The nurse made an incorrect referral to the MASH team for Mr B’s daughter
18. When we consider a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs that something has gone wrong, for the following reasons.
19. Mr B complains the nurse practitioner at the Practice made an incorrect referral to the MASH team, following his daughter’s assessment in which she was presenting with a urine infection and slight bleeding. He complains the nurse incorrectly concluded there were signs of trauma and bruising.
20. Mr B’s daughter attended the Practice with her mother at 4:37pm on 15 January 2025 after noticing blood after urinating. She was seen by the nurse practitioner who diagnosed her with a urine infection and also noticed what they believed to be bruising around her vagina. As a result of these symptoms, the nurse made a referral to the MASH team, who later investigated her case further.
21. The medical records from the appointment on 15 January show the nurse noted a small area of bruising at the vaginal entrance, that was tender on contact. The nurse prescribed antibiotics and gave safety netting advice (guidance provided to parents or caregivers after medical consultation to ensure they are equipped to monitor their child’s health).
22. The records show Mr B’s daughter’s pain score to be four out of ten (with ten being the score for the highest amount of pain) and she reported no known trauma or injury. The records note her mother reported previously her daughter had been picking her eyelashes out but that had ceased some months before.
23. At 6:09pm the nurse spoke with the Practice safeguarding lead. The safeguarding lead advised the nurse to contact the on-call hospital paediatrics consultant, and the nurse did so and left a voicemail message.
24. At 6:20pm the nurse spoke to Mr B who advised his daughter had been trampolining over the weekend and had not complained of vaginal pain. He also reported that when asked his daughter had denied anyone had touched her genitals. The nurse advised Mr B the next step was to wait for the paediatric consultant to call back and they would notify the family of the outcome following that.
25. After speaking to the children’s safeguarding department on 16 January, the nurse made a referral to the SARC, as advised. The records show the nurse advised Mr B of the referral and of the potential for a social worker to call and the referral to the SARC.
26. Following the referral, the SARC referred Mr B’s daughter for a social work assessment. Following the social work assessment Mr B’s daughter was discharged and no further action requested.
27. The Practice explained it followed all safeguarding processes and that the nurse referred appropriately using the national framework put in place to safeguard all children.
28. This is all in line with the Practice’s Safeguarding Policy. This says the Practice is required to act promptly ‘where abuse of any child or young person is suspected, the welfare of the patient takes priority’. Staff are required to respond to safeguarding issues discovered during inspections, ‘raise them with providers and, where necessary, refer safeguarding alerts to the local authority or police where appropriate’.
29. The policy lists indicators of various types of abuse and neglect, including sexual abuse, which may prompt a safeguarding referral. The indicators for sexual abuse include ‘unexplained ano-genital symptoms’. This can include pain, discomfort and signs of infection.
30. Within the Practice’s Safeguarding Policy it says where abuse is suspected, concerns should be ‘immediately reported to the Practice’s safeguarding lead’.
31. The policy states where sexual abuse is suspected, the Practice is expected to ‘contact the Social Services or Police Child Protection Team directly’.
32. We can see from the records A attended the Practice with symptoms indicative of a urine infection. A also had symptoms of genital bleeding and suspected bruising around her vagina. We understand the nurse believed there to be bruising and discussed with A’s mother any known causes for that. The records note A and her mother were not aware of any injury or other known cause of the injury. These symptoms meet the indicators of possible sexual abuse within the Practice’s Safeguarding Policy.
33. The Practice’s Safeguarding Policy says where sexual abuse is suspected, the designated person will contact Social Services or the Police. The policy also says members of the Practice’s team should not carry out investigations into any suspicions of sexual abuse and should instead provide the information relating to any suspicion to the child protection agencies (in this case Social Services).
34. We can see the Practice suspected sexual abuse as a cause for the injury seen, based on A’s presentation and therefore referred her to the MASH team, seeking input from the Practice’s safeguarding lead. This was in line with the Practice’s Safeguarding Policy.
35. We recognise Mr B has concerns about the Practice’s actions and what happened caused him and his family significant distress. We do not underestimate how traumatic it must have been.
36. Having reviewed the evidence, we can see the Practice reviewed A’s symptoms and took action in line with the Practice’s Safeguarding Policy. We hope we have clearly explained the reasons for this and why we did not see the Practice got things wrong.
The nurse was dismissive, unapologetic and communicated inappropriately in front of A during the initial appointment
37. As previously mentioned, when we look at a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. Sometimes, where there is a lack of information or evidence available, we are unable to say what did happen, meaning we cannot reach a decision on the balance of probabilities as to whether anything went wrong.
38. In this case, we have been unable to reach a decision on whether the way the nurse communicated with the B family was inappropriate.
39. Mr B says the nurse was dismissive, unapologetic about the referral and communicated inappropriately in front of A. We can see from the consultation information sheet provided by the Practice, that A ‘denied injury, trauma and interference from another’ at the initial consultation on 15 January 2025. It is clear the nurse asked questions about A and the potential cause of her symptoms, and it is this that Mr B later suggested was inappropriate.
40. Whilst we appreciate the complex and distressing nature of such questions, we cannot determine from the evidence available the appropriateness of the nurse’s tone in this instance. Also, how the nurse asked their questions, and whether their tone was dismissive, is a subjective consideration.
41. We see no fault in the nurse asking the kind of questions they posed during the consultation to gather information to ensure the Practice could provide enough information to the safeguarding team. The Practice’s Safeguarding Policy says staff will clarify and obtain more information about the matter as appropriate and assess that information promptly. We consider the questions the nurse asked about how A acquired her injury to be in line with this given their suspicions.
42. We have also considered communication between the nurse and Mr B as part of the complaints process. We looked at the minutes taken from their complaint review meeting on 12 February 2025 following the referral.
43. Those minutes show the nurse explained why they made the referral and said they ‘stood by’ their actions and would make the same decisions should the situation arise again. The nurse said throughout that the injuries they saw without explanation meant they had to make the referral. The nurse expressed regret that A was anxious and upset by what had happened.
44. We understand Mr B says the nurse was dismissive towards him. As the nurse stood by the actions they took at that time and reflected they would do the same again we recognise this may have made Mr B feel like his point of view was dismissed. While we are not questioning Mr B's view of the events that took place, we have to consider the evidence available and weigh this appropriately.
45. For the same reasons we described in paragraph 42, we cannot reach a view on the tone of any party at the meeting. We appreciate Mr B felt ‘frustrated’ and thought something should be in place for the after effects of what his daughter and family experienced. We saw Mr B rang the practice on 13 February, and the notes of that call say he ‘blames’ the nurse for making the safeguarding call and starting the safeguarding process his daughter then went through.
46. Whilst we cannot determine the tone used in the meeting by any parties, we can see the Practice has taken steps to fully address the complaint. It held a meeting on 12 February and follow up calls on 13 February with Mr B and with his wife, in both of which the Practice gave detailed explanations for why the referral was made. The Practice acknowledged that the safeguarding process meant that some people found not to be at risk go through the process, as in this case. The Practice told Mrs B it was looking into informing staff about the process after the referral, so that clearer information can be shared with families.
47. The nurse did not apologise for the action they took but acknowledged the impact it had on A. As we have not seen failings in the actions the nurse took when they made the referral, we cannot see they should have apologised about this, or any failing because they did not apologise.
48. We appreciate Mr B wanted the nurse to apologise and how them standing by the actions they took must have felt, for him, unapologetic.
49. We hope we have explained why we have seen that both the Practice and the nurse offered clear reasons for the actions taken, which were in line with the Practice’s Safeguarding Policy. For this reason, we have not seen indications of failings in how the Practice, and specifically the nurse, responded to the matter.