Safeguarding Referral Medical Report

Section 17/47 Safeguarding Referral Letter and Report To: Local Authority Children's Services From: Willow Creek Surgery, 123 High Street, Willow Creek, WC1A 1AA Date: 1 November 2024 Re: Safeguarding Request - SC-2024-5678 Family Member 1 Demographics: Master Leo Davies DOB: 15/03/2018 Age: 6 years Address: 45 Elm Road, Willow Creek, WC1A 1BB NHS Number: 123 456 7890 Surgery Attendance: Leo typically attends surgery accompanied by his mother, Mrs. Sarah Davies. On occasion, he has attended with his grandmother, Mrs. Susan Smith, who is Mrs. Davies's mother. School: Willow Creek Primary School Recent Surgery Attendances: 20/10/2024: Reason for attendance: Persistent cough and fever. Accompanied by Mrs. Sarah Davies (mother). Outcome: Diagnosed with viral upper respiratory infection, advised symptomatic management. 05/09/2024: Reason for attendance: Routine 6-year-old check-up. Accompanied by Mrs. Sarah Davies (mother). Outcome: Generally well, growth and development on track, minor skin rash noted, advised over-the-counter cream. 12/07/2024: Reason for attendance: Fall at home, minor head injury. Accompanied by Mrs. Sarah Davies (mother). Outcome: Superficial graze to forehead, no loss of consciousness, advised to monitor for symptoms of concussion. A&E Attendances: 25/06/2024: Reason: Suspected broken arm after falling from a climbing frame. Circumstances: Mrs. Davies reported Leo fell while playing in the park. Injuries: Hairline fracture to left radius. Outcome: Arm put in cast, referred to orthopaedics. Immunisation Status: Leo's immunisation status is up to date according to the UK national schedule. Other Services Involved: Orthopaedic services (following fracture). Social Concerns: Concerns have been raised by school staff regarding Leo's frequent absences and reports of him appearing withdrawn. There have been noted inconsistencies in the explanations provided by Mrs. Davies for Leo's injuries, particularly regarding the recent arm fracture. Mrs. Davies has also struggled to consistently attend appointments. Leo has presented with poor personal hygiene on several occasions during surgery visits. There is a documented history of domestic disputes at the family home, with police attending on two occasions in the last year, though no formal charges were pressed. Family Member 2 Demographics: Miss Chloe Davies DOB: 28/11/2020 Age: 3 years Address: 45 Elm Road, Willow Creek, WC1A 1BB NHS Number: 987 654 3210 Surgery Attendance: Chloe is always accompanied by her mother, Mrs. Sarah Davies, when attending surgery. School: Willow Creek Nursery Recent Surgery Attendances: 18/10/2024: Reason for attendance: Earache. Accompanied by Mrs. Sarah Davies (mother). Outcome: Otitis media, prescribed antibiotics. 01/09/2024: Reason for attendance: Routine 3-year-old check-up. Accompanied by Mrs. Sarah Davies (mother). Outcome: Generally well, advised on healthy eating habits. A&E Attendances: None recorded. Immunisation Status: Chloe's immunisation status is up to date according to the UK national schedule. Other Services Involved: None currently. Social Concerns: Similar to Leo, Chloe's nursery has noted some instances of poor hygiene and occasional unkempt appearance. Mrs. Davies has been inconsistent in collecting Chloe from nursery on time. There have been no specific injury concerns for Chloe, but the general family environment and the domestic issues reported by police are relevant risk factors. Summary This report highlights concerns regarding the welfare of Master Leo Davies and Miss Chloe Davies, arising from inconsistent explanations for injuries, frequent absences from school/nursery, poor hygiene, and documented domestic issues within the family home. The inconsistencies in Mrs. Davies's accounts and her challenges with appointment adherence raise further concerns about her capacity to consistently meet the children's needs. The recent hairline fracture sustained by Leo, coupled with previous minor injuries, warrants further investigation into the circumstances. These factors combined indicate a potential safeguarding risk for both children. This report is based on a review of the medical records. The children/individuals have not necessarily been seen at the time of this report being compiled unless specifically stated otherwise. Yours sincerely, Dr. Eleanor Vance GP Partner, Willow Creek Surgery