13-month-old Aisha is brought to the emergency department by her mum because she’s not using her left arm. She has a mid-shaft radius and ulna fractures. At first, Mum cannot recall Aisha injuring herself, but later on remarks that she was crying a lot a couple of days ago when she was left alone with Mum’s partner. After chatting with the team, you agree that this needs to be managed under your safeguarding procedure. You go to talk to Aisha’s mother.
Talking to families about safeguarding can be tough. You’re delivering a difficult message that can provoke a strong emotional reaction. The conversation is likely to go better if you have a plan before you go in. Be clear about your concerns and what will happen next.
Honesty is the best policy unless you think it puts the child at risk.
Use the team
Always discuss your concerns with a senior colleague first. They can help you to make sense of them and provide a second opinion. If you are a senior, it’s still good practice to voice your concerns. At this stage, it is also worth discussing the patient with your safeguarding team.
Practicalities and staying safe
Ensure you and the family have privacy during this tricky conversation; this should not be overheard. Avoid interruptions (hand over your bleep/phone if you can). Have someone else look after the child(ren) during the conversation so they don’t hear the conversation if they’re old enough to understand. This allows the parents to focus on your words entirely. Consider your safety: always let your team know you’re about to have a challenging conversation. If you think you are at risk, alert security, but keep them out of sight.
Always keep the child at the centre
Starting this tough conversation can feel awkward. Keep your focus on the child.
One way to approach this is:
“Your child has sustained an injury that can’t easily be explained (by how you describe the fall, for example), and we must follow certain procedures when something can’t be explained. Sometimes we find no answers; sometimes, we find hidden illnesses that make a child more prone to injuries, and sometimes we find that someone has hurt a child. We’re not suggesting any particular outcome, just that we have something we can’t explain, and we need to do what we can to get some answers. The protocol we have to follow means that….”
You could also say:
“Sometimes we see children who have had injuries that weren’t an accident, and when we see certain types of injuries, we have to consider that, as a possibility, someone may have hurt your child.”
Give some details of tests that may take place and remind the parents that all of this takes time and the child may be in hospital for a few days while we get all the necessary information. While this can feel invasive and stressful, the parents must work with us because we all want what’s best for the child. It can be challenging to process complex information in the heat of the conversation, so provide some written information if you have it.
Be confident about the plan. You have agreed to it as a team. Spend time listening to parents, clarifying anything they don’t understand, and recording any explanations they offer. A decision has been made, and it is not negotiable.
Things to avoid
Avoid terms such as child abuse and child protection – instead, use words such as concerns, welfare and duty of care. Similarly, avoid false reassurance. It’s very tempting to say, “I’m sure everything will turn out okay”, but it may not, and at this early stage, we are gathering information that will inform the outcome.
When we might not talk to parents about our concerns
Our default position is to be honest with parents. There are some situations, however, where we might not want to be completely transparent.
- Fabricated or induced illness (FII) because the illness-inducing behaviour may escalate and put the child at risk of harm. Information should only be withheld if there is a strong suspicion of illness-inducing behaviour: The most recent guidance from RCPCH (2021) differentiates between FII and Perplexing Presentations (PP). In PP, they advise disclosure of our concerns. Always involve a senior in these conversations.
- Forced marriage because the marriage date could be brought forward, and the child may be moved out of the country.
- Familial sexual abuse occurs because the perpetrator may pressure the child regarding their evidence, and the child may withdraw allegations and risk being further abused.
- When you are concerned that telling the family may put your safety at risk, this doesn’t mean you shouldn’t tell them, but it does mean that you should make arrangements with security.
- Other circumstances where you think not disclosing the investigation may put the child at further risk – should be discussed with the safeguarding lead and police.
After your conversation with Aisha’s mum, her partner arrives. After a few minutes in the cubicle, they tell you they’re leaving. Mum says it’s all been a misunderstanding, and there is no way that one of them could hurt Aisha.
Many families express a desire to leave at this point. Explain that things will be better if they stay and work with the team to ensure their child is safe. Be clear that if they do try to leave, the police will be called. From a practical perspective, writing down a description of anyone you think may try to abscond, including what they’re wearing, can make it easier for the police to stop them.
You persuade Aisha’s mum to stay, and she reluctantly returns to the cubicle. You ensure that Aisha’s medical needs are met and her pain is controlled. Once a ward bed is available, she is admitted to the ward for the relevant safeguarding investigations to be carried out.
Selected References
NICE (2017). Child maltreatment: when to suspect maltreatment in under 18s (update). Available from https://www.nice.org.uk/guidance/cg89
Royal College of Paediatrics and Child Health (2017) Child Protection Companion. Available from https://childprotection.rcpch.ac.uk/child-protection-companion/ (subscription required).
Royal College of Paediatrics and Child Health (2021) Perplexing Presentations (PP)/Fabricated or Induced Illness (FII) in children – guidance. Available from https://childprotection.rcpch.ac.uk/resources/perplexing-presentations-and-fii/
