Role of medical practitioners in prevention and investigation of violence against children, and need to strengthen interdisciplinary cooperation in Latvia

Attempts to promote interinstitutional cooperation and reduce the likelihood of secondary victimisation of victims with greater or lesser success are ongoing. Some time ago, an international project called ‘Form a Chain’ was introduced (at the level of the European Union (EU)), whose main aim was to establish a chain of cooperation between different national and international authorities, with a focus to encourage the protection of the child's interests. In 2017, ‘Dardedze’ was started as the pilot project whose aim was to implement the Barnahus model in Latvia (CBSS Expert Group on Children at Risk, Barnahus model, 2022). The model provides implementation of interdisciplinary and interinstitutional cooperation that works in the best interests of the child victim to minimise the possibility of re-victimisation. At the same time, a qualitative recording of evidence with modern methods was be carried out. Overall, the results of the pilot project were successful and 22 children received assistance during the 6-month period (Dardedze, 2022). The project highlighted the measures needed to fully implement the Barnahus model in Latvia – with increased and legally regulated involvement of medical workers and the exchange of high-quality data between institutions. Therefore, the new project started in 2021 with the aim to implement this idea with sustainable results (EEA Project, Support to the Implementation of Barnahus in Latvia, 2023). The experience of bringing together the expertise of all professionals under the auspices of one institution is widely known in other Member States of the EU, especially in medical institutions. In Finland, for example, Barnahus is directly under the wing of the Helsinki Children's Hospital, which makes it possible to maximise the support and knowledge of medical workers. The primary institution where Latvian children arrive with health issues of different natures is the CCUH.

In 2018, the CCUH registered 96 cases of physical violence against children and 60 cases in 2019. Suspicion of sexual abuse was identified in 11 cases in 2018 and in 20 cases in 2019. Emotional violence was identified in 60 cases in 2018 and in 64 cases in 2019. The lack of neglect/care has been identified in 223 cases (2018) and 222 cases (2019). In total, there were 390 cases reported during 2018 and 366 cases in 2019. Today, according to the latest information gathered, the number of problems identified in 2020 is 374, while the 2021 figures reach 508 cases per year, indicating that the situation is likely to be affected by COVID and the overall world security situation. There is an increase in cases of sexual abuse (11 cases more), emotional violence (55 cases more) and abandonment cases (71 cases more). These data are limited only to CCUH (CUHH database, 2023). To get a complete picture of the situation, we need data from hospitals in other regions, which are not available. One of our biggest stumbling stones when tracking down cases of violence is when a child changes his place of residence.

It should also be noted that in CCUH, the number of identified problems is recorded and not the number of victims. For example, if a child has suffered from physical and emotional violence, two cases are recorded. In order to obtain accurate figures on the number of victims, information should be analysed using a personal identity number.

Apart from the data on physical and sexual abuse, it is mentioned during interviews with social service workers at CCUH that, abandonment is a social problem that has not abated over the years. There are many children who come to CCUH from disadvantaged families, whose rights to care for children have already been taken away. This contributes to the emergence of a variety of problems relating to the rights of children, which go not only to CCUH, but also to other institutions. From a medical and prevention point of view, the initial observation of the situation in risk families should start at a time when a mother, who has previously been deprived of the right to care for her oldest children, is pregnant with the next child and is on maternity leave.

There is no single database in the country's medical establishments that compiles statistics on violence (Shaw, M., & De Jong, M.) The practice of each regional hospital is also different. According to the size of the data and information provided during interviews with medical workers, the most common form of violence is neglect and lack of care, often accompanied by physical violence, which often leads to emotional and/or sexual violence. It is concluded that both medical workers and social workers should give increased attention to identify any signs and symptoms that could indicate a lack of adequate care and supervision (Sokol RL, Victor BG, Mariscal ES, et.el. 2021). In the context of the pursuit of preventive action as quickly as possible, it is important that they take place at the earliest possible stage with interinstitutional cooperation, the use of modern technologies, and if necessary, with use of databases to identify potential child violence. It is also important to understand the data security and privacy policy that is protected by the Personal Data Protection Law.

Latvia, as a full member of the UN, the CoE and the EU, has undertaken international commitments to respect and promote the protection of children's rights. The basic document at the UN level is The Convention on the Rights of the Child (1989), which lays down the main principles of working towards the best interests of the child and without discrimination. It sounds simple, but the introduction of this principle in life is not so easy and is unambiguous.

Other international legislations that are worth mentioning are the CoE Convention on Protection of Children against Sexual Exploitation and Sexual Abuse (Lanzarote Convention), which provides for specific measures and the State's obligation to encourage prevention of such types of offence, with the help of interdisciplinary and interinstitutional cooperation and prevent re-victimisation of children. One of them is the Barnahus model. Directive 2012/29/EU of the European Parliament and of the Council and Directive 2011/93/EU of the European Parliament and of the Council on combating sexual abuse and sexual exploitation of children and child pornography also states to provide responsibility in legislation, conduct prevention measures, investigation into cases of violence that have occurred, and the need for professional, legal and psychological assistance and support to children affected by violence.

According to the Medical Treatment Act, the primary duty of medical workers is to provide the child first, with medical treatment and to take care of his or her state of health.

The Law on the Protection of Children's Rights (Sections 51 and 73) states that any person has an obligation to report to the police or another competent person about violence or other child-related criminal offences. At the national level, this information is neither listed nor analysed in a unified way. Such data are recorded by the police within the framework of the investigation, but are not separately listed or analysed. In 2013, Dardedze conducted research to find out who reported sexual abuse cases – a medical worker, social worker, educator, family or another person. The results showed that only in 3.1% of cases, it was reported by a medical worker.

In addition to the Medical Treatment Law, the Ministry of Health (Ministry of Health, 2019) has developed guidelines to recognise violence against children (hereinafter Guidelines). Following the current guidelines developed by the Ministry of Health, medics have to watch for multiple signs that may indicate alleged negligence or violence from parents:

Reduced weight, delayed development, frequent health problems. During the interviews, it was revealed that children often come to the CCUH with various types of severe health problems. This information is used to assess the existence of signs of violence. If the signs are obvious, then the State Police, Social Services and Orphan's and Custody Court are immediately involved. However, there is no unified system where you can see whether a child came to a medical institution with repeated injuries. The question here is not only about the existence of information in the CCUH electronic system, but also about the possibility of analysing and viewing these data in the long term; for example, in cases where the mother (a paramedic by profession) took targeted action against the life and health of children (the mother is currently in custody). The children had repeatedly come to CCUH for help with various symptoms. The symptoms were nonspecific and it took a while to diagnose them. In this case, CCUH placed more emphasis on cooperation between medical workers; however, there is no mandatory nature for this. There are professionals in CCUH who have skills in recognising cases of violence, but these are very few in the country overall. We require regular training in all regions of Latvia.

At the same time, there is a responsibility and obligation to report suspected violence as per Section 51, Paragraph 3 and Section 73 of the Law on the Protection of the Children's Rights. It is required to notify the relevant institutions within a day. For the time being, the Law defines the responsibility for information, but does not specify a penalty for non-reporting or for the failure to inform the relevant institutions. At the end of 2019, the Ombudsman directed the Human Rights and Public Affairs Committee of Saeima to assess the need to foresee administrative responsibility (warning or fine) for non-reporting.

Interviewing doctors revealed information about cases in which families avoid supervision from general practitioners by regularly changing their residence. There are also situations in which a child does not attend a pre-school until the mandatory starting age. This aspect is particularly highlighted by experienced children's rights protection professionals. Since it is not possible to observe a child daily at pre-school and there is no other information available about the family, general practitioners are the only ones who have the opportunity to observe the child and find out more about him and his development and identify suspicious cases. In big cities, where general practitioners are overloaded, there may be situations where signs are not noticed.

The child has undeveloped language, communication skills and social skills that do not match his age. It is not evidence of violence on its own, but it may be an indication of neglect.

General practitioners working in rural areas have a special role to play. It is important to notice potential youth risk groups, which could become victims for any criminal offence (e.g. involvement in human trafficking).

Medics and police officers have mentioned that social care facilities and any closed-type medical institutions are special and separate risk groups. They are a world of their own, with their own rules and, unfortunately, there are also groups of people who have not been specifically protected, who cannot defend themselves and recognise their rights. It is these children and young people who are often at risk of violence. The preventive role here is for teachers and medical workers who work in institutions, but unfortunately in practice there have been cases where employees fail to notice what is happening, or look the other way. There are also situations in which the head of an institution considers the reputation of the institution more important than the well-being of a child. If the officials of the institution identify a violence-related event, the manager will do anything to avoid it from going public, or influence the investigation process. In closed-type institutions, violence occurs not only towards children, but also against educators and employees (Barkans, 2019).

Specialists in CCUH regularly participate in various training programmes on how to recognise and report cases of violence. Internal rules were adopted on 27 May 2014 (CCHD internal regulations to recognise and report cases of violence, 2014). They demonstrate how the institution takes care that reporting on violence and prevention of violence are embedded in their daily processes, thereby guaranteeing the best possible outcome for the child.

The procedures have been developed in accordance with the Medical Treatment Law (adopted on 12.06.1997), the Law on the Protection of the Children's Rights (adopted on 19.06.1998), the Law on the Rights of Patients (adopted on 17.12.2009) and other laws of the LR.

The duties of the personnel are as follow:

To inform the doctor;

After reasonable suspicion that a child has suffered from violence, the doctor's responsibility is to notify the State Police within 24 hours and record the case into the electronic system of CCUH. If necessary, a code is also assigned from the internal system, Andromeda (please see the following section). A clinical psychologist is assigned. CCUH social workers should be informed, who should notify the Orphan's and Custody Court and social services. The future responsibility of the family is then transferred to the local municipality and support services, which provide social rehabilitation, if necessary. When a child needs to find a place to stay outside the family, responsibility lies on the shoulders of CCUH social services. In the interviews were mentioned cases where the child is returned to the family with concerns and legitimate suspicion that violence may continue. The Orphan's and Custody Court decides to leave or remove a child from the family.

There has been developed a list of over 40 signs that can indicate violence towards a child. These signs are most commonly observed directly by the nursing staff who perform day-to-day procedures and supervision at the hospital, and report them to the doctor. There was a case in CCUH where a child had seizures of uncertain origin and the nurse recognised the connection between the mother's visits and the deterioration of the child's health. She was adding drugs to the child's food.

In cases of physical violence, experienced medical workers recognise the nature and localisation of damage if it does not correspond to the injury or to the problem of a child.

At CCUH, it is a regular practice to record and monitor every head injury, especially if it is a recurring injury.

Employees also observe the response of parents when they act inappropriately to a situation, that is, deny violence. Some parents do not seek medical treatment, or use different medical institutions. In a number of cases where a child has suffered from physical or sexual abuse, the family changed general practitioners.

The available studies show that only less than 1/10 of victims are prepared to address sexual abuse and report violence. The situation is gradually improving, and children are encouraged to use different hotlines. Despite the fact that phone calls are anonymous, their availability stimulates children to turn for help and allows them to be understood and listened to. It is concluded that recognition of violence is a set of skills, experience and knowledge that medical workers must possess.

CCUH's emergency services provide first aid and issue electronic patient cards for a child in Andromeda. On suspicion of violence, a special code is recorded in the system, indicating possible violence and the need for other medics or police to be involved.

CCUH's Emergency officers are trained to recognise signs of violence and take appropriate action to notify the relevant services. The primary responsibility to report violence is on doctors. In the case of signs of violence, the doctor should inform the police, who then decides to take further action. There have been cases in which parents have acted with aggression towards doctors who reported violence to authorities. Doctors had to give repeated testimony in serious cases and take time off patients and their family. The question is not about wanting to report and/or to give evidence, but about the effective use of medical information already provided initially. It is even harder in repeated cases, which is also a proved fact that it is very typical for cases of sexual violence and also proved by the study of the State police of Latvia (Landmane D, Rinkevics A, Einats K, 2019).

There are instances in which medics are consulting with each other to minimise the possibility of erroneous reporting when the signs are not clear. In dubious cases, it is difficult to make a decision about whether to inform the authorities. Everyone who is involved in the child's care in CCUH can see the treatment history and make informed decisions. The question is what information should be passed on to the authorities. Medical staff have reiterated that, even if their assistance is not needed anymore, it would be good to have feedback from authorities about the child's welfare and what actions have been taken to prevent further endangerment to the child.

According to medical staff, the time of arrival of a forensic expert to CCUH is different. There are times when a forensic expert arrives immediately and sometimes it takes several days.

There are two types of forensic experts: a duty forensic expert who (employee of the State Police) and a State Center of Forensic Medicine (Ministry of Health), who works in cases where criminal proceedings have already been initiated. Forensic experts have received basic training on how to work with victims of violence, but not all experts are specialised in these matters. In cases of sexual abuse, every word or activity can play an important role.

In relation to the time of arrival, there are cases where an expert is said not to be driving in the near future because the victim has died or a girl who has been sexually abused has a period. In the meantime, wounds would have already healed and evidence has been partially lost.

Another question is whether photographs and other evidence recorded by medical workers can be used as evidence in criminal proceedings. At the moment, these kinds of photographs are taken with private photo cameras and can be easily challenged in court during testimony. What if there was a possibility in creating a single internal system with which photographs are taken, that is, a photo camera would be placed at the disposal of CCUH and photographs can be used as evidence in criminal proceedings. Doctors can record evidence in writing as well, describing the symptoms and their manifestations.

Legislative changes may also be needed. According to the CCUH internal guidelines on “Sexual violence against girls. Emergency recommendations” there is already a system that allows medical workers to take DNA samples, if this is necessary, for wound processing. However, these guidelines apply only to girls and not to boys. This is somewhat surprising, as hospital staff clearly face cases of violence against children of both sexes. Assistance to boys should be provided by urologists or surgeons, and all the same internal procedures should be applied in practice, but are not specified in the guidelines. A document in the annex to the study states recommendations that could be included in such guidelines.

The role of SEMS is to provide first medical treatment and, if necessary, to deliver the child to a nearby medical institution. Following the first medical treatment, an entry is made in the SEMS database. The databases between different medical institutions are not connected, but the data can be obtained on request. The SEMS database contains information about all the residents of Latvia. It can be a very useful source of information for the police or forensic experts during investigation.

It should be mentioned that ambulances are the ones who see the place of residence and are able to assess the circumstances of the event immediately after the situation. Conditions at the place of residence can be an indicator and proof of possible violence, such as scattered chairs, smashed dishes or the smell of alcohol. Availability of such information is essential for investigation.

SEMS has internal guidelines for the recognition of violence, and they are very detailed. These documents contain information on how to act in situations when there are signs of violence at the site of emergency. One of the recommendations is to be on good terms with the perpetrator and gain their trust in order to help the victim as much as possible, and bring the child to the hospital. At the same time, medical personnel are asked to observe the relationship between them, the tone of voice, gestures, movements and the attitude of adults to the event itself.

Codes are also applied, similar to CCUH, but they are not the same. It would be more useful if all medical institutions and authorities had unified codes and systems.

There is a totally different situation in Latvia's regions. The issue is that institutions do not exchange information between themselves, even if they work in the same field (e.g. social workers in different cities), not to mention cases in which information needs to be requested from authorities in another field. Everything is often dictated by the human aspect. Some of this sensitive patient information is protected by the Data Protection Regulation. Personal sensitive data are protected and medical data are used only to the extent that it is necessary to provide medical assistance. And yet, the situation of medical data on the identification and prevention of potential violence may prove to be very different. Especially when it comes to child violence. If the data are in the hands of a skilled and knowledgeable paramedic, police officer and forensic expert, and they suspect violence against children, any previous records or extracts of a patient's health status may make a significant contribution to the investigation of the case.

In addition to data protection and patient safety, Cabinet Regulation No. 60 on mandatory requirements for medical treatment institutions and their departments, in paragraph 17.5. asks for a patient safety system. The specialist who supervises it may be in full-time or part-time employment. This position ensures quality monitoring and monitoring of the effectiveness of internal processes in medical establishments. Paragraph 17.5 introduces and maintains a system for the safety and reporting of non-identifiable internal patients, which provides for the collection and analysis of information on cases that could lead to health-related harm to the patient and risk mitigation measures in order to reduce the likelihood of recurrence of relevant cases and to ensure feedback in the case of patient safety medical practitioners. Specialists working in regional hospitals are aware of child violence issues and may pay additional attention to their identification and internal accounting within the institution.

The hospital's discharge documents are given ‘on hand’, which means that there may be a situation in which a general practitioner or other specialists may not even know about it. In cases of violence this information is essential.

The guidelines developed by the Ministry of Health for the recognition of violence have been specifically applied to general practitioners whose records include minors. Doctors are aware of them and abide by them.

According to interviewers, mostly in the practice of general practitioners, the patient's cards are written by hand. Use of electronic systems is not mandatory. For example, data systems provided by Micronetwork Ltd. and databases such as Blue Bridge and Professional Document. eHealth is mainly used to prescribe prescriptions and sick-leave certificates. Recently, the possibility of sending a patient through eHealth to examinations and writing assignments to other institutions has also started working. According to interviewers, eHealth currently offers very little of the opportunities that were mentioned when this project started. As mentioned above, if a patient is discharged from a regional hospital, general practitioners may not be aware of this, while professionals at CCUH say that they inform general practitioners about the treatments in their hospital.

Regarding the situation in the regions, the positive aspect is that people know each other and it is difficult not to see or know about the violations. Positive cooperation with social services and other institutions is mentioned. It is also mentioned that an experienced doctor will always pay additional attention to a family that has changed residence or to families with several half-siblings. In the context of reporting violence, information is mostly passed to social services and the police is not involved immediately.

During interviews, it was reiterated that medics needed feedback on what had happened to the child and that he/she would be given all the necessary help.

It is also important to have correct communication with parents and the family, especially when it is necessary to provide support to a parent or guardian who will continue to take care of a child. This requires training in practical skills on how to report what has happened and provide emotional support. Doctors also need skills to deal with the situation, and if the case is overwhelming for the doctor himself, there should be support and motivation to continue the hard work and cooperation with the law enforcement. This should ideally be the responsibility of the interdisciplinary team and the case manager, who would work in the Barnahus model.

Social services in CCUH are involved in the child's case until it is decided about the place where the child is going to stay. Orphan's and Custody Court decides whether to remove the child from the family or not.

During the interviews, it was noted that CCUH staff and other key experts in their fields are prepared to share their knowledge and provide training, exchange experience and offer a variety of other support that would encourage and support involvement of medics in preventing violence and finding the truth. Barnahus will serve as a starting point for the sustainable accumulation and exploitation of knowledge and experience in the interests of children.