ℹ️ This is the case information for the doctor.

Name

Chloe Matthews

Age

7 years

Address

34 Ash Grove, Highfield

Social history

School: Chloe attends Willowvale Primary School

Living cirumstances: Chloe lives with her maternal grandmother, Mrs. Williams.

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Past history

No significant long-term conditions or chronic illnesses known to the practice.
No past hospital admissions.

Investigation results

No recent blood tests.
No clinic attendances in the last 12 months.

Medication

Chloe is not on any regular medications.
No known allergies.

Booking note

Grandma called regarding letter from school asking her to book in with us for welfare check of Chloe.

ℹ️ This is the information for the person role playing the patient.

Case overview

Name

Chloe Matthews

Age

7 years

Address

34 Ash Grove, Highfield

Social history

School: Chloe attends Willowvale Primary School

Living cirumstances: Chloe lives with her maternal grandmother, Mrs. Williams.

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Past history

No significant long-term conditions or chronic illnesses known to the practice.
No past hospital admissions.

Medication

Chloe is not on any regular medications.
No known allergies.

Opening statement

"Hello doctor, I got this letter from the school and they asked me to book an appointment with you saying they are worried about Chloe. What is it all about?"

Information freely divulged

Chloe has lived with you (grandmother) since she was 4 years old because her mother couldn't look after her properly.
You admit Chloe has been missing school more than usual, "She’s had colds, or sometimes I just can’t cope with getting her there in the mornings."
Chloe sometimes looks a bit scruffy, especially on days you aren’t feeling well. "It can get on top of me sometimes, you see."
You’ve received letters and calls from the school about Chloe’s attendance, appearance, and hygiene, and felt they were exaggerating things. "They don’t know how hard it is."
You have refused offers of extra support from the school and social services, believing "I can manage, she’s better off with me than with anyone else."
Regarding Chloe’s bruises: "She’s a clumsy child, always bumping into things whilst playing."

Information given on questioning

On direct questioning, you acknowledge sometimes you “forget” meals, especially dinner, “if it’s been a hard day.” but she can always get herself a snack from the cupboard.
Sometimes you skip Chloe’s baths, “if I’m not up to it.”
You occasionally leave Chloe to look after herself for a bit in the evenings.
When asked, you mention that you are Chloe’s ‘main carer’ but are unsure about formal legal status: "No one’s ever asked me for papers; she just lives here with me."

Ideas

You believe the school is overreacting: "She’s a child—kids get bruised, and sometimes a bit mucky, that’s normal, isn't it?"

Concerns

You are worried about social services “interfering” and possibly taking Chloe away. You think, "She’s my granddaughter. I can look after her—I don’t want her going into care."
You’re struggling with your own health and sometimes stress, but are ashamed to admit it unless the doctor is very empathetic.
You worry about what will happen if Chloe goes back to her mother, given past problems.

Expectations

You want the GP to help get the school and social services "off your back," ideally by saying everything’s fine with Chloe.
If trust is established, you might accept some practical support or advice—especially if reassured it is for Chloe’s welfare, not to punish you.

Family History

Chloe’s mum has a history of substance misuse. She has periods of disappearing for weeks/months, then irregularly turning up.

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Behaviour

Initially defensive, minimising concerns and justifying yourself. "I'm not a bad gran, doctor!"
Worried and guarded, especially about involvement of social services, but not aggressive or hostile unless you feel accused.
If the doctor is empathetic, calmly explains their safeguarding responsibilities and the need to prioritise Chloe's safety, you become less defensive and may concede you’re struggling at times.
If pressured or made to feel blamed, you become more closed and may threaten to leave the call.
If the doctor explains clearly that safeguarding is about supporting both Chloe and yourself, and offers practical support or advice, you may accept this, especially if reassured Chloe will not be removed without cause.
If the doctor asks about legal parental responsibility, say you're unsure what the formal arrangements are, "I just look after her, I always have since she was little."
If asked directly, admit Chloe sometimes misses meals: "I sometimes get so tired, I just forget, but I make sure she eats...usually."

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ℹ️ To mark data gathering & diagnosis select from the descriptors below.

Positive descriptors

Negative descriptors

Data gathering was systematic and targeted ensuring patient safety.

Initiates with open questions to allow Mrs. Williams to voice her concerns and understanding of the school’s letter.
Progresses to focused, targeted closed questions about Chloe’s wellbeing: frequency of absences, hygiene routines, bruises, meals, and daily care.

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Data gathering was incomplete, lacking structure and focus.

Fails to clarify the specifics of the school’s concerns or the timeline of Chloe’s issues.
Omits questions about Chloe’s daily care, routines, and the context of her absences or bruising.

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Makes effective use of existing information and considers the wider context.

Reviews and integrates details in the school letter—concerns about neglect, hygiene, bruising, absence—and the context of Chloe living with grandmother due to mother’s substance misuse.
Considers the involvement (or lack thereof) of mother, grandmother’s refusal of previous support, and the grandmother’s own wellbeing when evaluating risk.

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Fails to use the information provided or understand the wider context.

Does not refer to the contents of the school’s letter or relevant background about mother’s substance issues and previous social services offers.
Overlooks family context: does not explore who else is involved, or the wider home environment.

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The presence or absence of relevant red flags was established.

Elicits or checks for safeguarding red flags: frequent school absences, inadequate hygiene, unexplained bruises, missed meals, and Chloe’s reported distress at home.
Asks about other possible indicators of neglect or abuse (e.g., exposure to drugs/alcohol, unsafe home environment, emotional neglect).

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Fails to assess key information necessary to determine risk.

Does not check for red flag features of potential child neglect/abuse.
Omits systematic enquiry about basic care (food, warmth, supervision, emotional wellbeing).

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Information gathered placed the problem in its psychosocial context.

Explores grandmother’s mental, emotional, and physical health as factors affecting her care of Chloe.
Assesses the impact of financial, social, and familial support, as well as the grandmother’s willingness/ability to cope.

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The social and psychological impact of the problem was not adequately determined.

Does not enquire about the grandmother’s own health, stress, or barriers to caring for Chloe.
Fails to ask about other sources of support, isolation, or stressors within the household.

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A working diagnosis was reached using a structured, evidence-based approach.

Uses structured information gathering to build a picture of potential neglect/abuse, including from third-party reports and primary carer interview.
Considers differential diagnoses (e.g., accidental injury vs. non-accidental, cultural or resource deprivation vs. wilful neglect).

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The evidence collected was inadequate to support the conclusions reached.

Assumes or dismisses neglect/abuse without thorough and structured evidence collection from available sources.
Jumps to conclusions about risk or safety based on incomplete data or subjective impression.

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Addresses legal (confidentiality and consent) and accuracy issues appropriately.

Checks who has parental responsibility, asks about the legal status of Chloe’s living arrangements, and clarifies what information can/cannot be shared.
Recognises limitations of second-hand history, and appropriately arranges for Chloe to be directly assessed by a safeguarding professional.

Does not address legal/consent or accuracy issues adequately.

Does not clarify the legal status of the guardian’s authority or consider implications for consent/confidentiality.
Fails to seek independent corroboration of Chloe’s lived experience or neglects to refer for a formal child protection assessment.

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ℹ️ To mark clinical management & medical complexity select from the descriptors below.

Positive descriptors

Negative descriptors

Offers management options that are safe and appropriate:

Clearly explains to grandmother that safeguarding concerns have been raised, and outlines why safety must be prioritised, referencing concerns about neglect, hygiene, bruising, absences, and hunger.
States the need to involve social services, seeking consent for information sharing, but also clarifies that proceeding is mandatory if consent is refused due to Chloe’s risk.
Applies a structured, evidence-based escalation pathway for suspected child abuse/neglect in line with local/national safeguarding guidance.

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Fails to provide appropriate and/or safe management choices:

Avoids discussing or downplays the gravity of the reported concerns and does not explain or act upon safeguarding processes.
Fails to escalate to social services or other safeguarding authorities, leaving Chloe at ongoing risk.
Does not act on national/local guidelines regarding concern about a child at risk.

Continuity of care is prioritised:

Clearly outlines to both grandmother and safeguarding partners (social, school) the next steps and assures ongoing monitoring and follow-up.
Offers coordination with school, social care, and within the practice team to ensure Chloe’s wellbeing is tracked after the initial referral.

Ongoing care is uncoordinated:

Fails to establish or explain any plan for follow-up with social services, school or GP practice.
Leaves responsibility unclear, resulting in a lack of oversight or further review for Chloe and missed opportunities for ongoing support.

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Empowers self care and independence:

Offers supportive suggestions to grandmother about sources of help for herself and Chloe (parenting classes, financial, or practical help, emotional support), showing non-judgemental encouragement for engagement.
Helps the grandmother to recognise areas where additional support is needed, and reinforces that her seeking support is a positive step for Chloe’s wellbeing.

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Management fails to foster self care and patient involvement:

Provides no guidance or reassurance to encourage the grandmother to accept additional support.
Fails to highlight support services or empower the carer to take active steps to improve Chloe’s and her own wellbeing.

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Refers appropriately being mindful of resource:

Initiates timely referral to children’s social services and informs safeguarding lead/practice team.
Considers urgent review for Chloe if immediate physical assessment is indicated.

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Sends patients for specialist input unnecessarily:

Fails to refer or refers to inappropriate/ineffective agencies (e.g., adult services, non-safeguarding health teams).
Makes no attempt to access relevant local resources or support, or makes referrals without urgency or clarity.

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Manages uncertainty, including that experienced by the patient:

Acknowledges the limits of the information (third party, not Chloe directly), and acts to resolve uncertainty by arranging for direct safeguarding assessment.
Provides clear reassurance and explanations to grandmother about process and next steps, managing anxiety and confusion about social services involvement.

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Struggles with uncertainty, leading to inconsistent decisions:

Is paralysed by lack of direct evidence from Chloe, fails to act or delays whilst awaiting further facts.
Gives inconsistent or confused messages about the process, increasing anxiety for grandmother and risk for Chloe.

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Tailors management options responsively according to circumstances, priorities and preferences:

Considers the grandmother’s own vulnerabilities and anxieties, explains the rationale for safeguarding, and offers support tailored to her needs (e.g., signposting, emotional/mental health help for her).
Clarifies Chloe’s and grandmother’s role in next steps, taking into account wishes where possible, but not compromising safety.

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Management options fail to adequately consider patient preference and circumstance:

Provides a rigid, ‘one size fits all’ response without acknowledging the grandmother’s expressed fears or barriers.
Fails to consider how the family dynamic or grandmother’s willingness to engage may affect Chloe’s safety and care going forward.

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ℹ️ To mark relating to others select from the descriptors below.

Positive descriptors

Negative descriptors

Positive Area Shows ability to communicate in a person-centred way:

Acknowledges Mrs. Williams’ distress and defensiveness upon receiving the school’s letter.
Validates her feelings of being overwhelmed and her fears about Chloe’s welfare and possible removal.
Keeps explanations clear and compassionate, ensuring Mrs. Williams feels heard throughout.

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Negative Area Communication is doctor-centred and lacks empathy:

Focuses solely on policy or the letter’s content, without recognising Mrs. Williams’ emotions, anxiety, or exhaustion.
Launches directly into factual explanations or procedural warnings, missing opportunities to build rapport.

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Makes effective use of existing information and considers the wider context.

Reviews and integrates details in the school letter—concerns about neglect, hygiene, bruising, absence—and the context of Chloe living with grandmother due to mother’s substance misuse.
Considers the involvement (or lack thereof) of mother, grandmother’s refusal of previous support, and the grandmother’s own wellbeing when evaluating risk.

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Negative Area Decisions fail to prioritise the patient’s rights and interests:

Uses accusatory or prejudicial remarks, implying unworthiness or ‘failure’ as a grandparent.
Dismisses her perspective or worries about social services, increasing her sense of alienation.

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Positive Area Shows understanding of medical-legal principles and regulatory standards:

Explains the duty to share safeguarding information, seeking consent where possible but clearly outlining the need to act if refused.
Discusses parental responsibility and consent, clarifying what information can be shared and with whom.
Communicates transparently about next steps in the context of safeguarding laws.

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Negative Area Fails to give appropriate regard to key legal aspects of consulting:

Neglects to mention or explain the need to inform social services or safeguarding leads.
Does not address parental responsibility or consent issues, causing confusion or mistrust.

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Positive Area Explores the patient’s agenda, health beliefs and preferences:

Invites Mrs. Williams to share her perception of the situation, views on Chloe’s care, and her preferences regarding support.
Explores her reasons for declining prior help, uncovering practical or emotional barriers to engagement.

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Negative Area Fails to recognise the patient's agenda and impact of the problem:

Ignores Mrs. Williams’ explanation or belief that she can ‘cope’ alone.
Fails to enquire about her underlying fears, stress, or previous experience with services.

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Positive Area The patient’s agenda was understood:

Clearly identifies Mrs. Williams’ main concerns: protecting Chloe, avoiding removal, and not feeling blamed.
Demonstrates makes efforts to align next steps (safeguarding, support) with these concerns, where possible.

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Negative Area The patient’s agenda was not well explored:

Misses cues about her worries or expectations for the consultation.
Fails to ask her to elaborate on what support, if any, she might accept.

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Positive Area Recognises what matters to the patient and works collaboratively to enhance patient care:

Acknowledges both Chloe’s safety and Mrs. Williams’ desire to remain involved in Chloe’s life.
Works towards a transparent safety plan and signposts supportive services, seeking buy-in from Mrs. Williams where possible.

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Negative Area Fails to work with the patient to plan care:

Imposes immediate steps without any regard to Mrs. Williams’ feelings or input.
Makes no attempt to gain agreement or discuss possible support.

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ℹ️ Insights from the examiner

Case summary:

A safeguarding case. Mrs. Williams (grandmother) calls the GP following a school letter about Chloe—with concerns about neglect, poor hygiene, bruising, frequent absences, and missed meals. Mrs. Williams is defensive and reports she can cope, declining school/social care offers. Chloe is not present in the consultation.
NICE NG76: Child abuse and neglect in decision-making. (NICE Child abuse and neglect)

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1. Time efficient data gathering

The focus in safeguarding is the identification of risk and urgency. Your task in data gathering is to to collect information about risk and to build a picture of what is going on in Choe's life. i.e. at home, at school and with mum. There is a lot to be covered so being time efficient is crucial. You can be most efficient by:

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Use broad open questions to harvest the majority of your data:

“Can you tell me what the school’s main concerns were?”,

"How is Chloe doing at school",

"How are you coping with looking after Chloe"

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Clarify the context with focused open questions:

"Can you tell me more about why Chloe lives with you".

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Use targeted questions to identify key missing information not picked up through your open questioning i.e. red flags:

“How often does Chloe miss meals?”

“School reports Chloe has a lot of bruises, have you noticed that?”

“What support do you have?”

Aim for clear language and shorter sentences to make it easy for Grandma to understand, process and answer your questions.

Reference: NICE NG76 Recognising abuse/neglect

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2. Language

Language must be simple, clear, and non-judgemental, aiming to minimise defensiveness and foster engagement:

“It’s not about blaming you or thinking you haven’t done your best. My job – and the school’s job – is to make sure Chloe is as safe and well as possible, so whenever concerns like these come up, we have a duty to ask for extra help.”

Can you help me understand more about how things are at home for you and Chloe?”

Adapt to the carer’s level of understanding; avoid medical/legal jargon.

(BMC MedEd sociolinguistic perspective).

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3. Cues

Watch for verbal cues (minimisation, defensiveness) and non-verbal cues (hesitancy, emotional distress). Respond with curiosity and empathy:

“You sound worried about social services—why is that?”

Acknowledge concerns without direct confrontation; avoid collusion but do not ignore red flags.

Unexplained injuries (bruises, burns, fractures) that don't match the explanation given, or frequent injuries.

Injuries in "atypical" places (e.g., upper arm, forearm, chest, abdomen, inner thighs, genitals, ears, neck, back).

Signs of untreated injuries or delays in seeking medical treatment.

Poor personal hygiene, inadequate clothing for the weather, or constant tiredness.

Significant changes in weight (under or overweight) without a clear medical reason.

Frequent medical issues that seem unaddressed.

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4. Goals

Work with Grandma to agree a shared goal

“By the end of this call, I’d like us to agree on what needs to happen to support you and Chloe”

Whilst it is important to support Grandma any plan must have the best interests of the child as the primary focus.

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5. Flow

The flow should be logical, starting with reported concerns and progressing from general open questions to specific targeted questions. Whilst it is important to gather key information avoid a rigid tick list of questions. Instead use a conversational approach that follows Grandma's responses with related questions.

And example of flow

Grandma: "Yes well sometimes I'm absolutely exhausted and I don't make a meal, but Chloe can always get something out of the cupboard, she looks after herself"

Doctor: "Caring for children can be exhausting, how often does Chloe make her own meals?"

In this example there is good flow because in the doctor's reply there is acknowledgement of Grandmas response and the question that follows builds on the topic being discussed.

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6. Differential

Differential diagnosis (NICE NG76 and GMC safeguarding guidance):

Neglect (including physical, emotional and educational as per NICE).
Physical abuse (unexplained bruising).
Poor carer mental/physical health impacting ability to care.
Accidental injury (less likely with recurring, unexplained bruises).
Child emotional distress due to separation from parents.
Carer burnout or carer strain/overload.

Red flags and recurring safeguarding concerns must never be dismissed.

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7. Impact

Explicitly seek the impact on Chloe in daily life, again as per NICE recommendations:

“How does Chloe usually seem at home"

"How is Chloe coping being away from mum"

"Does Chloe sleep well?”

Explore effect on school attendance, hygiene, and emotional wellbeing.

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8. Conciseness

Keep explanations and questions short and focused:

Use open and non-judgemental language.
Acknowledge the grandmother’s position, stress and good intentions.
State your professional responsibility clearly and gently.
Emphasise the support element, not just the investigation/policing aspect.
Reassure her that referral is routine when concerns arise, not an accusation or a judgement.

“Mrs. Williams, I can see how much you care about Chloe and want the best for her. At the same time, the school and I have picked up on a few things that make us worried about her health and wellbeing.”

Avoid unnecessary clinical detail or jargon. Use plain English, as per NICE: “If you are worried about a child’s welfare, you must act.”

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9. Sharing

The aim is to avoid causing unnecessary distress or shame and to encourage cooperation and engagement with the process. Verbalise your thought process for transparency and reassurance:

““I’d like to let our safeguarding team and children’s services know about what’s been going on. They can look into things further and see what extra help or advice can be put in place for you both, is that okay”

This builds trust and ensures the carer and examiner understand your reasoning and next steps. Explain that you will contact the safeguarding team the same day.

Note, if Grandma says no, you still have a duty to report.

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10. Options

Provide a menu of suitable, NICE-compliant options for child safeguarding:

Refer to local children’s social care (urgent referral per NICE “If there is evidence or suspicion of abuse or neglect, refer promptly”)
Explain information sharing—seek consent but proceed if refused since Chloe is at potential risk (NICE: act if the child may be at risk of harm)
Contact school safeguarding team, with appropriate information sharing
Arrange urgent child-in-need or child protection assessment of Chloe (likely via social care)
Offer support and signposting for Mrs. Williams (parenting classes, carer support, local mental health services)
Recommend welfare benefits advice or social support services for practical challenges
Document all information given by school and carer faithfully in the clinical record per NICE
Arrange practice safeguarding team review and notify named safeguarding GP

If the carer expects you to “make it go away,” be clear that NICE and the law require you to act for Chloe’s safety even if that is not her preference.

Reference: NICE NG76: Taking action/referral

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11. Understanding

Check the carer’s understanding and agreement at key points:

“Does what I’ve explained about why we need to get more help make sense to you?”

“Do you have any other worries about what will happen next?”

This ensures she is informed, less fearful, and that the consultation is collaborative, as per NICE focus on working with families where possible.

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12. Bespoke solutions

Offer a personalised, safeguarding plan:

Summarise Chloe’s risks and grandmother’s difficulties.
Combine child protection (referral/assessment) with pathways supporting the carer (“I know you’ve been struggling—it’s OK to accept help, and we want to support you both.”)
Arrange team review if needed (practice safeguarding lead/named GP involvement).
Make clear that acting now may prevent greater harm or removal later (“By acting, we help keep Chloe, and you, safer.”)

Reference: NICE: Working with families, Chapter 1.4

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Additional NICE/RCGP Key Points for Safeguarding

Act non-judgementally, make it clear your duty is to safeguard the child, not to apportion blame. (NICE NG76)
Check parental responsibility and who has authority for consent/confidentiality.
Document accurately for legal and safeguarding purposes.
If child may be at immediate risk of serious harm, act without delay—notify police in urgent cases (NICE, RCGP).
Recognise importance of multidisciplinary working and coordinate with school and social care.
Follow-up for the whole family and promote access to local support (mental health, domestic abuse, carer support).

References:
NICE NG76: Child abuse and neglect

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Safeguarding children

Case overview

Opening statement

Information freely divulged

Information given on questioning

Ideas

Concerns

Expectations

Family History

Behaviour

Case summary:

1. Time efficient data gathering

2. Language

3. Cues

4. Goals

5. Flow

6. Differential

7. Impact

8. Conciseness

9. Sharing

10. Options

11. Understanding

12. Bespoke solutions

Additional NICE/RCGP Key Points for Safeguarding