Safeguarding – Paramedic Quick Reference

UN Convention on the Rights of the Child (Art. 1) – ratified UK 1991 | Children Act 1989 & 2004 Any person below the age of 18 years. There is no single UK law defining a child, but the UN Convention applies. NWAS policy applies to those who have not had their 18th birthday.

Child Abuse Categories

Abuse includes acts of omission or failure to act (NWAS Policy 2.4)

Care Act 2014 | Law Commission Definition Law Commission: "A person aged 18 years or over who appears to have health and social care needs and appears to be at risk of harm."

Care Act 2014: "A person aged 18 or over who is at risk of abuse or neglect because of their need for care or support."

Adult Abuse Categories

• Physical, sexual, psychological/emotional
• Exploitation (financial or material)
• Neglect or acts of omission
• Self-neglect
• Discriminatory abuse
• Institutional and organisational abuse
• Modern slavery
• Domestic abuse
• Hate crime and elder abuse

Vulnerability Factors to Consider

Injury (physical or psychological) caused by abuse or neglect, or by failure to act. Harm can be considered unexpected if it is not related to the natural course of the patient's illness or underlying condition.

Harm can occur within circumstances as diverse as the numbers of people at-risk. Abuse cannot be condoned or ignored for religious, cultural or any other reasons. NWAS policy specifically recognises that culture and ethnicity may present challenges — use language line and other tools to ensure accurate assessment. Ethnicity must be recorded on the ePCR and within safeguarding concerns.

• Protecting children from abuse and neglect
• Preventing impairment of their health and development
• Ensuring they receive safe and effective care

Children Act 1989 & 2004 | Working Together to Safeguard Children 2018

Mental Capacity Act 2005

• A person must be assumed to have capacity unless established otherwise
• All practicable steps must be taken to help a person make a decision before treating them as lacking capacity
• A person is not to be treated as unable to make a decision merely because they make an unwise decision
• Any act or decision made under MCA must be in the person's best interests
• Before acting, consider whether the purpose could be achieved in a less restrictive way

NWAS Policy Section 5 | Data Protection Act 1998 | Caldicott Principles | NHS Confidentiality Code of Practice

• Responsible information sharing plays a key role in safeguarding — SCR evidence shows children and adults have come to harm when services did not share concerns
• The need to share must be distinguished from the principle of confidentiality — they are not mutually exclusive
• Where there is a risk to life or limb, information can and should be shared even without consent
• All information sharing must comply with legislation and NWAS Information Sharing Policy
• Caldicott principles: share only what is necessary, on a need-to-know basis, with appropriate records

When a child or adult dies or suffers significant harm and abuse/neglect is known or suspected, a Local Child Safeguarding Practice Review (LCSPR) or Safeguarding Adult Review (SAR) may be undertaken. Community Safety Partnerships may request a Domestic Abuse Related Death Review.

• Your ePCR entries will be scrutinised in any SCR
• Your decision-making and rationale will be reviewed
• Failure to refer where a referral was indicated is a significant risk exposure
• Document contemporaneously — if it is not written, it did not happen

• Safeguarding Procedures (primary procedural document)
• Sudden Unexpected Death in Infants and Children Procedure
• NWAS Capacity to Consent Policy
• Domestic Abuse Procedure and Guidance (Support for staff)
• Disclosure & Barring Procedures
• Prevent Guidance and Referral Process
• NW Regional Mental Capacity Act (2005) Joint Protocol
• Incident Reporting and Investigation Policy
• High Intensity User Policy and Procedure
• Raising Concerns Policy

Before deciding whether consent matters, identify which situation you are in:

Your assumption that it covers terrorism and homicide is correct — but the threshold is significantly lower than that. HCPC, NMC, and GMC guidance (which NHS guidance follows) are consistent that "serious crime" and "serious harm" include:

This is where the line is genuinely blurred. A competent adult has the right to make unwise decisions — but that right is not unlimited where others are at risk, or where the risk to the person themselves is serious enough.

Step 1 — Is capacity genuine?

Coercive control, fear, substance intoxication, or psychological manipulation can all impair capacity without meeting the formal MCA threshold. A patient who says "I'm fine, don't refer" in front of an alleged perpetrator is not demonstrating free and capacitous refusal. Assess capacity away from the alleged abuser where possible.

Step 2 — Apply the proportionality test

Step 3 — Children in the household change everything

Step 4 — If you decide to share against refusal

• Tell the patient you are going to refer and why, where it is safe to do so
• Document your reasoning in full on the ePCR — what harm, why serious, why proportionate
• Do not withhold the referral solely because the patient objects — document the objection and proceed if the threshold is met
• Seek advice from Advanced Paramedic or Safeguarding Team if uncertain — 01204 498 400

Use these sentence frames to structure your reasoning on the ePCR. Adapt to the specific situation.

When sharing with consent

"Patient was informed of my intention to raise a safeguarding concern and consented to this. They were advised that information would be shared with [Social Care / Police / relevant agency]."

When sharing without consent – public interest / serious harm

"Patient declined consent for a safeguarding referral. However, on the basis of [describe findings/risk], I assessed that there was a serious and imminent risk of [harm/significant harm to the patient / risk to children in the household]. In the public interest and in accordance with my professional duty under the NWAS Safeguarding Policy and [relevant legislation], a referral was made without consent. The patient was informed of this decision where it was safe to do so."

When not referring despite concern – document your reasoning

"Safeguarding concern noted. Patient assessed as having capacity and declined referral. No children in the household. Risk assessed as [low/not meeting serious harm threshold] at this time because [rationale]. Patient given information regarding [support services]. If concern recurs or escalates, referral should be considered. Discussed with [crew mate / AP / Safeguarding Team] at [time]."

When capacity is uncertain

"Formal capacity assessment was not possible at scene due to [reason e.g. intoxication / presence of third party / patient distress]. On the balance of available information, [I proceeded on a best interests basis / I was unable to establish whether the patient's refusal was a free and capacitous decision]. Referral made. Safeguarding Team / Advanced Paramedic informed at [time]."

National Data Guardian – Caldicott Principles (2020 update)

Mental Capacity Act 2005 s.2 | MCA Code of Practice

A person with a mental health condition must be assumed to have capacity unless you have established otherwise using the two-stage MCA test. Diagnoses — schizophrenia, bipolar disorder, personality disorder, depression — do not in themselves remove capacity. Someone can have florid psychosis and retain capacity for specific decisions. Someone can appear entirely coherent and lack it.

Both stages must be satisfied to find lack of capacity for a specific decision.

Unlike most medical conditions, mental health presentations can cause capacity to fluctuate rapidly — sometimes within minutes. This matters because:

• A capacity assessment is time and decision specific — capacity at 01:00 for one decision does not mean capacity at 01:30 for a different one
• Acute psychosis, manic episodes, and severe dissociative states can produce periods of apparent lucidity that do not reflect sustained capacity
• Alcohol or substance use concurrent with mental illness compounds this significantly
• A patient who was clearly capacitous at the start of the job may not be by the time you reach a referral decision

Mental Capacity Act 2005 | Mental Health Act 1983 (amended 2007)

These are separate legal frameworks with different triggers, powers, and safeguards. In prehospital practice the key distinction is:

s.136 MHA – When to Consider Involving Police

• Person appears to have a mental disorder
• In a public place (s.136 applies in public; s.135 for private premises requires a warrant)
• In immediate need of care or control
• Police can remove to a Place of Safety for assessment
• This is a Police power — you cannot invoke it, but you can request Police attendance and flag the concern clearly

This is where the "respect capacity and refusal" position becomes most contested, and where the consequences of getting it wrong are most severe.

Even where capacity is present and refusal is being respected, a safeguarding referral may still be appropriate or required:

• Children in the household — parental mental illness affecting ability to care is a child safeguarding concern. Refer for the children regardless of the adult's wishes.
• Third party at risk — expressed intent to harm another person meets the serious harm/public interest threshold. Inform Police.
• Known or suspected abuse by a carer — mental health patient being abused by carer or family member. Adult safeguarding referral regardless of patient's refusal.
• Exploitation — mental health vulnerability is frequently exploited (financial, sexual, cuckooing). Capacity for day-to-day decisions does not mean the person is not being exploited. Refer.
• High intensity user / frequent caller pattern — may indicate underlying safeguarding concern. Flag via HIU pathway in addition to any referral.

Capacity assessed, present, refusal respected

"Patient assessed using the MCA two-stage test. Stage 1: [describe presentation/impairment]. Stage 2: Patient was able to understand the information provided, retain it, weigh the risks and benefits, and communicate a decision. Capacity assessed as present for this decision at this time. Patient declined [referral/conveyance]. Refusal respected. [Safety information provided. GP/crisis team informed. AP discussed at time.] No children or third parties identified as being at risk."

Capacity assessed, absent — best interests decision

"Patient assessed using MCA two-stage test. Stage 1: [impairment identified e.g. acute psychosis / severe dissociation / intoxication]. Stage 2: Patient unable to [understand / retain / weigh / communicate — specify which] due to [reason]. Capacity assessed as absent for this decision at this time. Decision made in best interests to [refer / convey / share information] because [rationale — least restrictive option, life risk, etc.]. Patient informed of decision. [Family member / crew mate / AP] aware."

Capacity uncertain — risk too high to defer

"Full capacity assessment was not possible due to [patient's acute distress / fluctuating presentation / inability to engage]. On the information available I was unable to establish with confidence that the patient had capacity for this decision. Given the nature of the risk [describe], I proceeded on a precautionary best interests basis. AP [name] informed at [time]. Safeguarding referral raised."

MHA threshold — Police requested

"Patient presents with apparent mental disorder [describe]. Patient has capacity but is refusing assessment/treatment. Risk assessed as [describe — active suicidal intent / serious self-harm / risk to others]. MCA best interests does not apply as patient has capacity and this is a mental health treatment decision. Concerns meet potential threshold for MHA consideration. Police requested to attend re: possible s.136. AP informed. Patient not left alone pending Police arrival."