Background

1.1 Parliament made the decision to legislate to make permanent provision for the remote delivery of early medical abortion services in England and Wales, in line with the temporary arrangements introduced at the start of the COVID-19 pandemic. The Department of Health and Social Care (DHSC) are taking forward work to strengthen safeguarding for children and young people (CYP) under 18 years old accessing EMA services. This is to ensure that under 18s are appropriately safeguarded when accessing EMA services, and to ensure there is consistency across the system in the implementation of robust safeguarding processes and procedures. The UK Government commissioned the Royal College of Paediatrics and Child Health (RCPCH) to lead on the development of this safeguarding guidance for abortions under 10 weeks.

England and Wales

1.2 In England and Wales, the Abortion Act was amended on 30 August 2022 to allow service users in the first 10 weeks of pregnancy (nine weeks and six days) to take both pills required to induce an abortion at home. Of most relevance to this guidance, the new legislation states:

1.3 “The registered medical practitioner terminating the pregnancy is of the opinion, formed in good faith, that, if the medicine is administered in accordance with their instructions, the pregnancy will not exceed ten weeks at the time when the medicine is administered (or in the case of a course of medicine, when the first medicine in the course is administered).”

1.4 “If the pregnant woman’s usual place of residence is in England or Wales and she has had a consultation (in-person, by telephone or by electronic means) with a registered medical practitioner, registered nurse or registered midwife about the termination of the pregnancy, the medicine may be self-administered by the pregnant woman at that place”[1]

Scotland

1.5 At the time of writing in August 2022, Scottish Government are awaiting the results of an independent evaluation on the effectiveness and safety of future arrangements of early medical abortions at home, before making permanent changes to their legislation. The evaluation should conclude by the end of 2022.

1.6 EMAs at home in Scotland are available up to 11 weeks and six days. Young people aged 16 and 17 years old can be defined as adults in some Scottish policy and statute. Review of this RCPCH safeguarding guidance within the context of current child protection and safeguarding frameworks in Scotland is advised, ideally prior to the conclusion of the independent evaluation noted above.

Northern Ireland

1.7 The use of mifepristone (the medication to induce an abortion) at home is not allowed under law in Northern Ireland, and therefore all CYP must attend a clinic at least once for the administration of medication.[2]

Aims and scope

2.1 All RCPCH guidance is applicable to children and young people across the UK and sets out a standard of care that should be applied across the nations. The guidance is applicable to health organisations providing early medical abortions to children and young people under 18 years old across the UK.

2.2 Many of the safeguarding principles within this guidance will be applicable to other sexual health and maternity services.

2.3 The aim of this guidance is to ensure that:

• Every CYP has access to EMA in a timely manner
• CYPs holistic and safeguarding needs are identified and acted upon

2.4 The safeguarding aims will be achieved by ensuring that:

• opportunities to identify safeguarding concerns and appropriate support are maximised
• there is consistency across health organisations providing EMA services in the implementation of robust safeguarding processes and procedures
• unintended mid and late trimester abortions at home are prevented.

General principles

3.1 All health organisations providing EMA services for children and young people (CYP) under 18-years-old should follow these general principles when designing and providing services:

1. The best interests of CYP are paramount.
2. Policies and protocols should reflect the legal and professional frameworks in place throughout the four nations of the United Kingdom (UK).
3. CYP should have access to timely, high-quality, safe and effective EMA services.
4. EMA services should achieve equity by focusing on reducing health inequalities and championing diversity and inclusion principles.
5. All CYP have potential safeguarding needs; health professionals have a duty to undertake safeguarding risk assessments to determine potential safeguarding needs for CYP and these risks should be acted upon.
6. A significant number of CYP aged between 13 and 15 years have agreed to sexual intercourse/activity with a peer. This alone would not necessarily result in safeguarding concerns.
7. EMA services should be designed to respond to all the needs of CYP, with their views contributing to service planning and delivery.

Roles and responsibilities

4.1 Commissioners or service planners of EMAs

Commissioners or service planners of EMAs, which vary throughout the UK, must consider this guidance when planning abortion services for CYP. They will be responsible for the contract monitoring/management of the quality, safety and performance of the service for CYP.

 4.2 Health organisations providing EMAs for CYP

Health services are committed to promoting the safety, protection and welfare of all CYP. The safeguarding framework in England states, “All health providers including provider collaboratives are required under statute and regulation to have effective arrangements in place to safeguard and promote the welfare of children and adults at risk of harm and abuse in every service that they deliver. Providers must demonstrate safeguarding is embedded at every level in their organisation with effective governance processes evident.”[1] Further guidance is available in England[2], Scotland[3], Wales[4] and Northern Ireland. [5]

4.3 Section 11 of the Children Act 2004 for England and Wales states that health organisations have a duty to make arrangements for ensuring that their functions, and any services that they contract out to others, are discharged or provided having regard to the need to safeguard and promote the welfare of children.[6] Scotland and Northern Ireland have equivalent legislation.[7] [8]

Relationships between health organisations providing EMAs and other health services

4.4 There should be good working relationships and networks between providers of EMA services and wider health provision for CYP. This would include but is not limited to:

• Primary care
• Public health / school nursing / health visiting
• Pharmacy
• Family Nurse Partnerships
• Community and acute paediatrics
• Emergency Departments / Urgent Care settings
• Gynaecology services
• Sexual health and reproductive health services
• Sexual Assault Referral Centres
• Child and Adolescent Mental Health Services / CYP counselling services
• Looked After Children health teams
• Named and Designated Health Professionals for Safeguarding Children
• Named and Designated Health Professionals for Looked After Children

4.5 Wider health services should support the work of EMA services to promote the best interests of CYP and their safeguarding needs. By their nature, EMA services deliver time limited interventions. Some CYP may need longer term support for their health and wellbeing needs, which should be provided by partners in the wider health system.

4.6 CYP benefit from care that is person-centred and co-ordinated within healthcare settings, and across health and social care. Health professionals and organisations have a key role to play to support integrated care. CYP may need care that is provided by several different health and social care professionals, across different providers.

4.7 Models of integrated care can enhance patient satisfaction, increase perceived quality of care, and enable better access to services. Relationships with partners in the local authority, police, education and the third sector are also vital for delivering integrated care.

Health professionals
4.8 Protecting CYP is the responsibility of all health professionals who must act according to national safeguarding guidance, and professional guidance.[11].[12].[13].[14].[15].[16]

Capacity and consent

5.1 The law on capacity and consent in relation to CYP differs across the UK and this guidance does
not seek to restate the test and law in each country. However, the concepts of consent and capacity are relevant to safeguarding, particularly for CYP, and in relation to EMA.

5.2 Two important issues are:

1. The ability (or capacity) to consent for an EMA (medical consent)
2. The duty on professionals to safeguard CYP, which includes amongst other considerations, an assessment of whether they agreed and/or consented to sexual intercourse/activity or other sexual activity.

Ability to consent for an EMA

5.3 EMA services will assess whether a CYP is able to consent using national frameworks and their own internal guidance, which varies between the nations. CYP have an evolving capacity to make decisions about their lives and to consent to medical treatment. In general, CYP consenting to an EMA must be able to:

• understand the procedure including the benefits and risks
• remember what they have been told about the procedure long enough to make the decision to have an EMA
• be able to weigh up the potential benefits and drawbacks of the procedure
• communicate their views

5.4 They also need to be free from duress for consent for EMA to be valid. A safeguarding response will be required if a CYP is assessed to be under duress. If the CYP needs an EMA but is unable to give consent, further actions are required to obtain consent and this may include a safeguarding response.

5.5 In complex situations regarding consent, it is important to seek both professional and legal advice. Legal advice should be sought urgently to ensure that the timeframes are met for accessing EMA services.

Duty on professionals to safeguard children and young people

6.1 A child centred approach is fundamental to safeguarding [17]. This means building rapport and establishing trust with the CYP, maintaining professional curiosity, transparent and effective information sharing and an empathetic, professional response within clear boundaries.

6.2 Whether a CYP has the ability to consent to an EMA and/or sexual intercourse/activity or activity will not, alone, dictate whether that CYP requires a safeguarding intervention. For example:

• A CYP may not be able to consent to an EMA, but may still require one, and in this scenario, a safeguarding response is likely to be required.
• A CYP may be assessed as having capacity to consent to an EMA, but not to have consented to sexual intercourse/activity or be deemed to lack capacity to consent to sexual intercourse/activity, which would require a safeguarding response.
• A CYP may be able to consent both to sexual intercourse/activity, and an EMA, however there may be factors identified in the risk assessment that require a safeguarding response.

6.3 If a health professional has a safeguarding concern for a CYP, they have a professional duty to act appropriately, regardless of whether the CYP agrees to this. Wherever possible, this should be done collaboratively and supportively, giving the CYP appropriate choices and explanations for why the professional is needing to take these actions.

A. Ability to agree to sexual intercourse/sexual activity

6.4 There are various types of criminal sexual activity defined in criminal statutes in the four nations, e.g. the Sexual Offences Act 2003 and the Sexual Offences (Scotland) Act 2009.

6.5 If the CYP reports that they have been subject to sexual assault or rape, or the professional suspects that this may be the case, there must be a referral to social care for an urgent supportive multi-agency response, social care will involve the police in the risk assessment. This process should not impede timely access to the EMA.

6.6 In other cases the safeguarding position may be more complex. A crime may have taken place even where the CYP feels that they agreed to the sexual intercourse/activity. Professionals should be alert to this and be aware that:

• Children under 13 years old cannot legally consent to any sexual activity, and a safeguarding response is always required.
• If a CYP aged 13-15 is deemed to have been able to, and did, agree to sexual intercourse/activity with a peer, that CYP may not need a safeguarding referral unless there are other safeguarding concerns.
• Sexual intercourse/activity between a person who is 18 years or older and a CYP aged 13-15 years old often constitutes a criminal offence.
• The safeguarding response in this situation will depend on the circumstances but is likely to result in referral to social care and the police.

6.7 It is important to note that sexual activity by a person who is 18 years or older, with CYP 13-15 years old is also unlawful, as the younger party is unable to consent in law to sexual activity.

6.8 CYP aged 16 and 17 are presumed to have capacity to consent to sexual intercourse/activity, unless there is a reason to doubt their capacity. There may be a variety of reasons why a CYP in this category did not have capacity to consent at the time. For example, if the 16- or 17-year-old has significant learning difficulties, was/is under duress, was intoxicated or has other vulnerabilities, this may affect their capacity to consent, regardless of whether they seem to have agreed to sexual intercourse/activity. In this situation a safeguarding referral is appropriate.

B. Safeguarding concerns that do not relate to the ability to agree to sexual intercourse/activity

6.9 Interventions may be needed around other forms of sexual abuse or exploitation, or other adverse childhood experiences (ACEs), including physical abuse, emotional abuse and neglect. It is important to identify and respond to contextual safeguarding concerns. CYP who have been sexually abused or exploited, or maltreated in other ways, may not recognise that this is happening, or may be frightened to disclose this information to professionals.

6.10 CYP may not identify that they have vulnerabilities, and it is a professional’s duty to be curious, including considering the factors or experiences of the CYP that may underpin other risk-taking behaviours and vulnerability. Therefore, robust risk assessment for all CYP is essential.

Safeguarding risk assessments

7.1 Communicating effectively with CYP requires clinical expertise, professional curiosity and the use of a trauma-informed, gender sensitive and age-appropriate approach. Initial contact with a CYP will focus on building rapport and establishing trust from the outset, to ensure the CYP remains engaged with the service.

7.2 Initial contact may be by telephone, via video call, or on the providers’ website. The CYP will be asked for basic demographic data and contact details. This will include questions about their safety, including whether they can share information about themselves and their needs freely.  It is best practice for CYP to be given a ‘safe word’ in case the CYP can no longer communicate freely, for example, if someone comes into the room. When a safe word is used, providers should have a plan to ensure the CYP’s safety and how they are going to access the EMA in this situation. Further information about the use of a safe word can be adapted from national domestic violence guidance.

7.3 A comprehensive safeguarding risk assessment must be undertaken by an appropriately trained health professional [refer to training & supervision section below]. If the health professional is unable to undertake a safeguarding risk assessment with the CYP, this may result in further information gathering to determine what response is required. This may include a safeguarding referral.

7.4 Health professionals have a duty to document safeguarding risk assessments for all CYP. Risk assessments will be informed by every contact with the CYP throughout the care pathway and requires skilled analysis once information has been gathered.  A CYP’s responses to the risk assessment questions may trigger more in-depth assessment about a particular issue. Health professionals should use their clinical skills to explore any issues of concern and should supplement their assessment with appropriate nationally accredited risk assessment tools such as Spotting the Signs,[18] Domestic Abuse, Stalking and Harassment and Honour Based Violence (DASH, 2009-16) Risk Identification and Assessment and Management Model,[19] Female Genital Mutilation,[20] and psychosocial screening (for example a paediatric or adolescent HEADSS assessment[21]) if necessary.

7.5 Safeguarding risk assessments should include information about the following factors:

• Telephone / video call safety (can the CYP talk freely? Use of safe word)
• Relationship with the person that resulted in pregnancy (including age, proximity, criminal activity and other factors)
• Support from a responsible adult
• Attitude to pregnancy (is this termination their choice)
• Sexual / reproductive history (number of sexual partners, previous pregnancies, previous abortions)
• Lifestyle behaviours (use of alcohol, drugs, high risk internet activity)
• Their living arrangements (who they live with, and how secure or stable an environment is)
• Family / support networks (parental awareness, or other support)
• School / college / employment
• Previous or current social care involvement
• Any comments or suggestions about coercion, duress, manipulation or other concerns, which could raise safeguarding concerns
• Their perspective on the sexual acts: their agreement (or not) or ability to consent (or not) to sexual intercourse/activity
• Non-attendance or engagement for follow-up consultations

7.6 It is acknowledged that the safeguarding risk assessment will be included as part of the overall clinical assessment. Further guidance for EMA providers to consider including in their safeguarding risk assessments is in the appendix. This appendix has been compiled using current best practice from EMA providers for CYP.

7.7 It is good practice for all CYP to be spoken to on their own prior to receiving their first EMA pill to ensure the termination is their choice and they are free from duress. CYP should be encouraged to inform a responsible adult during and after the treatment, to ensure support. A responsible adult (over 18 years old) may include a parent, carer or sibling, professionals such as a social worker, school nurse, teacher, pastoral care, key worker or youth worker. If the CYP does not want to inform a responsible adult, this should be considered in the risk assessment.

Appropriate safeguarding actions following risk assessment

8.1 In most situations, there is time to reflect and seek appropriate advice on case management. Health organisations providing EMAs to CYP must have systems in place to facilitate timely case management advice for those health professionals concerned about the outcome of the safeguarding risk assessment and advice about next steps in case management. In a small minority of cases urgent action is appropriate. This may necessitate calling 999 to request police support if the CYP is in imminent danger.

8.2 There are differing actions to consider in the following three age groups based on both legislative and national guidance frameworks, and CYPs evolving maturity. Providers of EMAs should aim for all CYP to be given an appointment for an in-person consultation at some point in the EMA care pathway unless there is a compelling indication to do otherwise. In some clinical scenarios, telemedicine can improve access to EMA services.

8.3 CYP who request an EMA should have timely access to a service that provides planned EMA. Not providing an EMA to a CYP when it is required is a safeguarding issue. CYP told us it is important that they know what to expect from their EMA. [22] Providing the EMA before 10 weeks in England and Wales, or 11 weeks and six days in Scotland, is a critical requirement for this type of service. Not only does this comply with legislation, but it allows the CYP to be given appropriate information about their choices and what to expect from their abortion. Unplanned medical abortions over 10 weeks may lead to potentially poor physical and mental health outcomes for CYP.

8.4 In the case of CYP under 13 years old at the time of conception

1. CYP must have a safeguarding risk assessment.
2. Arrange an in-person appointment as soon as possible, preferably on the same day.
3. Health professional must make an urgent referral to social care (or if there is an immediate risk of harm then a referral should be made to the police). Whether to obtain support from / inform a responsible adult will be considered at the subsequent strategy meeting if this is not already in place.
4. The EMA provider refers the CYP to an appropriate inpatient health setting with gynaecological and paediatric input. This will facilitate a clinical assessment to confirm gestation, and safeguarding action. CYP must be treated by the right people, at the right time, in the right place.[23]
5. There will be consideration of how forensic evidence is collected, including the products of conception.
6. The inpatient health setting caring for the CYP must inform their Named Doctor/Nurse for Safeguarding Children and the Designated Doctor/Nurse for Safeguarding Children for the local authority area (and equivalents in Scotland, Wales and Northern Ireland).
7. CYP will be given safety netting advice and information about how to contact health professionals should they have concerns after their treatment.
8. Further support will be offered or signposted to the CYP (i.e. sexual health services / counselling / GP).

8.5 In the case of 13 to 15 year olds

1. CYP must have a safeguarding risk assessment to determine whether a referral should be made to social care (or if there is an immediate risk of harm then a referral should be made to the police).
2. CYP under 16 will normally be required to complete their consultation in-person, unless there is a compelling indication to do otherwise. The in-person consultation must facilitate a clinical assessment to confirm gestation and a more in-depth safeguarding risk assessment as appropriate.
3. For CYP that decline the in-person consultation, despite arranging support for them to attend in-person (e.g. providing transport, an alternative venue or professional), health professionals must:
   1. act to ensure the CYP accesses their EMA
   2. confirm the CYPs identity via the NHS Spine, or by other means (this will help to inform the safeguarding risk assessment)
   3. ensure their safeguarding needs are addressed.
4. CYP will be given safety netting advice and information about how to contact health professionals should they have concerns during their treatment. The safety netting advice should also include advice on how to report abuse or assault if the CYP develops concerns about abuse or assault.
5. Further health support will be offered or signposted to the CYP (i.e. sexual health services / counselling / GP).

8.6 In the case of 16 and 17 year olds

1. CYP must have a safeguarding risk assessment to determine whether a referral should be made to social care (or if there is an immediate risk of harm then a referral should be made to the police).
2. An in-person consultation should be offered and the CYP should be actively encouraged to attend. The in-person consultation will facilitate a clinical assessment to confirm gestation and a more in-depth safeguarding risk assessment as appropriate.
3. For CYP that decline the in-person consultation, despite arranging support for them to attend in-person (e.g. providing transport, an alternative venue or professional), health professionals must:
   1. act to ensure the CYP accesses their EMA
   2. confirm the CYPs identity via the NHS Spine, or by other means (this will help to inform the safeguarding risk assessment)
   3. ensure their safeguarding needs are addressed (this will be guided by the safeguarding risk assessment, which will take into account the difference in statute and guidance, and likely maturity at this age).
4. CYP will be given safety netting advice and information about how to contact health professionals should they have concerns during their treatment. The safety netting advice should also include advice on how to report abuse or assault if the CYP develops concerns about abuse or assault.
5. Further support will be offered or signposted to the CYP (i.e. sexual health services / counselling / GP).

8.7 If their age or comments or answers provided by the CYP raise concern that a sexual assault or rape may have taken place, or that they did not agree or were not able to consent, then explore further, and specifically consider referring to social care. Social care will perform a safeguarding risk assessment and decide upon further action as appropriate. The safeguarding risk assessment will involve the police, but this does not necessarily mean the CYP has to speak to the police directly as part of the parallel criminal investigation.

8.8 Providers should promptly identify CYP who do not attend an appointment, and should have an appropriate pathway in place to action with the appropriate urgency, given the risks to the CYP. Even a CYP with capacity to consent may need individual input and support to engage within the necessary timescale.

8.9 Where the health professional has identified the need to refer to other agencies (health, social care or police), and is unable to achieve an appropriate and timely response, concerns must be escalated. Health organisations providing EMA will have an escalation pathway within their organisations. This pathway must be supported by local Named and Designated Health Professionals, or their equivalents, in the local health system where the CYP is resident.

8.10 Where risks are identified for other CYP known to the client, or other vulnerable adults, appropriate safeguarding actions should be taken.

Holistic needs of children and young people

9.1 CYP presenting for EMAs may have other unmet health needs. In discussion with CYP, appropriate referrals should be made with their agreement for sexually transmitted infection (STI) screening and contraception. Other health needs may also be identified which with agreement may require onward referral directly or via the CYP’s GP or other health professional/health service.

9.2 It is envisaged that EMA services will be appropriately responsive to those CYP who are neurodiverse or have mental health conditions that require appropriate adjustments to communication style and service delivery.

9.3 All health services need to adopt equality, diversity and inclusion principles to meet the individual needs of every CYP. This includes use of appropriate language in both written and verbal communication.

9.4 Commissioners/service planners are responsible for commissioning EMA services that:

• achieve equity
• focus on reducing health inequalities
• champion diversity and inclusion principles

9.5 This will include provision of transport to facilitate attendance for in-person appointments, or for transport home if required. There must be timely access to interpreter services for CYP.

Information sharing

10.1 CYP have told us that they are concerned about confidentiality[24]. Whilst acknowledging the need for CYP to be assured of confidentiality within EMA services, robust information-sharing is at the heart of safe and effective safeguarding practice[25]. Balancing CYPs’ concerns about confidentiality, with the duty of health professionals to safeguard their health and wellbeing can be challenging.

10.2 The quality of information shared by CYP with health professionals will contribute to the safeguarding risk assessment. For example if a health professional is concerned that a CYP is unable to adequately communicate about relevant factors in their history and is therefore unable to complete a safeguarding risk assessment, this in itself may necessitate a referral to social care.

10.3 CYP must be reassured that their information will be treated in confidence. If possible, consent should be obtained from a CYP if information is to be shared. However, in England, Working Together (2018) states that, “effective sharing of information between practitioners and local organisations and agencies is essential for early identification of need, assessment and service provision to keep children safe” and “practitioners should be proactive in sharing information as early as possible to help identify, assess and respond to risks or concerns about the safety and welfare of children” [26]. Similar advice about information sharing is in safeguarding guidance for all nations [27][28][29] . Legally, confidential information may be shared with a third party (such as the CYP’s GP, social worker, the police or other healthcare organisations) without their consent where this is required by law or a court order or can be justified in the public interest (including to prevent harm to the CYP or others).

10.4 Abortion services must be accessible, and do not require proof of identity. However, in the case of CYP where the safeguarding risk assessment raises concerns, establishing identity is an important part of the assessment process. This allows providers to be certain of a CYP’s age and demographic details, which will be necessary in order to initiate an effective safeguarding referral/response if required. It also allows the provider to check the existing information for safeguarding flags. In England, identity checking may be done on the NHS Spine.[30] Commissioners and service planners should ensure EMA services have access to the NHS Spine (or alternative in the devolved nations) in order to do this.

10.5 Health organisations providing EMA in England will normally have access to the Child Protection Information Sharing (CP-IS) system. If the safeguarding risk assessment raises concerns then EMA providers should consider whether access this system to ascertain whether a CYP is on a Child Protection Plan or Looked After. Careful thought is needed as checking the CP-IS will automatically inform the CYP’s social worker of their access to the EMA service, which involves sharing confidential and sensitive health information (please see paragraph 10.3). Similarly, where a CYP has support from a social worker, the EMA providers should consider whether information should be shared with the social worker to inform any safeguarding plans and to provide appropriate support. The health professional will normally inform the CYP that confidential information will be shared but again care is needed: in some cases health professionals may need to have a strategy discussion regarding how and when the CYP is informed (for example to ensure the safety of the CYP and others and/or to avoid prejudicing a police investigation).

10.6 Primary care is best placed to provide holistic and longer-term support to CYP should this be required. They also hold other information on the CYP that the EMA providers may be unaware of. Informing the GP of the EMA, acts as a safety net, since the GP is best-placed to piece all the information together. There should be a discussion with all CYP about the advantages of informing their GP by letter about their EMA; the holistic role of general practice and confidentiality of their records should be explained. If a letter is sent to the GP, it must be marked ‘not for online access’ in line with primary care guidance. If the CYP does not agree to this information being shared with their GP, then this position should be respected, and the GP will not be informed. The exception to this would be if significant safeguarding concerns are identified (please see paragraph 10.3). Information about any onward referrals should also be included in the letter to the GP.

10.7 In complex scenarios, health professionals should seek advice, when necessary, from information governance leads within their service, and check national guidance for information sharing for child protection purposes, which is available in England[31], Wales [32], Northern Ireland [33] and Scotland. [34]All information sharing must be undertaken in line with UK General Data Protection Regulation (UK GDPR), Data Protection Act 2018 and Caldicott Principles.[35]

Training and supervision

11.1 Health professionals undertaking safeguarding risk assessments for CYP must be trained to the Level 3 standard within the Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff guidance.[36] and Looked After Children: Roles and Competencies for Healthcare Staff..[3] This will include understanding of the relevant national legislation and the national and local guidance relating to safeguarding children where the health professional is practising.

11.2 Specifically, they need to have an understanding about domestic abuse, adult safeguarding, child sexual abuse and exploitation, modern slavery, trafficking and honour-based violence, and Female Genital Mutilation (FGM).

11.3 Healthcare professionals providing abortion care to CYP should receive training on compliance with the Equality Act 2010.

11.4 Health professionals must be trained and competent in having enabling conversations with CYP, including use of a trauma-informed approach. They also require training around specific incidents where lessons may be learned, either resulting from good practice or adverse incidents.

11.5 The health organisation’s named safeguarding professional must be trained to Level 4 standard within the Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff guidance.[38]

11.6 Safeguarding clinical supervision supports staff and encourages professional development with the aim of improving patient care. Health organisations providing EMA services need to provide both individual safeguarding clinical supervision and group supervision to their clinical staff on a regular basis, which is normal practice across health services for CYP. Peer review chaired by named professionals from the EMA service can also provide supportive learning opportunities. Abortion providers will debrief staff after adverse events and serious incidents.

11.7 Safeguarding leads within health organisations providing EMA may benefit from having safeguarding clinical supervision from a single Designated Safeguarding Children health professional whom they choose to support them.

Clinical governance to support safeguarding processes

12.1 Clinical governance is “a system through which NHS 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”.[39]All  health organisations providing EMA to CYP must have safeguarding children and young people guidance, which will include: detailed information on risk assessment and pathways; escalation processes for non-attendance; when and how to make safeguarding referrals outside of their organisation.

12.2 Clinical governance systems will enable audit and monitoring of safeguarding CYP issues, information about quality and safety performance and patient safety. There should be systems to debrief health professionals within EMA services about safeguarding CYP incidents and learning from best practice. Information relating to any adverse safeguarding events must be shared between EMA providers, NHS services, and commissioners/service planners.

12.3 Data collection and analysis is a key component of clinical governance. It is recommended that commissioners ensure that data is collected and stratified by the three age groups outlined in this guidance (under 13 years, 13 to 15 years, and 16 and 17 years), and includes:

• The numbers of CYP accessing the service
• Exception reporting for those CYP not seen in-person at some point during the care pathway
• CYP who do not have a responsible adult (over 18 years old) to support them through the process
• The number of CYP who could not be contacted for follow up
• Adverse incidents which will include unplanned mid or late trimester abortions at home where gestation was incorrectly assessed
• The number of CYP who have a letter sent to their GP about their EMA
• Number of referrals to:
  • social care (including information on the risk categories that triggered the referral)
  • police
  • other health providers

12.4 This information will support a continuous evaluation of the quality of safeguarding components of EMA services for CYP by providers and their commissioners/service planners. It also allows commissioners to assure themselves that safeguarding systems are equitable throughout the UK.

12.5 Health organisations providing EMAs for CYP should share information annually about safeguarding children with their commissioners/service planners. This may be contained within a standalone document, or as part of a larger safeguarding children and adults annual report. This is in line with other national health service practice, who report annually for quality assurance.[40]

Appendix 1 – Factors to consider when designing a safeguarding risk assessment

Factors to consider when designing a safeguarding risk assessment

The below factors are a collection of best practice examples from current providers of EMA services to CYP. This list is not intended to be exhaustive as providers will likely adapt their process depending on clinical need, of both their population, and the needs of each CYP.

Telephone / video call safety

• Is anyone else in the house or room with you?
• Do you feel safe to talk today?
• Will it be safe for you to pass the pregnancy at home?

Relationship with the person that resulted in the pregnancy

• Status of current relationship
• Age and information about the relationship with the person that resulted in the pregnancy
• Is the person that you got pregnant with aware of your decision to terminate?
• How long have you known them?
• Any suggestion of coercion to have sexual intercourse/activity
• Any suggestion of coercion about accessing the EMA

Attitude to pregnancy

• Is accessing this early medical abortion your choice?

Sexual history

• What age were you when you first had sexual intercourse/activity?
• How many sexual partners have you had in the last 12 months?
• How many sexual partners have you ever had?
• Have you had any previous pregnancies?
• Have you had any previous terminations?

Lifestyle behaviours

• Do you ever use alcohol or drugs?
• Do you ever use alcohol or drugs before you have sex?
• Have you ever sent or received a message of sexual nature?
• Does anyone have any pictures of you of a sexual nature?

Family

• Parental awareness
• Who do you live with?
• Does anyone you live with know you are having sex?
• How are things at home?

School / college / employment

• Do you attend school/college regularly?
• Are you in employment?

Previous or current social care involvement

Any statements that would raise safeguarding concerns

• Domestic Abuse
• Mental health issues
• Female Genital Mutilation (FGM)
• Substance/Alcohol Misuse
• Learning Disability
• Trafficking / modern slavery
• Honour based violence

Consent to sexual intercourse/activity

• Did you agree to have sexual intercourse/activity with the person that resulted in this pregnancy?
• Have you ever been made to feel scared or uncomfortable by the person you have been having sexual intercourse/activity with?
• Have you ever been made to do something sexual that you didn’t want to do?
• Do you feel you could say no to sexual intercourse/activity?
• Has anyone given you anything like gifts, money or alcohol/drug in exchange of having sex with them?
• Is anyone else around when you have sex?

Non-attendance or engagement for follow-up.

Appendix 2 – Development of the guidance: process and methodology

Development of the guidance: process and methodology

The RCPCH convened a clinical reference group to provide professional clinical expertise to develop the first draft of guidance. Members of the clinical reference group included clinicians trained in paediatrics, gynaecology, midwifery, nursing, sexual and reproductive health, and CYP safeguarding and came from England, Wales and Scotland.

A public call for evidence was issued on the RCPCH website to understand current best practice in early medical abortion services, and to hear views about what should be in the guidance.

The RCPCH developed a specific commission to engage young people, young adults and young people’s health experts advocating on behalf of these groups, to understand their views in relation to early medical abortions. The Association for Young People’s Health supported the process of involving young people and young people’s health experts in the consultation process.

These groups were asked for their views on:

• Before: what would help to make accessing a service like this as accessible as possible?
• During: when using the service, what would support children, young people and young adults?
• After: once children, young people and young adults have used the service, what would you want to happen next?

Once the first draft of guidance was developed by the clinical reference group, the document was shared with a wide range of stakeholders to ask for their views on the work. Young people and young adults were also offered an opportunity to comment on those main themes using a trauma-informed approach.

Over 90 responses were received during the consultation period, and a final document was drafted using these comments.