About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Children Act 1989: the child's welfare is the PARAMOUNT consideration. Section 47: local authority duty to investigate if child at risk of significant harm
- Types of abuse: physical, emotional, sexual, neglect (most common). Recognise patterns, not just individual injuries
- Non-accidental injury (NAI) red flags: injuries inconsistent with developmental age, multiple injuries in different stages of healing, specific patterns (cigarette burns, grip marks, bite marks), delay in presentation, changing story
- Doctor's duty: if you suspect abuse, REFER to children's social care — you do NOT need proof, only reasonable concern. Document meticulously
- Confidentiality CAN and SHOULD be broken to protect a child — child safety overrides parental confidentiality
- FGM: mandatory duty to report to police if you discover FGM in a girl under 18 (Serious Crime Act 2015)
Overview
Safeguarding children is the responsibility of all healthcare professionals. The legal framework is provided by the Children Act 1989 and 2004, supplemented by statutory guidance "Working Together to Safeguard Children" (2023). The fundamental principle is that the welfare of the child is paramount. Child abuse encompasses physical abuse, emotional abuse, sexual abuse, and neglect. Doctors must be able to recognise the signs of abuse, make appropriate referrals to children's social care, and participate in multi-agency child protection processes. Unlike adult safeguarding, parental consent is NOT required to make a referral — the child's safety takes precedence.
Epidemiology
Over 650,000 children in England were referred to children's social care in 2022-23. Approximately 60,000 children are on a child protection plan at any time. Neglect is the most common category (around 50%), followed by emotional abuse (35%), physical abuse (8%), and sexual abuse (4%). Serious case reviews consistently highlight missed opportunities by health professionals — the Victoria Climbié, Baby P, and Daniel Pelka inquiries all identified failures in information sharing and professional curiosity. Approximately 50 children per year die from abuse or neglect in England.
Recognising Abuse
Symptoms
Physical abuse: bruises in unusual locations (ears, neck, buttocks, inner arms), patterned injuries (belt, bite, cigarette burns), fractures inconsistent with developmental stage
Neglect: failure to thrive, poor hygiene, inadequate clothing, missed medical appointments, dental caries, persistent nappy rash in an older infant
Emotional abuse: developmental delay, excessive clinginess or withdrawal, low self-esteem, witnessing domestic violence
Sexual abuse: genital injuries, STIs in a pre-pubertal child, sexualised behaviour inappropriate for age, pregnancy in a child
Fabricated or induced illness (FII/Munchausen by proxy): unexplained recurrent illness, symptoms only when parent present, multiple hospital admissions, parent seeking attention from medical involvement
Signs
Injuries inconsistent with the explanation given (the "story doesn't fit the injury")
Multiple injuries in different stages of healing
Delay in seeking medical attention
Changing or inconsistent history from caregivers
Child appears frightened of a parent/carer
Parent hostile, avoidant, or overly anxious about medical assessment
Specific fracture patterns in infants: rib fractures (from squeezing), metaphyseal corner fractures (from shaking/twisting), skull fractures in non-mobile infants
Assessment
First-line
Detailed historyTake from EACH caregiver separately. Who was present? What happened? When? How was the child behaving? Is the injury consistent with the mechanism described and the child's developmental stage?
Full examinationFull skin survey (undressed), document all injuries on body map, measure and describe (size, shape, colour, age). Photograph with consent where possible
Second-line
Skeletal surveyAP and lateral radiographs of entire skeleton — standard investigation in suspected physical abuse in children <2 years. Repeat at 11-14 days to detect healing fractures
BloodsFBC (platelet count — exclude ITP), coagulation screen (exclude bleeding disorder), bone profile, vitamin D
Ophthalmology reviewRetinal haemorrhages — strongly associated with abusive head trauma (shaken baby syndrome). Must be assessed by ophthalmologist with indirect ophthalmoscopy
Specialist
CT/MRI headIf suspected abusive head trauma: subdural haematomas (especially bilateral, different ages), cerebral oedema, hypoxic-ischaemic injury
Child protection medical assessmentConducted by a paediatrician with child protection expertise. Comprehensive medical assessment documented in a structured report
1
Immediate actions
- Ensure the child's immediate safety — treat any injuries
- If the child is in immediate danger, contact the police (999)
- Refer to children's social care (local authority) — a verbal referral followed by written referral within 48 hours
- You do NOT need proof of abuse — a reasonable concern is sufficient to refer
- Do NOT confront the alleged abuser or investigate — that is social care's and the police's role
2
Confidentiality and information sharing
- Confidentiality CAN and SHOULD be overridden to protect a child
- Share information with relevant agencies (social care, police) — child safety is paramount
- Do NOT promise a child or parent that you will keep information confidential if safeguarding is a concern
- GMC guidance: the duty to protect children overrides the duty of confidentiality
3
Multi-agency response
- Section 47 enquiry: local authority investigates if reasonable cause to suspect significant harm
- Strategy meeting/discussion: police, social care, health — determines whether joint investigation needed
- Child protection conference: multi-agency meeting to decide if child needs a child protection plan
- Participate in conferences, provide reports, attend court if required
4
Mandatory reporting
- FGM: mandatory duty to report to police if you discover FGM in a girl under 18 (Serious Crime Act 2015) — failure to report is a criminal offence
- No general mandatory reporting law for child abuse in England (unlike FGM), but strong professional duty to refer
Complications
- Failure to recognise and act: Continued abuse, serious harm, or death. Every professional who encounters a child has a responsibility
- Death or serious injury: Triggers a Child Safeguarding Practice Review (formerly Serious Case Review)
- Long-term consequences for the child: PTSD, attachment disorders, behavioural difficulties, educational underachievement, mental illness, intergenerational cycle of abuse
- Professional consequences: GMC investigation, fitness to practise proceedings, personal accountability at criminal and civil law
UKMLA Exam Tips
- 1Child safety is PARAMOUNT — overrides parental confidentiality, parental wishes, and any other consideration
- 2You do NOT need proof to refer — only reasonable concern. The investigation is social care's job, not yours
- 3Bruises in non-mobile babies = highly suspicious (babies who can't cruise don't bruise)
- 4Rib fractures in infants (especially posterior) are highly specific for non-accidental injury
- 5Retinal haemorrhages + subdural haematomas + encephalopathy = triad of abusive head trauma (shaken baby)
- 6FGM in under 18 = mandatory police report. This is a criminal offence if you fail to report
- 7Fabricated/induced illness: parent seeks medical attention, child's symptoms resolve when parent is absent — very difficult to recognise
- 8Do NOT promise confidentiality to a parent if safeguarding is a concern — you cannot keep that promise
practicetest your knowledge on safeguarding childrenApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — ethics & law and beyond.
open q-bank