Ethics · Advanced · Paediatrics

Child with Suspicious Injuries - Safeguarding Concerns

Practise this PLAB 2 ethics station on Suspected Non-Accidental Injury. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the Emergency Department. You see Daniel, a four-year-old boy, brought in by his grandmother with bruising on his arms and legs. The explanation given does not fully match the pattern of injuries. Please take a careful history while maintaining professional rapport, assess for safeguarding concerns, and discuss appropriate referral and documentation.

Background notes: PMH: Nil significant

What this station tests

  • Injury pattern recognition: bruises in unusual locations (upper arms, trunk, buttocks) versus normal play sites (shins, forehead)
  • Inconsistency between mechanism and injury: the explanation does not match the bruise pattern or developmental stage
  • Non-confrontational approach: do not accuse, do not investigate, document and refer to safeguarding
  • Safeguarding pathway: inform named safeguarding lead, do not discharge before assessment, document with body maps
  • Maintaining professional composure: calm, non-judgmental, focused on the child's safety

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself. Establish the ethical issue and your role.
  • 1-3 min — Explore Perspective: Listen to patient/relative perspective. Understand their reasoning and concerns.
  • 3-5 min — Ethical Framework: Apply ethical principles: autonomy, beneficence, non-maleficence, justice. Reference relevant guidelines (GMC, Mental Capacity Act).
  • 5-7 min — Negotiate and Plan: Find common ground. Explain your professional obligations. Involve MDT where appropriate. Document plan.
  • 7-8 min — Closing: Summarise agreed position. Outline next steps. Offer further discussion.

Consultation approach

The opening

Suspected non-accidental injury is the most sensitive paediatric station. The candidate must maintain a professional, non-judgmental demeanour, document carefully, involve the safeguarding team, and prioritise the child's safety above all else. Daniel is 4, brought by his grandmother with bruising on arms and legs. The explanation does not match the injuries. Open with: 'Thank you for bringing Daniel in. Can you tell me how he got these bruises?'

Core approach

Assess the injuries. Note the pattern: are the bruises consistent with the explanation? Bruises in unusual locations (upper arms, trunk, cheeks, ears, neck, buttocks) are more concerning than bruises on shins and forehead (normal play injuries). Multiple bruises of different ages (different colours suggesting different times) raise concern. Any patterned bruises (belt marks, finger grip marks, bite marks)?

Listen to the explanation carefully. Grandmother says he is 'a very active boy,' 'plays rough,' 'fell off the climbing frame.' Do the injuries match this? A climbing frame fall causes bruises on knees, shins, and forearms (impact sites), not on upper arms, trunk, or buttocks. Inconsistency between mechanism and injury pattern is the key concern.

Do not confront the grandmother or make accusations. This is critical. The consultation is about documenting findings, not investigating abuse. Do not say 'these look like they were inflicted' or 'who did this to him?' Maintain a calm, professional manner. Document everything meticulously: location, size, colour, shape of each bruise, and the explanation given.

Check Daniel's developmental milestones and general wellbeing. Is he interactive, well-nourished, appropriately dressed? Any signs of neglect? Check previous medical records for similar attendances.

Closing and safety netting

Follow the safeguarding pathway. Inform the named safeguarding lead or consultant paediatrician. Do not investigate yourself. Do not interview the child. Do not contact the parents about your concerns (this is for the safeguarding team to manage). Document everything with body maps, photographs if possible, and exact quotes of explanations given.

Maintain the grandmother's trust. You may need to explain: 'I am going to ask my senior colleague to also see Daniel because the bruising pattern is something we always take extra care with.' This avoids confrontation while initiating the safeguarding process.

The child's safety is paramount. If there is immediate risk, Daniel should not be discharged until the safeguarding team has assessed. In the meantime, treat any injuries, ensure he is comfortable, and maintain a safe environment. Do not let the grandmother leave with the child before the safeguarding team has been involved.

How examiners mark this station

Examiners will assess your ethical reasoning and interpersonal skills. Domain 2 (Clinical Management) is primary: marks for applying an ethical framework, referencing relevant legislation and guidelines, and reaching a reasoned position. Domain 3 (Interpersonal Skills) is equally weighted: marks for non-judgmental exploration, empathic communication, and negotiation skills. Domain 1 (Data Gathering) assesses your ability to fully explore the situation before forming a view.

Domain 1: Data Gathering, Technical and Assessment Skills (Primary focus)

Scores well: Injury pattern documented (location, size, colour, age). Mechanism-injury inconsistency identified. Previous attendances checked. Development and wellbeing assessed. Body map completed. Photographs taken.

Costs marks: Not documenting injuries in detail. Not identifying inconsistency. Not checking previous attendances.

Domain 2: Clinical Management Skills (Primary focus)

Scores well: Safeguarding lead informed. Child not discharged before assessment. Injuries treated. Documentation complete. Correct not to investigate or interview child. Senior involvement.

Costs marks: Not involving safeguarding. Discharging before assessment. Attempting to investigate. Not involving senior.

Domain 3: Interpersonal Skills (Primary focus)

Scores well: Non-confrontational throughout. Professional composure maintained. Grandmother's trust preserved. Child-centred approach. Senior review framed appropriately.

Costs marks: Confronting. Being accusatory. Losing professional composure. Allowing discharge.

Common examiner feedback (and how to fix it)

Did not demonstrate adequate ethical reasoning or application of relevant guidelines

Fix: Structure your response around the four ethical pillars (autonomy, beneficence, non-maleficence, justice). Reference specific guidelines (GMC, Mental Capacity Act) where relevant.

Did not sufficiently recognise or respond to the patient's feelings, concerns, or expectations

Fix: Acknowledge the emotional weight of the situation early. Show that you understand why this is difficult before applying ethical reasoning.

Common mistakes in this station

  1. Confronting the grandmother. Saying 'these injuries look inflicted' or 'who hurt Daniel?' jeopardises the safeguarding investigation, destroys trust, and may put the child at greater risk if the carer flees. Candidates must not confront.
  2. Discharging the child before safeguarding involvement. If NAI is suspected, the child must not leave the department until the safeguarding team has assessed. Candidates who treat and discharge fail the child's safety.
  3. Not documenting meticulously. Body maps, measurements, colours, photographs, and exact quotes are essential evidence. Candidates who note 'multiple bruises, ?NAI' without detailed documentation provide inadequate evidence for child protection proceedings.

Resitting PLAB 2?

If you have found ethics stations difficult, focus on learning a clear ethical framework (the four pillars) and practising how to apply it conversationally rather than reciting principles. Examiners reward candidates who can explore the tension between competing ethical principles while remaining empathic and non-judgmental.

Example opening

Thank you for coming in to speak with me. My name is Dr [Name]. I understand there is something important we need to discuss. Could you tell me your understanding of the situation?

Frequently asked questions

What is the right way to handle the suspected non-Accidental injury scenario in this station?

Suspected non-accidental injury is the most sensitive paediatric station. The candidate must maintain a professional, non-judgmental demeanour, document carefully, involve the safeguarding team, and prioritise the child's safety above all else. Daniel is 4, brought by his grandmother with bruising on arms and legs.

Where are marks won and lost in this suspected non-Accidental injury station?

Examiners reward: Injury pattern documented (location, size, colour, age). Mechanism-injury inconsistency identified. Previous attendances checked. Development and wellbeing assessed. Body map completed. Candidates are penalised for: Not documenting injuries in detail. Not identifying inconsistency. Not checking previous attendances.

Where do candidates most often go wrong in this station?

Confronting the grandmother. Saying 'these injuries look inflicted' or 'who hurt Daniel?' jeopardises the safeguarding investigation, destroys trust, and may put the child at greater risk if the carer flees. Candidates must not confront.

Can I do well in this station without real-world experience of suspected non-Accidental injury?

Structure beats experience here. Focus on inconsistency between mechanism and injury: the explanation does not match the bruise pattern or developmental stage. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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