Key Facts

Safeguarding is a core responsibility of all healthcare professionals. Primary care is uniquely positioned to identify abuse due to longitudinal relationships with patients and families. Recognition, documentation, and appropriate referral are essential skills.

Epidemiology

• Approximately 1 in 5 children experience some form of maltreatment
• >500,000 adults are estimated to experience abuse in England annually
• Domestic abuse affects approximately 2 million adults/year in England and Wales
• Child protection plans: approximately 50,000 children at any time in England
• Serious case reviews highlight recurring themes: poor information sharing, failure to recognise risk, inadequate professional curiosity

Legal Framework

• Children Act 1989 and 2004: duty to safeguard and promote welfare
• Care Act 2014: local authority duty to safeguard adults at risk
• Mental Capacity Act 2005: protection for adults lacking capacity
• FGM Act 2003 (amended 2015): mandatory reporting for professionals
• Modern Slavery Act 2015: duty to notify National Referral Mechanism
• Domestic Abuse Act 2021: recognises children as victims in their own right

Risk Factors for Abuse

• The 'toxic trio': domestic abuse + parental substance misuse + parental mental illness
• Social isolation, poverty, housing instability
• Learning disability, physical disability
• Previous history of abuse
• Frequent A&E attendance, missed appointments, non-concordance with treatment

Child Abuse Recognition

• Physical abuse: bruising (non-mobile infant — highly suspicious), burns (cigarette, scald patterns), fractures (especially in non-ambulant children), bite marks
• Neglect: faltering growth, poor hygiene, dental caries, recurrent infections, inappropriate clothing
• Emotional abuse: developmental delay, behavioural disturbance, attachment difficulties
• Sexual abuse: genital/anal symptoms, STI in prepubertal child, sexually inappropriate behaviour, pregnancy in young adolescent

Adult Abuse Recognition

• Physical abuse: unexplained injuries, injuries inconsistent with history, multiple injuries at different stages
• Neglect/self-neglect: malnutrition, poor personal hygiene, untreated medical conditions, unsafe living conditions
• Financial abuse: unexplained loss of money, changes to wills, pressure to sign documents
• Domestic abuse: pattern of controlling behaviour, injuries inconsistent with explanation, frequent presentations with anxiety/depression

Red Flags

• Injuries inconsistent with developmental stage (bruising in non-mobile baby)
• Delay in seeking medical attention
• Inconsistent or changing history between carers
• Frequent ED/GP attendances with unexplained injuries
• Disclosure by child or adult — always take seriously
• Professional instinct ('gut feeling') — document and act upon
• FGM: disclosed or suspected in any female <18

Assessment

• Thorough history (from child and each carer separately if possible)
• Full physical examination with documentation (body maps)
• Growth chart review (faltering growth)
• Development assessment in children
• Assessment of mental capacity in adults

Bloods (to exclude medical causes before attributing to abuse)

• FBC, coagulation screen: exclude bleeding disorder
• Bone profile, vitamin D: exclude metabolic bone disease
• Skeletal survey: if physical abuse suspected in children <2 years

Documentation

• Document findings verbatim (using patient's own words)
• Use body maps for injury documentation
• Record who was present, who gave the history
• Document professional concerns and actions taken
• Secure record-keeping with appropriate coding

Immediate Actions

• If child/adult is in immediate danger: contact police (999)
• If concern about abuse/neglect: discuss with safeguarding lead/named GP
• Make a referral to children's social care (MASH — Multi-Agency Safeguarding Hub) or adult social care
• You do NOT need parental consent to make a referral if doing so would place the child at further risk

GP Practice Responsibilities

• Named safeguarding lead for children and adults
• Regular safeguarding training (Level 3 for GPs per RCGP guidance)
• Safeguarding policies and procedures
• Information sharing at MARAC and child protection conferences
• Coding and flagging at-risk patients

Multi-Agency Working

• Attend child protection conferences when invited
• Provide reports/chronologies for multi-agency meetings
• Contribute to serious case reviews/safeguarding adult reviews
• Engage with MARAC for domestic abuse
• National Referral Mechanism for modern slavery/trafficking

Specific Mandatory Reporting

• FGM in girls <18: mandatory duty to report to police
• Terrorism concerns: PREVENT duty (refer to local PREVENT team)
• Female patients disclosing FGM: offer support and referral to specialist services

Referral Criteria

• Any concern about abuse or neglect: referral to social care (MASH)
• Child with suspicious injury: paediatric assessment (refer to named/designated paediatrician)
• Domestic abuse: offer support, provide information (national helpline, local services, MARAC referral if high risk)
• Vulnerable adult at risk: adult social care referral
• FGM: mandatory police report + specialist referral

• Adverse childhood experiences (ACEs): dose-response relationship; 4+ ACEs associated with 4× increased risk of depression, 7× increased risk of alcohol misuse, 12× increased risk of suicide attempt
• Early intervention improves outcomes significantly
• Domestic abuse: leaving an abusive relationship is the most dangerous period; ongoing risk assessment essential
• Child protection plan: majority of children are no longer on plan within 2 years, but recurrence of abuse is a risk
• Safeguarding referrals: approximately 60% of referrals lead to further assessment; 20% lead to child protection plan

Types of Abuse Summary

Safeguarding Referral Pathway