Cases/Patient < 19 years old

Health Visitor Has Safeguarding Concerns for An Infant — Free SCA Practice Case

Health visitor has safeguarding concerns for an infant

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Karen

Age

0 years

Consultation Type

Telephone

Age

6 Months (DOB: 12/08/2025)

Mother's Name

Sarah Jenkins (Age 19)

Situation

You are the Duty Doctor. Karen, the Health Visitor, has called the surgery asking to speak with you urgently about a patient.

Reason for Encounter

Karen has requested an urgent discussion regarding "safeguarding concerns" for Baby Leo. She is aware that the mother, Sarah, has an appointment with you later today (at 4:00 PM) for a medication review.

Medical Records (Leo)

●Born: 38 weeks. Normal delivery.
●Growth: 8-week check weight on 25th centile. No concerns raised.
●Immunizations: 1st set given. 2nd (12-week) and 3rd (16-week) sets are overdue.
●Recent Coding: "Was Not Brought" (WNB) x 3 for practice nurse clinics.

Medical Records (Sarah)

●PMH: History of Anxiety and Postnatal Depression. Currently on Sertraline 50mg.
●Social: History of Domestic Violence (DV) from ex-partner, Mark. Social Services involvement ended 3 months ago when Mark was imprisoned.

Patient Script

For the friend playing the patient role

Character Overview: You are Karen, the Health Visitor. You are a professional colleague, not a patient. You are articulate and factual, but you are carrying a high level of anxiety about this child. You feel that the "system" is losing sight of Leo, and you need the GP to step up and take clinical ownership of the plan for today.

Opening Sentence: "Hi Doctor, thanks for taking the call. I'm contacting you because I have some escalating concerns about baby Leo Jenkins. I see Sarah is booked in with you later today, and I think we need a coordinated safety plan before she arrives."

History if Asked (Data Gathering Phase)

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The "Was Not Brought" Pattern: "Sarah has missed the last three clinic weigh-ins. More concerningly, she didn't bring Leo for his 12-week or 16-week immunizations. She's essentially 'off the radar' for child health surveillance."
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Recent Home Visit Failure: "I tried an unannounced visit yesterday. I could hear the TV and someone moving inside, but the door wasn't opened. This is a significant change in her behavior; she used to be very welcoming."
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The "Soft" Intel: "A neighbor caught me this morning and mentioned seeing a man coming and going from the house again. They think it might be Mark (the ex-partner who was in prison for DV). Sarah hasn't told me anything about him being released."
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The Goal of the Call: "I need to know if you think we've reached the threshold for a Section 47 (Child Protection) referral, or if you think we can manage this by seeing them today."

ICE — Ideas, Concerns, Expectations

These surface only if the candidate explicitly explores Karen's perspective and professional reasoning — she does not deliver them unprompted as a monologue.

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Ideas: "Honestly? My gut tells me Mark is back. The pattern fits — she was engaging well with services, the door was always open, and now suddenly she's gone silent and isn't bringing Leo to appointments. That's what happened last time before the DV escalated. I think she's being controlled again and that's why we're being shut out."
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Concerns: "What worries me most is that we haven't laid eyes on Leo in weeks. We don't know his weight, we don't know his developmental progress, and if Mark is back and there's violence in the house again, that baby is at direct risk of physical harm — or at the very least significant neglect. Sarah's mental health was fragile enough with just the postnatal depression. If she's back in a coercive relationship, I don't think she can safeguard Leo on her own."
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Expectations: "I need you to take clinical ownership today. If Sarah comes in at four, I need to know that you'll assess Leo properly — check his growth, look at him physically — and that you'll have a clear threshold in your mind for when we escalate to Children's Social Care. I can't do this on my own from the community. I need the practice to be part of the safety net."

If Asked — Medical History and Medications

These responses represent what Karen knows from the shared professional record and her own Health Visitor notes. She provides this information if the doctor asks for clinical detail about Leo or Sarah's background.

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Leo's birth and early history: "He was born at 38 weeks, normal delivery, no neonatal concerns. At his 8-week check he was on the 25th centile, which was fine — no concerns were raised at that point. But we haven't had a weight since then, so I genuinely don't know where he is now."
●
Leo's immunisation status: "He had his first set on time, but the 12-week and 16-week sets are both overdue now. That's two missed rounds. The practice nurse coded all three missed appointments as 'Was Not Brought'"
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Sarah's mental health history: "She had anxiety before the pregnancy and was diagnosed with postnatal depression after Leo was born. She's on Sertraline 50mg — or at least she was. I don't actually know if she's still taking it. That's another thing I'd want you to check today if she comes in."
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History of domestic violence: "Mark was her partner — there was documented domestic violence. Social Services were involved, and it only ended about three months ago when he was imprisoned. I don't know the details of his sentence or release, but if the neighbor is right and he's back, that changes everything."
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Social Services involvement: "Their involvement was stepped down three months ago after Mark went to prison. At the time, the assessment was that the risk had been removed. But if he's back, that risk assessment is out of date and they need to know."

Social History and Lifestyle Impact

Karen provides this context naturally during the conversation to paint a picture of Sarah and Leo's circumstances. She does not deliver it as a list — it comes out as part of her professional narrative.

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Sarah's situation: "She's only 19. She was doing really well for a while — she was engaging with me, bringing Leo to all his appointments, seemed to be bonding nicely. She doesn't have much family support locally. Her mum lives up north and they're not particularly close. When Mark was around before, she was quite isolated — he didn't like her going out or having visitors."
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Housing and environment: "She's in a council flat — two-bedroom. It was always clean and tidy when I visited before. The last time I actually got in was about six weeks ago and everything seemed okay, but she was a bit flat. I put it down to the depression at the time, but looking back now I wonder if things were already starting to change."
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Impact on Leo: "The real concern is that Leo is invisible to services right now. He's six months old, he should be having regular contact with the health visiting team, he should be up to date with his immunisations, and we should know his weight. Instead, we've got nothing. If there's something going on in that house — whether it's neglect because Sarah's mental health has deteriorated, or risk because Mark is back — we're not going to know until something serious happens. That's what keeps me up at night with cases like this."

If Asked — Associated Safeguarding Indicators

These represent Karen's professional observations and knowledge about the case. She provides them factually if the doctor asks targeted questions about specific risk factors or indicators.

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If asked about physical signs of harm on Leo: "The last time I saw him — which was about six weeks ago — there were no visible injuries. He looked clean and appropriately dressed. But that was six weeks ago. I haven't been able to assess him since."
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If asked about Sarah's presentation or signs of current DV: "Last time I saw her she seemed withdrawn and flat, but there were no visible injuries. She wasn't her usual chatty self. I asked if everything was okay and she said she was just tired. I didn't push it at the time, but I wish I had."
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If asked about Leo's feeding and nutrition: "She was breastfeeding initially and then moved to formula around 8 weeks. When I last saw them she was feeding him appropriately. But again, I don't have current information — I don't know if he's started weaning or how his feeding is going now."
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If asked about Leo's developmental progress: "At the 8-week check everything was age-appropriate. He was smiling, fixing and following. But he's due a developmental review and I haven't been able to do one. At six months I'd want to see him sitting with support, reaching for objects, babbling — but I simply don't know where he is."
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If asked about substance misuse concerns: "There's nothing on record and I've never had any concerns about drugs or alcohol with Sarah. Mark had a history of cannabis use, but I don't know the detail — that would be in the Social Services records."
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If asked about financial concerns or benefits: "I believe she's on Universal Credit. She mentioned money being tight a few months back but didn't go into detail. Financial pressure could be another factor if Mark is back — he was controlling with money before."
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If asked whether there are other children or pregnancies: "No, Leo is her only child. There's no indication of a current pregnancy."
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If asked about the Multi-Agency Risk Assessment Conference (MARAC) or previous safeguarding referrals: "The case went through MARAC when the DV was first identified. There was a referral to Children's Social Care and they did a Section 17 (Child in Need) assessment. It never reached Section 47 (Child Protection) because Mark was imprisoned before it escalated further. But I think we may be at that threshold now."

Responses to Management (The Negotiation Phase)

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If the Doctor is too passive/vague: "I've given you the background, but I'm struggling with the next step. Based on the fact that he's missed his jabs and Mark might be back, what is your 'bottom line' for the 4 PM appointment?"
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If the Doctor mentions confidentiality regarding Sarah: "I know Sarah is your patient, but Leo is mine. The GMC guidance is clear on public interest when a child is at risk. Do you feel we have justification to share my concerns with her?" (Tests the doctor's knowledge of information sharing).
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If the Doctor proposes a plan to see them: "Okay. If she turns up at 4 PM without the baby, what do we do? Do we call Social Services immediately, or do we give her another 24 hours?" (Forces the doctor to commit to a contingency).
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If the Doctor suggests a joint visit: "I could potentially meet you there tomorrow if today's appointment goes badly or she doesn't show. Would you be willing to do a joint home visit?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 10 indicators checked+0−0

Positive (0/5)

Negative (0/5)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 10 indicators checked+0−0

Positive (0/5)

Negative (0/5)

Clinical Learning Points

The Toxic Trio and Cumulative Risk

The Toxic Trio — domestic abuse, parental mental ill-health, and substance misuse — is the most extensively researched predictor of child maltreatment and is embedded in all UK child protection frameworks.

●In this case, two of the three are confirmed (domestic violence, postnatal depression/anxiety) and a third (substance misuse in Mark) is a background possibility from Social Services records. This alone places Leo in a high-risk category.
●Critically, the Toxic Trio functions as a cumulative risk, not a checklist. Three separate concerns become a qualitatively different risk picture when they converge in the same household. Candidates who treat the missed immunisations, Sarah's mental health, and Mark's potential return as three separate administrative problems have missed the point of the case.
●The pattern of disengagement — a period of good engagement followed by sudden withdrawal from services — is itself a recognised safeguarding signal, particularly in the context of coercive control.

Statutory Framework: Section 17 vs Section 47

Understanding the distinction between these two thresholds is essential for every GP.

●Section 17, Children Act 1989 (Child in Need): The child's health or development is likely to be significantly impaired without the provision of services. This is a welfare concern — the appropriate response is a referral to Children's Social Care for a Child in Need assessment and access to support services.
●Section 47, Children Act 1989 (Child Protection): There is reasonable cause to suspect a child is suffering, or is likely to suffer, significant harm. This triggers a formal Child Protection investigation. The threshold does not require certainty — only reasonable cause to suspect.
●Application to this case: Leo is a pre-verbal infant who cannot self-report, is invisible to services for six weeks, has missed two rounds of immunisations, lives with a mother whose mental health is uncertain, and may be in a household where a known perpetrator of domestic violence has returned. This case is at or beyond the Section 47 threshold. A Section 17 response alone is insufficient.

GMC Guidance on Confidentiality and Child Protection

The duty of confidentiality to an adult patient is overridden where disclosure is necessary to protect a child from risk of significant harm.

●GMC Confidentiality: good practice in handling patient information (2024) and Protecting children and young people: the responsibilities of all doctors (2012) are unambiguous: where a doctor believes a child may be at risk of significant harm, they must act and may disclose relevant information to appropriate agencies without the patient's consent.
●GDPR and the Data Protection Act 2018 both contain explicit exemptions for disclosures made for the purpose of protecting vulnerable individuals.
●The Children Act 1989 and the statutory guidance Working Together to Safeguard Children (2023) place a duty on all professionals — including GPs — to share information when they believe a child is at risk.
●Candidates who cite "patient confidentiality" or "GDPR" as a barrier to discussing Sarah's situation with Karen are making a serious clinical and ethical error. The legal framework is explicit and well-established.
●In practice: the GP should state clearly to the health visitor that they are satisfied the threshold for information sharing has been met, name the basis (risk of significant harm to Leo), and document that decision in the record.

Was Not Brought (WNB) — What It Means and Why It Matters

The shift from "Did Not Attend" (DNA) to "Was Not Brought" (WNB) is not merely semantic.

●WNB is the correct coding for any child who misses an appointment, because a child under 16 has no capacity to self-refer or self-attend. The responsibility lies with the parent or carer, not the child.
●Three or more WNB entries, particularly for immunisations or routine health surveillance, are a recognised indicator of neglect and should trigger a safeguarding review in any practice.
●In this case: Leo has three WNB entries for nurse clinics plus two missed immunisation rounds (12-week and 16-week). No recent weight is recorded. He is, in safeguarding terms, "invisible to services" — a phrase that should prompt immediate escalation.
●At the 4pm appointment, the GP should access Leo's Red Book and growth chart. The absence of recent measurements is clinically significant and should be documented as an unresolved clinical unknown driving the urgency of the plan.

Safeguarding Examination Standards

If Leo attends the 4pm appointment, a full safeguarding-standard examination is required — not a cursory check.

●Weight: Plot current weight against the 25th centile baseline from the 8-week check. Failure to thrive or significant centile drop is a clinical safeguarding concern.
●Full skin survey: The baby must be fully undressed. Examine all skin surfaces for bruising, petechiae, marks, or signs consistent with non-accidental injury (NAI). Pay particular attention to the back, buttocks, ears, and any area not normally visible.
●Developmental assessment: At 6 months, expected milestones include sitting with support, reaching for and grasping objects, transferring objects between hands, and babbling. Any significant developmental delay warrants urgent referral.
●General appearance: Assess hygiene, nutritional status, and affect. Note whether Leo appears appropriately dressed, clean, and well-nourished.
●Documentation: Record all findings in detail. A contemporaneous, precise record is essential for any future Child Protection conference or Serious Case Review.

MARAC and Multi-Agency Escalation

MARAC (Multi-Agency Risk Assessment Conference) is the primary mechanism for managing high-risk domestic abuse cases in the UK.

●This case previously went through MARAC when Mark was first identified as a perpetrator. If Mark has returned to the household, this is not a new case — it is a recurrence of a known pattern with an added vulnerability (a 6-month-old infant).
●A MARAC re-referral should be considered where: the perpetrator has returned, there is a child in the household, the victim is assessed as being at high risk of serious harm or homicide, or the overall risk profile has materially changed.
●The DASH (Domestic Abuse, Stalking, Honour-Based Abuse) Risk Identification Checklist is the validated tool used to assess whether a MARAC referral is indicated.
●MARAC operates separately from, and in addition to, any Children's Social Care referral. Both may be necessary simultaneously.

Contingency Planning and the "Non-Attendance" Scenario

A safeguarding plan that has no contingency for non-attendance is not a safeguarding plan.

●If Sarah does not attend the 4pm appointment, or attends without Leo, the GP and health visitor must have agreed in advance what happens next. This is not optional.
●In this case, the appropriate escalation is a same-day welfare check via Children's Social Care and, if there is immediate concern for Leo's safety, the Police (via a Safe and Well check / Section 17 welfare check). The GP should agree a specific trigger time with Karen — for example: "If she is not here by 4:30pm, I will call MASH directly."
●"We'll rebook" is not a safe response. A pre-verbal infant who has been invisible to services for six weeks cannot safely be left for another 24–48 hours without a verified welfare check.

Approaching Sarah at the 4pm Appointment

Sarah is simultaneously a vulnerable young woman and a parent with safeguarding responsibilities. The consultation must hold both.

●Mental health and medication review: Sertraline 50mg is the standard starting dose for postnatal depression. If Sarah has deteriorated — which is clinically plausible given the timeline — this dose may be subtherapeutic. The medication review is a genuine clinical opportunity to reassess her mental state, screen for worsening depression, check adherence, and sensitively explore her home situation.
●Asking about Mark: A coerced individual will often deny a partner's presence or minimise risk, particularly if the partner is monitoring them or has threatened them. Direct confrontation ("Is Mark back?") may be unsafe or counterproductive. A more effective approach uses open questions about how things have been at home, whether she has felt safe, and who has been around to help — allowing her to disclose at her own pace. This approach should be planned before the appointment, not improvised.
●Safety planning: If Sarah discloses or the GP suspects that Mark has returned, a brief safety planning conversation is appropriate — including knowledge of local domestic violence services and the DASH risk identification tool.

Multi-Agency Documentation and Communication

Documentation in safeguarding cases must be contemporaneous, precise, and cross-referenced.

●Record the content of the discussion with Karen in both Leo's and Sarah's records, including: the concerns raised, the "soft intelligence" about Mark (documented as "third-party information received from [source]" without identifying the neighbour by name), the agreed plan, the escalation triggers, and who is responsible for each action.
●Use appropriate safeguarding READ/SNOMED codes in the electronic record.
●Agree a communication pathway with Karen: who will contact Children's Social Care (MASH) if the threshold is crossed, who will follow up if Sarah does not attend, and how the outcome of the 4pm appointment will be fed back to the health visitor.
●In the event of a Serious Case Review (SCR) or Child Safeguarding Practice Review (CSPR), the contemporaneous GP record will be central to the multi-agency chronology. Inadequate documentation in safeguarding cases is a recurring finding in national SCR reports.

Free MRCGP SCA practice case for GP registrars covering Health Visitor Has Safeguarding Concerns for An Infant — Patient < 19 years old. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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