General Practice · Full case
Safeguarding
Safeguarding (Children & Adults) · Clinical Reasoning Framework v2
GP & SCA · recognise the signs · respond & share · refer to the right pathway · record · domestic abuse · MCA & capacity · the GP's statutory duty
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 (except where others are at risk, a serious crime, or duties like FGM/terrorism). 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 — unless others at risk, serious crime, or statutory duty (FGM). 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:
1
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)
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/at risk in an under-18 | Mandatory reporting duty. | Report to police (under-18 FGM); safeguarding referral |
| 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
👶 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
2
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"
3
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.
🎓 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
4
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.
🎓 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)
5
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.
🚩 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
6
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.
🎓 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
7
Step 7
Manage & Follow Through — Safety · Support · Record · Multi-Agency · Review
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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.
🎓 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
Safeguarding — SCA Consultation Scorecard
Recognise · respond · refer · record · child welfare paramount · domestic abuse · Think Family
0/ 33 pts
Global Skills
Structure, language, responsiveness
0/7
Tasks
Clinical reasoning, duty, management
0/15
Relating to Others
Communication, rapport, shared decisions
0/11
RAG Self-Assessment
🔴 Red
Accepts the story; promises secrecy; no child/sibling safeguarding; misses DA; no referral; waits for proof
🟠 Amber
Recognises a concern; some safety/recording; referral intended but vague; DA/Think Family partial; ICE partial
🟢 Green
Recognises NAI + DA; honest re confidentiality; immediate safety; children's social care + DA referral; Think Family; record/share lawfully; safeguarding lead; ICE all three
Complete the checklist to see your score and feedback
"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
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🧭 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
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🎯 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