Legislation in all provinces and territories mandates physicians to report suspected child abuse to child protection agencies when there are reasonable grounds to believe or suspect that a child has been or is being abused, or is at risk of abuse. Child abuse may be emotional, physical, or mental in origin and may include involvement in child pornography.
Although the CMPA is aware of some cases in which physicians have been the subject of complaints to regulatory authorities (Colleges) or legal actions for having made a report, concerns about potential medico-legal difficulties must not discourage physicians from fulfilling their statutory obligation to report reasonable concerns of abuse. Physicians who fail to meet their responsibility to report suspected child abuse in a timely manner may be subject to legal sanction by their College.
In the CMPA's experience, Colleges and courts are rarely critical of a physician's good faith decision to report suspected abuse. While courts have indicated that individuals who report suspected child abuse must act responsibly and avoid unfounded damaging reports, physicians are generally protected from legal liability when the report is made in accordance with the legislation, in good faith, and without malice. Physicians who report abuse may still face a legal action and be required to participate in court proceedings. Yet, the risks to patients experiencing abuse are greater than the medico-legal risks.
During a 10-year period (2002-2011), 28 medico-legal matters were opened by the CMPA related to a physician's reporting of suspected child abuse. Family physicians, pediatricians, and psychiatrists were most often involved. The majority (71%) of these cases involved complaints to a hospital or College, while the remainder (29%) involved threats of or actual legal actions. In the majority of cases, caregivers were upset with their family having been reported to a child protection agency. The typical allegation was that the concerns were reported without supporting evidence or based on misinterpreted physical findings. Nevertheless, the large majority of cases had a favourable medico-legal outcome for members.
The threshold for reporting suspected child abuse is based on a reasonable suspicion or belief, not actual proof of abuse. Physicians are not required to know for certain that the situation represents abuse, nor do they necessarily need to know the identity of the alleged abuser. The duty generally applies even if the physician is aware that similar concerns have already been reported by another person.
A previously well 18-month-old male was brought to his family physician by his mother.
The physician was concerned about penile bruising and buttock bruising for which the mother had no explanation. The mother raised the possibility that the injuries were sustained at daycare. Unable to find a medical explanation, the family physician consulted with a pediatrician. Before assessing the child, the pediatrician advised the family physician to report her concerns to the local child protection authority.
After her evaluation, the pediatrician also had concerns about the injuries. She discussed this with the child's mother and advised that further medical testing was necessary. She made a report to the child protection authorities, advising that in-hospital evaluations would take place the following day. Later that evening, RCMP officers accompanied the child protection worker to the family home to conduct an investigation. The child protection worker advised the parents they could not be alone with the child until such time as the medical and social investigations were completed. The family had to arrange for in-house supervision and the child underwent an extensive medical workup over the ensuing days. No other injuries were found and the pediatrician provided a report to the child protection worker stating the bruises were concerning but that no conclusions could be drawn as to their origin.
The mother complained to the College, alleging that the physicians overreacted. She alleged that the medical investigations were excessive, had unduly exposed her and her child to diagnostic radiation, and required her to take time off work to comply with medical testing and attend interviews by child protection authorities.
The College dismissed the complaint against both physicians, acknowledging they had acted in the best interests of the child and in accordance with their legal obligation to report suspected abuse.
Making a report
It is understandable that some physicians may question whether their concerns are reasonable and meet the threshold for reporting.
Physicians who are unfamiliar with reporting child abuse and who have concerns about suspected abuse should call the CMPA for advice on their obligations in this regard. The CMPA's medical officers can help members through the decision-making process. They can also inform members of the appropriate agency to whom a report should be made and review the steps to help minimize the chance of a complaint or legal action. In general, member physicians are encouraged to carefully consider all of the relevant facts and the specific legal and ethical obligations applicable in the circumstances.
Although the legislation varies among jurisdictions, reports must generally be made to child protection authorities. However, physicians may choose to report to the police in circumstances where they have reason to believe there is an imminent risk of serious bodily harm or death to a child.
Physicians who have reason to believe a child is in need of protection are responsible for seeing that the appropriate authority is informed in a timely manner. A child should not be put at risk by any unnecessary delay or delegation of the act of reporting.
A carefully planned approach with the family is helpful. Discussing in a professional, straightforward, and sensitive way, the duty and threshold for reporting, and the importance for the child, may help physicians maintain a positive relationship with the family. While it is generally preferable to be honest and transparent in these circumstances, it may not always be appropriate to inform caregivers in advance of the decision to report. Consider the safety of all those involved including the child, other family members (e.g. other siblings), the physician, and the physician's staff.
A suspicion or belief of child abuse may come as a surprise to some families. Physicians are not responsible for determining the identity of the perpetrator of the alleged abuse. They should avoid drawing unwarranted conclusions and remain professional, objective, and nonjudgmental in making the report and in discussions with the family.
Physicians should consider communicating the following information to the family, when appropriate:
- the nature of, and reasons for, the concerns
- the statutory duty to report, emphasizing that it is not discretionary
- the threshold for reporting, which is based on suspicion or belief of abuse or the risk of abuse, even if it is unproven
- the intent of the report, which is not to be judgmental, but rather a general legal requirement in the interest of the safety of children
- the physician's role, which is limited to factually reporting concerns to the child protection authorities, and not to legally investigate
Physicians should document in the patient's medical record the concerns, discussions with family members and others, and reasons for the decision of whether to report. Discussions with child protection authorities and others in the context of making the report should also be documented. Accurate documentation can be important in establishing the facts at a later time, if necessary.
Being the subject of a report of suspected child abuse is difficult for families. If appropriate and once emotions have settled, physicians may consider offering ongoing support for the family. For example, consider whether a trust relationship still exists with the family that will allow the physician to continue to provide care to the child and other family members. Some families who resent the physician for having reported to child protection authorities may complain to the hospital or the College. In rare cases, the family may commence a legal action.
Members should contact the CMPA if they have questions or need assistance related to the duty to report child abuse, or if faced with a complaint, legal action, or threat.
Relevant information only
Physicians should provide only relevant information necessary to make a proper report, including the facts and circumstances that gave rise to the belief or suspicion of abuse.
While privacy legislation may permit physicians to disclose patient information in certain circumstances, it does not relieve physicians from their general obligations regarding patient confidentiality. In response to requests from child protection authorities or the police for additional clinical information, the physician should determine what information the authorities are legally entitled to receive. In most jurisdictions, child protection agencies are not entitled to a copy of the clinical record without appropriate authorization. In these circumstances, the physician may wish to advise the child protection agency that, while prepared to cooperate, he or she is not able to provide the requested information without the consent of the patient (or legal guardian) or a court order. Physicians are encouraged to contact the CMPA for advice on responding to such requests.