A12: Safeguarding Vulnerable Patients

Kristen Steary
Updated: March 2, 2020
Reviewed: 

Child Abuse

Paramedics are legally obligated to report disclosed and/or suspected child abuse.  In British Columbia, a “child” is defined as an individual up to and including 18 years of age.  This obligatory reporting includes physical, psychological/emotional, and sexual abuse; neglect; abandonment; and deprivation of necessary health care.  Reporting is required even if the information obtained is confidential (e.g. related to personal health information divulged in confidence). No actions will be brought against an individual reporting suspicions of child abuse unless the person knowingly reported false information.  Reporting is also required even if the paramedic is aware that a child welfare worker is already involved with the child, as the welfare worker needs to be notified of all events.

When preparing to notify a child welfare worker of suspicions of abuse, gather the following information to convey, when possible:

• the child/youth’s name, age, and location
• whether there are immediate concerns about his/her safety
• what you observed or heard that led to suspicions of abuse
• information about the parent/caregiver
• presence of other siblings, children, or youth who may be at risk
• information about possible witnesses to the alleged abuse

Paramedics are in the unique position of observing children and their family members in the home.  This allows paramedics to collect information about the child’s living conditions and interpersonal relationships with other family members that may not be possible to obtain in hospital.

There are a number of risk factors for abuse, including a history of family violence, caregiver drug/alcohol abuse or mental health issues, poverty, and poor maternal or child health.  Multiple risk factors are often present in affected families.

Indications of Child Abuse

1. Suspicions of Abuse
   1. A parent or caregiver seems unwilling to leave the child alone with paramedics
   2. The child’s behaviour changes when the parent or caregiver is nearby
   3. The child appears nervous, ashamed, or evasive when asked about injuries or relationships
   4. The parent or caregiver delays or does not seek appropriate medical treatment for a child’s injury or illness
2. Physical Abuse
   1. Unusual injury patterns or locations (e.g. burns in the shape of a specific object, grip marks, injuries to a generally protected area such as the neck or trunk)
   2. Bruises or trauma in children who are not yet crawling or walking
   3. An inconsistent or unusual explanation of the injury
3. Psychological/Emotional Abuse
   1. Children witnessing other family members experiencing violence
   2. Diminishing a child’s dignity, identity, or self-worth
   3. Making threats, verbal assaults, insults, or humiliating a child
   4. Isolating or confining the child from others
   5. Emotional harm to a child by the parent’s conduct (e.g. witnessing a parent overdose on drugs or self-harm), where emotional harm is defined as the child demonstrating severe anxiety, depression, withdrawal, and/or self-destructive/aggressive behaviour
4. Sexual Abuse
   1. Torn, stained, or bloody undergarments
   2. Bruising, pain, or itching to genitals or breasts
   3. Sexually transmitted diseases
   4. Unexpected vaginal or anal bleeding
   5. Sexual exploitation by a parent or other person
5. Neglect/Abandonment
   1. A child left alone or unsupervised at an inappropriately early age while the parent is absent or incapacitated (e.g. by consumption of drugs or alcohol), and adequate provisions have not been made for the child’s care
   2. Inappropriate clothing for weather conditions
   3. Failure to provide necessary food or appropriate living conditions
   4. Deprivation of necessary health care, and/or the child is likely to be seriously injured by a treatable condition and the child’s parent/caregiver refuses to allow the child to be treated
      
      

Reporting Suspected Child Abuse

If the child or youth is in immediate danger, call for police attendance.

Suspected child abuse must be promptly reported to a child welfare worker. This is facilitated by calling 1-800-663-9122. This number is answered at all hours of the day. All individuals who suspect, or have knowledge of, child abuse must make a report by calling the child welfare worker. [Insert procedure followed when calling here].

If sexual abuse is suspected, consider transporting the patient to the appropriate facility with forensic capabilities. (LIST FACILITIES) The patient’s clothing should accompany the patient, in separate paper bags where possible.

Notes

Empathy, support, and compassion are crucial when treating a suspected victim of abuse.  Ensure patient privacy when possible.  Explain your concerns prior to asking sensitive questions (e.g. “I’m concerned for your safety”).

Paramedics should only ask victims of suspected child abuse questions necessary for assessment and treatment, and avoid forensic questioning (i.e. excessive questioning about the event or the abuser).  Questioning by inexperienced providers has been demonstrated to later affect the child’s ability to accurately recall the event and potential credibility of the child’s testimony.

If criminal activity is suspected, take measures to prevent disturbance of the crime scene and related evidence.  Ensure thorough documentation of scene details, statements made by the patient and parent/caregiver, and other persons present on scene.

Calls involving suspected abuse and/or interpersonal violence can be challenging for paramedics for various reasons.  Consider contacting the Critical Incident Stress Management (CISM) team at 1-855-969-4321, or the Employee Assistance Program at 1-800-663-1142.

Adult Abuse

Paramedics may report suspected adult abuse to the appropriate agency in British Columbia when it is suspected that an adult is being abused and/or neglected, and is unable to seek support and assistance for him/herself.  This inability may be due to physical restraint; a physical handicap; or an illness, disease, injury, or condition that affects his/her ability to make decisions.  Reporting is permitted even if the information obtained is confidential (e.g. related to personal health information divulged in confidence).  No actions will be brought against an individual reporting suspicions of adult abuse unless the person knowingly reported false information.

Indications of Adult Abuse

1. Suspicions of Abuse
   1. A caregiver seems unwilling to leave the adult alone with paramedics
   2. The adult’s behaviour changes when the caregiver is nearby
   3. The adult appears nervous, ashamed, or evasive when asked about injuries or relationships
   4. The caregiver delays or does not seek appropriate medical treatment for an adult’s injury or illness
2. Physical Abuse
   1. A deliberate act of violence, rough treatment, or use of physical force
   2. Bruises, burns, grip marks, and/or an unusual pattern of injury
   3. Fearfulness, anxiety, or apprehension during interactions with caregiver
3. Psychological/Emotional Abuse
   1. Diminishing an adult’s dignity, identity, or self-worth
   2. Making threats, verbal assaults, insults, or humiliating an adult
   3. Isolating or confining the adult from others, including not allowing him/her to speak with friends or attend appointments
4. Sexual Abuse
   1. Any sexual behaviour directed toward an adult without that adult’s knowledge and/or consent.  
   2. Sexual abuse is a form of physical and emotional control over another person
      1. Signs and symptoms include pain, itching, or bruising around breasts or the genital area; sexually transmitted diseases; vaginal/anal bleeding; depression and/or anxiety; social withdrawal
5. Financial Abuse
   1. Unauthorized or illegal use of another individual’s money or resources for another’s benefit
   2. Possible signs include unpaid bills; lack of money for food, medications, or necessities; refusal of family member or representative to spend money on an individual’s behalf
6. Neglect
   1. Lack of essential daily living needs (food, clothing, shelter, medications, etc) provided by a caregiver to an adult dependent upon him/her
   2. Signs and symptoms include malnourishment; dehydration; inappropriate clothing; under or over-medication; absence of required aids, canes, or walkers; deprivation of necessary health care

Reporting Suspected Abuse

If the adult is in immediate danger, call for police attendance.

Suspected adult abuse can be reported to the following agencies depending on the patient’s residence:

• Fraser Health: 1.877.REACT.08 (1.877.732.2808)
• Interior Health: 1.844.870.4754
• Island Health Authority
  • South Island: 1.888.533.2273
  • Central Island: 1.877.734.4101
  • North Island: 1.866.928.4988
• Northern Health: 1.250.565.7414
• Vancouver Coastal (Providence Health): 1.877.REACT.99 (1.877.732.2899)

If sexual abuse is suspected, consider transporting the patient to the appropriate facility with forensic capabilities.  The patient’s clothing should accompany the patient, in separate paper bags where possible.  In Greater Vancouver, these facilities include Royal Columbian Hospital, Vancouver General Hospital... In Victoria, transport to Victoria General Hospital.

Notes

Empathy, support, and compassion are crucial when treating a suspected victim of abuse.  Ensure patient privacy when possible.  Explain your concerns prior to asking sensitive questions (e.g. “I’m concerned for your safety”).

If criminal activity is suspected, take measures to prevent disturbance of the crime scene and related evidence.  Ensure thorough documentation of scene details, statements made by the patient and caregiver, and other persons present on scene.

Calls involving suspected abuse and/or interpersonal violence can be challenging for paramedics for various reasons.  Consider contacting the Critical Incident Stress Management (CISM) team at 1-855-969-4321, or the Employee Assistance Program at 1-800-663-1142.