Aim There have been a number of high profile cases around safeguarding. To compare CP medical reports to current gold standard and identify what needs improving, so that CP medical reports offer a clear opinion of the nature of the injuries identifiedThe aim of this study was to identify the gold standard for compiling safeguarding reports, and to highlight any shortfalls compared to this locally agreed standard, so that these can be improved upon for future reports.
Methods 329 child protection reports were collected over an 18-month period at a single NHS trust. Key areas assessed included documentation of: consent, date/time, any past medical/social history, growth parameters, injuries seen and location, conversations, referrals and management plans, and whether a clear opinion was given.
Results Written or verbal consent was documented in only 42% of cases. Date was documented in 97% and time in 24 hour clock in 85% of cases respectively. Reason for referral was clearly documented in 79% of cases. A background to the case was including past medical history, development, social history was poorly documented (fig.1). Cleanliness and general appearance was commented upon in 55% of cases (fig. 2). Opinions, conversations, investigations and referrals had variable reporting (fig. 3) with investigations in 152/329 (46%), treatment in 143/329 (43%), referrals 205/329 (62%) and conversations documented in 247/329 (75%) cases.
Conclusion Injuries were documented in 270/329 (82%) cases. An interpretation of the injuries was given in 280/329 (85%) cases, with an opinion on whether these may be consistent with the mechanism of proposed injury in 260/329 (79%). Even though a good proportion of injuries were documented correctly and interpretation was likewise reported in >80% of cases, this should in fact be reported in all cases and therefore although good, there is still room for improvement.
The major area of disparity was in the consent documentation which was poor. The recommendation of the study was that clear consent must always be sought and documented (including verbal consent) every time. The type and location of injury should likewise be clearly documented as well as any opinion given as to the nature of these injuries, so that there can be no ambiguity and therefore a clear judgement can be made.