is affected adversely by the disability of any other person in his or her family.

Persistent failure in engagement can contribute to significant harm of children (Care Inspectorate 2019).

Staff should recognise when the family is not engaging so as to avoid
collusion or avoidance – early recognition of resistance and failure to achieve progress with plans and agreements for the child is essential. Where non-compliance, disguised compliance or resistance is an issue, it is important to appreciate the significance for the child living in the family.

Protecting children means recognising when to be concerned about their safety and understanding, when and how to share these concerns, how to investigate and assess such concerns and fundamentally, what steps are required to ensure the child’s safety and well-being (Scottish Government, 2021)

Services have a responsibility to identify how this policy will be implemented within their own clinical areas. Services also have a responsibility to make best use of patient information systems.

All NHS Borders staff who regularly comes into contact with children and
families during the course of their work must attend training in child protection in line with the Scottish Borders Joint Learning and Development framework and strategy.

Further advice and information about policies/procedures and training to
support child protection practice within NHS Borders, can be found on the
NHS Borders Child Protection intranet pages.

Any NHSB staff involved with a child/young person/pregnant woman (unborn child) where there is a pattern of non-attendance for health appointments or they cannot gain access to the home to see the child/young person/family should take the following actions:

1New referrals or child/YP/pregnant woman not previously seen by a service

• Check address and contact details are correct (check with Child Health Department, BGH)
• Check available information for any indication of concerns
• If there are no concerns then follow clinical service’s Did Not Attend (DNA)/Child Not Brought policy
• If concerns are identified inform referrer and take further action (see Appendix 1)
• Document in child’s record (if recording on EMIS, send task to health professionals involved to share information)

2 All other DNA/Child Not Brought or No Access Visits (see Appendix 1 for flow chart)

As per 4.1 and in addition:

• Review the known facts for the not brought/no access visit and the risk to the child/YP/ pregnant woman’s (Unborn) health and well-being. The following 5 questions identified within ‘Getting it Right for Every Child’ (GIRFEC) are a useful guide:
  • What is getting in the way of this child/young person/unborn’s
    well-being?
  • Do I have all the information I need to help this child/young
    person/unborn?
  • What can I do now to help this child/young person/unborn?
  • What can my agency do to help this child/young person/unborn?
  • What additional help, if any, may be needed from others?

Additionally ask the 5 Risk Questions:

• What has been happening?
• What is happening now?
• What might happen?
• How likely is it?
• How serious would it be?

• Consider any factors that may be preventing access/engagement (e.g. is the time and place mutually convenient, is the location acceptable to the child, young person, pregnant woman or family, financial hardship, domestic abuse).
• Are there any known difficulties regarding literacy, language or
  communication.
• Review relevant health records / electronic systems as appropriate to establish if there is any information that would suggest increased vulnerability / risk.
• Assess the possible risk - see suggested assessment tools on Child
  Protection intranet pages or National Risk Framework to Support the Assessment of Children and Young People.
• Ensure that the chronology is up-to-date.
• Arrange another appointment with the pregnant woman or family via appropriate communications – check address is up-to-date (e.g. letters, cards, texts, e-mail)
• For all No Access visits leave written communication stating you have called as arranged, with contact details and record action in
  child/YP/pregnant woman’s case notes.
• Monitor the situation by regular liaison with other professionals who are in contact with the child/YP/pregnant woman/family (e.g. General Practitioner, Playgroup, Nursery, Family Centre, School, School Nurse, Health Visitor, FNP, mental health services) to establish the child/YP/pregnant woman has been seen recently and if there are any current concerns.
• If it appears that a family have moved to an unknown address, all
  efforts should be made to identify the new address.
• Persist in efforts to make contact until satisfied there is not a risk of significant harm.
• Contact your line manager or NHS Borders Public Protection Team for further advice.

Assessment of information from 4.1 and 4.2 indicates concerns:

This may indicate a child/YP/Unborn needs are not being met or that the child is at increasing risk. If you have a concern you must ensure that the child/YP/Pregnant woman is seen.

• If there are concerns that a child/YP/Unborn is at risk of harm, refer to the Children & Families Duty Social Work Team as per Child Protection Procedures.
• Seek advice and guidance from Child Protection Nurse (01896 664580)
• For children/unborn on the Child Protection Register, contact the child’s social worker and confirm the discussion and action agreed with the Social Worker. If the child’s social worker is unavailable, ask to speak to the Social Work Team Leader. Ensure communication and actions are documented in the child/YP/pregnant woman’s record.
• Inform other relevant professionals who are involved with child/YP/pregnant woman and family health, of concerns and the action taken.
• If there is an immediate concern/risk to the child/ren, contact the Police.
• Consider if this meets criteria for a missing family and follow NHSB missing family Policy.
• Prior to raising a Missing Family Alert (MFA)/risk of flight for pregnant woman, discuss with NHSB Public Protection Team who will agree the appropriateness of raising a NHS Scotland Missing Family Alert Form (MFA1).

Every child has the right to the best possible health (Article 29, UNRC).

Under the Age of Legal Capacity Act 1991, those under 16 may consent to medical treatment if, in the health professional’s opinion, they are capable of understanding the nature and possible health consequences of the procedure or treatment. Equally children and young people may have capacity to withhold/withdraw consent even if their parents want them to. See the NHS Borders Consent to Treatment Policy for further information.

In circumstances where children are denied these services by their
parents/carers, health professionals should assess all available information. It is advised that professionals consider each individual child’s circumstances and the likely implications of the failure to receive appropriate services. (NOTE: Babies and very young children are particularly vulnerable).

Professionals should take steps to ensure that parents are able to make informed choices and be flexible in negotiating alternative means of offering services.

Where services would normally be accessed in a clinic, a surgery or school, consideration should be given to home visits as an alternative means of offering services. Children who are persistently missing from school or who have been excluded may require home visits to facilitate uptake of services.

If parents/carers continue to fail to engage and there are concerns that the child’s health and development may be significantly impaired as a result of this, referral should be to the ICS Locality Team in which the child lives.

Refusal of Prescribed Treatment

Where parents, the child/YP or others refuse, withdraw or actively withhold commonly available foods or fluids, or fail to co-operate with prescribed medical or therapeutic treatment such that a child suffers, or is likely to suffer significant harm, or neglect, a Referral should be made immediately to the Children & Families Duty Social Work Team as per the Scottish Borders Child Protection Procedures.

Attempts may be made to justify the above neglect on some basis, for
example:

• The religion of the child/parent/carer
• Cultural expectations
• Disability of the child including learning difficulties

These attempts may be misguidedly believed to be in the child’s best
interests. Such information and reasons do not change the legal duties of all agencies to protect the child’s best interests, which may result in NHS Borders or Scottish Borders Council taking legal advice.

For further information refer to the Scottish Borders Child Protection
Procedures under the category of physical neglect.

In circumstances where children are repeatedly denied access to routine health services designed to promote their health and development, health professionals should ensure when communicating with parents/carers that they give sufficient information about the importance of the services to their child, outlining alternative means of provision and enabling them to make informed choices.

It is important for professionals to demonstrate that they are seeking
opportunities to work in partnership with parents in order to achieve good outcomes for the child.

Legally, it is important to have written evidence to prove that you have
attempted to gain co-operation with parents/carers in the routine delivery of services. The following information should be documented:

• The number of contacts / appointments not attended, including the dates and times (e.g. home visits, clinic / hospital appointments, phone calls).
• Information provided to parents/carers.

Consider referral to Children & Families Social Work and/or Meeting Around the Child/pre-birth MAC to discuss issues and possible solutions to engaging and supporting family

Management of the unseen child/YP/unborn flow chart (PDF)

Letter to family template (PDF)