Previous changes

May 2023 — reviewed. A literature search was conducted in March 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. No major changes to the recommendations have been made. The topic has undergone minor restructuring.

November 2016 — minor update. A typographical error has been corrected.

October 2013 to March 2014 — this is a new CKS topic. The evidence base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 March 2023.

HTAs (Health Technology Assessments)

No new HTAs since 1 March 2023.

Economic appraisals

No new economic appraisals relevant to England since 1 March 2023.

Systematic reviews and meta-analyses

No new systematic review or meta-analysis since 1 March 2023.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 March 2023.

New policies

No new national policies or guidelines since 1 March 2023.

New safety alerts

No new safety alerts since 1 March 2023.

Changes in product availability

No changes in product availability since 1 March 2023.

Barriers to recognition and disclosure of child maltreatment

• Possible barriers to recognizing and responding to child maltreatment include [NICE, 2017b; RCGP, 2019]:
  • Concern about missing a treatable disorder.
  • Fear of losing a positive relationship with a family already under their care. 
  • Discomfort of disbelieving, thinking ill of, suspecting, or wrongly blaming a parent or carer.
  • Fear of breaching confidentiality. 
  • Seeking other, more comfortable explanations for observations, especially when, for example, feeling compassionate towards parents of a disabled child or young person. 
  • Losing control over the child protection process, and doubts about its benefits. 
  • Concern about personal and professional safety.
  • Personal experience of abuse or neglect, including domestic violence.
  • Concentrating more on the parents than the child — parents can easily overshadow the child removing the focus of attention away from the child.
  • Not seeing the adult.
  • Uncertainty about local procedures or contacts.
  • Acceptance of different cultural practices as normal even when harmful to the child — for example, a health professional may assume that females are less valued in some cultures and more readily accept neglect of female children.
  • Poor communication between health professionals — information from different sources often needs to be shared to properly understand the problem. Concerns about confidentiality, consent, and data protection may impair the sharing of this information.
• Children and young people may find it difficult to disclose child maltreatment. Possible barriers to disclosure include [NSPCC, 2023]: 
  • Feelings of fear, confusion, shame, or guilt.
  • Fear of being stigmatized.
  • Not recognizing their own experiences as abusive or neglectful, for example, if they have been groomed. 
  • Being coerced by (or having an attachment to) the person or people abusing or neglecting them.
  • Fear of the consequences of disclosure, for example, that no one will believe them, the abuse or neglect might get worse, their family will be split up or excluded by their community, or they will go into care.
  • Negative experience from previous disclosure.
  • Worry about confidentiality.
  • Lack of trust in the people around them (including parents) and in the services provided to help them.
  • Worry they will be causing trouble and making the situation worse.
  • Fear of formal procedures (may find them overwhelming).
  • Communication difficulties, including language barrier.

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guidelines Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017b] and Child abuse and neglect [NICE, 2017a]; the General Medical Council (GMC) guideline Protecting children and young people: the responsibilities of all doctors [GMC, 2018], Child safeguarding toolkit published by the Royal College of General Practitioners (RCGP) [RCGP, 2019], the National Society for the Prevention of Cruelty to Children (NSPCC) guideline Recognising and responding to abuse [NSPCC, 2023], and a review article [BMJ, 2023].

• The RCGP advises that abuse and neglect should always be considered when seeing children and young people of any age for any presentation. It is important that abuse is asked about directly using age-appropriate language, bearing in mind that children and young people may not recognize that they are victims of abuse [RCGP, 2019].
• Prevention and early identification of child maltreatment may depend on the early recognition of risk factors and warning signs, including those related to parents and the environment [RCGP, 2019].
• The recommendation to consider non-abusive causes for potential signs and symptoms of child maltreatment is based on expert opinion in the General Medical Council (GMC) guideline [GMC, 2018]. The recommendations on questions to ask to confirm/rule-out potential non-abusive causes are based on expert opinion in a review article [BMJ, 2023].

When should I suspect or consider physical abuse?

Suspect physical abuse if any of the following are present and the explanation is absent or unsuitable:

• Bruising:
  • In the shape of a hand, ligature, stick, teeth mark, grip, or implement.
• Bruising or petechiae (tiny red or purple spots): if not caused by a medical condition (for example a causative coagulation disorder) and the explanation for the bruising is unsuitable. For example:
  • Bruising in a child who is not independently mobile.
  • Multiple or clustered bruises.
  • Bruises of a similar shape and size.
  • Bruises on any non-bony part of the body or face, including the eyes, ears, and buttocks. 
  • Bruises on the ankles and wrists resembling ligature marks.
  • Bruises on the neck resembling attempted strangulation.
• Bites:
  • If there is a report or appearance of a human bite mark that is thought unlikely to have been caused by a young child.
  • Consider neglect if there is a report or appearance of an animal bite on a child who has been inadequately supervised. 
• Lacerations, abrasions, or scars:
  • On a child who is not independently mobile.
  • On areas that are usually protected by clothing (for example the back, chest, abdomen, axilla, and genital area).
  • On the eyes, ears, and sides of the face.
  • On the neck, ankles, and wrists that look like ligature marks.
  • That are multiple, especially with a symmetrical distribution.
• Burn or scald injuries:
  • On a child who is not independently mobile.
  • On any soft tissue area that would not be expected to come into contact with a hot object in an accident (for example the backs of hands, soles of feet, buttocks, and back).
  • In the shape of an implement (for example a cigarette or iron).
  • That suggests forced immersion, for example:
    • Scalds to buttocks, perineum, and lower limbs.
    • Scalds to limbs in a glove or stocking distribution.
    • Scalds to limbs with symmetrical distribution.
    • Scalds with sharply delineated borders.
• Fractures:
  • One, or more, in the absence of a medical condition that predisposes to fragile bones (for example osteogenesis imperfecta or osteopenia of prematurity). Presentations include: 
    • Fractures of different ages.
    • X-ray evidence of occult fractures (fractures identified on X-rays that were not clinically evident), for example, rib fractures in infants. 
• Intracranial injury: 
  • In the absence of major confirmed accidental trauma or known medical cause, in one or more of the following circumstances:
    • The child is aged under 3 years.
    • There are also retinal haemorrhages, rib or long bone fractures, or other associated inflicted injuries.
    • There are multiple subdural haemorrhages with or without subarachnoid haemorrhage with or without hypoxic-ischaemic damage (damage due to lack of blood and oxygen supply) to the brain. 
• Eye trauma:
  • Retinal haemorrhages or injury to the eye in the absence of major confirmed accidental trauma or a known medical explanation, including birth-related causes. 
• Spinal injuries: 
  • If a child presents with signs of a spinal injury (injury to vertebrae or within the spinal canal) in the absence of major confirmed accidental trauma. Spinal injury may present as: 
    • A finding on skeletal survey or magnetic resonance imaging.
    • Cervical injury in association with inflicted head injury.
    • Thoracolumbar injury in association with focal neurology or unexplained kyphosis (curvature or deformity of the spine). 
• Visceral injuries:
  • If a child has an intra-abdominal or intrathoracic injury in the absence of major confirmed accidental trauma, and there is an absent or unsuitable explanation or a delay in presentation. There may be no external bruising or other injury. 
• Poisoning:
  • If one or more of the following apply:
    • There is a report of deliberate administration of inappropriate substances, including prescribed and non-prescribed drugs.
    • There are unexpected blood levels of drugs not prescribed for the child.
    • There is reported or biochemical evidence of ingestion of one or more toxic substances.
    • The child was unable to access the substance independently.
    • There have been repeated presentations of ingestions in the child or other children in the household.
• Repeated apparent life-threatening events:
  • Where the onset is witnessed only by one parent or carer and a medical explanation has not been identified. Consider maltreatment if there is an apparent event with bleeding from the nose or mouth and a medical explanation has not been identified.
• Submersion injury:
  • If a child has a non-fatal submersion incident (near-drowning), or the child's presentation is inconsistent with the account.
    • Consider child maltreatment if a non-fatal submersion incident suggests a lack of supervision. 
• Note: a child should be considered independently mobile if they can do any of the following:
  • Crawl.
  • Bottom shuffle.
  • Pull themself up into a standing position using an object, for example, furniture.
  • Move into a standing position unaided.
  • Cruise (that is, move from place to place holding onto an object, for example, furniture).
  • Climb, for example, onto furniture or stairs.
  • Walk using a push-along walker.
  • Walk unaided.
  • Children under 12 weeks typically lack the muscle strength, coordination and neurological maturity needed for independent mobility. However, age alone should not be used to determine whether a child is independently mobile.

Consider physical abuse/maltreatment if any of the following are present and the explanation is absent or unsuitable:

• Cold injury (for example, swollen, red hands or feet). 
• Hypothermia.
• Oral injuries.
• Serious or unusual injuries.
• Hypernatraemia. 
• Unusual pattern of presentation to and contact with healthcare providers, or frequent presentations or reports of injuries. 

When should I suspect or consider sexual abuse?

Sexual activity of any kind between adults and children under 16 years is unlawful. A child under the age of 13 years cannot legally consent to any form of sexual contact. It is an offence for a person in a position of trust to engage in sexual activity with a child or young person under 18 years or a person with learning difficulties or a psychiatric illness. Sexual activity between two young teenage people under 16 years and of similar age is unlawful too, although is unlikely to result in prosecution if mutually agreed unless it involves abuse or exploitation.

Ano-genital signs and symptoms

• Suspect sexual abuse in a boy or girl with:
  • Genital, anal, or perianal injury (as evidenced by bruising, laceration, swelling, or abrasion) and the explanation is absent or unsuitable.
  • A persistent or recurrent genital or anal symptom (for example bleeding or discharge) that is associated with behavioural or emotional change and that has no medical explanation.
  • An anal laceration, constipation, Crohn's disease, and passing hard stools have been excluded as possible causes.
• Consider sexual abuse in a boy or girl with:
  • Dynamic anal dilation and there is no medical explanation (for example a neurological disorder or severe constipation). 
  • A genital or anal symptom (for example bleeding or discharge) without a medical explanation.
  • Dysuria or anogenital discomfort that is persistent or recurrent and does not have a medical explanation (for example worms, urinary infection, skin conditions, poor hygiene, or known allergies).
  • Evidence of one or more foreign bodies in the vagina or anus. Foreign bodies in the vagina may be indicated by offensive vaginal discharge.

Sexually transmitted infections (STIs)

• Suspect sexual abuse if a child younger than 13 years has:
  • Gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV, or trichomonas infection and there is no clear evidence of mother-to-child transmission during birth or blood contamination.
• Consider sexual abuse if a child younger than 13 years has:
  • Hepatitis B and there is no clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, or blood contamination.
  • Anogenital warts and there is no clear evidence of mother-to-child transmission during birth or non-sexual transmission from a member of the household.
• Consider sexual abuse in a young person aged 13 to 15 years if they have:
  • Hepatitis B and there is no clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination, or that the infection was acquired from consensual sexual activity with a peer. 
  • Anogenital warts and there is no clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, or that the infection was acquired from consensual sexual activity with a peer. 
  • Gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV, or trichomonas infection and there is no clear evidence of mother-to-child transmission during birth, blood contamination, or that the STI was acquired from consensual sexual activity with a peer. In these circumstances, consider discussing your concerns with a named or designated professional for safeguarding children. 
• Consider sexual abuse in young people aged 16 or 17 years if they have:
  • Hepatitis B and there is:
    • No clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination, or that the infection was acquired from consensual sexual activity, and
    • A clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example teacher, sports coach, or minister of religion), or 
    • Concern that the young person is being exploited. 
  • An anogenital wart and there is:
    • No clear evidence of non-sexual transmission from a member of the household or that the infection was acquired from consensual sexual activity, and 
    • A clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example teacher, sports coach, or minister of religion), or
    • Concern that the young person is being exploited. 
  • Gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV, or trichomonas infection and there is: 
    • No clear evidence of blood contamination or that the STI was acquired from consensual sexual activity, and
    • A clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example teacher, sports coach, or minister of religion), or 
    • Concern that the young person is being exploited. 

Pregnancy 

• Sexual intercourse with a child younger than 13 years is unlawful. Therefore, pregnancy in such a child means the child has been maltreated.
• Consider sexual abuse if:
  • A young woman aged 13 to 15 years is pregnant.
  • A young woman aged 16 or 17 years is pregnant and one or more of the following apply: 
    • There is a clear difference in power or mental capacity between the young woman and the putative father, in particular when the relationship is incestuous or is with a person in a position of trust.
    • There is concern that the young woman is being exploited.
    • There is concern that sexual activity was not consensual. 

When should I suspect or consider neglect?

• Suspect neglect if:
  • A child or young person is persistently dirty and smelly. Consider that children often become dirty and smelly during the course of the day. Use judgement to determine if a persistent lack of provision or care is a possibility. Examples include: 
    • Children seen at times of the day when it is unlikely that they would have had an opportunity to become dirty or smelly (for example an early morning visit). 
    • If the dirtiness is ingrained.
  • There are repeated observations/reports of any of the following in the home that is in the parents' or carers' control:
    • A poor standard of home hygiene that affects a child's health.
    • Inadequate provision of food.
    • A living environment that is unsafe for the child's developmental stage.
  • Parents or carers fail to seek medical advice for the child or young person to the extent that their health and wellbeing are compromised, including if the child or young person is in ongoing pain.
• Consider neglect if a child or young person:
  • Has severe and persistent infestations, such as scabies or head lice.
  • Wears clothing or footwear that is consistently inappropriate (for example for the weather or the child's size). 
    • Instances of inadequate clothing that have a suitable explanation (for example a sudden change in the weather or slippers worn because they were closest to hand when leaving the house in a rush) or result from behaviour associated with neurodevelopmental disorders, such as autism, would not be alerting features for possible neglect. 
  • Displays faltering growth because of lack of provision of an adequate or appropriate diet. For more information, see the National Institute for Health and Care Excellence (NICE) guideline on Faltering growth.
  • Is not being cared for by a person who can provide adequate care. 
• Consider neglect if:
  • The explanation for an injury (for example a burn, sunburn, or ingestion of a harmful substance) suggests a lack of appropriate supervision.  
  • Parents or carers: 
    • Fail to administer essential prescribed treatment for their child or young person. 
    • Repeatedly fail to bring the child or young person to follow-up appointments that are essential for their health and wellbeing. 
    • Persistently fail to engage with relevant child health promotion programmes, including immunization, health and development reviews, and screening. 
    • Have access to but persistently fail to obtain treatment for the child or young person's dental caries (tooth decay). 
    • Fail to seek medical advice for the child or young person to the extent that their health and wellbeing are compromised, including if the child or young person is in ongoing pain. 
• Consider child maltreatment if a child or young person has poor school attendance that the parents or carers know about that has no justification on health, including mental health grounds, and home education is not being provided. 
• Be aware that abandoning a child or young person is a form of maltreatment. 

When should I suspect or consider fabricated or induced illness?

• Suspect fabricated or induced illness if the child or young person's history, presentation, examination, or investigation does not match a recognized clinical picture, and one or more of the following is present:
  • Reported symptoms and signs only appear or reappear when the parent or carer is present.
  • Reported symptoms are only observed by the parent or carer. 
  • An inexplicably poor response to prescribed medication or other treatment.
  • New symptoms are reported as soon as previous ones have resolved.
  • A history of clinically unlikely events (for example infants with a history of very large blood losses who do not become unwell or anaemic).
  • Despite a definitive clinical opinion being reached, multiple opinions from both primary and secondary care are sought and disputed by the parent or carer, and the child or young person continues to be presented for investigation and treatment with a range of signs and symptoms. 
  • The child or young person's normal daily activities (for example school attendance) are being compromised, or the child or young person is using aids to daily living (for example wheelchairs) more than would be expected for any medical condition that they have.
    • Note that inappropriate substances, including prescribed and non-prescribed drugs, may be given to induce symptoms of illness. For more information, see the section on physical abuse.
• Consider fabricated or induced illness if the child or young person's history, presentation, examination, or investigation does not match a recognized clinical picture. Note that fabricated or induced illness is a possible explanation even if the child or young person has a past or concurrent physical or psychological condition. 

Basis for recommendation

These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017b].

Sexual abuse 

• The information on legislation and consent is taken from the Crown Prosecution Service (CPS) guidance Rape and Sexual Offences - Chapter 7: Key Legislations and Offences [CPS, 2022] and the British Association for Sexual Health and HIV (BASHH) National guidelines for the management of individuals disclosing sexual violence in sexual health services (2022) [BASHH, 2022].
• According to the Crown Prosecution Service, a child is defined as any person under the age of 18 years.

Neglect 

• NICE states that [NICE, 2017b]:
  • While there are differences in how parents and carers choose to raise their children, including the choices they make about healthcare, failure to recognize and respond to the child's needs may amount to neglect. There is no diagnostic gold standard for neglect. Therefore, decision-making can be very difficult and thresholds hard to establish. It is essential to place the child or young person at the centre of the assessment.
  • Achieving a balance between an awareness of risk and allowing children freedom to learn by experience can be difficult. However, if parents or carers persistently fail to anticipate dangers and to take precautions to protect their child from harm it may constitute neglect. 

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017b].

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017b].

Basis for recommendation

These recommendations are based on the National Institute for Health and Care Excellence (NICE) guideline Child maltreatment: when to suspect maltreatment in under 18s [NICE, 2017b].

How should I manage a child or young person with clinical features associated with child maltreatment?

• If a child or young person presents with clinical features associated with child maltreatment (alerting features):
  • Carefully assess the situation, considering the following:
    • Any history given.
    • The child or young person's appearance, behaviour, or demeanour.
    • Interaction between the parent/carer and the child or young person.
    • Any physical signs or symptoms.
    • Report of maltreatment, or disclosure from the child or young person (or a third party). 
    • Results of any investigation(s).
  • Seek an explanation for any injury or presentation from both the parent/carer and the child or young person in an open and non-judgemental manner. If the child or young person presents with clinical features associated with sexual abuse, use clinical judgement to determine whether it is appropriate to enquire as to whether there may be a suitable explanation for the features/injury.
    • An unsuitable explanation is one that is considered to be implausible, inadequate, or inconsistent with the child or young person's presentation, normal activities, existing medical condition, age, or developmental stage. Accounts may differ between the child/young person and their parent/carer, between parents or carers, and/or over time. An explanation based on cultural practice should not justify hurting a child or young person.
    • When discussing with the child or young person and/or their parents/carer, consider additional needs, such as physical, sensory, or learning disabilities, or the inability to speak or read English. Also, consider the cultural needs of the child or young person and their family/carer. 
  • Document all actions in the child or young person's clinical record, including:
    • What was observed and/or heard, from whom, and when.
    • Any concerns, including those considered minor.
    • Decisions or actions relating to those concerns. 
    • Any outcomes.
• Exclude child maltreatment if a suitable explanation is found for the alerting features.
  • This may be the decision following discussion of the case with a more experienced colleague or after gathering collateral information as part of considering child maltreatment.
  • An unsuitable explanation is one that is considered to be implausible, inadequate, or inconsistent with the child or young person's presentation, normal activities, existing medical condition, age, or developmental stage. Accounts may differ between the child/young person and their parent/carer, between parents or carers, and/or over time. An explanation based on cultural practice should not justify hurting a child or young person.
• If there are injuries or features that have led you to suspect child maltreatment:
  
  • Manage individual injuries as appropriate. Arrange hospital admission where required. Ensure that the receiving paediatrician is aware of your concerns.
  • If the child or young person is thought to be in immediate danger, refer immediately to children's social care and/or the police. Consider the safety of other children living with or in contact with the suspected perpetrator.
  • If the child or young person is not thought to be in immediate danger, contact children's social care to discuss the need for a referral to them, using local multi-agency safeguarding procedures. 
  • A referral may trigger a child protection investigation, a family assessment to determine whether supportive services need to be offered, or alternative explanations may be identified.
• If sexual abuse is suspected:
  
  • Do not perform an intimate examination unless there is an urgent health need to do so. 
  • If appropriate, use open-ended questions to enquire about the causes and circumstances of the presenting features and record these questions and responses verbatim.
  • Where appropriate (depending on the timescale and the wishes of the person), refer urgently for the collection of forensic evidence. 
    
    • A forensic intimate examination should only be undertaken by professionals specifically trained in forensic aspects of sexual assaults (such as the police if the person wishes to report the assault, or to a Sexual Assault Referral Centre (SARC) if locally available).
    • DNA can be gathered for up to 7 days after vaginal penetration, up to 2 days in oral penetration and for up to 3 days in anal/penile penetration irrespective of washing or bathing.
  • Assess the need for emergency contraception (EC). For more information on EC, see the CKS topic on Contraception - emergency.
  • Assess the need for prophylaxis against sexually transmitted infection (STI).
    • If STI prophylaxis is required, this may be offered at some SARCs (check local availability) or arranged through a genito-urinary medicine (GUM) clinic.
    • Information on the management of specific STIs and STI prophylaxis is available in Section 7 of the British Association for Sexual Health and HIV (BASHH) guideline on the management of STIs in Children and Young People.
  • A general examination may be appropriate to assess the person's general health and to look for other injuries.
• If there are features that have led you to consider child maltreatment:
  • Look for other alerting features in the child or young person's history, presentation, or interactions with their parents or carers, now or in the past. Then, do one or more of the following:
    • Discuss your concerns with a more experienced colleague, a community paediatrician, a child and adolescent mental health service colleague, or a named or designated professional for safeguarding children.
    • Gather information from other agencies and explain to the family that this information is needed to make an overall assessment of the child or young person. If this is likely to place the child or young person at risk, seek advice from children's social care.
    • Arrange a review of the child or young person, with the timing dependent on your level of concern. Continue to look for the alerting feature being repeated, or for any other alerting features.
  • After taking these steps, if the level of concern increases to 'suspect', discuss the need for a referral with children's social care.
    • If it is decided that a referral to children's social care is not required, and if training and expertise permit, consider undertaking an Early Help assessment in line with local procedures. Otherwise, arrange for an Early Help assessment with another professional, such as a family support worker, school nurse, health visitor, or special educational needs coordinator.
• If you are unsure whether a child or young person is at risk, or how best to act on your concerns:
  • Seek advice from named or designated colleagues, and/or your practice safeguarding lead/deputy lead.
  • You can also seek advice at any time from the NSPCC helpline — help@nspcc.org.uk, or telephone 0808 800 5000.
• If a child or young person discloses maltreatment, it is standard practice to refer to children's social services even though the disclosure may not be precise in every detail.
  
  • Any concerns about a child’s or young person’s safety or welfare should ideally be discussed with their parents. However, in some cases, a child/young person may request that information is not shared with a parent, or you may decide that discussion with the parents may increase their risk of harm. If there is uncertainty, seek advice from named or designated colleagues, and/or your practice safeguarding lead/deputy lead. 

What do I need to know about referral to children's social care?

• Referral and assessment protocols vary between local authorities. 
  
  • All local safeguarding children boards (LSCBs) and local authorities have websites with details of their referral pathways, referral forms, thresholds and eligibility criteria, and children’s services provision within their area. Clinicians must be familiar with their local processes. 
• Referral of a child or young person for whom maltreatment is suspected will involve sharing confidential information with the relevant agencies.
  • Before sharing confidential information, seek consent from the child or young person (if they have the capacity) or their parent/carer to share this information, unless there is reason to believe that this will increase the risk of harm to the child or young person. Also, seek consent from any adults whose personal information will be shared.
  • See the section on consent for more information.
• After a referral, children's social care should decide within one working day of receipt of a child protection referral, and should provide feedback on the decisions taken both to the family and to the referrer.
  
  • Note that when children's social care receive a referral they have tight timeframes set down in statutory guidance to carry out further investigations and action, and this may not match primary care working practices.
• Advise the child or young person and/or their parent/carer on sources of independent support, including: 
  • The National Society for the Prevention of Cruelty to Children (NSPCC) — a national charity campaigning on behalf of children/young people. They offer helplines for children as well as adults.
  • Childline — a free, private, and confidential service for people aged under 19 years in the UK to discuss any issue they’re going through.
  • The Family Rights Group (FRG) — provides free confidential advice and support to families whose children are involved with local authority children's services.
  • The Coram Children's Legal Centre (CCLC) — provides free legal information, advice, and representation to children/young people, their families, and to carers and professionals.
  • Family lives (previously known as Parentline) — a national charity providing help and support on all aspects of family life. It is a confidential helpline service that offers emotional support, information, advice, and guidance on any aspect of parenting and family life.
• Arrange follow up as required:
  • Check that support services are in place and that the initial concerns have been addressed appropriately. Escalate your concerns upward if you believe they have not been acted on appropriately.
  • Keep parents informed about what is happening, give them opportunities to ask questions, and be willing to answer their questions openly and honestly.
• Further information is available in:
  
  • The National Society for the Prevention of Cruelty to Children (NSPCC) guide on Information sharing.
  • The Royal College of General Practitioners (RCGP) guide on Information sharing.
  • The General Medical Council (GMC) guide on Protecting children and young people: the responsibility of all doctors.
  • The GMC guide on Confidentiality: good practice in handling patient information.

When and how should I seek consent to share information?

• Always obtain consent before sharing confidential information unless there is reason to believe that this will increase the risk of harm to the child/young person.
  • Do not let obtaining consent delay the disclosure of important information regarding children/young people at risk of significant harm.
  • Ideally, obtain consent in writing (in case there are any disputes in the future). If it is only given verbally, document it in the child or young person's medical record. 
  • Be very clear with children and young people about confidentiality and its limits.
    • If concerns of child maltreatment resulted from consultations with adults rather than a child or young person, be very clear with the adult about confidentiality and its limits, and the professional duty to safeguard children and young people. 
    • Advise that they can withdraw consent at any time.
  • Confidential information can be shared without consent if it is required by law, or directed by a court, or if the benefits to a child/young person that will arise from sharing information outweigh both the public and the individual's interest by keeping the information confidential.
• A child/young person who has the capacity to understand or make their own decisions may give (or refuse) consent to share information. 
  • It is generally expected that a child over the age of 12 years has sufficient understanding, and it is presumed by law that a young person aged 16 and older has the capacity to consent to medical treatment.
  • The Gillick Competency and Fraser guidelines help healthcare professionals to assess whether a child is mature enough to make decisions about their treatment.
  • Where parental consent is required, the consent of one such person is sufficient. If the parents/carers are in conflict, careful consideration should be given to whose consent will be sought. In the situation where parents are separated, consent is usually sought from the parent with whom the child resides.
• When requesting consent, discuss the following with the child or young person and/or their parent/carer:
  • The reason for sharing the information and how it will benefit the child or young person.
  • The information that will be shared.
  • Who the information will be shared with.
  • How the information will be used.
  • The consequences of their information not being shared.
• If the parent/carer or the child/young person with capacity refuses to consent, consider their reasons for refusal and weigh up the possible consequences of not sharing the information against the harm that sharing the information could cause. If a child or young person is considered to be at risk of, or is suffering child maltreatment, it will usually be in their best interest to share information with the appropriate agency.
  • The Data Protection Act 2018 does not prevent or limit the sharing of information for the purposes of keeping children and young people safe.
  • If there are concerns about sharing confidential information without consent, seek advice from:
    • A child protection professional on an anonymized basis, but remember that the child or young person's safety is paramount and central to the process.
    • The National Society for the Prevention of Cruelty to Children (NSPCC) helpline.  
• If information is shared without consent, explain the reason to the child or young person (if they have capacity) or their parent/carer, unless there is reason to believe that doing so will increase the risk to the child/young person.
• Document all actions in the child or young person's clinical record, including:
  
  • The reason for the decision to share (or not share) confidential information. 
  • What was shared, with whom, and for what purpose?
• Further information is available in:
  • The NSPCC guides on Seeking consent to share information and General Data Protection Regulation (GDPR) and children.  
  • The General Medical Council (GMC) guide on Confidentiality and sharing information.
  • HM Government guide on Information sharing: Advice for practitioners providing safeguarding services to children, young people, parents and carers.