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Safeguarding in the COVID-19 pandemic: a UK tertiary children’s hospital experience
  1. Kavitha Masilamani1,
  2. William B Lo2,
  3. Ashish Basnet2,
  4. Jane Powell3,
  5. Desiderio Rodrigues2,
  6. William Tremlett4,
  7. Deepthi Jyothish5,
  8. Geoff Debelle1
  1. 1 General Paediatrics, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
  2. 2 Neurosurgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
  3. 3 Safeguarding Team, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
  4. 4 Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
  5. 5 Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
  1. Correspondence to Dr Kavitha Masilamani, General Paediatrics, Birmingham Women's and Children's NHS Foundation Trust, Birmingham B4 6NH, UK; kavitha.masilamani{at}

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There is emerging evidence of increase in injuries to children associated with abuse or neglect during the lockdown in response to the COVID-19 pandemic.1 We report an increase in the numbers of children under 16 years, during the COVID-19 lockdown period, with safeguarding concerns, and who were admitted under neurosurgery for head/spinal injuries following falls from height.


Retrospective analysis of referrals from our hospital to children’s social care (CSC) from 1 April to 30 June 2020 was compared with data from the same period in 2018 and 2019. Children admitted with neurosurgical trauma, including falls out of buildings during school closure, were analysed. Referral to CSC and multiagency strategy meetings were used as an indicator of verifiable safeguarding concerns, justified by established organisational processes for convening strategy meetings after individualised case review, when there is risk of significant harm.


During the study period, referrals from our hospital to CSC under all categories increased by 31%, in comparison to 2018 and 2019. A 69% increase in the number of referrals for suspected physical abuse was also noted with strategy meetings convened in 44% (table 1).

Table 1

Overall referrals to CSC, suspected physical abuse and eventual multiagency strategy meetings

The overall number of admissions for neurosurgical trauma was similar from 2018 to 2020. Notably, the number of children requiring paediatric intensive care unit admission, as a measure of severity of neurosurgical injury, increased in 2020 by 120% (from 6 and 4 to 11, p=0.0119) Referrals of children with neurosurgical trauma to CSC increased in 2020 by 140% (7 and 8 to 18, p=0.0001). During the study period, we observed an increasing number of children falling from a building of at least one floor high. Analysis of this cohort from 20 March 2020 (first day of school closure) to 19 July showed that eight children were admitted for tertiary neurosurgical care, representing a threefold increase compared with the same period in 2018 and 2019 (2 and 2 to 8, p=0.0001). Of this cohort, 38% (3/8) were under 2 years, of which two proceeded to craniotomy. The threshold for referral to CSCs and neurosurgery remained unchanged during the study period, although this cannot be supported by our data because an objective assessment of the appropriateness of referral does not exist.


Our data demonstrate a significant increase in CSC referrals and severity of neurosurgical trauma. Overcrowding, economic pressures and lack of the protective role of school with disrupted social support networks are contributors of increased risks to children during natural disasters.2 It is vital that special considerations be given to additional risk factors associated with COVID-19, as vulnerable children have become less visible, given the altered ways of working of agencies and school closures. The increase in fall from windows during lockdown, predominantly in younger children, underlines COVID-19-related increased childcare burden on parents/carers, leading to supervisory neglect.3 Multiagency partnership working, effective information sharing and raising awareness are required to reduce the preventable mortality and morbidity from injuries, including falls from height, and to ensure that children are adequately safeguarded.4


We acknowledge the support of the Birmingham Women and Children’s Hospital NHS Foundation Trust staff and patients, including Drs Seby Sebastian, Tina Newton, Habib Ali, Ms Caroline O’Callaghan, Professor Julie Taylor, Dr Fiona Reynolds, Professor Moiemen, Drs Ian Wacogne and Jeremy Kirk, General Paediatric, Neurosurgery and Safeguarding teams.



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  • Contributors Conceptualisation, study design and writing the first draft: KM, WBL, DR, WT, GD and DJ. Acquisition of data: JP, WBL, AB and DR. Analysis of data: WBL, KM, WT, JP, DJ and GD. Review and approval of the final manuscript for submission: KM, WBL, DJ, GD, DR and WT.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.