What documentation and reporting procedures should I follow when I suspect a case of non-accidental injury?

Record in the child's clinical record exactly what is observed and heard from whom and when, and why this is of concern. At this point, consider, suspect or exclude child maltreatment from the differential diagnosis ¹.

If you suspect child maltreatment, refer the child or young person to children's social care following local multi-agency safeguarding arrangements. This may trigger a child protection investigation, and supportive services may be offered to the family following an assessment or alternative explanations may be identified ¹.

Record all actions taken and the outcomes of these actions ¹.