Case 6 A young girl with a vaginal discharge
Gemma, a 5-year-old girl, is brought to the ED by her mother, Sara, who says that Gemma has had a thick yellow vaginal discharge for 4 days. Despite Canestan cream from the GP it has got more profuse and her ‘knickers are soaked’.
What is the differential diagnosis?
Sara tells the ED FY2 doctor that she has asked her daughter if anyone has touched her genital area and Gemma said ‘no’ and Sara believes her. Gemma is said to be behaving and playing normally. General physical examination is normal.
What would you do next?
On examination of the genitalia, a thick, yellow, bloody discharge is seen. The vulva appears sore but there is no swelling or signs of trauma. A bacterial swab is taken. Gemma is referred to the paediatric registrar who takes a more detailed history. Gemma lives with her mother, spends Friday nights with her father and visits her maternal grandfather every weekend but is not left alone with him. The family are known to social services but only in relation to housing. The paediatric registrar examines Gemma again and agrees with the previous findings. He then refers Gemma to the gynaecology registrar who repeats the examination, takes swabs for bacteria and Chlamydia and prescribes amoxicillin as she thinks this is likely to be an infection due to Group A beta haemolytic streptococcus. Sara is advised to bring Gemma back if the symptoms persist.
What do you think of the management so far?
The following day the swab grows gonococcus. Gemma is recalled, admitted to hospital and examined jointly by a consultant paediatrician and a forensic medical examiner. The examination shows a tiny hymenal opening, which is smooth and annular (penetration impossible). A small amount of discharge is seen on Gemma’s pants but none on her genitalia. A repeat swab is taken and blood is taken for HIV, Hepatitis B and TPHA, and chain of evidence procedures are followed. The swab result this time is negative. The Chlamydia swab taken in ED is also negative.
The case is referred to children’s social care (CSC) and the police, a strategy meeting is held and a child protection Section 47 investigation is commenced. Gemma is allowed home with Sara, with a plan that she should have no contact with her father or grandfather. The police plan to interview the father and grandfather who are also requested to attend the sexual health clinic for testing, as is Sara.
Sara’s swabs are negative for gonococcus but positive for Chlamydia. The father’s swab is positive for gonococcus. The grandfather refuses to attend for a sexual health check. Unfortunately, the swab material is destroyed so that it is not possible to see if Gemma’s and her dad’s gonococcus were the same type.
Gemma is allowed home with Sara but contact with her father is not allowed. Sara is thought by CSC to be ‘in denial’ and ‘trusts the child’s father and does not feel the child is at risk from him’. However, some time later Sara becomes pregnant by him and subsequently has a termination. Soon after that Gemma discloses sexual abuse by her father.
Expert opinion
Vaginal discharge in young girls is a common complaint and in most cases is due to simple vulvo-vaginitis with anaerobic organisms secondary to poor hygiene. This usually presents as a chronic complaint and the discharge is usually minimal and is not blood stained. A profuse, bloody, offensive or green discharge should alert a doctor to other possibilities including sexually transmitted infections and a vaginal foreign body. In this case, where there were obvious concerns about possible sexual abuse, there should have been a discussion with a consultant paediatrician at an early stage. Gemma should not have been subjected to multiple examinations by inexperienced doctors. A single joint examination (consultant paediatrician and forensic medical examiner) would have been preferable. The main problem in this case was that a swab was taken by the FY2 without ‘chain of evidence’ and Gemma was then given antibiotics. This made it impossible to prove beyond all reasonable doubt that she had a gonococcal infection.
Chain of evidence is a legal term referring to the need to ensure the integrity and history of physical evidence, from its collection to its production in court. For example, the doctor who took the swab in this case must put it in a sealed, labelled package, with details of the patient, the nature of the swab, the date it was collected and who collected it. When it is handed to the next person in the chain on its journey to the microbiology lab, details must be recorded of the time and date of the handover, the person to whom it is given and so on, down the chain. If this chain is broken, the quality of the evidence is damaged and is open to challenge. In some cases the evidence will be rendered inadmissible.
It is unfortunate that Gemma’s swab material was destroyed as it was processed as a routine sample. Had it been saved it might have been possible to show that Gemma’s and her father’s gonococcus were of the same type and the case could then have been resolved much more quickly.
Legal comment
It is difficult to secure a conviction for child abuse without very reliable evidence. The standard of proof in the criminal courts is ‘beyond reasonable doubt’, so that a jury has to be ‘sure’ of the defendant’s guilt. Without the swab material, the only evidence is the testimony of Gemma herself. If she is interviewed it will be by trained police officers. A recording of that interview could be used as evidence at trial. The Crown Prosecution Service will have to weigh up the strength of the evidence overall before deciding whether to prosecute. In this case, the decision is likely to be that the evidence is simply not strong enough.
The standard of proof for civil proceedings is lower and it certainly appears, on the balance of probabilities, that Gemma has been abused by her father and her mother Sara has failed to protect her. However, this is a matter for the family judge to decide. Gemma is now likely to be placed in short-term foster care, with regular contact with her parents, while enquiries are made in the course of child care proceedings about what future arrangements are in Gemma’s best interests. If Sara acknowledges that she has failed and accepts that the father is not to be trusted, then there is a chance that Gemma will be restored to Sara. Otherwise, Gemma is likely to be placed in long-term foster care (the prospects for adoption of a child this age and with this history are not as good as for a younger child).
As for the doctors in the hospital, they have clearly not managed the case at all well. Gemma was examined three times before she was seen by a consultant, and then important evidence was compromised. The doctors appear not to be familiar with child protection guidelines. Therefore an investigation needs to be conducted into how this has happened, and steps need to be taken to improve awareness of and adherence to local procedures.
