General Practice · Full case

Safeguarding

Children & adultsRecognise · respond · refer · recordImmediate danger = 999

Recognise · Respond · Refer · RecordThe four Rs of safeguarding. Recognise the signs and listen; respond appropriately and don't promise confidentiality you can't keep; refer to the right pathway (children's social care / adult safeguarding / police / MARAC); record contemporaneously, factually, including what was said in the person's own words

Safeguarding is everyone's businessEvery clinician has a duty to safeguard children and adults at risk. If in doubt, discuss with the practice safeguarding lead/named professional and the local safeguarding hub. You don't need proof to refer — reasonable concern is enough. Acting on suspicion is the duty

Think family / think the whole householdA concern about one person often signals risk to others — children of a parent with mental illness/substance use/domestic abuse ("Think Family"), or other dependents/vulnerable adults in the home. Always consider who else may be at risk, including unborn babies and siblings

Children: types & red flagsAbuse types: physical, emotional, sexual, neglect, fabricated/induced illness. Red flags: injury inconsistent with the history/development, delayed presentation, a non-mobile child with a bruise/fracture, disclosure, neglect, FGM, child sexual exploitation/trafficking, parental risk factors. Bruising in a non-mobile baby is a major red flag

Adults at risk & the 6 principlesAn "adult at risk" has care/support needs and cannot protect themselves. Care Act categories: physical, psychological/emotional, sexual, financial, neglect/self-neglect, discriminatory, organisational, domestic, modern slavery. Principles: Empowerment, Prevention, Proportionality, Protection, Partnership, Accountability — making safeguarding personal

Capacity changes the routeFor adults, mental capacity (Mental Capacity Act) and the person's wishes matter — a capacitous adult can decline a referral for themselves, except where others (e.g. children) are at risk, where disclosure is needed to prevent or detect serious crime, or where the law requires it (e.g. information about terrorism, Terrorism Act 2000 s38B). The FGM mandatory reporting duty covers girls under 18 only, not adult women. Where capacity is lacking, act in best interests. Coercion/undue influence may impair capacity in domestic abuse

Domestic abuse — ask & actDomestic abuse (physical, sexual, psychological, financial, coercive control) is common and dangerous; enquire sensitively when indicated, assess risk (e.g. DASH), safety-plan, and refer (IDVA/MARAC for high risk). Children in the household are affected — consider them. Never raise it in front of the suspected perpetrator

Information sharing is justifiedConfidentiality is not absolute. Where there is a risk of serious harm, sharing relevant information without consent is justified and expected; for children, the child's welfare is paramount. Mandatory reporting applies to FGM in under-18s. Document the rationale for sharing or not sharing

📋 Clinical Stem — Safeguarding

A mother attends with her toddler for a minor rash — but you notice a finger-mark bruise on the child's arm, a delayed presentation, an inconsistent story, and the mother seems frightened of her partner

Chloe Davies, 24, brings her 14-month-old son for what she says is a rash. While examining him you notice a cluster of finger-tip bruises on his upper arm and an older bruise on his cheek. When you ask how they happened, Chloe gives a vague, changing account ("he's always bumping into things"), avoids eye contact, and flinches when her phone buzzes — it's her partner. She mentions, quietly, that things at home are "stressful" and that her partner "has a temper". She seems exhausted and low. There is a 6-year-old sibling at home. Chloe asks you not to "make a fuss" and says her partner will be angry if she's late.

This stem tests safeguarding reasoning across children and adults at once: recognising the red flags of possible non-accidental injury in a young child (bruising in a barely-mobile toddler, finger-mark pattern, an injury inconsistent and changing in the history, delayed presentation), AND the signs of possible domestic abuse of the mother (fear of the partner, coercive control, low mood) with a "Think Family" risk to both children; responding appropriately (listening, not promising confidentiality you can't keep, not raising domestic abuse if the perpetrator were present, ensuring immediate safety); referring correctly (children's social care for the child — the child's welfare is paramount and consent is not required where there is risk of significant harm; domestic-abuse services/MARAC and adult safeguarding as appropriate); recording factually in the child's and mother's own words; sharing information lawfully; and involving the practice safeguarding lead. The SCA challenge is to act decisively to protect the child and support the mother, balancing engagement with the duty to refer, without colluding with "don't make a fuss".

Scenario A — Child NAI + maternal domestic abuse (this stem) Recognise NAI red flags + domestic abuse; ensure safety; refer children's social care (child welfare paramount, consent not required where significant-harm risk); domestic-abuse/IDVA/MARAC; Think Family (sibling); record & share lawfully; safeguarding lead.

Scenario B — Child neglect / FII / CSE Neglect (failure to thrive, missed appointments, dirty/unsafe), fabricated/induced illness, child sexual exploitation/trafficking, FGM (mandatory reporting in under-18s). Refer per pathway.

Scenario C — Adult at risk (Care Act) Vulnerable adult with care/support needs unable to protect themselves — financial abuse, neglect, self-neglect. Adult safeguarding; capacity (MCA); making safeguarding personal.

Scenario D — Capacitous adult declining referral A capacitous adult can decline a safeguarding referral for themselves. The exceptions are where others (especially children) are at risk, where there is serious crime, or where a statutory duty applies (e.g. known FGM in a girl under 18; an adult woman with FGM is not a mandatory report, but any daughters need risk assessment). Support, safety-plan, keep the door open; document.

Scenario E — Immediate danger A child or adult in immediate danger → 999/emergency; don't delay for process.

Key variables to adapt for Child vs adult; abuse type; NAI red flags (non-mobile child, inconsistent history); domestic abuse & coercive control (DASH/MARAC); capacity & the person's wishes (MCA); Think Family/other dependents; consent & lawful information sharing; mandatory duties (FGM); immediate danger; recording; the safeguarding lead.

Steps:

Step 1

Recognise & Respond — The Signs · Listen · Don't Over-Promise · Think Family · ICE

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The first task is to recognise the concern and respond well: notice the red flags, listen without leading, respond with empathy but without promising a confidentiality you cannot keep, ensure immediate safety, and think about everyone in the household. Here there are two intertwined concerns — possible non-accidental injury to the toddler, and possible domestic abuse of the mother — with a sibling also at risk.

🎓 SCA framing — empathic, honest, child-focused

"Thank you for telling me things are stressful — that took courage, and I want to help. I need to be honest with you: my first job is to make sure your little boy and you are safe, and if I'm ever worried about that, I can't keep it just between us — but I'll always be open with you about what I'm doing and why."

Never promise to keep a safeguarding concern secret. Being honest about the limits of confidentiality, while remaining supportive and non-judgmental, is both ethical and a marked skill.

1A — Recognise the signs (child & adult)

Question / observation	Why it matters	Changes what?
🟢 OPEN / OBSERVE"Tell me how the bruises happened" — and note the explanation, the child's development, and the interaction.	The history is the key safeguarding tool. An injury that is inconsistent with the given mechanism or the child's developmental stage, a changing or vague account, and delayed presentation are core NAI red flags. Finger-tip bruising and bruising in a barely-mobile toddler are especially concerning — most importantly, bruising in a NON-mobile infant.In SCA: noticing the inconsistency and the pattern, and not accepting the vague story, is the pivotal recognition step.	Inconsistent injury in a young child → NAI concern
🚩 Child NAI red flags"Has this happened before? Who looks after him? Are there other children at home?"	Pattern injuries, multiple injuries of different ages, a non-mobile child with bruising/fracture, delayed/inconsistent presentation, disclosure, neglect signs and parental risk factors all raise NAI. The 6-year-old sibling must be considered (Think Family). The child's welfare is paramount.NAI red flags → safeguard the child; refer children's social care.	Refer children's social care (welfare paramount)
🚩 Domestic abuse (the mother)"You mentioned things are stressful and your partner has a temper — can you tell me more? Do you ever feel frightened or controlled at home?"	Chloe's fear, flinching, low mood and "his temper" suggest possible domestic abuse (including coercive control). Enquire sensitively WHEN SAFE — never with the suspected perpetrator present. Domestic abuse endangers her and the children. Assess risk and consider IDVA/MARAC.Domestic abuse → risk assess (DASH); safety plan; IDVA/MARAC; consider the children.	Domestic abuse → safety plan + MARAC/IDVA
Respond appropriately"I'm not going to share this with your partner, and I'll explain anything I do — but I can't promise to keep concerns about safety just between us."	Respond with empathy and honesty: don't promise unconditional confidentiality, don't collude with "don't make a fuss", don't alert a suspected perpetrator. Ensure immediate safety. Listening and not leading the child/parent (avoid suggestive questioning) preserves any future investigation.Honest, non-colluding response → protects the child while keeping engagement.	Don't over-promise; ensure safety
Think Family / who else is at risk"Who else lives in the home, and are there other children or vulnerable adults?"	A concern about one person signals risk to others — the sibling, an unborn baby, other dependents or vulnerable adults. "Think Family" is core: safeguard everyone potentially affected, not just the person in front of you.Other dependents → include in the safeguarding response.	Safeguard siblings/others too
Capacity & wishes (for adults)(For the adult dimension) "What would you like to happen, and what are you worried about?"	For the adult (mother), her wishes and capacity matter (making safeguarding personal). A capacitous adult can decline help for herself — but NOT where the children are at risk (their welfare overrides), or a serious crime/statutory duty applies. Coercion can impair capacity.Capacity/wishes shape the adult route; child risk overrides.	Empower the adult; protect the child regardless
Development & mobility — is the injury plausible?"Is he walking yet? Crawling, cruising round the furniture? What can he do now that he couldn't a month ago?"	Whether a child is mobile changes how an injury is interpreted. In Sugar's cohort (1999), only 2.2% of infants not yet cruising had any bruise, against about half of walkers. NICE CG89 (updated December 2025) now defines "independently mobile" as crawling, bottom shuffling, pulling to stand, cruising, climbing, or walking with or without a push-along walker, and says age alone should not be used to decide mobility. At 14 months Chloe's son is probably mobile, so the non-mobile rule is not the trigger here. What makes these bruises concerning is the pattern (finger-tip grip marks on the upper arm), the site (the cheek, not the shins or forehead where toddlers usually bruise), and the vague, changing explanation.Toddlers' accidental bruises are typically over bony prominences at the front: shins, knees, forehead. Bruises on soft areas (cheeks, ears, neck, upper arms, trunk, buttocks) and grip or implement shapes are the ones CG89 asks you to suspect.	Non-mobile + any bruise → same-day referral per local protocolPattern / site → refer regardless of mobility
Previous attendances, health contacts & "was not brought"(From the record) Previous injuries, ED attendances, missed immunisations or health visitor contacts, other agencies' alerts?	A single bruise may look minor on its own. The record may show a pattern, for example repeated ED visits, missed appointments, or a sibling with previous concerns. Serious case reviews repeatedly find that the information was held across several records and no one put it together. Children who are "not brought" to appointments should be treated as a possible safeguarding signal, not a simple DNA.Check both children's records and, where appropriate, the mother's (domestic abuse codes, antenatal booking disclosures, mental health). Record what you found and that you looked.	Check records: pattern of concernShare with social care in the referral
Parental risk factors — the "toxic trio" and beyond"How are you feeling in yourself? Does anyone at home drink heavily or use drugs? Has anyone ever hurt you or the children?"	Domestic abuse, parental mental illness and parental substance misuse often occur together, and together they sharply increase the risk to children. Other factors include young or unsupported parents, a new partner, previous children removed, and social isolation. Chloe is exhausted and low, and afraid of a partner with a "temper". These do not prove anything happened, but they raise the level of concern and shape the support she needs.Risk factors help you interpret a finding. They never replace one. Many families with risk factors are safe, and some children with no known risk factors are harmed.	Mother's mood + DA → support and risk planInclude in referral
Who cares for the child, and who else is in the home?"Who looks after him during the day? Who else lives with you, and does anyone else look after the children?"	Social care need to know every adult caring for the child and every child in the household. That includes the partner (who may not be the children's father), relatives, childminders and nursery. It also includes any pregnancy, because an unborn baby is part of the Think Family picture, and pregnancy is a known time when domestic abuse starts or escalates.Ask this neutrally ("who else lives with you?"). Don't imply blame, and don't let the answer be heard by anyone outside the room.	Every child and carer named in referral

1B — Red flags

🚨

Red Flags — when to act now

Red flag	Why it matters	Action
Child or adult in immediate danger	Risk to life/serious harm now.	999 / emergency; ensure immediate safety; don't delay for process
Bruising/fracture in a non-mobile infant; injury inconsistent with history/development	Strong marker of non-accidental injury.	Refer children's social care urgently; paediatric assessment; don't accept the explanation at face value
Disclosure of abuse (child or adult)	Must be taken seriously and acted on.	Listen, don't lead; reassure; record in their words; refer
High-risk domestic abuse	Risk of serious harm/homicide; affects children.	DASH risk assessment; safety plan; IDVA/MARAC; never raise with the perpetrator present
FGM in an under-18 (known) or a girl at risk of FGM	Known FGM in a girl under 18 (she discloses it, or you see it) triggers the personal mandatory reporting duty. A girl at risk, or a disclosure by a parent, does not trigger the police duty, but still needs safeguarding action.	Known case under 18: report to police via 101 (by the next working day) + safeguarding referral. At risk: children's social care referral per local procedure
Adult at risk unable to protect themselves (Care Act)	Neglect/self-neglect, financial/sexual/physical abuse, modern slavery.	Adult safeguarding referral; capacity assessment; making safeguarding personal

1C — ICE

💭 Ideas

"What do you think has been happening — and what's worrying you about home?"

Surfacing the mother's understanding may bring a disclosure or reveal her fear and the coercive control. It also helps gauge insight and safety, and keeps her engaged in a process that must, regardless, protect the children.

😟 Concerns

"What are you most frightened of — for yourself and for the children?"

Her concern is likely her partner's reaction and losing her children. Naming and addressing these fears (you'll be honest, you'll support her, the aim is safety not punishment) is what allows her to engage rather than flee.

🎯 Expectations

"You've asked me not to make a fuss — let me explain what I have to do and why."

She wants you to do nothing. Naming this lets you explain, honestly and kindly, that you cannot ignore a concern about a child's safety — that you'll act transparently and supportively, but you must act.

1D — Psychosocial context

Safeguarding consultations are uncomfortable: they sit between compassion for a struggling, frightened adult and an absolute duty to protect a child who cannot protect themselves. The pull to collude — to accept the vague explanation, to "not make a fuss", to keep a parent on side — is exactly the pull that lets abuse continue. The skilled clinician holds empathy for the adult and decisive protection of the child together: listening without leading, being honest about confidentiality, ensuring immediate safety, and acting on reasonable concern by referring — because in safeguarding, doing nothing is itself a decision with consequences.

👶 The child comes first

The child's welfare is paramount and overrides the parent's wish for secrecy.

"I can hear you don't want a fuss, and I'll be as supportive as I can — but my first duty is your son's safety, and that's something I can't set aside."

🤝 Support, not punishment

Frame safeguarding as help for the family.

"This isn't about blame or taking your children — it's about getting your family the right support and keeping everyone safe. I'll be honest with you every step."

🔒 Honest about confidentiality

Never promise to keep safety concerns secret.

"I won't tell your partner anything, but I can't promise to keep worries about safety just between us — I'll always tell you what I'm doing and why."

🆘 Safety now

Address immediate safety for mother and children.

"Before anything else — are you and the children safe to go home today, or do we need to sort somewhere safe right now?"

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"I can't promise to keep safety concerns just between us." — honest about confidentiality.

"My first duty is your son's safety." — child welfare paramount.

"Are you and the children safe to go home today?" — immediate safety + Think Family.

Deductions

Colluding with "don't make a fuss"; promising secrecy
Accepting an inconsistent injury history at face value
Not recognising domestic abuse / not thinking of the sibling
Raising domestic abuse with the perpetrator present; leading questions

🔴 Red

Accepts the story; promises secrecy; no child/sibling safeguarding; misses domestic abuse; no referral

🟠 Amber

Recognises a concern; some safety enquiry; confidentiality handled partly; referral intended but vague; ICE partial

🟢 Green

Recognises NAI + domestic abuse; honest re confidentiality; immediate safety; Think Family; plans children's social care + DA referral; ICE all three

Step 2

Triage — Immediate Danger · Urgent Referral · Support & Monitor

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Triage by risk: immediate danger means 999/emergency and ensuring safety now; significant-harm concerns (NAI, high-risk domestic abuse, adult at serious risk) need urgent referral to the right pathway; lower-level concerns need support, early help and monitoring — but always discuss with the safeguarding lead if unsure.

🔴 Immediate danger

Now / 999

Protect now

Child/adult at risk of serious harm now999/emergency; ensure safety
Acute injury / unsafe to go homeAdmit/paediatrics; safe place
High-risk domestic abusePolice/IDVA; do not alert perpetrator

🟠 Urgent referral

Same day

Right pathway

Suspected NAI / significant harm (child)Children's social care (consent not required)
Adult at risk (Care Act)Adult safeguarding
FGM under-18Police (mandatory) + safeguarding

🟢 Support

Early help / monitor

With lead

Lower-level concernEarly help; health visitor; support
Capacitous adult declining (self only)Support; safety-plan; door open
UncertainDiscuss with safeguarding lead/hub

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"Because of the bruising and the worries at home, I need to refer to children's social care today to keep your son and his sibling safe, and get you support around the domestic situation — and I'll check you're safe to leave here."

Deductions

Not referring suspected NAI urgently
Delaying protection for "process"

Step 3

Assessment — Examine Carefully & Document · Risk · Capacity · The Whole Picture

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Examination is careful, documented and proportionate: assess and accurately record the injuries (site, size, pattern, age, with body maps), the child's development and demeanour, the parent's presentation, and the risk — and assess capacity where the concern is an adult. Don't conduct a forensic examination you're not trained for; refer to paediatrics/specialists.

🔎 Examine & record

Check	Why
Injuries — site/size/pattern/age (body map)	Document factually; pattern/inconsistency = NAI clue.
Development & mobility	Is the injury plausible for the child's stage?
Demeanour / interaction	Fear, frozen watchfulness, parent-child interaction.
Growth / neglect signs	Failure to thrive, hygiene, missed appointments.

🧠 Risk & capacity

Check	Why
Domestic-abuse risk (DASH)	Gauge severity; MARAC threshold.
Adult capacity (MCA)	Where the concern is an adult at risk.
Mother's mental health	Low mood/risk; impact on parenting/support.
Other household members	Sibling, vulnerable adults (Think Family).

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Doing it well

"I'll carefully document the bruises with a body map and note exactly what you told me, in your words — that's important for getting your family the right help."

Deductions

Not documenting injuries/history accurately
Attempting a forensic exam beyond competence rather than referring

Step 4

Information — Record Factually · Share Lawfully · Check the Records

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"Investigation" in safeguarding is information: contemporaneous factual recording (including the person's own words and the rationale for decisions), lawful information sharing where there is a risk of serious harm, and checking existing records and other agencies' information to build the picture.

📝 Record

Element	Detail
Contemporaneous & factual	What you saw/heard, in the person's own words; date/time; distinguish fact from opinion.
Body maps / injury documentation	Objective injury record.
Rationale for decisions	Why you did/didn't refer or share — defensible.
Flag the record	Safeguarding flags; alert the team appropriately.

🔗 Share & gather

Element	Detail
Lawful information sharing	Without consent where risk of serious harm; child welfare paramount; proportionate & relevant.
Check existing records	Previous concerns, attendances, family history.
Multi-agency information	Health visitor, school, social care, police.
Mandatory duties	FGM (under-18) reporting; document.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"I'll record exactly what I've seen and what you've said, check whether there have been any previous concerns, and share the relevant information with social care — which I'm able to do because it's about keeping a child safe."

Deductions

Not recording factually / not checking records
Withholding information that should be shared (or sharing more than necessary)

Step 5

Formulation — Who Is at Risk · From What · How Urgently

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The "diagnosis" is a safeguarding formulation: who is at risk (the child, the sibling, the mother), from what (NAI, domestic abuse, neglect), how urgently, and what the right response and pathway are — anchored to the principle that a child's welfare is paramount.

At risk	From / response
The toddler	Possible non-accidental injury (inconsistent bruising in a young child) → children's social care referral; paediatric assessment; consent not required where significant-harm risk.
The 6-year-old sibling	At risk in the same household (Think Family) → include in the safeguarding response.
The mother	Possible domestic abuse/coercive control → risk assessment, safety plan, IDVA/MARAC; support; her wishes/capacity matter for her own safety, but the children's safety overrides.
Urgency	Immediate safety today; same-day referral; emergency if immediate danger.

🚩 Act on reasonable concern — the child's welfare is paramount

The formulation: a young child with possible non-accidental injury, a sibling at risk, and a mother experiencing possible domestic abuse. You do not need proof — reasonable concern is enough to refer. The plan: ensure immediate safety, refer to children's social care today (consent not required given the significant-harm risk), risk-assess and refer the domestic abuse (IDVA/MARAC) without alerting the perpetrator, record factually, share lawfully, involve the practice safeguarding lead, and follow up.

🎓 SCA Checkpoint — Step 5Tasks

Stating the formulation

"My concern is that your son's bruises may not be accidental, that his sibling could be at risk too, and that you may be experiencing abuse at home. I don't need to be certain to act — I have to refer to keep everyone safe, and I'll support you through it."

Deductions

Waiting for "proof" before acting
Forgetting the sibling/the mother

Step 6

Refer — Children's Social Care · Adult Safeguarding · Police/MARAC · Safeguarding Lead

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Referral is the decisive action: the right pathway for each concern — children's social care, adult safeguarding, police, MARAC/IDVA — coordinated through the practice safeguarding lead and the local safeguarding hub, with emergency services for immediate danger.

Referral	Who / when	Urgency
🔴 Emergency (999/police)	Immediate danger; suspected serious crime.	Now
Children's social care	Suspected significant harm/NAI/neglect (consent not required where risk).	Same day
Adult safeguarding	Adult at risk (Care Act) — neglect, financial/sexual/physical abuse, modern slavery.	Per risk
Domestic abuse — IDVA / MARAC	Domestic abuse; MARAC for high-risk; IDVA support.	Per risk
Practice safeguarding lead / hub	Discuss, coordinate, document; named professionals.	Always

🎓 SCA Checkpoint — Step 6Tasks

The decisive action

"I'm going to refer to children's social care today and speak to our safeguarding lead, and get you connected to a domestic-abuse worker. If at any point you or the children are in immediate danger, call 999."

Deductions

Not referring / wrong pathway
Not involving the safeguarding lead

Step 7

Manage & Follow Through — Expectation · Goals · Protective Actions · The Law · Referral Routes · Psychosocial · Follow-Up · Safety-Netting

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Management is following through: ensuring immediate safety, making and documenting the referrals, supporting the family (without colluding), participating in multi-agency work (strategy/conference), safety-planning the domestic abuse, considering all household members, and reviewing — safeguarding is a process, not a single act.

🛡️ Act & support

Element	Detail
Immediate safety	Ensure the child/adult is safe today; emergency if needed.
Make & document referrals	Children's social care, DA services, safeguarding lead; record rationale.
Support the family	Empathic, non-colluding; support the mother; early help.
Safety plan (domestic abuse)	Don't alert the perpetrator; IDVA; risk-led plan.

🔁 Follow through

Element	Detail
Multi-agency working	Strategy discussion/case conference; share information.
Think Family	Sibling, other dependents, unborn baby — all considered.
Review & continuity	Follow up the referral outcome; ongoing vigilance.
Reflect / supervision	Safeguarding supervision; learn from the case.
Keep the door open	Maintain the therapeutic relationship where possible.

7A — Address the patient's expectation first: validate → explain → agree what happens next

🤝

Chloe's expectation is that you will do nothing. You cannot meet it, but you can meet the fears underneath it: being punished, losing her children, and her partner finding out

Validate: name the expectation and the fear

Chloe wants "no fuss" and wants to leave quickly because her partner is waiting. Behind that are two fears: her partner's reaction, and the belief that social services will take her children. Say both out loud before you explain anything. A parent who feels judged will leave, and a parent who leaves before a plan is in place may take the child back into danger. Naming the fear is not collusion. It is what keeps her in the room long enough to make the child safe.

"I can see you're frightened, both about getting home late and about what might happen if I'm worried. Those are completely understandable fears, and I'd like to talk about them properly with you."

Explain: the duty, and what a referral actually means

Be plain that a bruising pattern like this in a young child, with an unclear explanation, is something every doctor has to act on. You do not need proof and you are not accusing her. Explain what a referral usually leads to. Children's social care decide within a working day what response is needed. Most referrals lead to assessment and support, not removal. Removing a child without the parents' agreement needs a court order, or police protection in an emergency, and that is reserved for serious risk. Being honest about the process takes away the imagined worst case that makes parents run.

"When a doctor sees bruises like these on a little one and we're not sure how they happened, we always ask children's services to help look into it. That isn't me deciding anything bad has happened. It's the system every doctor uses so that a child is never left at risk because someone wasn't sure. For most families it means support, not children being taken away."

Agree: offer control over what she can control

She cannot veto the child referral, but she can shape almost everything around it. That includes whether she stays while you make the call, how social care contact her safely (not via a phone her partner monitors), whether she agrees to a domestic-abuse referral for herself, who collects the 6-year-old, and whether she is safe to go home tonight. Offering real choices restores some of the control that coercive abuse takes away. If going home is unsafe, the plan changes to same-day protection: social care, and police if there is immediate danger.

"Here's what I'd like to do. I'll ring children's services now, while you're here, so nothing happens behind your back. You can sit in on the call. I'd also like to put you in touch with a domestic abuse worker, and that part is your choice. And we'll work out together the safest way for people to contact you."

Key principle — be open, unless openness increases the risk: in most cases you tell parents that you are referring and why. The DfE's Information sharing advice (2024) and GMC Protecting children and young people guidance both support this. The exception is when telling a parent could put the child or anyone else at greater risk of harm, or could compromise a police investigation. An example is where the suspected perpetrator might be told before the child is safe. If you are unsure, speak to children's social care before you tell the family and record that decision. In this stem, doing the referral call with Chloe present is usually the safest and most honest approach, because it keeps her engaged and the partner is not in the room. Do not let the child leave into possible immediate danger while you "think about it".

7B — Why acting matters: goals tailored to this family, and the numbers behind them

2.2%

Infants not yet cruising who had any bruise, against 51.9% of walkers (Sugar et al., Arch Pediatr Adolesc Med 1999). "Those who don't cruise rarely bruise"

3.8 million

People aged 16+ in England & Wales who experienced domestic abuse in the year ending March 2025 (7.8%; women 9.1%, men 6.5%). ONS Crime Survey, Nov 2025

2.3 years

Average time high-risk victims live with domestic abuse before getting effective help (SafeLives). Every missed opportunity makes that longer

14 "yes"

SafeLives DASH ticks that normally meet the MARAC "visible high risk" criterion. Professional judgement and escalation can justify referral below 14

1 working day

Working Together timescale for children's social care to acknowledge a referral and decide on the response. Chase it if you hear nothing

Next working day

Home Office best practice for an FGM mandatory report (known case, girl under 18) to police via 101. Longer only in exceptional cases

223 vs 12

Referrals to domestic-abuse advocacy from GP practices with IRIS training vs control practices (Feder et al., Lancet 2011, 48 practices)

Golden rules of DfE Information sharing advice (2024). Rule 1: protecting a child from harm takes priority over privacy

6 + 5

Care Act six safeguarding principles, plus the five statutory principles of the Mental Capacity Act 2005, which govern the adult route

Goals for this family: what "success" looks like

Toddler safe today; same-day referral to children's social careChild protection medical by a paediatrician if social care / local protocol direct 6-year-old sibling included in the referral (Think Family)School nurse and health visitor informed through agreed channels Chloe offered a DASH risk assessment, safety plan and IDVA referral; MARAC if high riskHer low mood assessed and supported (perinatal / NHS Talking Therapies) Factual, contemporaneous record in the child's and the mother's notes, with rationaleSafeguarding lead informed; follow-up booked; outcome of the referral chased

Motivational language, tailored to Chloe

"You brought him in today, and you told me things are hard at home. That tells me you want him safe as much as I do. What I'm doing now is getting you both the help you shouldn't have to find on your own."

"None of what's happening at home is your fault. There are people whose whole job is helping mums in exactly your situation stay safe with their children. I'd like you to meet one of them, when it's safe for you."

7C — Non-medication management: protective actions, with mechanism, evidence and target

In safeguarding, the "treatment" is a set of protective actions, not a prescription. Each card below explains why the action works, what evidence or guidance supports it, and the practical target for this consultation. NICE PH50 and quality standard QS116 on domestic violence and abuse set the expectation. Trained frontline staff should ask about domestic abuse in private when indicators are present, respond supportively, and refer to specialist services.

🆘

Immediate safety check & plan

Target: before she leaves the room

Mechanism

The most dangerous moment can be the one right after a disclosure or a professional's intervention, especially if the abuser finds out. A simple safety plan reduces that risk. It covers who is at home tonight, whether she can go somewhere else, an agreed safe way to contact her, a bag and documents, emergency numbers, and the Silent Solution (dial 999 from a mobile, then press 55 if unable to speak).

Practical

See her alone. Do not use her partner or family to interpret. Ask directly whether she and the children are safe to go home today. If not, contact social care (and police if in immediate danger) before she leaves. Give the National Domestic Abuse Helpline number (24 hours; on their website), and only in a form that is safe to carry. Check whether her phone is monitored.

Safety today comes before any paperwork

🗣️

Ask safely & refer to specialist advocacy (IDVA)

Target: DASH offered; IDVA referral with consent; MARAC without consent only if high risk and justified in the public interest

Mechanism

Independent Domestic Violence Advisers (IDVAs) work with high-risk victims on safety planning, housing, legal protection (non-molestation orders, Domestic Violence Protection Notices and Orders) and the criminal justice process. Their job is to reduce risk. Asking in a private, supportive way makes disclosure more likely. Being dismissed or judged makes it less likely.

Evidence

In the IRIS cluster RCT (Feder et al., Lancet 2011), practices that had training plus a named advocate recorded 641 disclosures against 236, and 223 advocacy referrals against 12. NICE PH50 recommends that frontline health professionals are trained to ask about domestic abuse and to refer on. Use the SafeLives DASH checklist to structure the risk assessment. A score of 14 or more "yes" answers normally meets the MARAC threshold.

Training + a named advocate multiplies referrals (IRIS)

👨‍👩‍👧‍👦

Family Help & universal services

Target: health visitor + school nurse linked in; Family Help as appropriate

Mechanism

Protection is not a single event. Families at risk need continuing, relationship-based support. Working Together 2026 brings targeted early help and section 17 "child in need" support together as one Family Help offer with a lead practitioner. The health visitor (universal service to age 5) and school nurse see the children regularly and can spot changes that a GP may not.

Practical

Suspected non-accidental injury (NAI) is not an early-help case. It needs a child protection referral first. Family Help is the right route for lower-level concerns, or alongside a protection plan. Tell the health visitor through the agreed safeguarding channel. Check whether the 6-year-old's school knows. Many police forces run Operation Encompass, which tells schools after a domestic abuse incident.

Many eyes over time pick up patterns that one appointment misses

🧠

Mother's mental health & substance use

Target: mood and risk assessed today; follow-up within 1–2 weeks

Mechanism

Chloe is exhausted and low. Depression, trauma and substance use, whether hers or her partner's, are common in households affected by domestic abuse. They reduce a parent's capacity to protect, and they are also consequences of the abuse. Treating her mood supports her own recovery and her ability to keep the children safe.

Practical

Ask about self-harm and suicidal thoughts. Her son is 14 months old, so specialist perinatal mental health services may still be relevant: in England these generally cover the first 24 months after birth (check local criteria). Offer NHS Talking Therapies. If you start medication, it is dosed per SPC like any other depression. Ask about alcohol and drugs in the household without judgement, because they change the level of risk.

Supporting the protective parent protects the child

📝

Documentation as an intervention

Target: same-day record in both records; body map; rationale

Mechanism

A clear record written at the time is what later conferences, courts and serious case reviews depend on. It also protects the next clinician, who can see the pattern. Record exact words in quotation marks, observations (site, size, colour, shape, with a body map), who was present, what you did and why, and what you decided not to do and why.

Practical

Use safeguarding codes and alerts according to practice policy. Record domestic abuse information in a way the partner cannot see, for example in online record access. Review third-party information and restrict online visibility where it could put someone at risk. The RCGP safeguarding toolkit has a whole section on documenting safeguarding concerns.

"If it wasn't written down, it didn't happen"

🧭

Safeguarding lead, supervision & practice systems

Target: lead informed today; case at next practice safeguarding meeting

Mechanism

Safeguarding decisions are better and safer when shared. The practice safeguarding lead, named GP for safeguarding and ICB designated professionals give advice, consistency and escalation routes. Regular practice meetings with the health visitor, where they exist, pick up children who have gone missing from services.

Practical

Talk to the lead the same day, but do not delay an urgent referral while waiting for them. The duty to refer is personal. The RCGP Safeguarding Standards (2024) set out training expectations for everyone in general practice. Reflect afterwards. These consultations are distressing, and supervision is part of doing this safely.

Shared decisions are safer decisions, but never a reason for delay

7D — The statutory & professional framework: what the law and guidance require of a GP

In safeguarding, the law and statutory guidance play the part that a prescribing guideline plays elsewhere. You do not need to quote section numbers in the SCA. You do need to know what each framework requires of you, because that is what makes your actions defensible. This applies to England. Wales, Scotland and Northern Ireland have their own statutes and procedures, although the principles are shared.

Framework	What it establishes	What it means for the GP
Children Act 1989s17 · s47 · s44/46 · s1	s17: the local authority's duty to children in need. s47: the duty to make enquiries where there is reasonable cause to suspect a child is suffering, or likely to suffer, significant harm. s44 Emergency Protection Orders and s46 police protection (up to 72 hours) for immediate risk. s1: in court decisions, the child's welfare is paramount.	Your referral can trigger a strategy discussion and s47 enquiries. You may be asked for information and a report. You do not decide the threshold, the local authority does. Your job is to refer reasonable concern.
Children Act 2004s10 · s11	Duties on named agencies, including NHS bodies, to cooperate to improve children's well-being (s10) and to exercise their functions with regard to the need to safeguard and promote the welfare of children (s11).	General practice meets these duties through the NHS contract, ICB safeguarding arrangements and CQC Regulation 13 (safeguarding). Practices need a lead, a policy, training and a way to escalate.
Working Together to Safeguard Children 2026 (DfE)replaced the 2023 edition, March 2026	Statutory multi-agency guidance for England. It covers safeguarding partner arrangements (local authority, ICB, police), referral and assessment, strategy discussions, s47 enquiries, child protection conferences and plans, and Family Help. The 2026 edition adds emphasis on babies, the impact of domestic abuse, and multiple or simultaneous harms. It brings targeted early help and s17 support together as "Family Help", and asks safeguarding partners to set up multi-agency child protection teams to support s47 work (arrangements are still being rolled out locally).	Refer to children's social care (often through a MASH, "front door" or single point of access) when you are concerned about significant harm. Contribute to assessments and conferences. Escalate if you disagree with a decision, using the local escalation or resolution policy.
NICE CG89 — Child maltreatment: when to suspect maltreatment in under 18supdated Dec 2025	Sets out clinical features to "consider" or "suspect" for each type of maltreatment. Bruising in a child who is not independently mobile is a trigger to suspect maltreatment. So is bruising in the shape of a hand, grip, ligature or implement. The December 2025 update added a definition of "independently mobile": crawling, bottom shuffling, pulling to stand, cruising, climbing, or walking with or without a push-along walker.	"Suspect" means refer to children's social care. "Consider" means look for other features, discuss, and arrange review. Your local "bruising in non-independently mobile children" protocol sets out the practical steps. Usually any such bruise means same-day referral to children's social care and paediatrics.
NICE NG76 — Child abuse and neglect (2017)	How to recognise and respond to abuse and neglect across agencies. Covers communicating with children, early help, assessment, and interventions for children and families.	Listen to the child and give them time. Explain what will happen. Do not ask leading questions. Work with other agencies, not alone.
Care Act 2014s42 · s44 · statutory guidance	s42: the local authority must make enquiries (or ask others to) where an adult has care and support needs, is experiencing or at risk of abuse or neglect, and cannot protect themselves because of those needs. All three criteria must be met. Six principles: Empowerment, Prevention, Proportionality, Protection, Partnership, Accountability. "Making Safeguarding Personal" means outcomes the person chooses.	Refer an adult at risk to adult social care safeguarding. Ask what outcome the person wants. Chloe herself may not meet s42 criteria, since domestic abuse alone is not a care-and-support need. Her route is usually through domestic-abuse services, IDVA and MARAC.
Mental Capacity Act 2005	Five principles: presume capacity; give all practicable help to decide; an unwise decision is not incapacity; best interests if capacity is lacking; least restrictive option. Capacity is specific to the decision and the time. The person must be unable to understand, retain, use or weigh the information, or communicate a decision, because of an impairment or disturbance of mind or brain.	A capacitous adult can decline help for themselves. That does not stop referrals made to protect others, such as the children. Coercion and fear can undermine a decision without removing capacity, so record both. The High Court's inherent jurisdiction can be used in rare cases of coercion.
Domestic Abuse Act 2021 & Serious Crime Act 2015 s76	Statutory definition of domestic abuse between people aged 16+ who are personally connected. It covers physical or sexual abuse, violent or threatening behaviour, controlling or coercive behaviour, and economic, psychological, emotional or other abuse. Children who see, hear or experience the effects of the abuse are victims in their own right. Controlling or coercive behaviour in an intimate or family relationship is a criminal offence (Serious Crime Act 2015 s76).	Domestic abuse in a household with children is a child safeguarding issue as well as an adult one. Coercive control counts as abuse even without physical violence. Chloe's fear, the monitoring of her phone and her need to be home on time all count.
FGM mandatory reporting — FGM Act 2003 s5B (inserted by Serious Crime Act 2015)	Regulated health and social care professionals and teachers in England and Wales must personally report to the police "known" cases of FGM in girls under 18. A case is "known" if the girl discloses it or you see physical signs of it. Report via 101, best practice by the close of the next working day (Home Office procedural information).	The duty does not apply to adults, to girls merely "at risk", or where a parent is the one who discloses. Those cases go through normal safeguarding referral, which is still required for a girl at risk. Also record FGM in the notes and follow NHS England's FGM data requirements.
Prevent — Counter-Terrorism and Security Act 2015 s26Prevent duty guidance 2023	NHS bodies must have due regard to the need to prevent people from being drawn into terrorism. Concerns are referred to police Prevent, who assess whether a case goes to a multi-agency Channel panel. Taking part in Channel is voluntary.	Discuss a concern about radicalisation with the practice or ICB Prevent/safeguarding lead. Prevent is safeguarding support, not a criminal sanction. Call 999 if there is an imminent threat.
Information sharing — DfE advice (May 2024), UK GDPR / Data Protection Act 2018	Seven golden rules. Protecting a child from harm takes priority over privacy. Data protection law is not a barrier to sharing for safeguarding. The DPA 2018 has a specific safeguarding condition for processing special category data without consent. Share information that is necessary, proportionate, relevant, accurate, timely and secure. Record the decision and the reason, whether you share or not.	You do not need a parent's consent to share information about a child at risk of significant harm. Share what is relevant, not the whole record. Write down the reason.
GMC — Protecting children and young people (updated Dec 2024); Confidentiality (2017); 0–18 years	All doctors must act on concerns about a child's safety. They must share information to protect children, and follow up or escalate if the concern has not been acted on. Disclosure without consent can be justified in the public interest to prevent serious harm. That includes domestic abuse where children or others are at risk, and disclosure to MARAC.	You don't have to be certain before you act. A doctor who acts honestly and in good faith on a reasonable concern will be able to justify it, even if the concern turns out to be unfounded (GMC). Not acting is the greater professional risk.
Gillick competence & Fraser guidelines	A young person under 16 can consent to their own treatment if they have enough understanding and maturity (Gillick, 1985). The Fraser criteria apply specifically to giving contraception or sexual health advice without parental involvement. Under the Sexual Offences Act 2003, a child under 13 cannot legally consent to sexual activity.	Confidentiality for competent young people is important, but it gives way to risk of serious harm, for example exploitation, abuse, or an older or controlling partner. Information about sexual activity involving a child under 13 should usually be shared with social care or police (GMC 0–18).
RCGP Safeguarding Standards for General Practice (2024) & RCGP Safeguarding toolkit	Covers the whole life course, children and adults. Sets out knowledge, capabilities and training for everyone in general practice. The toolkit has five areas: professional responsibilities, identification, response, documentation, and information sharing and multi-agency working.	Keep your training current, know your practice lead and the local procedures, and use the toolkit's templates for conference reports and recording.

Level 1–2 — Universal & Family Help

Needs met by universal services, or by Family Help with consent

Parenting stress, housing, finance, lower-level neglect worries
Health visitor, school, children's centre, Family Help lead practitioner
Consent-based. The family can decline, but record it and keep watching

If a concern escalates, or support is refused while risk remains, move up a level

Level 3 — Child protection (s47)

Reasonable cause to suspect significant harm (this stem)

Same-day referral to children's social care / MASH. Phone first, then confirm in writing as local procedure requires
Strategy discussion, s47 enquiry, child protection medical, conference
Consent is not required. Tell parents unless that would increase the risk

Suspected NAI goes straight here, not to early help first

Level 4 — Immediate danger

Risk of serious harm now

999 / police. Police protection (s46) or Emergency Protection Order (s44) are for the agencies to decide
Seriously injured child: emergency department / paediatrics
Do not send the child home into danger to "sort it out tomorrow"

Don't delay for certainty, for the lead, or for process

7F — Key frameworks & referral routes: reference cards

Children's social care referral (MASH / "front door")

Children Act 1989 s17 / s47 · Working Together 2026 · NICE CG89

✓ This stem: required today

Same dayPhone, then written referral per local procedure

✓ Use when

Reasonable cause to suspect a child is suffering, or likely to suffer, significant harm: suspected NAI, sexual abuse, serious neglect, FII, CSE/CCE, trafficking, or a child living with high-risk domestic abuse

Any bruise or injury in a child who is not independently mobile, per NICE CG89 and your local protocol, usually with same-day paediatric assessment

A disclosure by a child, or a child in the household of an adult who poses a risk

✗ Pitfalls

Waiting for proof, for the safeguarding lead, or for a parent's consent before referring suspected significant harm

Sending the child home into possible immediate danger. Call social care or police while the child is still with you

Referring only the child in front of you. Name every child in the household, and any unborn baby

⚠ What happens next

Social care decide within 1 working day and acknowledge the referral. Then a strategy discussion (GP input often requested), s47 enquiry, child protection medical, and possibly an initial child protection conference

🔬 Document

Date and time, who you spoke to and their role, what was agreed, the reference number, and whether parents were told (and if not, why). Chase if there is no acknowledgement. Escalate if you disagree with the outcome

💬 What to say

"I'm going to call children's services now, with you here, so you know exactly what I say. I'll tell them what I've seen and what you've told me, and that you've been open with me about things being hard at home."

SCA: the examiner is looking for a same-day referral that you state clearly, explained honestly, without asking for consent you don't need, and without leaving the sibling out. "I'll discuss it with a colleague and let you know" is a fail if it is the whole plan.

Domestic abuse: DASH risk assessment → IDVA / MARAC

SafeLives Dash risk checklist · Domestic Abuse Act 2021 · NICE PH50 / QS116

✓ This stem: offer today

Risk-led≥14 "yes" normally = MARAC

✓ Use when

Disclosure or strong indicators of domestic abuse, including coercive control, fear of a partner, monitoring, isolation, or injuries. Ask only when she is alone and it is safe

MARAC referral when: visible high risk (normally 14+ DASH "yes" answers); professional judgement of serious risk even below 14; or escalation (repeated police call-outs in the past year)

An IDVA or specialist DA service for anyone at high risk. Local DA services and the National DA Helpline (number on their website) for others

✗ Never

Raise it with the suspected perpetrator present, or use family members or the partner as interpreters

Offer couples counselling or mediation where there is coercive control. It is unsafe

Treat the adult referral as optional when children live in the household. The children's route stands on its own

⚠ Consent

Seek consent for the adult referral where it is safe to do so. MARAC referral without consent can be justified in the public interest when risk is high, especially with children at risk (GMC Confidentiality). Record the reasoning

🔬 Follow up

Record the DASH score and the plan in the victim's notes only. Check online record access. Share MARAC actions with the practice lead. Note the MARAC flag according to local policy

💬 What to say

"I'd like to ask you some questions that help us understand how safe you are. They're the same for everyone. Then I'd like to put you in touch with someone whose job is to help you stay safe, and that's someone who works for you, not for anyone else."

SCA: marks come from asking safely and at the right time, from not blaming her, and from linking her safety to the children's safety without making her feel responsible for the abuse.

Adult safeguarding (Care Act 2014 s42)

Six principles · Making Safeguarding Personal · local Safeguarding Adults Board procedures

Scenario C route

Per riskAdult social care safeguarding

✓ Use when

An adult with care and support needs is experiencing or at risk of abuse or neglect and cannot protect themselves because of those needs. All three s42 criteria must be met

Categories include physical, sexual, psychological, financial or material, discriminatory, organisational, neglect or acts of omission, self-neglect, domestic abuse, and modern slavery

✗ Pitfalls

Overriding the wishes of a capacitous adult when only that adult is at risk and there is no serious crime and no risk to others

Ignoring coercion. A "capacitous refusal" made under duress still needs support, a safety plan and a documented review

⚠ Proportionality

Choose the least intrusive response that fits the risk. Ask "what would you like to happen?" and record the outcomes the person wants

🔬 Document

The person's views and capacity for this decision, who else is at risk, what you shared and why. Look for patterns: missed appointments, repeated injuries, changes in finances

💬 What to say

"It's your life and your choice, and I'll respect that. I also want to make sure you have all the support that's available. Can I tell you what the options are, and what would happen with each one?"

SCA: to score well with an adult at risk, show empowerment and proportionality, and still act where others are at risk or where capacity is in doubt.

Mental Capacity Act 2005: capacity & best interests

Five principles · decision-specific functional test · best-interests checklist

Adult route

Decision-specificPresume capacity

✓ Use when

An adult at risk declines help and you have a reason to doubt their capacity for that decision, for example cognitive impairment, acute illness, intoxication, or severe mental illness

Test: can they understand, retain, use or weigh the relevant information, and communicate a decision? Is any inability because of an impairment or disturbance of mind or brain?

✗ Pitfalls

Treating an unwise decision as proof of incapacity

Doing a blanket assessment ("lacks capacity") instead of one for the specific decision and time. Not giving practicable support first, such as an interpreter, time, or a better moment

⚠ Coercion

Fear and coercive control can distort a decision without removing capacity. Consider the MCA, safeguarding and legal advice. The High Court's inherent jurisdiction exists for vulnerable adults under coercion

🔬 Document

The decision in question, how you assessed each element, the support you gave, the outcome, and, if capacity is lacking, the best-interests reasoning, including the person's wishes and who you consulted

💬 What to say

"Can you tell me in your own words what you think might happen if you go back home tonight, and what the other options are?"

SCA: Chloe clearly has capacity. Her wishes shape the adult route, but they cannot veto the child referral. Stating that difference is a high-value point.

FGM: mandatory reporting & safeguarding

FGM Act 2003 s5B · Home Office procedural information · Working Together 2026

Scenario B route

Next working dayPolice via 101 (known case, under 18)

✓ Mandatory report when

A girl under 18 tells you she has had FGM, or you see physical signs that appear to show FGM, with no medical or birth-related explanation. This is a personal duty. You cannot hand it to the safeguarding lead

✗ Not the mandatory duty (but still act)

Girl "at risk" of FGM, or a parent or other person discloses it: normal safeguarding referral to children's social care / police per local procedure

Adult woman with FGM: no mandatory police report. Support her, record it, and risk-assess any daughters or girls in the family

⚠ Timing

Best practice is to report by the close of the next working day. Take longer only in exceptional cases where an immediate report could put the child at risk and you need to consult first. Tell the family you are reporting unless that would increase the risk

🔬 Document

Record the report, the police reference, and the safeguarding referral. Follow NHS FGM recording requirements. The duty does not replace a safeguarding referral

💬 What to say

"FGM is illegal in the UK and it causes real harm. Because you're under 18, the law says I have to let the police know. My aim is to keep you, and any sisters, safe and supported."

SCA: be exact about the scope. It applies to under-18s and "known" cases (disclosed by the girl or seen). The GP must report personally. Adults and "at risk" cases go through normal safeguarding.

Prevent: concern about radicalisation

Counter-Terrorism and Security Act 2015 s26 · Prevent duty guidance 2023 · Channel

Specialist route

Discuss with lead999 if imminent threat

✓ Use when

Concern that someone, often a vulnerable young person or adult, is being drawn towards terrorism or extremist ideology. Discuss with the practice or ICB Prevent/safeguarding lead, who may refer to police Prevent

✗ Pitfalls

Confusing Prevent with policing of lawful beliefs, religion or protest. The threshold is concern about a person being drawn into terrorism

Delaying if there is an imminent risk to life. Call 999

⚠ Consent

Taking part in Channel support is voluntary. Sharing information for the initial referral follows the same public-interest principles as other safeguarding

🔬 Document

The observed behaviour or statements (not your assumptions), who you discussed it with, and the outcome

💬 What to say

"Some of what you've told me worries me for your safety. There's a support service that works with people in this situation, and I'd like to talk it through with our safeguarding lead."

SCA: treat it as safeguarding, keep it proportionate, discuss with the lead, and act immediately if there is imminent danger.

7G — Psychosocial impact: home, children, work and money, identity, and the clinician

🤝

Safeguarding: the frightened mother, the silent toddler, the watchful 6-year-old

A safeguarding referral reaches every part of a family's life: housing, money, work, school, identity and trust in professionals. Coercive control works by taking away independence, and a poorly handled intervention can repeat that. A well-handled one gives back choice wherever it can. Thinking about these effects is not a distraction from protection. It is how you keep the family engaged in a plan that protects the children.

🏠

Housing, refuge & leaving

Leaving an abusive partner can be the most dangerous time, and it may also mean losing a home, a school place and a support network. Many victims stay because of the practical barriers, not because of the relationship. An IDVA can help with emergency accommodation, refuge, local authority homelessness duties, and legal protection that can remove the abuser rather than the victim.

"You don't have to decide anything about leaving today. What matters today is that you and the children are safe tonight, and that you have someone to help you work out the options."

👧

The children

Under the Domestic Abuse Act 2021, children who live with domestic abuse are victims in their own right. The effects include anxiety, behavioural change, sleep problems, poor school attendance and developmental delay. The 6-year-old may have seen or heard things. Their school and school nurse are key sources of support and of information. A toddler cannot tell you anything, so what you see and write down speaks for them.

"Children often notice more than we think. His big sister's school can be a real source of support. Would it be all right for them to know she might need a bit of extra care right now?"

💷

Money, work & economic abuse

Economic abuse, such as controlling money, preventing work, or running up debt in the victim's name, is included in the statutory definition of domestic abuse. It keeps victims dependent. Chloe may have no money of her own, no bank card, or a job her partner controls. Benefits advice, and help with a fit note if her mental health affects work, are practical steps towards independence.

"Sometimes controlling money is part of what happens at home. Do you have access to your own money? There's help available with that too."

📱

Technology & safe contact

Her phone buzzing, and her flinching, suggest monitoring. Perpetrators often track location, read messages or control social media. Letters, texts, and even the practice app or online record access can give away a disclosure. Agree a safe contact method and record it prominently. Review what the partner could see online.

"Is it safe for us to text or call you on this phone? Is there a better way, or a time, when it's safe for us to reach you?"

👤

Identity, shame & fear of judgement

Many parents in Chloe's position feel shame and self-blame, and fear being seen as a "bad mother". Coercive control wears down confidence and the ability to trust one's own judgement. Hearing a professional say plainly that the abuse is not her fault, while still acting to protect the children, can be a turning point. She may not disclose fully at first. Keeping the door open matters more than getting everything in one visit.

"Nothing you've told me makes you a bad mum. Asking for help when things are this hard is what good parents do."

🚗

Driving, practicalities & getting home

There is usually no DVLA question here. The practical question is how she gets home and whether it is safe. The partner is waiting outside, so running late matters. Think about how long the call will take, whether she needs a reason for the delay, and who will collect the 6-year-old from school. In immediate danger, the police can help her leave safely.

"You mentioned he'll be cross if you're late. Is it safe for you to leave with him today? If not, we can make other arrangements right now."

⚕️

The clinician's own response

Safeguarding consultations bring out strong feelings: anger at a suspected abuser, sympathy that slides into collusion, fear of getting it wrong, and worry about the relationship with the family. These feelings are normal. They should be taken to supervision and to the safeguarding lead, and never allowed to drive the decision. Vicarious trauma is real, and debriefing is part of safe practice.

(To a colleague) "That was a hard consultation. Can I talk it through with you, both the decision and how it felt?"

7H — Follow-up schedule: safeguarding is a process

Today: before the family leaves

Immediate safety confirmed or arranged. Phone referral to children's social care / MASH (toddler and sibling). Agree with social care whether a same-day child protection medical is needed and how to arrange it, often through the on-call paediatrician. DASH offered to Chloe alone, with IDVA or local DA service referral. Safe contact method agreed. Safeguarding lead told. Contemporaneous notes and body map completed.

Same-day referralSafety tonightLead informed

Within 1–2 working days: confirm and chase

Written referral submitted if local procedure requires it after a phone call. Acknowledgement and decision from social care expected within 1 working day (Working Together). Chase if you hear nothing, and escalate through the local resolution procedure if you disagree. Health visitor and school nurse informed through agreed channels. Records coded and alerts set.

Chase outcomeEscalate if concerned

Days to weeks: strategy discussion, s47 and conference

Provide information to the strategy discussion when asked. If an initial child protection conference is called, Working Together has set this within 15 working days of the strategy discussion that started the s47 enquiry (the DfE has consulted on loosening this, so check your local procedures for the current timescale). Submit a GP report and attend where possible. Include facts, health history, attendance, and concerns, including domestic abuse and parental health.

GP conference reportTimely

1–2 weeks: Chloe's review

Book a follow-up with Chloe alone, at a time that is safe for her. Review mood, risk and safety plan. Check whether the IDVA or DA service has made contact. Review any treatment for depression. Keep the relationship going. Acknowledge that the referral may have strained trust, and repair it.

Mood + riskSee alone

Ongoing: plan reviews & vigilance

If the children are on a child protection plan, review conferences follow Working Together and local timescales (traditionally the first within 3 months, then at least every 6 months). Contribute to core group information. At every contact, watch for new injuries, missed immunisations or appointments, and changes in growth, development and demeanour. Discuss at practice safeguarding meetings.

Was not brought = concernPractice meeting

7I — Monitoring: what to keep checking, and when to escalate

Memory rule: "SAFER" at every contact

See the child: new injuries, growth, development, demeanour. Attendance: children who are not brought are a concern, not just "DNA". Family: who is in the household now, any new partner, any pregnancy. Escalation: repeat incidents, police call-outs, rising DASH risk. Record and refer: new information goes to the social worker and the lead.

What / who	Monitor	Timing	Action threshold
The toddler	Injuries (body map), growth, development, interaction with carers	Every contact	Any new unexplained injury → new referral or information to the allocated social worker the same day
The 6-year-old	Behaviour, school attendance, health contacts, disclosures	Through school / school nurse; at GP contacts	Disclosure or new concern → children's social care; Think Family
Chloe: risk	DASH / safety plan; any escalation (pregnancy, separation, threats, strangulation, weapons)	Each contact, alone	Escalating or high risk → IDVA / MARAC referral; immediate danger → 999
Chloe: mood	PHQ-9, suicidal ideation, substance use, engagement with support	1–2 weeks, then per plan	Suicidal intent → same-day crisis assessment; worsening → step up treatment and review parenting capacity with the social worker
Engagement	Missed appointments, immunisations, health visitor contacts	Monthly practice meeting review	Children not brought → follow up actively and tell the social worker; do not simply discharge
The referral itself	Acknowledgement, outcome, plan, lead professional	Within 1–2 working days, then at key milestones	No response, or an outcome you disagree with → chase, then use the local escalation / resolution policy
The record	Coding, alerts, restricted online access, third-party information	At referral; after each update	Information visible to the perpetrator → restrict it and review with the lead / Caldicott guardian

7J — Safety-netting: exact phrases, RAG marking and danger zones

⚠ Three scenario-specific safety-nets: use these word for word

Why documentation matters beyond clinical care

"Finger-tip pattern bruising L upper arm ×4, 0.5–1cm, blue-purple; older yellow-brown bruise R cheek 2cm. Mother's explanation: 'he's always bumping into things'. Body map completed." Facts and exact words, not interpretation

"Referred by phone to children's social care [time], spoke to [name, role]; agreed [plan]; ref [number]. Mother informed and present for the call." A clear audit trail

"Consent not sought for child referral because child at risk of significant harm (Working Together; DfE information sharing advice 2024)." Rationale recorded

"Domestic abuse discussed with mother alone. DASH offered [score / declined]. IDVA referral [with consent / without consent, public interest, children at risk]." Record in the victim's notes only

"Safe contact: [method]. Online record access reviewed." Protects her from discovery

"Discussed with practice safeguarding lead [name] [time]. Follow-up [date]." Shows shared decision-making and continuity

Tasks

🟢

Recognises NAI pattern and domestic abuse; same-day children's social care referral including the sibling; immediate safety for tonight; DASH / IDVA offered safely; body map and factual record; safeguarding lead; follow-up and chasing the outcome

🟠

Plans a referral but vague on timing ("I'll speak to our lead"); sibling or domestic abuse addressed only partly; no safety check for tonight; documentation mentioned but not specified

🔴

No referral; accepts the explanation; waits for proof or consent; sends child home without a plan; raises abuse unsafely; treats only the rash

Relating to Others

🟢

Names her fears (partner, losing the children); honest about confidentiality from the start; non-blaming; offers real choices; makes the call with her present; "not your fault"; keeps the door open

🟠

Kind but not honest (implies nothing will happen), or honest but cold and procedural; ICE partial

🔴

Accusatory or punitive ("you should have protected him"); promises secrecy; dismisses her fear of the partner

Global Skills

🟢

Moves from the rash to the concern smoothly; prioritises safety within the time available; clear summary; safety-net given safely

🔴

Runs out of time before a plan; gets sidetracked by the rash; no safety-net

💭 Opening the concern

"While I was looking at his rash, I noticed some bruises on his arm and cheek. Can you tell me how he got them?"

😟 Naming the fear

"I wonder if part of you is worried that if I'm concerned, your children will be taken away. Can I tell you what actually usually happens?"

🎯 Declining "no fuss"

"I understand you want to leave this. I can't, because his safety comes first. But I promise I'll be open with you about everything I do."

🛑 Confidentiality limits

"I won't say anything to your partner. But if I'm worried someone could be hurt, I can't keep that just between us."

🏠 Asking about home

"You said he has a temper. Do you ever feel frightened of him, or feel he controls what you do, who you see, or your money?"

📋 Closing the loop

"So: I'm calling children's services now with you here, I'm putting you in touch with a domestic abuse worker, and I'll see you again next week. If you're ever in danger, 999. Is it safe for you to go home today?"

Waiting for certainty or proof

Reasonable concern is the threshold. Social care and police investigate; the GP refers

"I'll discuss with the lead and get back to you"

Discuss by all means, but the same-day referral is your personal duty. Don't delay

Asking a parent for consent to refer suspected NAI

Consent is not required where there is risk of significant harm. Inform, don't ask, unless informing increases the risk

Forgetting the 6-year-old

Name every child in the household (and any unborn baby) in the referral

Asking about abuse with the partner present

See her alone, use a professional interpreter, choose a safe time

Promising "this stays between us"

Be honest about the limits of confidentiality before a disclosure, not after

Recording "NAI" as a diagnosis, or opinion as fact

Record observations, exact words and rationale. "Concern re possible NAI" if needed

Reporting an adult's FGM, or an "at-risk" girl, as a mandatory report

Mandatory duty = known FGM, under 18. Others go through safeguarding / risk assessment

Referral made, never followed up

Chase the outcome, escalate disagreement, keep seeing the family

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"So today: I'll make sure you and the children are safe to leave, refer to children's social care and speak to our safeguarding lead, connect you with a domestic-abuse worker, and document everything carefully. This is to support your family and keep everyone safe — and I'll follow it up and keep seeing you."

Deductions

Referring but not ensuring immediate safety / not safety-planning DA
Forgetting the sibling/multi-agency working
Colluding or being punitive toward the mother

"It's just a rash, doctor, that's all — he's fine, he's always bumping into things. Please don't make a fuss, I really need to get going, my partner's waiting and he gets cross if I'm late."

Who you are (Chloe, the mother)

Chloe Davies, 24, with your 14-month-old son (you came about a "rash"). You're exhausted, low, and frightened of your partner, who "has a temper". There are finger-tip bruises on your son's arm and an older bruise on his cheek; when asked, you give vague, changing explanations ("he's always bumping into things") and avoid eye contact. You flinch when your phone buzzes (it's your partner). You have a 6-year-old at home too. You're terrified of your partner finding out you've said anything, and terrified your children will be taken away — so you want the doctor to do nothing and let you leave.

Hidden concerns (reveal if explored gently)

Fear of the partner (main): you're scared of his reaction; you'll hint at coercive control / his temper if the doctor is gentle and you feel safe.

Fear of losing the children: this is why you want no fuss; reassurance that it's about support and safety, not removal, helps you engage.

Your own low mood: you're worn down; you'll admit it if asked kindly.

Details if asked

Finger-mark bruising on the toddler's arm + older cheek bruise; vague/changing explanation; delayed coming in
Partner with a "temper"; you feel frightened and controlled; phone buzzing = him
A 6-year-old sibling at home
You're exhausted and low; you don't want anyone told; you fear your children being removed

Reactions at key moments

If the doctor promises secrecy / accepts the story / lets you leave: you're relieved — so a strong candidate must NOT collude and must act.
On honest "I can't keep safety concerns secret, but I'll support you": anxious but you stay if treated with warmth.
On "this is about support and safety, not taking your children": you soften.
If the partner's name/abuse is raised carelessly (e.g. with him present): you shut down/panic.
Challenge line: "Please, just leave it — you'll make everything worse for me at home."

"Please don't report anything — you don't understand, you'll make it so much worse for me at home. Can't you just let it go?"

Resolution: The consultation succeeds if the GP: (1) recognises the red flags of possible non-accidental injury (finger-mark bruising in a young child, inconsistent/changing history, delayed presentation) AND possible domestic abuse of the mother, with a sibling also at risk (Think Family); (2) responds empathically but honestly — listening without leading, not promising secrecy, not raising domestic abuse unsafely, ensuring immediate safety; (3) acts on reasonable concern (no proof needed) by referring to children's social care today (child's welfare paramount, consent not required where significant-harm risk) and arranging domestic-abuse support/risk assessment (IDVA/MARAC), involving the safeguarding lead; (4) records factually and shares information lawfully; (5) supports the mother without colluding, framing it as safety and support, and follows through. It fails if the GP colludes with "don't make a fuss", accepts the story, promises secrecy, or fails to refer.

🏥

Clinic Quick Reference

Safeguarding — Clinical Decision Framework

Recognise · respond · refer · record

▼expand

🧭 1 — The four Rs & who's at risk

Recognise the signs (children: inconsistent injury, non-mobile child with bruise/fracture, delayed presentation, disclosure, neglect, FGM, CSE; adults: Care Act categories incl. neglect/self-neglect, financial, modern slavery; domestic abuse incl. coercive control). Respond (listen, don't promise secrecy, ensure safety). Refer (right pathway). Record (factual, own words, rationale). Think Family — who else is at risk?

⚖️ 2 — Act & the law

Children: welfare paramount; consent NOT required where risk of significant harm; refer children's social care; FGM in under-18s = mandatory report. Adults: capacity (MCA) & wishes matter (making safeguarding personal) — a capacitous adult can decline for themselves unless others at risk / serious crime / statutory duty. Information sharing without consent is justified where risk of serious harm. Immediate danger → 999. Involve the safeguarding lead; act on reasonable concern (no proof needed).

🎓

SCA Quick Reference

Safeguarding — Consultation Playbook

Recognise · respond honestly · refer · record · Think Family

▼expand

🎯 The three pivots that pass this case

1 · Recognise & don't collude

Spot NAI + domestic-abuse red flags; don't accept the vague story or promise secrecy; ensure immediate safety.

2 · Child welfare paramount

Act on reasonable concern (no proof needed); refer children's social care (consent not required where significant-harm risk); Think Family.

3 · Refer, record, support

Domestic-abuse/IDVA/MARAC (never with perpetrator present); record factually; share lawfully; safeguarding lead; support without blame.

⛔ Don't collude with "don't make a fuss" or accept an inconsistent injury history · Don't promise to keep safety concerns secret · Don't raise domestic abuse with the perpetrator present · Don't wait for proof — reasonable concern is enough · Don't forget the sibling/other dependents (Think Family) · Record factually, share lawfully, involve the safeguarding lead

Safeguarding (Children & Adults) · GP Clinical Reasoning Framework v2 · RCGP Safeguarding Standards for General Practice (2024) & RCGP Safeguarding toolkit · Working Together to Safeguard Children 2026 (DfE; replaced the 2023 edition) · NICE CG89 Child maltreatment (updated Dec 2025) · NICE NG76 Child abuse and neglect · NICE PH50 / QS116 Domestic violence and abuse · Children Act 1989 & 2004 · Care Act 2014 (adult safeguarding) · Mental Capacity Act 2005 · Domestic Abuse Act 2021 · SafeLives DASH / MARAC · FGM Act 2003 s5B mandatory reporting (Home Office procedural information) · Prevent duty guidance (2023) · DfE Information sharing advice (2024) · GMC Protecting children and young people, Confidentiality and 0–18 years

Recognise · Respond · Refer · Record — the four Rs · Children: welfare is paramount; consent is NOT required to refer where there is risk of significant harm; non-mobile child with bruising, inconsistent/changing history and delayed presentation are major NAI red flags; FGM in under-18s is a mandatory report · Adults at risk (Care Act): consider capacity (MCA) and wishes (making safeguarding personal); a capacitous adult may decline for themselves unless others are at risk / serious crime / statutory duty · Domestic abuse: enquire safely (never with the perpetrator present), risk-assess (DASH), safety-plan, IDVA/MARAC · Think Family; share information lawfully where there is risk of serious harm; act on reasonable concern; involve the safeguarding lead; immediate danger → 999

Teaching clinicians why each step matters — not just what to do · Always follow local safeguarding procedures and current statutory guidance · Clinical judgement and the duty to protect take precedence

Safeguarding

Red Flags — when to act now

👶 The child comes first

🤝 Support, not punishment

🔒 Honest about confidentiality

🆘 Safety now

Now / 999

Same day

Early help / monitor

🚩 Act on reasonable concern — the child's welfare is paramount

Validate: name the expectation and the fear

Explain: the duty, and what a referral actually means

Agree: offer control over what she can control

Housing, refuge & leaving

The children

Money, work & economic abuse

Technology & safe contact

Identity, shame & fear of judgement

Driving, practicalities & getting home

The clinician's own response

Today: before the family leaves

Within 1–2 working days: confirm and chase

Days to weeks: strategy discussion, s47 and conference

1–2 weeks: Chloe's review

Ongoing: plan reviews & vigilance

Memory rule: "SAFER" at every contact

⚠ Three scenario-specific safety-nets: use these word for word

Why documentation matters beyond clinical care

🎭 Patient actor brief — click to practise (the mother)

Who you are (Chloe, the mother)

Hidden concerns (reveal if explored gently)

Details if asked

Reactions at key moments