A practice in the Guildford area

3. Mr N complains the Practice’s nurse pursued referrals to the local authority’s safeguarding unit in March and May 2024 without informing him and based on fictitious evidence.

4. Mr N says the Practice’s actions: • upset him and his family deeply • made him feel depressed and he lost trust in the Practice – he moved to a new GP practice • made him scared to ask healthcare professionals questions for fear of reprisal or another referral • the Practice’s May referral caused the council’s safeguarding unit to reconsider striking the March referral from their records.

5. As an outcome to his complaint, Mr N would like: • a full investigation into what happened and why the referrals were made • an acknowledgment from the Practice it made mistakes.

6. Mr N attended the Practice with his two year old son at the end of January 2024, as his son had developed a small number of dark spots around his face.

7. The Practice determined the spots were freckles and no treatment was provided, despite Mr N requesting removal. The Practice explained the NHS does not cover cosmetic procedures. In the initial notes made by the Practice, they described Mr N’s child as being “well”.

8. The next day, after speaking with a clinician, the nurse added retrospective notes to their consultation record. The notes raised concerns about Mr N’s behaviour during the appointment. The notes also raised concerns for Mr N's son and their relationship.

9. On 5 March 2024, the Practice referred Mr N to the safeguarding unit without his consent. They stated the reason for the referral was that they hadn’t seen Mr N’s son since their last visit, which they stated was unusual. They also had outstanding concerns from the last appointment.

10. The Practice followed up their referral on 15 May 2024, after the safeguarding unit closed the initial referral with no assessment or observation of Mr N’s child.

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The safeguarding unit decided that no further action was required, after investigating the referral.

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15. Before we decide if we should conduct a detailed investigation of 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.

16. We have done this and have not found any indications that something has gone wrong in this case. We appreciate that this decision will be upsetting for Mr N and understand the impact that being referred to the safeguarding unit has had on him and his family.

17. Mr N complains that the Practice’s nurse pursued referrals to the safeguarding unit in March and May 2024 without his consent and based on fictitious evidence.

18. In its complaint response, the Practice explained why it made referrals to the safeguarding unit and why it did not inform Mr N of these. The Practice said it followed the GMC guidance when deciding whether to consult Mr N before making the referral, and that this referral was based on the nurse’s concerns surrounding her observations.

19. In reaching a decision on this case, we have considered whether the Practice acted correctly in response to what it considered to be a safeguarding issue.

20. In January 2024, Mr N and his son attended a consultation due to ‘dark spots’ on his son’s chin and face, which appeared to be freckles. After the consultation, the nurse raised concerns regarding the child’s wellbeing with clinicians and added retrospective notes the following day. These notes documented the nurse was concerned about how Mr N spoke about his son, how he interacted with him, and that Mr N’s son’s appeared very withdrawn compared to his usual presentation when he was with a different family member.

21. Mr N told us he believes the added notes were the result of the nurse viewing his original complaint about their consultation, and changing her notes as a result, with malicious intent.

22. The Practice’s safeguarding policy states that “Any member of practice staff who becomes aware of concerns of abuse must report those concerns as soon as possible and if possible, within the same working day to the relevant senior manager/safeguarding lead within the practice”.

23. The nurse followed this procedure and added to her notes after speaking to colleagues about her concerns. It is reasonable to believe this took one day to complete. The Practice states, in its response dated 20 March 2025, that they believe the nurse did not make the referral maliciously.

24. In March 2024, the Practice made the first referral to the safeguarding unit, without Mr N’s consent. Mr N told us the nurse did not follow relevant safeguarding guidelines and stereotyped him based on his appearance, as he had never been aggressive. We understand that this experience must have been very frustrating for Mr N, and we recognise the importance of ensuring that everyone is treated with fairness and without assumptions.

25. Mr N also told us that the Practice made the referral as it had not seen his son in over a month. Mr N stated this was simply due to the fact his son had been well and had not needed an appointment during this time.

26. According to the referral’s rationale, Mr N’s son was much more reserved than usual. He did not speak or interact with anything or maintain eye contact. It states Mr N was shouting, saying his son was “damaged” and “ruined” because of the freckles on his face, and pulling his son’s head back to show the nurse what he was referring to. The nurse spoke to the health visitor, who also shared some concerns about Mr N.

27. The Practice provided a timeline of Mr N’s son’s previous appointments, before the last time he was seen in late January 2024. The Practice saw him eight times between November 2023 and January 2024. The referral states that not seeing him since was a concern for both the nurse and the health visitor, and one of the reasons they put the referral forward. The nurse also stated Mr N’s son did not attend an appointment the family had booked in February 2024.

28. The Practice’s safeguarding policy states that after concerns are reported, “All referrals should be followed up in writing by completing the Surrey Children’s Services Request for support form. Consent should be obtained from the family wherever it is possible to do so without increasing risk to the child.” The nurse completed the correct form within a timely manner.

29. The GMC guidance also states “You should only withhold information about your concerns, or about a decision to make a referral, if you believe that telling the parents may increase the risk of harm to the child or young person or anyone else. If this is difficult to judge, or you are not sure about the best way to approach the situation, you should ask for advice from a designated or named professional or a lead clinician or, if they are not available, an experienced colleague.” The GMC guidance is relevant as the safeguarding referral was co-signed by the Practice’s safeguarding lead, who is a doctor.

30. The Practice sought advice from the health visitor, who advised that gaining consent may increase the risk to Mr N’s child. Therefore, the Practice followed the Practice’s safeguarding policy and GMC guidance in deciding not to contact Mr N about the referral. We appreciate this element of the complaint had an especially large impact on Mr N, and that the decision not to contact him may have been difficult to understand from his perspective. We hope he can find some comfort in knowing the Practice correctly followed the policy.

31. According to Mr N, the Practice made a second referral to the safeguarding unit in May 2024. He told us this referral was baseless and centred on non-attendance to the Practice, despite no appointments being arranged.

32. From the information we have seen, it appears this second referral was actually a follow up. This was in line with the government’s safeguarding guidance, which says “Practitioners should always follow up their concerns if they are not satisfied with the local authority children's social care response and should escalate their concerns in line with local procedures if they remain dissatisfied”. Since the Practice never received a response from the safeguarding unit, it was reasonable to follow up the original referral.

33. When the Practice chased the March referral, they discovered the council had closed the case without any assessment of Mr N’s son or the team making any enquiries of the Practice. They requested a re-opening of the case, so Mr N’s son’s safety could be investigated.

34. We have seen that the Practice followed local and national policy and guidelines when it made a safeguarding referral on behalf of Mr N’s son and when it logged a further follow up. Therefore we have decided to take no further action.

35. We understand the safeguarding referral and follow up were distressing to Mr N. It must have been worrying to know the Practice had concerns about his child’s safety. We hope we have clearly explained why the Practice acted in line with safeguarding guidelines. We are sorry that this is not the outcome that Mr N was hoping for.

1. We have carefully considered Mr N’s complaint about the Practice. We understand that Mr N has concerns about the Practice pursuing referrals to the county council’s safeguarding unit. As a result, Mr N has a safeguarding referral on his record, which he does not believe is an accurate representation of himself or his relationship with his son. We acknowledge this has been a distressing situation for Mr N and his family.

2. Having considered Mr N’s complaint, we have seen no indication that anything went wrong in the Practice’s decision to refer Mr N’s son to the safeguarding unit. This is because the Practice has a duty of care to safeguard children if they have concerns. We recognise the importance of this issue and we explain our reasoning in more detail below.