Recognising Child Maltreatment and Steps to Safeguarding Children and Young People in the Emergency Department

recognizing child maltreatment

Safeguarding Children and Young People

In the busy and stressful environment of the emergency department (ED), it is often easy for us to miss the inexplicit signs or calls for help from children and young people! When looking at it from a broader view, the paediatric population is sometimes a part of the category of vulnerable patients who cannot ask for help, and may at times not realise they need it. Of the millions of children that pay visits to the ED a year, some present with non-accidental or non-intentional illnesses that had been brought upon by abuse or neglect. The ED can often be the first contact these children have with healthcare professionals, making it imperative that we notice the faint signs of maltreatment that may direct us towards acting for their protection.

The term safeguarding, as described by the government document, Working Together, encompasses the act of protecting children and young people from maltreatment, ensuring children and young people are growing up in a safe and healthy environment, and ensuring the best outcomes for all children and young people.

Who’s at Risk?

Parental issues, including alcohol/substance misuse, mental health problems, and domestic abuse, can indicate an unsafe environment for children. Additionally, poverty, poor housing, poor relationships with carers/parents, and a lack of support for the child can increase the risk of child maltreatment. Babies and disabled children are at an even greater risk of physical abuse.

Whose Responsibility is it to Protect and Safeguard Children and Young People?

According to various legislations, including the Children Act 2004, all healthcare staff and organisations must respond in times of suspected child maltreatment and take effective action to safeguard and protect these children. All healthcare staff should be prepared to amend their practice into a child-focused approach if there is any recognition of the risk of abuse or neglect in a child.

All NHS Trusts will have a specifically allocated doctor or nurse for safeguarding. Make sure to know who this is; they will be your point of contact if you have any concerns on safeguarding and child protection issues! This named healthcare professional will have the expertise to advise other professionals on the appropriate action to take.

What to do if a child reveals abuse:

  • Listen attentively
  • Let them know they have done the right thing by telling you
  • Tell them it is not their fault
  • Tell them you take them seriously
  • Do not confront the alleged abuser
  • Explain what you will do next
  • Report what the child has told you as soon as possible

Recognising Maltreatment

There are many forms of maltreatment a child may suffer from, including physical, emotional and mental. Many of these signs and symptoms don’t always point towards maltreatment immediately. The background history and presentation of the child will often be key to identifying issues. However, it may be worth considering child maltreatment if you notice the following:
  • A child that regularly has injuries (– check their records!)
  • Previous or current involvement with Children Social Care
  • The pattern of injury doesn’t make sense or match the history/explanation
  • A delay in seeking medical help (without appropriate explanation)
  • If the parent/carer leaves with the child before they are seen at the ED
      • Although there may be credible reasons for this, the Trust was responsible for ensuring all children in their care have a safe discharge. If the child leaves without the staff having been informed, action is required to ensure their safety.
  • Child missing appointments
  • Child not being registered with a GP

Physical symptoms of abuse:

  • Bruises/Swelling
  • Burns or scalds
  • Bite marks
  • Broke or fractured bones
  • Scarring
  • Signs of poisoning (vomiting, drowsiness, seizures)
  • Difficulty breathing  (as a result of drowning, suffocation, poison)
  • Evidence of neglect (unkempt, malnourished, smelly, dirty) 

Behavioural symptoms of abuse:

  • Anti-social behaviour
  • Anxiety, depression, suicidal thoughts
  • Drug/alcohol use
  • Eating disorders
  • Aggression/Tantrums
  • Bed-wetting, insomnia
  • Problems in school (slow development)

Next Steps if Maltreatment is Suspected

When abuse is suspected, a referral to social care must be made within 24 hours (the sooner, the better). Make sure records are kept! The child will have registered with the reception staff and given their demographics, but it is important that he child’s GP and school details are in the system, as well as recording the details and relationship of the person(s) accompanying the child. Have a look through previous history/attendances for any potential indicators of reoccurring/previous child maltreatment.

To prepare for making a social care referral, first discuss the concerns with a senior staff member in the ED. Ensure some of the indicators of child maltreatment (such as those listed above) are present to support the referral decision. Consider previous information available about the child that is relevant (such as those on previous medical attendances). The child’s demographics should be known and recorded, and then contact the Local authority of the area the child normally resides to see if the child is subjected to a child protection plan or maybe previously known to children’s care services. Carry out any relevant lateral checks (GP, school nurse, etc.) Consider looking at the Trust’s local Thresholds for referral document before continuing to make the referral. If any further advice is needed, the safeguarding team can be contacted.

Children presenting with self-harm or suicidal issues
Children (ages 0-16) should be referred to a paediatrician/child psychiatrist if they present with thoughts or acts of self-harm or suicide. Trust guidelines on dealing with self-harm in children 16 years and under are available at your local Trust, as well as by NICE guidelines. All children (aged 0-18) presenting with substance misuse issues or emotional issues should be further referred to CAMHS.

Upon discharge, all children should be given the appropriate resources within the department so they know who to contact for support or further information (this could include leaflets, phone numbers, etc.)

Safeguarding Children and the Data Protection Act 1998

The law permits the disclosure of confidential information when necessary to safeguard a child. Personal information (about the child or family) is confidential. Healthcare professionals are subjected to a legal duty of confidence. However, information that is relevant, pertinent, and justified in the child’s interest may be disclosed without consent.

References and Further Reading

Cite this article as: Nadine Schottler, Great Britain, "Recognising Child Maltreatment and Steps to Safeguarding Children and Young People in the Emergency Department," in International Emergency Medicine Education Project, February 3, 2021,, date accessed: September 21, 2023

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