Station 43
Ciaran Hughes
Age: 4 years old male
Full Case
Patient’s Data
Patient name: Ciaran Hughes
Age: 5-year-old male
Past medical history
- Nil
Drug and Allergy history
- Nil
Alert and QOFs
Up to date with immunization
Recent consultation
- Nil
Caller: Rosemary Marshall (mother), calling to discuss concerns about her 4-year-old son, Ciaran
Patient's Story (Role player’s brief)
Patient’s Story
You are Rosemary Marshall, the mother of Ciaran Hughes, a 4-year-old boy. You have called today to discuss concerns about your son’s wellbeing.
Two weeks ago, Ciaran spent the weekend (two days) with his father, Andrew Hughes, as part of a court-ordered joint custody arrangement. When he returned home, you noticed a bruise on his left arm. Although the bruise has since healed, you are still worried. You’ve also observed that Ciaran appears visibly upset every time he returns from his father’s home.
You are deeply concerned that Ciaran is being mistreated, not necessarily by his father directly, but possibly by his father’s new wife. You separated from Andrew two years ago due to infidelity, and while you’ve confronted both him and his wife, they both deny any wrongdoing. Despite this, you strongly believe they are responsible.
You are especially worried because Ciaran is due to visit his dad again tomorrow. He goes to stay with his dad every two weeks for the weekend — from Saturday to Sunday — as part of a regular court-ordered arrangement. You do not want him to go this time, but you feel you cannot stop it because of the joint custody order. You are not sure what to do, so you are asking the GP for help and advice.
Social History: You live alone with Ciaran. He is currently attending school, and there have been no concerns raised by his teachers.
Pregnancy, Birth, Immunisations, Nutrition and Development: There were no issues during pregnancy or birth. Ciaran is up to date with his immunisations. He is eating well, growing normally, and meeting his developmental milestones.
Ideas: You believe Ciaran is being mistreated, possibly by his father’s new wife
Concerns: Ciaran is due to visit his father tomorrow, but you don’t want him to go, yet you feel unable to stop it due to the court-mandated co-parenting order.
Expectations: You want a GP report or letter that could help stop Ciaran from going to his father’s home, as you believe the visits are distressing and potentially harmful to him.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data gathering and Diagnosis
- Elicit detailed facts about the incident in question- ask if the child has specifically said that someone hurt him or beat him or narrated an abuse incident (to explore direct disclosure of abuse)
- Ask whether the child has any bruises or other injuries currently, or has had similar injuries in the past, to identify patterns suggestive of repeated or non-accidental harm.
- Ask if the child is currently unwell — including symptoms such as fever, bruises elsewhere on the body, lumps or bumps in the abdomen, nausea, vomiting, or signs of recent viral infection (to rule out other serious causes of bruising in children such as leukaemia or immune thrombocytopenic purpura [ITP] following a viral illness)
- Ask about the current home environment — including who lives in the household, and where the child stays when not with the mother.
- Ask about other forms of abuse, including sexual abuse (e.g. unexplained genital injuries, urinary tract infections, pain on touching), emotional abuse (e.g. child becoming more withdrawn, not speaking up, tearfulness), and neglect (e.g. frequent illness or hospital visits, poor school attendance, or poor relationship with peers) — to screen for wider safeguarding concern
- Ask about pregnancy, birth, immunisation history, nutrition, and developmental milestones history.
Example of explanation to mother
Thank you for sharing this with me, Rosemary. I can see how concerned you are about Ciaran, and you’re absolutely right to speak up when something doesn’t feel right.
Although you mentioned that the bruise has healed, I would like to see Ciaran in person today. A face-to-face assessment allows me to check for any other marks, signs of injury, or changes in his general health that might not be obvious over the phone. It also gives me the opportunity to observe how he’s interacting and assess his overall wellbeing — which can help us pick up on anything that might need further attention.
Based on what you’ve told me; I will be making an urgent referral to the safeguarding team. They will carry out a full assessment and, if they find that there’s a risk of immediate harm, they can take steps to prevent Ciaran from going to his father’s home.
About writing a letter, I can’t write a letter to override a court-ordered custody arrangement. That falls outside of what I’m legally allowed to do as a GP. However, I will documenteverything you’ve told me in his notes and make sure the safeguarding team is aware of the situation and its urgency.
Meanwhile, if you feel that Ciaran is at immediate risk and the situation cannot wait, you should contact the police immediately.
You’re doing the right thing by speaking up. Let’s bring Ciaran in today so I can examine him properly and support you both through the next steps.
Management
Management
- Offer an urgent face-to-face appointment to examine the child — explain to the mother that although the bruise has resolved, this will allow you to check for any other bruises, old scars, or signs of injury, and to assess Ciaran’s overall health and wellbeing
- Inform the mother that you will make an urgent referral to the child safeguarding team today, clearly marking the urgency — and that they will usually review within 24 hours
- Reassure her that the safeguarding team treats cases like this as a priority and will take the necessary steps to ensure Ciaran’s safety while investigations are ongoing
- Advise that GPs cannot write letters to override or prevent a court-ordered custody arrangement, but reassure her that concerns like this are taken seriously and are referred promptly to the appropriate safeguarding services
- Advise the mother that if she believes Ciaran’s safety is in immediate danger, she should contact the police without delay
- Arrange a follow-up phone call in 3–5 days to check that support services are involved and the safeguarding process has been initiated appropriately
Learning point from this station:
This station highlights the GP’s crucial role in recognising and responding to safeguarding concerns, even when physical signs (like bruises) have resolved.
It reinforces that clinical judgement and parental concern alone may be enough to trigger safeguarding action, especially when a child displays behavioural changes or there are concerns about maltreatment during contact visits.
While GPs should not issue legal letters restricting parental access, they have a duty to refer to safeguarding teams or social services when child protection concerns are raised.
This case also reminds us to approach parents non-judgementally, explain the limits of our role clearly, and prioritise the child’s safety, ensuring all concerns are escalated and followed up appropriately
https://cks.nice.org.uk/topics/child-maltreatment-recognition-management/