The dilemma
During a consultation with a patient and his five-year-old son, you develop suspicions that the father may be physically abusing his child. There is nothing in the father's records to suggest this but during the consultation, the father grabs the child for refusing to sit still in his chair. You also notice some bruising on the child's arm. You feel compelled to investigate this further to ensure the child's safety, but don't want to make false allegations. What should you do?
A GP's response
Dr Louise Newson is a GP in the West Midlands
This is potentially a very difficult situation and needs to be managed carefully.
On one hand, you do not want to make false accusations that could undermine and damage your future relationship with this patient.
On the other hand, if your instincts are right, this might be the only opportunity you have to act. The safety of the child is paramount.
You should ask the father about the nature of the bruises you have seen, in an open manner; it can be very common for young children to have bruises.
You could also comment about his brusque manner with his son and ask if there are any behavioural problems with his son or any difficulties at home.
You should liaise with members of your practice team who have seen any of the family members and ask specifically if they have any concerns regarding the child's safety (and that of any other children the father may have in his care).
Presumably, this child is at school, so you could speak to the child's teacher or a member of staff at the school to explore possible concerns about his behaviour, attendance or relationship with his father.
It is unlikely health visitors are involved in the boy's care, but it is worth speaking to them to see if there has been recent contact and if there were any concerns in the past.
It would also be worth arranging to review the child in the near future - the more contact you have, the more likely you are to know whether your instincts are right.
A medico-legal view
Dr Susan Gibson-Smith is a medical adviser at the UK-wide medical defence organisation MDDUS
Child protection can be a real challenge for GPs. Where possible, doctors should work with parents to ensure children receive the care and support they need.
Even with no proof of physical violence, if there is still a perceived risk to the child, acting on these concerns early can help to protect the child.
Under GMC guidance, taking action is justified even if it turns out the child is not at risk. In this situation, the father's actions, coupled with the child's bruising, are reason enough for you to take your concerns seriously.
You should discuss your concerns with the father, without making allegations or attributing blame. If the father becomes defensive or objects, it should be explained to him that a doctor has a professional duty to raise any concerns if they think a child is at risk.
If you still feel there is a risk to the child, you may wish to raise this with the local child protection unit or your medical defence organisation and consider informing the local authority children's services. You should also inform the father of your planned course of action.
GPs need to consider the consequences of what may happen if they do not act on their concerns. Sharing information is appropriate and can be justified when acting on reasonable, honestly held concerns.
Doctors who do not share a concern must be able to justify that decision, having taken appropriate advice and making a record of the concern, the discussions and reasons for not disclosing the information.
You should familiarise yourself with local child protection procedures. Extra support can be provided by a lead child protection liaison contact, a senior colleague or your medical defence organisation.
A patient's opinion
Danny Daniels is an expert patient
You have a duty of care towards the child and you are ethically obliged to do something.
In the fullness of time, it may be proved that your suspicions are unfounded, but that is irrelevant when considering the safety and wellbeing of the child.
A suspicion of abuse may take the form of 'concerns' rather than 'known facts'. Concerns should be shared with the appropriate services. While these concerns will not necessarily trigger an investigation in themselves, they may help to build up a picture, with concerns from other sources, which suggests that a child may be experiencing harm.
The practice should have procedures in place for such events and training should be undertaken.
It is in the GP's interest to inform a senior partner and/or other colleagues. It may be the decision of the practice that the case should be referred to the bodies with statutory powers to investigate suspected abuse. This is obviously not an easy option, but nevertheless, the responsibilities are clear.
