Peer Review in child protection
This guidance aims to update the previous RCPCH Peer Review guidance, and address disclosure of unused material and the use of video conferencing.
For paediatricians, Peer Review in child protection has become an established component of the Clinical Governance Framework, providing a safe learning environment. Effective clinical governance ‘ensures that risks are mitigated, adverse events are rapidly detected and investigated openly, and lessons are learned’. Child Protection Peer Review is expected by the judiciary, GMC and professional bodies. Evidence of participation should be presented at appraisal and revalidation.
Child safeguarding knowledge and skills are a core competency for all health professionals who work with children and families. All paediatricians will be involved in child protection and in wider safeguarding work during their clinical duties, and therefore should participate in Peer Review. This guidance is intended to apply to all paediatricians, including, but not limited to, those seeing children for planned child protection medical assessment as part of Section 47 enquiries (or equivalent).
Since the publication of the RCPCH Peer Review Guidance in 2012, there have been several developments. Under the 2015 update to the Criminal Procedures Rule, Peer Review of a clinician’s work in child protection may have legal implications in relation to the disclosure of unused material. The Faculty of Forensic and Legal medicine (FFLM) have published guidance on Peer Review in sexual offences medicine. Joint guidance has been published by the FFLM and RCPCH on the management of intimate images (June 2020), which may have implications for Child Protection In addition, new ways of facilitating Peer Review and of meeting challenges have emerged, including the use of remote platforms.
Purpose of peer review
- To provide a proactive culture of learning, professional development and support, education and training, service improvement and improvement of multiagency processes.
- To provide support in a non-hierarchical environment, decrease professional isolation, promote the sharing of best practice and understanding of the complexities of safeguarding situations.
- Participation in Peer Review provides service-level assurance that case findings are objective, opinions are evidence-based and reports meet professional standards.
- The fact that a clinician regularly attends effective Peer Review may help reassure the courts as to the quality of their work. It will also contribute to the evidence collected by a clinician for the purposes of annual appraisal and revalidation.
Good practice recommendations
- All organisations hosting paediatric medical services should formally establish Peer Review processes for safeguarding children, in line with the standards of this document, and ensure the availability of appropriate equipment and time within job plans to allow for this.
- All paediatricians should participate in safeguarding/child protection Peer Review.
- All paediatricians with a general or community caseload should attend a minimum of four Peer Review meetings per year.
- The frequency of Peer Review meetings should be enough to meet the caseload of the department.
- All paediatricians should engage regularly with other forms of reflective practice, including clinical supervision. Peer Review should not be used to form opinion, but to test it.
- Detailed Terms of References should be produced and agreed; outlining membership and frequency of meetings.
- Specific patient/parental consent is not required, but children and families should be informed that Peer Review is an essential part of case management.
- Images should be commented on prior to disclosure of case details.
- Meeting minutes should be kept, documenting attendance list, learning points and actions. Patient-identifiable information should NOT be included in the minutes.
- Separate entries should be made in the case notes of each case discussed by the examining doctor (or supervising consultant), including date of Peer Review, a brief summary of the discussion, stating whether there is consensus agreement or any areas of disagreement (not routine challenge), any planned actions and the examining doctor’s final opinion.
- The examining doctor must be present when cases are discussed, unless agreed in advance.
- The examining doctor (or supervising consultant) always retains accountability and responsibility for the case, including entry of the Peer Review in the notes, and any subsequent management changes or addendum reporting.
- All participants must ensure a challenging yet supportive environment. Challenge themes should be documented in the central minutes, and audited to ensure robust review.
- Colleagues’ names or opinions should not be used without consent in reports.
- All participants must endeavour to avoid all forms of bias.
- Participants must produce all the evidence when presenting a case.
- Evidence of participation in Peer Review should form part of the evidence for both annual appraisal and subsequent revalidation.
- Particular consideration should be given to the information governance aspects of Peer Review conducted by remote video conferencing.
- The legal or safeguarding processes should not be delayed by Peer Review.
- Should a case which has been Peer Reviewed be the subject of criminal justice process the clinician will have a duty to disclose that Peer Review has taken place and, where applicable, to disclose if there was any significant dissent/comment and any relevant documentation. Names of those attending Peer Review do not need to be routinely disclosed.
Peer Review is the evaluation of work by colleagues in the same field in order to maintain or enhance the quality of the work or performance. It is a process to ensure that a child protection assessment and the medical opinion are as robust, accurate and evidence-based as possible.
All aspects of a child protection case may be Peer Reviewed including the findings, interpretation of findings, documentation, case management, and report or witness statement.
The word peer is often defined as a person of equal standing. However, in the context of Peer Review, it is generally used in a broader sense to refer to people in the same profession who are of the same or higher ranking.
Peer Review is a form of reflective practice. Peer Review involves a group of peers discussing and providing opinions which the individual can accept or reject.
This guidance is principally intended for formal Child Protection Peer Review Meetings, in which the findings and examining doctors’ opinions of child protection medical assessments are reviewed. It applies to both planned child protection medical assessment (those examinations booked by Children’s Social Care or the Police expressly for the purpose of child protection assessment) and unplanned child protection assessment (where the child protection concern has arisen following the child’s presentation to the hospital or paediatric setting). Other forms of Peer Review in child protection and safeguarding may also occur (see Principles and Scope, below).
Clinical supervision is also a form of reflective practice but differs from Peer Review as supervision involves both reflection and guidance or direction (an experienced supervisor may direct a supervisee towards an orthodox interpretation, action or evidence-base). It usually involves an experienced (senior or peer) supervisor providing a structured format in a one-to-one or group setting. In supervision, the supervisee’s opinion and action plan may be formed. Supervision may occur in a formal planned way and/or may be sought by the clinician in response to uncertainty about the interpretation of findings or course of action in a particular case.
By contrast, in Peer Review, the examining doctor’s existing opinion is reviewed against that of others of equivalent experience. Peer Review should not be used by the examining clinician to formulate their opinion, although they may reflect on the opinions of peers and revise their own in the light of this. Where the individual is uncertain about the findings, clinical supervision is appropriate. Where the finding or interpretation itself is ambiguous, or there is no clear peer consensus, this should be reflected in the discussion of opinion given by the examining clinician in the child protection report.
Clinical governance has been defined as: ‘a system through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.’ Peer Review is an established part of clinical governance in safeguarding practice.
Principles and scope
Terms of Reference should be produced, including purpose, objectives, process, membership, chairing arrangements and frequency of meetings. Attendance should be recorded. Regular attendance should be expected and monitored.
The term child protection Peer Review is used in this guidance, but any case where there are possible child safeguarding concerns may be reviewed. It may include cases where there are concerns about physical abuse, emotional abuse, perplexing presentations/fabricated or induced illness, neglect, or sexual abuse (see note below).
Who should attend Peer Review Meetings?
All paediatricians are involved in safeguarding and child protection, whether they are receiving referrals for planned child protection assessment or the concerns arise during clinical duties. It is essential that all paediatricians, whether generalists or subspecialists, maintain their safeguarding skills; it is therefore best practice for all paediatricians to attend Peer Review. However, it is acknowledged that within highly specialised tertiary units, other forms of safeguarding reflective practice (including psychosocial meetings, multidisciplinary meetings and safeguarding supervision) may be a more appropriate means to maintain recognition and response skills in child protection.
All paediatricians with a community or general workload (including ambulatory and urgent care settings) must take part in Child Protection Peer Review. Tertiary specialists should be invited to attend the local Peer Review meetings if they are directly involved in a case being discussed.
Specialists in tertiary centres may also benefit from Peer Review, as an adjunct to safeguarding supervision and child safeguarding training appropriate to their specialty. They should consider participating in meetings held by local general paediatric colleagues if they do not have specialty-specific Peer Review.
Other clinical staff such as specialist nurses or physician’s associates who are involved in child protection work should also participate in child protection Peer Review. Paediatric Trainees should be expected to attend routinely, and be facilitated to do so in job planning.
It is not appropriate for non-clinical professionals to attend, such as Police or Social Care staff, although a separate meeting (or part of the meeting) to discuss multi-agency working issues can be beneficial for shared learning and can be locally agreed.
This guidance is intended for Paediatricians, but may also be adapted for use by other professional groups such as General Practitioners and primary care staff.
Frequency of Peer Review Meetings and Participation
Paediatricians with general or community workloads should attend a minimum of four Peer Review meetings per year, or 50% of the meetings held, whichever is the greater. It is best practice for general and community units to have Peer Review meetings at least monthly, running at a minimum of an hour. Clinicians who regularly see planned child protection medical assessments may attend and present cases more frequently.
Exposure to case material and discussion is equally important for clinicians who see child protection cases infrequently. It is an important part of maintaining professional competencies. If a service has insufficient referrals/child protection cases to enable regular Peer Review, the service should consider combined meeting with other units regionally.
All aspects of practice may be subject to Peer Review, including the medical examination, case notes, opinion, photo-documentation, report/court statements, investigations and case management. The scope of Peer Review should include the range of opinion on the findings, range of possible interpretations, and the evidence base on which the interpretation is based.
The aim of the case discussion is not to generate either a second opinion or an expert opinion, and the examining clinician retains responsibility for the case management and opinion. The examining doctor’s peers are responsible for constructive evidence-based challenge, to ensure robustness of opinion, and clarity of the evidence-basis of the opinion.
Child safeguarding work is emotionally demanding. It is acknowledged that the opportunity to discuss cases with peers undertaking similar work, and to receive assurance around case management, has a significant role in maintaining the wellbeing and perspective of clinicians involved. Peer Review meetings should provide a supportive atmosphere; however the primary purpose is not to provide emotional support; Peer Review should not be considered a substitute for formal team or individual debrief following particularly challenging cases, nor should the need to support colleagues prevent robust discussion where necessary.
Similarly, although not its primary purpose, the Peer Review meeting provides excellent training opportunities for less experienced paediatricians/clinicians, with concentrated exposure to a range of findings and interpretations. Clinical supervision of individual cases should be provided separately where appropriate, and in advance of the case presentation at the Peer Review meeting.
Child Sexual Abuse Cases
This guidance may be used for Peer Review of any aspect of child safeguarding work, including suspected child sexual abuse cases; however it should be noted that it differs from the current FFLM Peer Review Guidance, in respect of the documentation of attendance and the attributing of individual opinions in the clinical notes (see documentation and legal considerations below). Both approaches are acceptable to the Family and Civil Courts.
It is important that there is consistency in which guidance is followed at a service level. The Service Lead should specify which guidance followed within the Peer Review Terms of Reference and/or Standard Operating Procedures. For all-age Sexual Assault Referral Centre-based services, the FFLM guidance is likely to be most suitable, while this RCPCH guidance may be preferred in Paediatric services, whether or not care is delivered within a SARC setting, where the majority of the clinicians are Paediatricians.
As Peer Review discusses specific cases and may influence the management of an individual case, it should be considered direct clinical care (DCC) for job planning purposes.
Employing organisations must ensure sufficient time is included in job plans to allow Peer Review participation.
Aims and objectives
Aims of Peer Review
- To retrospectively review cases, photo-documentation, the medical report/witness statement, the evidence-base, and multiagency process/working/communication
- To provide a proactive culture of learning, promote quality improvement, maintain high evidence-based clinical standards, provide training and support
- To provide a supportive environment to discuss cases with peers undertaking similar work, in order to help prevent professional isolation and aid sharing of best practice
Objectives of Peer Review
- To provide time for discussion of cases in a non-threatening atmosphere seeking to minimize time pressure at the meeting within the context of any concurrent clinical exigencies
- To view photo documentation accompanying the case presentation and provide an objective description of findings
- To review cases to ensure appropriate evidence-based management and opinion
- To provide support through the sharing of professional experiences of others
- To help identify areas for additional training for the group and/or individuals concerned
- To stimulate ideas for audit and/or research
Conducting the peer review meeting
Organisation and structure
- The Peer Review group should meet regularly. The frequency of meetings will depend on the nature of the service and caseload, but should be enough to ensure adequate time to discuss all relevant cases, and that individual clinicians can meet their attendance requirement over the appraisal year.
- A minimum of three doctors of equivalent standing (grade/experience) are required for Peer Review.
- Employing Trusts must ensure adequate equipment to facilitate the viewing of images for Peer Review, whether by digital projection, hard copy, or remote access. Similarly, Peer Review groups will require facilities for access to notes and reports, and to ensure appropriate documentation of the Peer Review meeting. They may require administrative support.
- Cases should be selected, and the examining clinician notified in advance. The process of case selection should be according to local arrangement (see below) and should allow for the addition of recent cases where urgent review is requested (e.g. where court is pending).
- It is not necessary to Peer Review all child protection medical assessments; however, a selection process should be in place which avoids self-selection, or bringing only those cases with positive or controversial findings (clinical supervision should be undertaken where the examining doctor is uncertain).
- Cases should only be discussed when the examining doctor is present, unless exceptionally agreed in advance. The Named Doctor for Safeguarding Children may provide remote supervision or quality assurance in lieu of Peer Review where the examining doctor has left the Trust and is unable to attend Peer Review.
- An identified individual should be responsible for organising the Peer Review meeting. This may be the Named Doctor for Safeguarding Children, but could be a specialist safeguarding nurse, secretary or other member of the safeguarding team. The organiser is responsible for case selection and ensuring images and notes/reports are available (where the organiser is non-clinical, case selection should follow a set system, and clinical advice should be available)
- Attendees should be fully informed of the aims and objectives of Peer Review.
Roles and responsibilities
- The Chair will be drawn from amongst the group and may rotate, or this role may be performed by the Named Doctor for Safeguarding Children.
- In each case, the Examining Clinician (or supervising consultant, where this is a trainee) retains accountability and responsibility for the management of their case, and for the opinion provided in their report. This responsibility extends to any subsequent document changes such as addendum reports. The examining doctor is responsible for documenting Peer Review in the case notes.
- In larger groups, to ensure robust review, to encourage all members to participate, and to avoid unchallenged consensus, it may be helpful to assign specific roles. These should rotate on a case-by-case basis (e.g. 1st and 2nd person to the examining doctor’s right):
- ‘The Describer’ initiates discussion by describing the findings shown on the image (photograph or body map) and proposes an initial interpretation, based on findings shown in the image(s) alone.
- ‘The Friendly Challenger’s task is to prompt the group to consider and discuss alternative possibilities for the findings and opinion, and to consider the evidence-base for the consensus or differing opinions. Examples of questions posed might include:
- Could this be an organic condition?
- Could this injury have occurred in another way?
- What is the evidence supporting this interpretation of this finding?
- What is the balance of probability?
- If this finding was seen in a general clinic context, would this prompt Multi Agency Safeguarding Hub referral (or equivalent)?
- A minute-taker should keep a central record of the meeting (see below), without patient identifiable information, including attendance, summary of discussion points and key learning points. This record should be available for the appraisal documentation of all attendees.
- Attendances should be recorded on a sign-in sheet kept within the department for a minimum of five years.
- In each case, all photographic evidence available should be presented.
- In Peer Review, photographs and/or body maps should be viewed by the meeting participants prior to the case information being presented, to avoid bias in describing and interpreting the findings. Discussion should include both the interpretation of the finding in isolation, and (then) in relation to any history or allegation.
- This is in no way to suggest that the child’s report of what happened and overall ‘jigsaw’ of the clinical history are not important: the examining doctor’s overall conclusions should be drawn on the basis of the case in its entirety. However, the practice of first considering the finding in isolation in peer review, allows the objectivity of that opinion to be tested, and encourages clarity on the forensic weighting of the finding(s).
Findings may be, in isolation:
- Suggestive of inflicted injury (based on their nature/number/site/pattern, etc.). These injuries would merit safeguarding action if seen even in the absence of an allegation
- Non-specific in isolation (it may still be consistent with the history given or more likely to be due to one explanation than another)
- Suggestive of an organic condition/alternative explanation.
In relation to specific allegations or concerns, finding may also be either:
- Consistent with the allegation made
- Incidental to the allegation made
- Not consistent with the allegation made (although the absence of marks does not preclude the possibility of reported events having occurred in the majority of cases).
For example, a collection of bruises to the shins, in isolation, could be described as non-specific in size, shape, number and location (being an area frequently injured accidentally in active mobile children); in the context of an allegation made by the child of being kicked by an adult, the presence of these injuries would be consistent and may therefore be considered supportive of the allegation. By contrast, a fan-shaped distribution of linear petechial marks to the cheek spaced by 1cm finger-shaped areas of sparing, would, in isolation, be suggestive of a slap mark; it would remain a finding of concern even in the absence of a history, or indeed in the presence of an incompatible history such as “I fell down the stairs”. Findings may also be suggestive of inflicted injury in isolation, but be consistent with an accidental mechanism offered in the history, such as an ear pina bruise with a history of having fallen with the side of the head on the metal rim of a trampoline.
- There are different approaches to how the case is Peer Reviewed. If the additional roles above are employed, an example format for each case is as follows:
- Images are shown to the group, with the examining clinician stating the age of the child, but without giving further history.
- ‘The Describer’ states what they can see on the images and gives their initial impression of interpretation.
- The Chair then invites comments and opinions from the remainder of the group.
- The Examining Clinician will then present the case details including any history offered, their findings and interpretation. They should comment on the quality of the image and whether this adequately reflects the findings at examination.
- The ‘Friendly Challenger’ puts questions to the examining doctor and prompts discussion by the wider group.
- The Examining Clinician will summarise their concluding thoughts, including any actions they will take as a result of discussion.
- The Chair will summarise the learning points for the minutes, before inviting the next case.
- The roles (apart from Chair and Minute-taker) will rotate for the next case.
- Open discussion should take place, ensuring the discussion remains balanced between constructive criticism and support, whilst avoiding collusion.
- Where possible the group will seek consensus in forming a view on the case
- In most cases, particularly in the planned child protection assessments, Peer Review will take place at some time after the Child Protection Report has been sent. All reports should include a statement that cases may be Peer Reviewed (see appendix for example phrasing)
- Where Peer Review discussion alters the opinion of the examining doctor or includes possibilities not previously addressed in their report, an addendum report should be produced, and relevant professionals notified (for example telephone discussion with social worker)
- It is not necessary to produce an addendum report merely to state that Peer Review has occurred. However, any legal discussion, report or statement produced subsequent to the Peer Review will make it clear that the case (or aspects of it) has been Peer Reviewed; this should state that there was consensus agreement if applicable; if Peer Review has raised new possible interpretations of the findings and highlighted evidence-base not previously considered, this must be stated by the examining doctor (see Records below).
- Any significant dissent at Peer Review must be recorded, with reasons for the counter-view listed. Significant dissent is not the same as routine challenge (“playing devil’s advocate’) but refers to fundamental disagreement about the nature of the finding or interpretation (i.e. the likelihood of it being inflicted injury).
- It is the examining clinician (or supervising consultant) for each case who is responsible for ensuring documentation of any actions and/or change of opinion; they are also responsible for ensuring actions are completed (including addendum reports if required).
Principles and considerations of documenting the Peer Review meeting
A record of all Peer Review meetings must be kept.
The recording of Peer Review has been a source of controversy for many paediatricians: there is a potential tension between the recording of friendly challenge and the risk of generating a court-admissible second opinion (see Legal Considerations below); there is a need for a central record that this auditable for Service-level assurance and individual appraisal purposes; at the same time, since there are case-management (and potential forensic) implications there is a need for patient-specific entries in clinical notes of each case discussed.
Meeting these various needs and resolving potential tension is best met by keeping a set of central minutes and making individual patient records entries. Care should be taken about what is documented and where, reflecting the purpose of Peer review.
- Names of clinicians attending and contributing to the meeting should not appear in the clinical case records (note, this differs from the FFLM Peer Review guidance (2021).
- Patient-identifiable details should NOT appear in the central meeting minutes.
The central minutes are primarily for audit, education and appraisal purposes; as they do not form part of the patient record, they would not be routinely disclosed under patient-specific subject access requests, but could be deemed unused material disclosable under section 3 of the Criminal Procedure and Investigations Act (see legal considerations) if inappropriately documented.
It should, however, be noted that for an individual case, should it be required (for example to comply with a court order), it is possible to trace the list of attendees on the day the case was discussed, by matching the date of Peer Review recorded in the case notes with the attendance list in the central meeting minutes.
The Central Meeting Minutes
- This may be used as evidence of participation for service inspection and for individual appraisal purposes.
- This may be a paper or electronic record.
- The central record should include:
- The date of Peer Review
- Names of those present
- Names or initials of those presenting cases (Examining Doctors)
- Non-patient identifiable brief details of all cases discussed and findings (e.g. “1 year old boy with circular bruises x 3 to R side of chest”)
- Themes of routine challenges (e.g. “organic conditions and accidental explanations considered” “evidence-base relating to bruising reviewed”)
- A summary of learning points (e.g. “reminder of importance of follow up film in skeletal survey”).
Recording in Patient Clinical Records
- An entry should also be made in the patient’s clinical notes, briefly documenting the themes of the discussion for that specific case.
- This should include:
- The date of Peer Review
- The fact Peer Review is “in accordance with the Terms of Reference”. This is to comply with legal advice that the clear purpose of Peer Review is recorded in the notes (i.e. not for supervision/opinion-forming).
- A brief summary of the discussion, e.g. record of consensus agreement, or of disagreement about the findings and interpretation. It may be appropriate in the event of dissent, to include a short synopsis of the issues discussed, but it is not necessary to record all routine challenge.
- The examining doctor’s final opinion (e.g. ‘opinion unchanged’ or ‘I accept, in light of systematic review evidence presented, this could be consistent with explanation offered’)
- Any required actions by the examining clinician and/or Named Doctor for Safeguarding Children, for example a further statement, or further investigation.
- When recording the discussion, it is important to distinguish between routine challenges considered to ensure robust review, and dissent or disagreement about the interpretation or findings. Compare, for example:
- Friendly challenge without dissent: “possibility of organic conditions considered; consensus agreement inflicted cigarette burn”
- Dissent: “2 Drs felt bullous impetigo not ruled out, 4 felt this unlikely; consensus not reached. Examining Dr opinion unchanged; action – dermatology opinion and 2/52 review of healing.
Disagreement and escalation
Where possible, having demonstrated robust challenge, the group should seek to reach an evidence-based unanimous consensus.
The examining doctor retains responsibility for the case management and their report opinion/conclusions. The examining doctor, should by the time of Peer Review, already have considered all reasonable possibilities and the relevant RCPCH systematic review of child protection evidence in respect of their findings, to reach a balanced conclusion. It is expected therefore that fundamental disagreements at Peer Review would be rare; all doctors have a professional duty to be reflective, acknowledge reasonable interpretations of findings, and ensure their final opinion is evidence-based.
It should be acknowledged that the review of images, particularly where these are taken at a time interval, is not the same as in person examination. If the images do not adequately demonstrate the findings, this should be documented in the patient record.
In the majority of cases without clear consensus, Peer Review discussion will have generated suggested interpretations or actions, on which the examining doctor has a duty to reflect. Child protection reports should include a discussion of the range of possible interpretations according to the evidence-base, before reaching concluding opinion on the balance of the evidence. It is sufficient for the report to state which possibilities have been considered, without attributing the suggestion to a specific individual’s opinion. Colleagues should not be named in the report or witness statement.
If Peer Review discussion raises a significant possibility (or possibilities) not previously considered by the examining doctor, or alters their opinion (as a result of the discussion itself, or as a result of the outcome of subsequent actions such as follow-up examination), an addendum report is appropriate. Telephone discussion as soon as possible with relevant professionals (Social Care Senior Practitioner or lead Police Officer in the case), should be arranged, in advance of the addendum. Further strategy discussion may be necessary in light of revised opinion.
It is rare that a fundamental disagreement arises with clinical, safeguarding or forensic significance, that cannot be resolved by further action (such as arranging a review of healing, seeking specialist opinion, or by clinical supervision). In such an event, for example where the examining doctor rejects a majority opinion that an injury is (or isn’t) likely to be inflicted, it may be appropriate for the Named Doctor for Safeguarding Children to write a short report stating that the findings and/or interpretation are disputed; this should be sent to all recipients of the original report, and a strategy discussion urgently called. It is rare for such disputed findings to reach the criminal justice system, but if they do, the Court should be advised to seek Expert Witness opinion.
When such strong dissent emerges at Peer Review and cannot be resolved, then this must be recorded in the patient record; this is likely to meet the test of disclosable material under section 3 of the Criminal Procedure and Investigations Act (see legal considerations). It may be appropriate for separate (signed) entries by both the dissenting doctor (or Named Doctor for Safeguarding Children/Meeting Chair on behalf of a group of dissenting doctors) and the examining doctor, explaining the grounds for their respective views. If such a case reached court proceedings, it is likely that statements from both doctors would be requested.
Where performance, professionalism, competency or training issues arise, these should be dealt with according to local escalation policies with patient safety as the foremost concern.
Using a circle of close colleagues may lead to a lack of challenge, and bias towards the views of the most experienced can lead to inappropriate dominance. The effect of this may be ameliorated by assigning specific roles for each case.
Atmospheres in which colleagues feel reticent to challenge must be avoided.
Failure to regularly attend and failure to produce all evidence may indicate poor practice.
Self-selection of cases may lead to bias, and/or failure of all members to present cases over time.
Peer Review should not be used to form opinion, but to ensure existing opinion is robustly evidence-based. It should not be used in place of clinical supervision.
Peer Review should not be used to generate second opinion or Expert opinion. Names of colleagues should not be used in reports or when appearing in court.
Confidentiality and patient consent
Clinical governance is essential to the care of all patients and therefore Peer Review does not require specific consent.
Patients/parent/carers should be informed of this during the consent process; Peer Review should not be discussed as an option, rather an essential element of care.
Specific consent must be obtained for the use of images for teaching (although it is likely there is an educational element in any Peer Review session).
Details of cases discussed at Peer Review will be given due confidentiality in accordance with General Medical Council (GMC) guidance.
Remote peer review and joint meetings
It may be desirable for groups of paediatricians based in different areas to hold joint Peer Review. This has the advantage of cross fertilisation of ideas; and it allows areas with smaller case numbers to benefit from the experience of areas with larger numbers of cases, and sharing of practice between acute and community providers Named and/or Designated Doctors for Safeguarding Children from across the locality on occasion may be invited to reciprocally attend Peer Review held by other services, to promote sharing of good practice.
The use of video conferencing has become increasingly common as technology has advanced and remote working has become established. Concerns have been expressed regarding the security of discussing confidential information such as patient identifiable details and the sharing of sensitive images (e.g. intimate images and images of faces).
There are some online platforms which, provided they have been confirmed as meeting the organisation’s or service’s information governance/data security requirements, should be suitable for use in Peer Review, including discussions of patient identifiable information and reviewing sensitive images provided that images are:
- Shown only via screen sharing, from a secure location (e.g. restricted-access Trust central hard drive)
- Not sent or uploaded via the platform e.g. Microsoft Teams, Zoom
- That element of Peer Review meeting where the images are shown, is not recorded on the platform.
- The clinicians must not save, copy, photograph, download or upload any of the images shared during Peer Review.
The Chair should ensure that all participants in the video conference meeting have been identified. Meetings should not proceed if a participant joins with an unidentified telephone number. It is good practice for the Chair to remind participants of their information governance responsibilities at the start of the meeting.
All participants must join the meeting from a location where they will not be overheard or disturbed, and images will not be accidentally viewed by person(s) not involved in the Peer Review.
Consideration should be given to showing line diagrams instead of particularly sensitive images (see the management of intimate images), and to obscuring facial features, where this is possible without compromising the robustness of Peer Review.
All participants in the Peer Review group must agree to these principles. These may be established as a formal written agreement, included in the meeting terms of reference, or verbally agreed by being stated by the Chair at the start of each meeting. It is particularly important to ensure they are understood and agreed when the meeting does not have a fixed membership, or is joined by occasional participants such as specialty colleagues.
Remote Peer Review has been conducted securely and successfully, but may require increased time for preparation and for the meeting itself than face-to-face meetings.
Unused material meeting the test for disclosure under section 3 of the Criminal Procedure and Investigations Act (1996) (CPIA). Applicable to England, Wales and Northern Ireland. Relevant material under Disclosure in Criminal Proceedings (Scotland).
A minority of child protection medical assessments, particularly those involving serious injury or death, will form part of the evidence in a criminal investigation and prosecution. Peer Review in such cases has implications in relation to the disclosure of unused material.
In criminal prosecutions, unused material is material that may be relevant to an investigation which has been retained but does not form part of the case for the prosecution against the accused. Relevant material is anything that appears to have some bearing on any offence under investigation or any person being investigated or on the surrounding circumstances, unless it is incapable of having any impact on the case (the test for disclosure under section 3 of the Criminal Procedure and Investigations Act 1996). Relevant material must be listed on the schedule of unused material provided to the Prosecutor and shared with the Defence.
An alternative medical opinion of the findings or interpretation of findings, as is the case where there is fundamental dissent (not routine challenge) at Peer Review, could potentially undermine the prosecution case or assist the case for the defendant. Whether or not any part of the Peer Review record could constitute legally disclosable unused material depends on how the Peer Review is recorded, and how cogent any dissent is to the examining doctor’s opinion.
Reports and statements
Where a case is subject of police investigation, the fact that Peer Review has occurred, and whether there was consensus agreement or not, must be revealed to the police and passed to the prosecution for consideration.
It is good practice to include a statement that cases may be subject to Peer Review as standard in all child protection reports.
It is also important that the child protection report (and/or addendum) discusses the range possibilities considered by the examining doctor in reaching their conclusions, including those discussed at Peer Review. It is not necessary, or indeed advisable, to ascribe opinions to individual Peer Review participants, in either the patient clinical record, or in the child protection report. It is necessary only to state which possibilities have been considered and on what grounds they are, or are not, deemed likely relative to other possibilities.
The report (and addendum if applicable) should be shared with the police where there is criminal investigation.
Patient clinical records
Clinical case records (‘notes’) are routinely disclosed in response to subject access requests and usually form part of Court Bundle in Child Protection cases in criminal or civil cases.
It is important to ensure that a high level summary of the Peer Review discussion is documented in the patient’s clinical record, and the recording includes reference to the purpose of Peer Review as per meeting Terms of Reference (i.e. a proactive culture of learning and routine challenge of an already formed opinion, not to form opinion, or generate second opinion).
There is no legal requirement to record the content of the Peer Review meeting verbatim, nor to attribute individual opinions or comments to named individuals, but an overview of the evidence-base/ reasons for each opinion should be documented.
Where there was strong dissent at Peer Review, the fact and nature of the dissent must be carefully documented in the clinical records to the satisfaction of both examining doctor and dissenting doctor (either as a jointly agreed entry, or an entry by each clinician).
Central meeting record/minutes
Whether or not the central meeting minutes meet the legal test for disclosure , will depend on whether the record could be linked to the child. It is unlikely to meet the test for disclosure provided that:
- relevant dissent is recorded in the patient record
- rhe fact Peer Review has taken place has been disclosed in the child protection report and patient notes
- rhe child protection report and addendum (if relevant) have considered all reasonable possibilities/evidence-base in respect of the findings, and
- the purpose of Peer Review is clearly stated (eg including the phrase “Peer Review according to ToR” in the notes, where the Terms of Reference clearly state the purpose of Peer Review).
References and further reading
Faculty of Forensic and Legal Medicine. Peer Review in sexual offences including child sexual abuse cases and the implications for the disclosure of unused material in criminal investigations and prosecutions 2021.
Faculty of Forensic and Legal Medicine / Royal College of Paediatrics and Child Health. Guidance for best practice for the management of intimate images which may become evidence in court (Updated June 2020).