What documentation and reporting procedures should I follow when I suspect a case of non-accidental injury?

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 22 August 2025Updated: 22 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

Record in the child's clinical record exactly what is observed and heard from whom and when, and why this is of concern. At this point, consider, suspect or exclude child maltreatment from the differential diagnosis .

If you suspect child maltreatment, refer the child or young person to children's social care following local multi-agency safeguarding arrangements. This may trigger a child protection investigation, and supportive services may be offered to the family following an assessment or alternative explanations may be identified .

Record all actions taken and the outcomes of these actions .

Related Knowledge Topics

Educational content only. Always verify information and use clinical judgement.

What documentation and reporting procedures should I follow when I sus