Unfortunately, it’s not uncommon for patients to regularly fail to turn up for a booked appointment with a GP or Nurse, but when that patient is a child we must be curious and ask why.
Not only could their health needs be unmet, but there may be safeguarding concerns. Missing appointments for some children may be an indicator that they are at an increased risk of abuse. There are many innocent reasons why children miss appointments, but numerous studies have shown that missing healthcare appointments is a feature in many serious case reviews including those into child deaths.
What age is a ‘child’?
To clarify, the Children Act 2004 states a ‘child’ is anyone who has not yet reached their 18th birthday. The fact that a child who has reached 16 years of age and may be Gillick/Fraser competent does not change their status or entitlement to services or protection under the Children Act.
DNA or WNB?
Although in Primary Care failed appointments are usually referred to as ‘Did not attend’ (DNA), there is a move towards the concept of describing children and young people (CYP) as ‘Was not brought’ (WNB) instead of DNA because it encourages us to think about the situation from the child’s perspective and potentially take action to safeguard them.
By building a picture we can start to pick up concerns which may cause alarm
Although non-attendances at hospital paediatric clinics is associated with greater social deprivation and likelihood of a child protection alert in hospital notes, we shouldn’t jump to conclusions each time a child is not brought for an appointment. However, questions should be asked to take a consistent approach to missed appointments and check if there is a potential safeguarding issue, such as:
- How often is the child not brought to an appointment?
Is it frequent enough to be of concern?
- Do we know what the child’s appointment was for?
E.g. acute or routine follow up?
- Is the child already on the safeguarding children register?
Is a child protection plan in place?
- If not, has the child been identified in any other safeguarding cases or concerns?
- Are there any general concerns about the welfare of the child?
- Is there a pattern or regularity to the instances where the child is not brought?
If so, are there genuine reasons e.g. transport difficulties?
What does CQC expect to see as evidence?
CQC review of safeguarding children arrangements in the NHS, July 2009, identified that there should be a process in place for following up children who fail to attend appointments. In a CQC inspection report of a GP Practice it stated that “systems were not effective across all areas such as following up on child missed appointments at hospital”.
As part of CQC inspections, Practices are required to evidence an effective process for monitoring and following up on missed hospital appointments, for both adult and child patients, and keep a record to evidence when the GP had reviewed missed hospital appointments. The CQC Mythbuster Nigel’s surgery 33: Safeguarding children also explains the important role that GP Practices play in safeguarding children and young people from abuse and neglect.
Ensure you have robust policies and procedures in place
“It’s important for GPs to have policies and procedures in place that clarify what they should do if a child is not brought to a GP appointment. Such non-attendance should not only be coded correctly but also trigger an appropriate response, perhaps a follow-up phone call from a receptionist or GP. Of course, hospitals should also have clear guidance on what action to take if a child is not brought.” British Journal of General Practice 2017
At QCS, in our Safeguarding Children and Child Protection Policy and Procedure, we explain that safeguarding children is a core statutory duty, and child protection is a part of safeguarding and promoting welfare. The policy also includes a register to record all safeguarding cases and a template which can be used to accurately record internal safeguarding children meetings.
Here are 5 top tips to help you review children who ‘WNB’ for an appointment
- Ensure all children with safeguarding concerns are read coded on the clinical system
- Regularly run DNA and WNB reports for children under 16
- Carry out an audit of children with a safeguarding concern who have not attended an appointment in the last 12 months and update the Practice Safeguarding Lead
- This includes all primary care, secondary care and other healthcare appointments
- Follow up missed chronic illness and out-patient hospital appointments
- If they have not attended their last 3 appointments without good reason:
- Add a reminder or flag in the clinical record so that it can be monitored
- Make a note to discuss with the parent or carer at the next visit, or contact them immediately if there are significant safeguarding concerns
- Ensure the reception team are also trained and empowered to report any concerns
- They are in a position where they may identify the signs of abuse or neglect or hear something that causes them concern
