Executive summary
- Every clinician has a professional and legal duty to act when they have concerns about a child's safety. Concerns do not need to be confirmed — a reasonable suspicion is sufficient to refer. The threshold to refer is low; the threshold to do nothing is high.
- Think family, not just patient. When an adult presents with domestic abuse, substance misuse, or severe mental illness, always consider the impact on any children in the household.
- FGM is a mandatory reporting duty: Clinicians in England are legally required to report to the police if they identify in the course of their work that FGM appears to have been carried out on a girl under 18.
- Confidentiality is not a barrier to referral. The welfare of the child is paramount. Information can and should be shared with children's social care and police when a child may be at risk of significant harm, even without parental consent.
Recognising abuse and neglect
- Physical abuse indicators: Injuries inconsistent with developmental stage (bruising in a non-mobile baby is abuse until proven otherwise), injuries inconsistent with the history given, injuries at unusual sites (ears, neck, buttocks, back), multiple injuries at different healing stages, unexplained fractures (especially posterior rib, metaphyseal, and skull fractures in infants), burns and scalds with a clear demarcation line or glove/stocking pattern.
- Neglect indicators: Persistent failure to attend medical appointments, poor growth not explained by medical cause, poor hygiene, inadequate clothing for weather, frequent dental caries, a child who appears constantly hungry or tired, and parents who appear indifferent to the child's needs.
- Sexual abuse indicators: Sexualised behaviour inappropriate for age, genital or anal symptoms without another explanation, or disclosure by the child. Physical examination findings are often absent even in confirmed cases.
- Emotional abuse: Often co-exists with other forms. Indicators include: frozen watchfulness, delayed emotional development, extreme behaviour (aggression or withdrawal), and impaired peer relationships.
- Key alert — unexplained intracranial injury in an infant: Subdural haematoma with retinal haemorrhages should prompt urgent paediatric assessment and a safeguarding referral. Do not accept an inadequate explanation.
What to do — the referral pathway
- If immediate danger: Call 999. Do not delay.
- If significant concern (not immediate danger): Contact children's social care (the local authority duty team) by telephone the same day. Follow up with a written referral within 24 hours using your trust/CCB safeguarding referral form. You do not need parental consent to make a referral if the child may be at risk of significant harm.
- Always inform your named safeguarding professional: Every GP practice should have access to a named GP for safeguarding children and a designated nurse. Discuss cases with them if uncertain — they can advise on whether to refer and support documentation.
- Tell the parent (unless it would put the child at greater risk): It is generally good practice to inform the parent you are making a referral, unless doing so would endanger the child. This can be challenging — use your professional judgement and discuss with your named safeguarding lead.
- Section 47 enquiry: Following a referral, children's social care will determine if a Section 47 enquiry (Children Act 1989) is warranted to assess whether the child is at risk of significant harm. Primary care clinicians may be asked to contribute to this assessment.
Documentation
- Document contemporaneously and factually: Record verbatim what the child or parent said (in quotes), your objective clinical findings (site, size, colour, and shape of any injuries), your clinical impression, and every action taken with date and time.
- Do not document opinion as fact — write "an injury inconsistent with the history provided" rather than "this child has been abused." Your records may become legal evidence.
- Body map: Use a body map diagram to record injury locations accurately. This is considered best practice in cases of suspected physical abuse.
- Record who you spoke to: Document every conversation — with parents, children's social care, police, and your named safeguarding professional — including the name and role of the person you spoke to.
Frequently asked questions
I am not sure it is abuse — should I still refer?
Yes, if you have a reasonable concern. The NICE NG76 threshold is "suspected" maltreatment — you do not need certainty. It is the role of children's social care and the multi-agency safeguarding process to investigate and assess. Your job is to identify and refer. Failure to refer when concerned is a greater risk than an investigation that concludes no harm occurred.
What are my obligations regarding FGM?
Since October 2015, all regulated health professionals in England are legally required to report to the police any girl under 18 in whom they identify (in the course of their professional duties) that FGM appears to have been performed. This is a mandatory duty — it is not a discretionary safeguarding referral. The report must be made personally by the clinician, not delegated to a social worker.
A parent threatens legal action if I refer — what should I do?
Proceed with the referral if your clinical concern is genuine. Clinicians acting in good faith and in the child's best interests are protected legally when making safeguarding referrals. Document the parent's response and discuss with your named safeguarding lead and medical defence organisation if needed. The parent's displeasure or threats cannot override the duty to protect the child.
How do I manage the consultation if I suspect abuse?
Remain calm and non-accusatory. Do not challenge the carer in the room if doing so could increase risk to the child. Conduct a thorough examination and document carefully. If the child is old enough and it is safe to do so, speak to them briefly alone. Do not coach the child or ask leading questions about what happened — this can compromise later forensic interviewing. Focus on clinical assessment, then refer.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.