Availability of social authorities in a simulated paediatric emergency

In the event of paediatric illness or injury, parents or legal guardians occasionally oppose examination or treatment of the child. Under Danish law, no medical intervention may be initiated in children below 15 years of age without informed parental consent, unless such intervention is otherwise authorised [1, 2]. However, health professionals hold the legal authority to act in certain circumstances, even despite parental opposition. This applies when immediate care is necessary for the child’s survival or to ensure a significantly better clinical outcome than may otherwise be expected [3].

An ethical-legal issue emerges if the child’s condition is not immediately life-threatening but detrimental nonetheless, e.g., if the child suffers substantial discomfort or risks receiving suboptimal care because the parents oppose medical intervention or insist on alternative methods. Under Danish law, the local authorities in the child’s municipality of residence must be notified when medical staff have assessed that intervention without parental consent is in the child's best interests. These authorities are also the ones to whom health professionals are obligated to report any suspicion of child abuse or neglect, for instance. Upon notification of opposed medical intervention, the relevant local children’s committee must then decide whether the intervention in question should be undertaken without parental consent. In urgent cases, the committee chairman may make a provisional decision, a so-called chairman's decision [4-6].

The primary aim of this study was to assess the urgent availability of the Danish social authorities in attendance to parental opposition to emergency medical care of a minor. Urgent availability was defined as obtained contact to a self-proclaimed accountable authority within 30 minutes.

METHODS

Setting

The Trauma Centre and Emergency Department of Copenhagen University Hospital – Rigshospitalet receives severely injured and acutely ill patients at all hours and from all Danish municipalities. An average of 12,000 patients are admitted to the emergency department, and more than 1,500 patients, of whom 10% are children, are admitted to the trauma centre annually [7, 8].

Local social authorities have established emergency services that may be contacted outside of regular operating hours in case of urgent situations involving children. In this context, most municipalities have in place child protective 24/7 hotlines.

Some of these hotlines may be reached directly. However, most municipalities refer to the respective police district for mediation of contact [9, 10].

Procedures

During regular hours, the accountable authorities were contacted via the main phone number of each city hall, identified via the official city hall websites. In cases in which the main number of a city hall was not displayed online, the corresponding children's department was contacted. Outside of regular hours, the municipal child protective 24/7 hotline was contacted. Contact was established either directly or by having the local police or fire department forward the call. Regular hours were defined as Mon-Fri from 8 a.m. to 3 p.m., and all calls were made within local telephone hours. Off-hour calls were made Mon-Fri between 6 p.m. and 8 p.m. and Sat-Sun. In the case of a missed call, we made a second attempt ten minutes later.

Urgent availability was predefined as obtained contact to a self-proclaimed accountable authority within 30 minutes.

Most municipalities refer to the police as gatekeeper for access to the accountable social authority off hours. Meanwhile, municipalities commonly use internal points of contact between the inquirer and the accountable authority during regular hours. Because of possible differences between municipalities in the efficacy of their internal organisation, we expected greater variation in regular-hour urgent availability. Regular-hour urgent availability was therefore chosen as the primary outcome.

Upon each inquiry, one simulated and anonymous case was presented as urgent (Appendix https://content.ugeskriftet.dk/sites/default/files/2023-04/a03220167-su…).

During regular hours, information about the study was provided only to the accountable authority. During off-hours, such information was provided to the person on duty at the 24/7 hotline. In some instances, employees at the municipal offices demanded the child's personal identifiable information. Because of the simulated nature of the case and our obligation to share information with relevant authorities, information on the study was revealed in these instances. During off-hours, each police department was contacted no more than once per day. To minimise any bias upon later inquiry, attending officers were not informed about the study. The case was not criminal in nature. Hence, information could be withheld from officers l by referring to the inquirer’s duty of confidentiality.

All calls were made unannounced  and with use of  an anonymous caller ID.

Primary outcome

Contact with an accountable authority within 30 minutes, during regular hours.

Secondary outcomes

Contact with the child protective 24/7 hotline within 30 minutes.

Time until obtained contact during regular and off-hours.

Number of contact links during regular and off-hours.

Off-hours gatekeeper function.

Denmark is divided into 98 municipalities, each with associated child protective 24/7 hotlines. In the children’s affairs area, the city of Copenhagen is further divided into five districts during regular hours but is covered by a single hotline during off-hours. As each office was contacted twice, we expected to collect data from a total of 200 inquiries on relevant contact, time and number of contact links. Furthermore, we expected to collect data from 98 calls regarding any gatekeeper function to the 24/7 hotlines.

Statistics

Data on contact during regular hours and off-hours, time and number of contact links, and gatekeeper function to the 24/7 hotlines were summarised by frequency (%) or by median with interquartile range.

Ethical considerations and data sharing

Presenting on-duty municipal and government officials with a simulated case may pose ethical concerns as the inquiries may potentially disrupt ongoing work tasks. We assessed, however, that this approach was warranted to attain results representative of actual urgent availability.

No personally identifiable data were collected. However, the date and time of attempted contact to individual offices may potentially be linked to individuals on duty. This information therefore remains confidential. Following publication, the results will be reported by email to the Danish National Board of Social Services, all Danish municipalities and the Danish Police. The study protocol and all collected deidentified data will be made available to anyone on request.

Trial registration: not relevant.

RESULTS

The study was conducted between 23 August 23 and 23 December 2021.

We completed all 200 expected inquiries; 102 during regular hours and 98 during off-hours (Figure 1). Upon reviewing the daytime telephone hours of the city halls, we established that they were operational for 27 hours per week on average. During regular hours, contact with an accountable authority within 30 minutes was obtained in 59 inquiries (~ 58%). During off-hours, the attending authorities at the 24/7 hotlines were urgently available within 30 minutes in 91 instances (~ 93%) (Table 1 and Table 2).

DISCUSSION

On 16 occasions, information about the study was provided to an employee at the municipal office who was not accountable as they requested the child’s civil registration number (CPR no.), full name or address. On eight of these occasions, we obtained contact with the accountable authority after 30 minutes had passed, whereas the authorities in question failed to return the inquiry in two occasions. Outside of regular hours, the person on duty at the 24/7 hotline was the only one informed of the study. On three occasions, the attending police officer could not obtain contact with the hotline within 30 minutes. In these cases, the officer in question was immediately called back and informed that the need was no longer relevant. However, information about the study was not revealed.

When contacting the police, officers often requested the child’s or its parents’ CPR no., full name or address. We consistently declined to comment on person-identifiable information, referring to the duty of confidentiality. On some occasions, we noticed a lack of cooperation, which delayed our contact with the social authorities. On one occasion, the attending officer refused to forward the call to the 24/7 hotline if we did not provide the child’s CPR no.

In this study, we found that an accountable social authority at the local municipal office was urgently available during regular hours in 59 (~ 58%) of Danish municipalities and districts.

Interestingly, the persons on duty at the child protective 24/7 hotlines were considerably more likely to be available within 30 minutes. Also, contact to the authorities was generally obtained faster during off-hours, and in most cases the number of contact links were fewer, even when the local police or fire departments were involved.

Our definition of urgent availability as contact with an accountable authority within 30 minutes is somewhat arbitrary. However, we believe that initial contact should be obtainable without any further delay as authorities are expected to spend additional time to mobilise a response once contact has been established. Since we did not have the opportunity to withhold personal identifiable information from employees at the municipal offices when such information was requested, someone other than the accountable authorities inevitably gained knowledge of the study. This may have affected our findings. For example, knowledge about the study may have worked as an incentive to respond urgently for some responders. Conversely, others may have lost incentive or wished not to participate. The only two offices that did not return our inquiry during regular hours were informed about the study. However, these cases made up no more than 10 out of 43 cases in which contact was not established within 30 minutes.

All Danish municipalities were included, and we used one consistent case to ensure that everyone involved responded to the same inquiry. Additionally, the case was presented to the responders as a real and urgent case. Therefore, the results should be considered representative of the availability of the local authorities in real-world, every-day practice – both during regular operating hours and off-hours, and across municipalities.

Looking towards other Western countries such as the United States, numerous examples exist of cases in which parents have opted out of medical care for acute and serious illness on behalf of their children, often for religious or spiritual reasons [11-13].

In a Danish context, similar known cases were reported in which members of the Jehovah's Witnesses opposed to vital treatment [14, 15].

In some instances, children are brought to the trauma centres and emergency rooms with conditions that are the result of abuse by caretakers. A study from 2016 showed that every sixth Danish child experiences domestic violence and that 5% of children between the ages of seven and 18 years have experienced gross domestic violence [16].

Furthermore, figures from Statistics Denmark from 2014 show that 7.5% of placements of children outside of the home were related to "gross neglect", which includes parents or legal guardians who have abandoned their children or prevented their medical care [17].

Anyone who becomes aware that a child is exposed to such circumstances has a legal duty to notify the social authorities’ office at the municipality of residence. Health professionals are subject to a stricter code of honor, which takes precedence over their duty of confidentiality and comprises an obligation to react even on suspicion of abuse or neglect [18].

In situations in which conditions around the child require immediate action, the authorities must be notified by telephone. It is the urgent availability of these authorities that we sought to assess in this study. Our results are thus relevant in a wide range of situations that reach well beyond parental opposition to emergency medical care.

Only few Danish municipal offices display direct phone numbers to the accountable social authority on their city hall websites. Obtaining contact via the main numbers of city halls therefore often required forwarding through several employees. In the United States, for instance, it is common practice to have direct phone numbers publicly available online. We anticipate that a similar practice may improve urgent availability in Denmark [19].

During off-hours, we noticed a certain discrepancy in the attending officers’ management of their role as gatekeepers to the social authorities. During each inquiry, we presented the case if requested to elaborate on the matter at hand, but consistently declined to comment on person-identifiable information, referring to the duty of confidentiality [20].

On some occasions, we noticed a lack of cooperation, which we attribute to our opposition to breach confidentiality. This is worrying as it is typically not possible to obtain contact with the social authorities outside of regular operating hours by other means than through the police department. Also, breaching confidentiality may potentially impair already fragile collaborations between health professionals and opposing parents. A breach of confidentiality should not be necessary to obtain off-hour contact to the child protective services.

CONCLUSION

We found that an accountable authority was urgently available within 30 minutes at the local municipal office in 58% of Danish municipalities where  attendance to a case of parental opposition to emergency medical care was required for a minor younger than 15 years of age.

Correspondence Katrine Bennett Gyldenkærne. E-mail: Katrinegyldenkaerne@gmail.com

Accepted 21 April 2023

Conflicts of interest none. Disclosure forms provided by the authors are available with the article at Ugeskriftet.dk/dmj

Cite this as Dan Med J 2023;70(7):A03220167