Information and Instructions

• About medical neglect
• Indicators of medical neglect
• Intersections
• Structural factors
• Family and domestic violence
• Harm resulting from medical neglect
• Practice considerations
• Specific medical neglect matters
• Legislative mandate

About medical neglect

​Medical neglect refers to a circumstance in which a child has an unmet need, directly harming the child, or placing the child at risk of harm. This can occur where there is a failure to attend to obvious signs of serious illness or failure to follow a health professional's instructions once medical advice has been sought. In either case, chronic disability or even death may occur for the child, whether through an isolated incident, intermittent, or chronic ongoing circumstances. Medical neglect may occur where there are missed prescribed treatments and appointments, the child has not presented for care, or where there are unaddressed modifiable contributors to illness.

Medical neglect is diagnosed when all five factors are evidenced:

1. A child is harmed or is at risk of harm because of lack of health care

2. The recommended care offers significant net benefit to the child

3. The anticipated benefit of the treatment is significantly greater than its morbidity

4. It can be demonstrated that access to health care is available and not used

5. The caregiver understands the medical advice given

In many cases, no harm will occur if the caregiver opts not to seek medical care for an ill child. For example, where a child has a minor cold or grazes a knee from a play-related fall.  Workers should encourage caregivers to seek health advice when in doubt of whether a child requires treatment for an injury or illness. 


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Indicators of medical neglect

Indicators that a child may be experiencing neglect are:

• failure to thrive

• severe, untreated nappy rash

• recurrent illness, infection,

• recurrent and untreated skin issues or parasite infestations such as scabies, ringworm, headlice

• developmental delay

• poor hygiene, smelly or dirty appearance

• untreated medical or dental conditions

• injuries sustained from non-age-appropriate activities which remain untreated

• Lack of management/mismanagement of diabetes
  

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Intersections

There are many factors which may contribute to why children do not receive appropriate medical care including:

• Poverty or economic hardship

• Homelessness

• Low social support

• Lack of access to care

• Family management tasks e.g., where there is difficulty organising appointments, attending such as due to the number of children in family group or ages of children

• Lack of familial awareness, knowledge, and skills / caregiver education levels

• Distrust of health care professionals

• Impairment of caregiver (e.g., due to drugs/alcohol)

• Caregiver level of cognitive functioning

• Caregiver belief systems

• The child's attitudes and behaviour

• Paediatrician's misunderstanding of different cultures / racial disparities

• Lack of parental health literacy

• Lack of communication in medical setting

• Healthcare provider's ability to communicate, cultural sensitivity, empathy, listening skills.
  

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Structural factors

Structural factors may contribute to neglect. Examples include poverty, unemployment, a lack of support services and transport, social and geographical isolation, inadequate housing/over-crowded household, and social dislocation or marginalisation. This can make it challenging for stakeholders to reach consensus during cases of neglect. Furthermore, external agencies may have unrealistic expectations for the level of intervention Communities should, or should not, provide.

When considering medical neglect, it is important to consider the ongoing harmful impacts of colonisation and cultural considerations which may influence how Aboriginal people engage with healthcare. For example, Country is inherent to Aboriginal identity, however, accessing healthcare may mean having to travel off Country. This may subsequently impact other cultural dimensions of health and safety such as spirituality and cultural connection. Furthermore, colonisation and the Stolen Generations have significantly jeopardised how safe Aboriginal people may feel when accessing healthcare due to historical abuse of power and traumatic events which were facilitated by healthcare systems.

People from CaLD backgrounds may also experience additional vulnerabilities to health inequality when migrating from a conflict-affected country, living in poverty, or where English is not a primary language. When migrating to Australia, changes to lifestyle may be challenging for families where access to food and lifestyle habits conflict with what was available within a person's country of origin. Consequently, risk of medical neglect may increase as people from CaLD backgrounds have heightened exposure to barriers in Australian healthcare including stigma, shame, lack of information, language and communication barriers and more. 





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Family and domestic violence

Medical neglect issues may present where emotional abuse (family and domestic violence) is also present. It is critical when assessing neglect, that workers are open to the possibility that harm may be as a result of Emotional Abuse (family and domestic violence).


Understanding the profound impact of perpetrator behaviour on the victim-survivor's parenting, and the overall family ecology, will contextualise the inadequate provision of care as part of the use of violence and coercive control, rather than neglect/omission of care by the victim-survivor.


Refer to entry 2.3 – Assessing Emotional Abuse – Family and Domestic Violence Casework Practice Guide entry for more information.


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Harm resulting from medical neglect

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Physical harm	Emotional harm	Psychological harm
Skin conditions and infections. Recurrent parasite infestations. Failure to thrive. Growth problems. Physical injuries sustained from lack of supervision such as burns, broken bones etc. Dehydration. Heat exhaustion Death	Poor self-esteem. Chronic sadness and impaired ability to experience joy or happiness. Early experimentation and/or harmful use of alcohol and other drugs. Increased aggression and/or antisocial /criminal activities. Fear and hypervigilance, even where a child would usually feel safe. Difficulties with emotional regulation. Impaired ability to develop and maintain safe and healthy. relationships with peers and adults Self-harm and suicidal ideation or related behaviours. Disconnection with culture and significant others. Increased vulnerability to re-victimisation.	Diagnosed mental illness or displaying behaviours associated with poor mental health. Learning and/or developmental delay and/or regression. Age-inappropriate sexualised behaviours, including harmful sexual behaviours. Dissociation and somatisation. Difficulties with concentration, memory and ability to integrate new knowledge/skills. Perception issues, such as hearing voices. Reduced capacity to engage in imagination-based play/activities. Trauma related distress including hypervigilance, stress intolerance, dissociation, intrusive thoughts and flashbacks.




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Practice considerations

​General approach and practice principles


Communities has a statutory role in assessing and responding to child neglect under the Children and Community Services Act 2004 (the Act).


Workers are to use the following practice principles when working with a child who has experienced neglect:

• Consider collaborative case consultation – as it is key to effective assessment due to neglect observations feeling like value-based judgements and those influenced by biases. Different workers can have different thresholds for what is considered 'adequate'.

• Have strong documentation - Well documented worker observations, assessments, and safety plans, as well as a chronology of events, are critical to inform an objective evaluation of the case and provide an appropriate response.

• A cultural lens - is necessary to appropriately assess and support the family. Strengths in the family, community and cultural child rearing practices[1] are important to consider as part of the assessment and in developing safety plans.
  

[1] SNAICC – Child Rearing Practices. https://www.supportingcarers.snaicc.org.au/caring-for-kids/child-rearing-practices/

Assessing and responding to allegations of neglect


Communities' role in relation to neglect may include:

• causing any inquiries to be made that is considered reasonably necessary for the purpose of determining whether action should be taken to safeguard or promote the child's wellbeing as set out under s31 of the Act.

• if it is determined that action should be taken to safeguard or promote a child's wellbeing, take one or more actions as set out under s32 (1) of the Act.

• work with the parents/caregivers and other relevant government and non-government agencies to enhance parental capacity and functioning

• progress to a CSI where a referral for medical neglect has been received from a paediatric specialist, unless a decision has been endorsed by a relevant Team Leader and recorded on file.

• undertake safety planning when there is significant harm, or likelihood of significant harm to the child, with consideration of involving family and community

• identify the strengths in the broader family and the community supports available to the child/ren and family

• provide, facilitate and/or coordinate culturally appropriate services to the child to help address the effects of neglect (and to support parents capacity)

• make an application to the Children's Court for a protection order under s35 of the Act or by way of application only where it is assessed that the child needs protection

• make a referral to the Western Australia Police Force if it is believed that a criminal offence may have occurred, such as child abandonment.
  

  The Signs of Safety Casework Practice Framework 'Prompts for Neglect' may support workers in the above assessment and planning activities.
  

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Specific medical neglect matters

​Structural disadvantage and medical neglect


Some parents may require additional support to meet the needs of their children due to structural factors outside of their control, which can contribute to disadvantage and medical neglect.


Where a child has, or is likely to experience, significant harm from medical neglect, Communities must assess the concern and provide an appropriate response, irrespective of whether it is due to inadequate parenting, the impact of structural disadvantage or a combination of both.


A whole-of-government response is required to address structural disadvantage. Local senior officers' forums should be used to identify and address existing and emerging issues and gaps in service delivery, as well as to implement interagency strategies to maximise safety for vulnerable families.


High-risk infants


A high-risk infant refers to an unborn infant or child aged under three that are considered to be at increased likelihood of significant harm, or death, due to the presence of risk factors (parental, environmental and/or infant).


Infants are totally dependent on adult care and either do not communicate through language or are very limited in their ability to do so. In addition, their restricted mobility does not provide any measure of self-protection. They are also at risk of being socially 'invisible' and may have limited contact with support services.


Communities must assess concerns that involve an unborn infant or child under three, due to their vulnerability and increased risk.


Where the parent or caregiver is known to use drugs and/or alcohol, Communities has a specific role to minimise the risk of sudden unexplained deaths in infants and promote a safe sleeping environment for the infant. 


For more information, see entry 2.2 – High-Risk Infants.


Failure to thrive

Failure to Thrive is used to describe inadequate growth or the inability to maintain growth, usually in early childhood.

The two kinds of Failure to Thrive are:

• organic– which occurs where there is an underlying medical cause for the condition.
• non-organic - is caused by environmental factors and/or the actions or inactions of a parent or caregiver.
  
  Failure to Thrive is most often multifactorial in origin. Inadequate nutrition and disturbed social interactions contribute to poor weight gain, delayed development, and abnormal behaviour^[2].
  
  Communities have a role in assessing Failure to Thrive and coordinating an interagency response.
  

[2] Block & Krebs 2005. Failure to Thrive as a Manifestation of Child Neglect.


Childhood obesity


Childhood obesity is not a child protection issue. However, referrals to Communities should be made when there are known, or predicted, high risks for the wellbeing of the obese child and when one, or a combination of, the following factors is an issue:

• the parents have consistently not complied with medical recommendations and have the resources available to do so

• social factors prevent, or diminish, the parent's capacity to implement and manage positive lifestyle change

• the child has existing health complications and the parents' literacy and cognitive capacity to understand the risks for the child is limited.  
  

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Legislative mandate

Specific provisions in the Act relevant to medical neglect are:

• Part 3, Division 3- Cooperation and assistance

• Part 3, Division 6- Information sharing

• Section 23- CEO may disclose or request relevant information

• Section 28 – When child in need of protection

• Section 31-CEO may cause inquiries to be made about a child

• Section 32- CEO's duties if action needed to safeguard child's wellbeing

• Section 35- Warrant (provisional protection and care), application for and issue of

• Section 37- Taking child into provisional protection and care without a warrant in certain circumstances

• Section 101 – Failing to protect child from harm
  

In performing a function under the Act in relation to a child, the paramount consideration is the best interests of the child.


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