When to suspect child maltreatment: summary of NICE guidanceBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2689 (Published 22 July 2009) Cite this as: BMJ 2009;339:b2689
All rapid responses
Current medical and social work management of the
possibility of a mother having seriously injured or killed
their child is often unsatisfactory from several
*Paediatricians are trained to work with parents.
Despite knowing that their primary responsibility is to the
child moving ones approach to that of a convincing forensic
professional one may be difficult. Also in this setting the
paediatrician may not be able to carry out an adequate
assessment of the mother’s mental state.
*The terminology of e.g. sudden death, murder and
Munchausen-by-proxy Syndrome, often fails to describe the
whole content of the episode.
*The strong underlying emotions of parents and
doctors need to be recognised and managed.
*The eventual assembly of the data as evidence in an
adversarial court setting involves being selective to suit
the trial whose business is to decide whether the mother or
father is ‘guilty’. However to align the complex and
conflicting parental emotions into ‘killing unlawfully with
malice aforethought’ is plainly unsatisfactory.
*Not all paediatricians who are attracted to this
area of work are temperamentally suited to it.
*On suspicion of unexplained or suspicious child
death or endangerment further investigation is put into the
hands of an expert team of forensic paediatricians and
psychiatrists funded outside the NHS with powers similar to
those of a coroner.
*Such referral by NHS staff would be when they felt
it would be needed or on specific indications.
*The aim is to arrive at the truth rather than a
*The investigations should be non-adversarial with
all interrogation through the Chairperson.
*Expert witnesses would advise the enquiry when
required including about the state of mind of those
*The enquiry should address how the risk to the child
*Only after the investigation would any case be
referred to the courts and most should not.
Another effect of having such forensic teams would be the
structured gathering of data as the basis for future audit,
research and teaching.
For most charges, sentencing and imprisonment are
inappropriate and achieve nothing. Through this approach
society recognises that not every parent can cope with every
child in their charge. They never did and they never shall.
The main energies of medical staff should be in prevention
and support of vulnerable parents. This involves the
structured development of insight into their emotional lives
by obstetricians, community nurses, general practitioners,
paediatricians and school nurses providing all can be
retained. There is much to be retrieved by prevention and
support not just of the severe end of this spectrum but also
for those who are more mildly disenchanted with parenthood.
Competing interests: No competing interests