In this article
Paramedics as a part of their role may encounter children, older people, those with a mental illness, persons with a disability and other persons who may be vulnerable because of illness or injury. Vulnerable patients are at an increased risk of harm or exploitation in healthcare. Paramedics may be the first health professionals to encounter these vulnerable children and/or adults and be the link to not only ensuring they receive the clinical care required at the time but also to breaking the cycle of harm or abuse through notifications or referrals to agencies and support services.
What is safeguarding?
Paramedics have a key role to play in safeguarding, particularly as they are granted access to homes and environments that many other professions are not, and can witness family and home life, often at the point of crisis.
Safeguarding adults and children is an integral part of patient care. Safeguarding means protecting people from harm including physical, emotional, sexual and financial harm and neglect. Paramedics have a duty to recognise the signs and symptoms of abuse and to act on any concerns. Duties to safeguard patients are required by professional regulators and service regulators and are supported by law.
Safeguarding adults at risk means protecting their right to live in safety and free from abuse and neglect.
Adults at risk means anyone aged 18 or over who:
- Has needs for care and support.
- Is experiencing, or is at risk of, abuse or neglect.
- As a result of those care and support needs, is unable to protect themselves from either the risk of or the experience of abuse or neglect.
Children means anyone aged under 18 years, or under 25 years if they have special educational needs or disability (SEND).
Safeguarding children and young people’s welfare are defined in ‘Working Together to Safeguard Children’ as:
- Protecting children from maltreatment.
- Preventing impairment of children’s health or development.
- Ensuring that children grow up in circumstances consistent with the provision of safe and effective care.
- Taking action to enable all children to have the best outcomes.
Safeguarding also means that individuals are adequately supported to access care and support where this is needed, so that they are able to stay well and maintain a high quality of life. This is achieved by different organisations working effectively together to prevent and stop both the risks and experience of abuse or neglect. Safeguarding aims to balance the right to be safe with the right of the individual to make informed choices and to have their wellbeing promoted at all times.
The Care Act 2014 lists six key principles of safeguarding. These are intended to form a core set of standards for anyone who has a responsibility for safeguarding. Although these principles have been designed with a focus on vulnerable adults, they should be applied to any type of vulnerable individual, children included.
The principles are as follows:
- Accountability – in the event of a disclosure, if an adult or young person entrusts you with information that you know could be indicative of abuse, you must be clear with the individual that you need to report what you have heard.
- Empowerment – it’s important for any person who has been a victim of abuse to feel that they have control over their situation. Support and encouragement are key to effective working with a victim of abuse or neglect.
- Partnership – it is important to work in partnership with your local authority and all services or organisations in your community that might be able to assist in detecting and reporting abuse.
- Prevention – it is sometimes possible to take action before harm has come to an individual. If you know the signs and indicators of abuse, you will understand when something is not quite right and will be better placed to report any concerns for an individual’s wellbeing.
- Proportionality – when a safeguarding incident occurs, you should report your concerns in a manner that is appropriate for the risk presented. For example, if you suspect that a child is in immediate danger, dialling 999 is the recommended response.
- Protection – it is crucial to be an ally for individuals who have experienced or who are at risk of abuse. Supporting and representing these individuals in the appropriate manner can help to protect them from further harm.
What risk factors make someone more likely to experience abuse?
Individuals encountered by paramedics, by the very nature of being patients in need, can be vulnerable, and may not have the capacity to consent to their own healthcare, or their vulnerability may mean their interests need protection. It is possible that a person’s decision-making capacity may be subject to change depending on circumstances such as the illness or injury being experienced at the time, and various other factors. Fluctuation of capacity means that a person’s ability to understand information, retain that information and make an informed decision can come and go which can make them more vulnerable.
Abuse and neglect can occur anywhere to anyone; however, there are risk factors that can make a person more vulnerable to abuse.
An adult at risk of abuse may:
- Have an illness affecting their mental or physical health.
- Be physically dependent on others.
- Have a sensory impairment.
- Have a learning disability.
- Suffer from drug or alcohol problems.
- Have low self-esteem.
- Be unable to make their own decisions.
- Have a previous history of abuse.
- Have negative experiences of disclosing abuse.
- Be frail.
- Have experienced a lack of access to health and social services or high-quality information.
Any child can be at risk of abuse; however, there are a number of factors that can increase a child’s vulnerability to abuse and neglect including, but not limited to:
- Socioeconomic factors such as poverty, poor housing and deprivation.
- Child factors, for example disabled children are more vulnerable to abuse or neglect.
- Family factors such as parental/carer substance misuse problems, parental/carer mental health problems and domestic abuse. These factors may be compounded if the parent/carer lacks support from family or friends and experiences social isolation.
- The parent or carer does not engage with services.
- There have been one or more previous episodes of child abuse or neglect.
- The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
- There is chronic parental stress.
- The parent or carer experienced abuse or neglect as a child.
- A family history of maltreatment.
- Being in care, a looked-after child.
- A history of offending, either parent or child.
These lists are not exhaustive, and other people might also be considered to be adults or children at risk.
The types of abuse children can encounter
Statutory guidance across the four countries of the UK describes four main categories of child abuse, and these definitions will normally be reflected in local organisations’ policies and procedures.
The four categories are:
- Physical harm/abuse – this may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child/young person. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child/young person. Harm can also occur due to practices linked to faith and culture, for example, Female Genital Mutilation (FGM).
- Emotional harm/abuse – this is the persistent emotional maltreatment of a child/young person such as to cause severe and persistent adverse effects on the child/young person’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child the opportunities to express their views, deliberately silencing them or “making fun” of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child’s developmental capacity, as well as overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill treatment of another. It may involve serious bullying, including cyberbullying, causing children/young people frequently to feel frightened or in danger, or the exploitation or corruption of children/young people. Some level of emotional abuse is involved in all types of maltreatment of a child/young person, though it may occur alone.
- Sexual abuse – this involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetrative acts, for example rape or oral sex, or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may include non-contact activities, such as involving children in looking at, or in the production of, pornographic sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse, including via the internet. Sexual abuse is not solely perpetrated by adult males; women can also commit acts of sexual abuse, as can other children.
- Neglect – this is the persistent failure to meet a child/young person’s basic physical and/or psychological needs, likely to result in the serious impairment of the child/young person’s development. Neglect may occur during pregnancy, for example as a result of maternal substance abuse, maternal mental ill health or learning difficulties or a cluster of such issues. Where there is domestic abuse and violence towards a carer, the needs of the child may be neglected.
Once a child is born, neglect may involve a parent or carer failing to:
– Provide adequate food, clothing and shelter, including exclusion from home or abandonment.
– Protect a child/young person from physical and emotional harm or danger.
– Ensure adequate supervision, including the use of inadequate caregivers.
– Ensure access to appropriate medical care or treatment, also including neglect of, or unresponsiveness to, a child/young person’s basic emotional needs.
The types of abuse adults can encounter
There are ten types of abuse listed in the Care Act (2014).
- Physical abuse – this may involve physical violence, misuse of medication, inappropriate restraint or sanctions.
- Sexual abuse – this can include verbal sexual abuse, non-consensual touching, fondling, physical restraint, cornering, tickling, kissing, excessive cleaning of genitals, enemas, intercourse, sodomy, oral sex, invasion of privacy and stalking.
- Psychological abuse – this includes emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, harassment and verbal abuse.
- Financial or material abuse – including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and misuse or misappropriation of property, possessions or benefits.
- Neglect and acts of omission – including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, withholding medication, and inadequate nutrition and heating.
- Discriminatory abuse – including racist and sexist abuse or abuse based on a person’s disability.
- Domestic abuse – including psychological, physical, sexual, financial and emotional abuse, and so-called honour-based violence.
- Modern slavery – includes slavery, human trafficking, forced labour and domestic servitude.
- Organisational abuse – including neglect and poor care practice within an institution or specific care setting such as a hospital or care home.
- Self-neglect – includes a wide range of behaviour neglecting to care for personal hygiene, health or surroundings and includes behaviour such as hoarding.
What safeguarding issues do paramedics need to be aware of?
Abuse and neglect can take many forms, ranging from exploitation and disrespectful treatment to physical harm. It can be at a low level, and take place over a long time, or it can take place over a short time and be more extreme. It is all abuse.
Organisations and individuals should not be constrained in their view of what constitutes abuse, neglect or harm and should always consider the circumstances on a person-centred basis. Safeguarding concerns vary according to the nature of harm, the circumstances it arose in and the people concerned. Paramedics often see patients in times of distress and difficulty. It is likely that you may come into contact with someone who is at risk or suffering from abuse or neglect. The abuse or neglect can be deliberate, or the result of ignorance. Recognising abuse or neglect is crucial.
Indications might include, but are not limited to:
- Physical signs such as hand-slap marks, bruising in unusual areas, bruised eyes, bite marks and other injuries.
- The story provided by the adult might be inconsistent with any injuries.
- Refusal by others to allow the patient into further care or to change environment.
- Poor physical care and inadequate hygiene, inappropriate dress.
- Physical sexual health problems, including soreness in the genital and anal areas, sexually transmitted infections or underage pregnancy.
- Deliberate self-harm and/or drugs and alcohol misuse.
- Be the result of deliberate intent, or be unintentional, through negligence or ignorance.
- Be a single act or repeated acts.
- Cause harm temporarily or over a period of time.
- Be an act of neglect or an omission to act.
- Occur through deliberate targeting/grooming.
The roles and responsibilities of a paramedic in regard to safeguarding
Paramedics will have an individual responsibility to safeguard people, to identify and respond to allegations of abuse and neglect. Health services have a duty to safeguard all patients, but also to provide additional measures for patients who are less able to protect themselves from harm or abuse. Safeguarding adults and children covers a spectrum of activity from prevention through to multi-agency responses where harm and abuse occurs. Multi-agency procedures apply where there is concern of neglect, harm or abuse to a patient defined under the Care Act (2014) guidance as vulnerable.
A paramedic’s role in safeguarding is to:
- Recognise – you should have a clear understanding of what the different signs and symptoms of potential abuse, harm and neglect can be. Robust safeguarding training can help you to spot these signs and symptoms.
- Respond – it is essential that you respond appropriately and do not ignore the situation.
- Report – concerns need to be reported without delay. Confidentiality is important, so only share information with those who are a part of the safeguarding process.
- Record – you should make precise, comprehensive notes that detail everything about your safeguarding concern.
- Refer – if the safeguarding risk is urgent and you suspect somebody is under immediate or severe threat, you should contact the relevant local authority or police services.
Paramedics have a duty to make sure that:
- Safeguarding concerns are dealt with promptly, appropriately and reported in a secure and responsible way to all relevant agencies.
- Steps are taken to escalate or alert those able to protect patients and/or other children and adults at risk from harm and minimise the risk of abuse.
- Appropriate and proportionate measures are in place to protect from harm all those who work for them, or with them, or come into contact with them.
People aged 16 or over are entitled to consent to their own treatment. Children under the age of 16 can consent to their own treatment if they are believed to have enough intelligence, competence and understanding to fully appreciate what is involved in their treatment. This is known as being Gillick competent. Paramedics may find it difficult to accept the patient’s choices such as declining services or acting against advice about how to manage their safety. They may be concerned that they are failing in their duty of care and that they could be found to be reckless or negligent. A duty of care is a requirement placed on an individual to exercise a reasonable standard of care while undertaking activities or omissions that could foreseeably harm others. However, duty of care also includes respecting the person’s wishes and protecting and respecting their rights.
The safeguarding issues paramedics may come across
Emergency Operations Centres (EOC) help to identify vulnerable people from the information received when members of the public call for help; this can identify possible safeguarding issues. EOC staff may refer calls involving domestic violence or children in environments where drug and alcohol abuse is suspected or known to the appropriate service.
Understanding what abuse and neglect might look like and how to recognise warning signs is an important aspect of safeguarding.
Some examples paramedics might encounter may include, but are not limited to:
- Someone who needs urgent help due to their mental health, for example if you think they might attempt suicide or self-harm or have seriously harmed themselves.
- A patient is developing a pattern of repeat ambulance attendances and triggers a further assessment to determine if the person is in need of additional support.
- Family members who can convincingly persuade paramedics that they have authority over a patient’s affairs and yet no evidence is produced to that effect.
- A person with advanced dementia shows signs of self-neglect and flags the need for additional support.
- A child’s behaviour may indicate that they have been abused. The child may show fear of adults or a fear of certain adults when they approach them, or display aggressive behaviour, or be excessively withdrawn, fearful or anxious about doing something wrong.
- Disclosure by an adult or a child of abusive activities.
- A colleague not complying with procedures to meet safeguarding needs.
Where should paramedics go with a safeguarding concern?
Paramedics must take appropriate action when they have concerns about the safety or wellbeing of children or vulnerable adults. Some concerns may be minor in nature but provide an opportunity for early intervention, for example advice to prevent a problem from escalating. Other safeguarding concerns may be more serious and need a response through multi-agency procedures and possible statutory intervention through regulators, the criminal justice system or civil courts.
Immediate concerns about abuse or neglect should be dealt with under local safeguarding procedures first. The person who raises a safeguarding concern within their own organisation should follow their organisation’s policy and procedures. This concern may result from something that you have seen, been told or heard. To assist paramedics in navigating these complex issues, Ambulance Service NHS Trusts provide guidance on how to refer vulnerable people to services which may investigate the circumstances and ensure the safety and welfare of the patient.
All NHS services are required to have a Safeguarding Children and Vulnerable Adults Lead as part of their organisational structure. The designated safeguarding lead will normally be someone who has been given special responsibility and training in dealing with employees’ concerns.
The role includes:
- Making sure appropriate systems for raising concerns are in place and that all staff can access them.
- Making sure staff can see all concerns are taken seriously, even if they are later seen to be unfounded.
- Investigating concerns promptly and including a full and objective assessment.
- Taking action to deal with the concern, and record and monitor this action.
- Keeping the employee who raised the concern up to date with what is happening.
- Having processes in place to support employees raising concerns.
- Having a role in highlighting learning and may facilitate or be part of learning events.
If you witness or suspect that there is a risk of immediate harm to a child or adult in your care, you must act straight away to protect their safety. You should report your concerns to the appropriate person or authority immediately; this may be the police in some situations. Involvement of the police is indicated in incidents of suspected theft and common assault, including sexual assault, and assault causing actual bodily harm. However, police may also be involved in other patient safety incidents such as wilful neglect of a child.
You should also keep an accurate record of your concerns and action that you have taken, and you should always inform the designated safeguarding lead of your actions.
If you have raised your concern internally but feel it hasn’t been dealt with properly, or if you feel unable to raise your concern at any level in your organisation, you may want to get help from outside your place of work. You can raise your concerns through the NHS Whistleblowing Helpline 08000 724 725.
Speaking up on behalf of people in your care is an everyday part of your role. Just as raising genuine concerns represents good practice, doing nothing and failing to report concerns is unacceptable. Failure to report concerns may bring your fitness to practise into question and put your registration at risk.
What legislation do paramedics have to follow in regard to safeguarding?
The Care Act 2014 sets out statutory responsibility for the integration of care and support between health and local authorities. NHS England and Clinical Commissioning Groups are working in partnership with local and neighbouring social care services. Local authorities have statutory responsibility for safeguarding. In partnership with health they have a duty to promote wellbeing within local communities.
Safeguarding Vulnerable Groups Act 2006 and the Protection of Freedoms Bill – this Act was passed to help avoid harm, or risk of harm, by preventing people who are deemed unsuitable to work with children and vulnerable adults from gaining access to them through their work. Organisations with responsibility for providing services or personnel to vulnerable groups have a legal obligation to refer relevant information to the Disclosure and Barring Service (DBS).
Working Together to Safeguard Children 2010 – the way that agencies and organisations should work together to carry out their duties and responsibilities under the 1989 Children Act and other legislation is set out in a document called ‘Working Together to Safeguard Children’.
It sets out the responsibilities of all agencies in the protection of children, and is aimed at staff in organisations that are responsible for commissioning or providing services to:
- Children, young people and adults who are parents/carers.
- Organisations that have a particular responsibility for safeguarding and promoting the welfare of children and young people.
The Mental Capacity Act 2005 – in order to protect those who lack capacity and to enable them to take part as much as possible in decisions that affect them, the following statutory principles apply:
- You must always assume a person has capacity unless it is proved otherwise.
- You must take all practicable steps to enable people to make their own decisions.
- You must not assume incapacity simply because someone makes an unwise decision.
- Always act, or decide, for a person without capacity in their best interests.
- Carefully consider actions to ensure the least restrictive option is taken.
The Deprivation of Liberty Safeguards 2009 (DoLS), an amendment to the Mental Capacity Act 2005, provide a legal framework to protect those who lack the capacity to consent to the arrangements for their treatment or care, for example by reason of their dementia, learning disability or brain injury and where levels of restriction or restraint used in delivering that care for the purpose of protection from risk/harm are so extensive as to potentially be depriving the person of their liberty.
The General Data Protection Regulations (GDPR) and the Data Protection Act 2018 introduced new elements to the data protection regime, superseding the Data Protection Act 1998. Practitioners must have due regard to the relevant data protection principles which allow them to share personal information. However, the GDPR and Data Protection Act 2018 do not prevent, or limit, the sharing of information for the purposes of keeping vulnerable adults safe.
Why is safeguarding training important?
It is important that we all understand safeguarding, and know what to do should safeguarding concerns arise.
Safeguarding induction and training is essential for all staff appropriate to their role, including:
- Information on types of harm, abuse and neglect.
- How to spot abuse.
- How to respond to concerns.
- Who to report concerns to.
Training should be directly applicable to the responsibilities and daily practices of the person being trained, and to the care and support needs of the patients that they are working with. An example of appropriate safeguarding training includes Safeguarding Children Level 2, designed for people who are working with children and teaches the skills needed to safeguard children who are at higher risk of abuse, and Safeguarding Vulnerable Adults (SOVA) Level 2, designed for people who are working with vulnerable adults and teaches the skills needed to safeguard people who are at higher risk of abuse.
Managers should evaluate changes in understanding and confidence before and after training, assessing this:
- Immediately after the training.
- In regular long-term evaluations, for example as part of supervision sessions.
- Annually, for example as part of the performance management/appraisal process.
Line managers should provide feedback through supervision and appraisals, acknowledging how paramedics have learned from their experience of identifying, reporting and managing safeguarding concerns.
How often should paramedics renew their safeguarding training?
Managers should assess paramedics’ safeguarding knowledge annually, and run refresher training if needed. To help paramedics increase their confidence in managing safeguarding concerns, they should at a minimum refresh their safeguarding training at least every 2 years and participate in continuing professional development (CPD).