NEO-SOP-004: Child protection and safeguarding in the neonatal unit

Standard operating procedure (SOP) · NEO-SOP-004 · Version 0.1 · Draft for local review

Supports: 37.4

1. Purpose

To protect neonates and infants from harm, including abduction, mistaken identity, unsafe care, unsafe sleep and abuse or neglect, and to make sure that every concern is recognised and acted on promptly (37.4).

2. Scope

Item	Coverage
Applies to	All staff, students, contractors, volunteers and visitors in the neonatal unit and any area caring for neonates or infants
Patients	All neonates and infants in the unit, including those on the maternity ward, in transfer and in the postnatal period
Locations	Neonatal unit, special care baby unit, maternity and postnatal wards, parents' accommodation linked to the unit, transport vehicles used for transfers

3. Definitions

Term	Meaning in this SOP
Safeguarding concern	Any worry that a baby or child is being or may be harmed, neglected or put at risk, by anyone, including staff, family members or visitors
Designated safeguarding lead	The member of staff named in the facility's safeguarding policy to advise and take action on concerns
Identification check	Matching the baby's identity band to the mother's or parent's band and to the medical record, using two identifiers, at the named points of care
Safe sleep	Sleeping the baby on its back, on a firm flat surface, in its own cot, with no soft items, and with the head and face uncovered

4. Background

Babies cannot tell staff when they are harmed or in danger. Most risks can be prevented by good identification, controlled access, safe handling and a culture where every concern is raised. Abduction and mistaken identity are rare but serious; both are prevented by consistent checks, not by reliance on any single system.

Staff who see something concerning often hesitate because they are unsure whether it counts. This SOP makes clear that every concern is raised, and that the person raising it is protected.

5. Responsibilities

Role	Responsibility
Unit manager	Keeps access controls, identification and safeguarding training in place, and carries out audits
Designated safeguarding lead	Advises on concerns, decides on referrals to child protection services, and keeps the record
Registered nurses and midwives	Carry out identification checks, supervise visitors, and report any concern immediately
Doctors	Examine babies for signs of harm, record findings, and lead the response to a suspected injury
Security lead	Manages access systems, CCTV and the response to suspected abduction
Medical director or chief executive	Approves this SOP, and receives audit results and serious incident reports

6. Materials and equipment

• Identity bands for baby and parent, with the same unique number on each set, applied at birth and checked at every change of location.
• Access control: keypad or card entry, with a visitor log and a list of approved visitors.
• Secure exit alarms or tagging, where the risk assessment requires them.
• Safeguarding policy, reporting form and referral pathways, displayed on the unit.
• Safe sleep equipment: firm mattresses, cots without loose bedding, and sleep-position guidance.
• Staff identity badges, which must be worn and visible at all times.

7. Safety

• Never leave a baby unattended in a bed, cot, trolley or room that is not under staff observation.
• Never allow a baby to be taken from the unit by anyone who is not identified and approved, including family members who are not on the approved list.
• Only the approved staff may remove a baby from the unit, for transfer or for a procedure, and the move is recorded.
• Never leave a baby alone with a visitor who has not been checked and approved for that baby.

8. Before you start

1. Check the identity band on the baby and the parent or the approved carer before any care, feed or movement.
2. Check that visitors are on the approved list, or that a supervised visit has been arranged.
3. Check the baby's sleeping position and environment at each sleep period.

9. Procedure

9.1 Identification

1. Apply the identity band at birth, before the baby leaves the delivery room, with the parent's band of the same number.
2. Check the two identifiers at each key point: before any medicine, before any feed, before any procedure, before any movement between areas, and before discharge.
3. If a band is missing, damaged or unclear, stop and re-identify the baby with the senior nurse, and record it.
4. Record each identification check in the notes.

9.2 Access and visitors

1. All doors to the unit are kept closed and access is controlled by the security system.
2. Visitors sign in, state their name and relationship, and are shown the visitor rules.
3. Only approved visitors may enter the baby's area, and an approved visitor is never left alone with a baby they are not approved to see.
4. Report any person who is refusing to identify themselves, is acting strangely, or is trying to remove a baby, to the security lead immediately, and follow the response in Section 13.

9.3 Safe handling and sleep

1. Hold and move babies safely, and never shake, drop or handle a baby roughly. Report any injury, including bruising, that is not explained.
2. Place every baby to sleep on its back in its own cot, on a firm flat mattress, with no pillows, duvets or soft toys.
3. Record the sleeping position and environment at each check.
4. Where a parent is asleep with a baby, follow the unit's safe sleep and co-sleeping advice, and act on any concern.

9.4 Raising a concern

1. Any member of staff who has a concern about a baby, a parent, a visitor or a colleague raises it with the nurse in charge or the designated safeguarding lead the same shift, in writing on the safeguarding form.
2. The designated safeguarding lead decides, the same day, whether the concern needs referral to child protection services, and records the decision.
3. If the concern involves immediate danger, call emergency services and inform the nurse in charge first, then complete the form.
4. The person raising the concern is protected from any detriment for raising it in good faith.

10. Decision points

Situation	Action
A baby is missing, or may have been taken	Activate the unit's missing-baby procedure immediately. Lock the unit, inform security and the police, and check all areas. Record every step with times.
Identity bands do not match	Stop the activity. Check with two staff and the medical record, and do not proceed until the baby's identity is confirmed.
A visitor is not approved and wants to see a baby	Refuse entry, explain the policy, and inform the nurse in charge. If the visitor is aggressive, call security.
An injury is found that is not explained by the history	Inform the consultant immediately, document the injury with a body chart and photograph where the policy allows, and inform the designated safeguarding lead the same day.
A parent or carer appears unable to care safely (intoxication, mental health crisis)	Inform the senior nurse and social work. Do not discharge or allow unsupervised care until a safe plan is agreed.
A member of staff's behaviour raises a concern	Follow the unit's staff conduct and safeguarding procedure, and inform the unit manager the same day.

11. Special situations

• Babies from families with a court order or protection plan: check the plan on admission, record who may visit and who must be refused, and agree the plan with social work.
• Babies in transfer: the sending and receiving teams check identity at handover, and the transport team checks identity on departure and arrival.
• Babies whose parents are under 18 or have a learning disability: involve social work to make sure the parent can give consent and receive support.
• Babies in the postnatal period on a shared ward: apply the same identification and access rules.

12. Escalation

• Immediate danger to a baby: call emergency services and the consultant, and follow the missing-baby procedure where relevant.
• Safeguarding concern without immediate danger: the designated safeguarding lead, the same day.
• Concern about a staff member: the unit manager and human resources, the same day, following the local staff conduct procedure.

13. Missing baby response

1. Raise the alarm and inform the nurse in charge and security. Say the baby's name, the time, and the last known location.
2. Lock the unit doors and do not allow anyone to leave until the search is complete, unless emergency services ask otherwise.
3. Search the unit, the parents' accommodation and any areas linked to the unit.
4. Inform the consultant, the unit manager, the police and the designated safeguarding lead.
5. Record every action with the time and the name of the person responsible. Inform the family in person, as soon as it is safe, and keep them updated.
6. After the event, review the response with the team within 72 hours and report under INC-SOP-001.

14. Monitoring

The unit manager audits identification checks, visitor records, safe sleep observations and safeguarding forms each month. Results are reported to the neonatal governance meeting each quarter, and any missing-baby event or safeguarding concern is reviewed at the next meeting.

Measure	Target
Identification checks recorded at each key point (audit of 20 babies a month)	100 percent
Visitors checked against the approved list	100 percent
Safe sleep position recorded at each check	100 percent
Safeguarding concerns raised and recorded in the same shift	100 percent
Staff completing safeguarding training on time	100 percent

15. Records

• Identification check record in the notes.
• Visitor log and approved visitor list.
• Safeguarding concern form and the designated lead's decision record.
• Missing-baby response record, with times.
• Incident reports and referrals to child protection services.

16. Training

All staff complete safeguarding training at induction and every year, and a refresher on identification and missing-baby response every six months. Staff complete a practical drill of the missing-baby response at least once a year.

17. Related documents

Code	Document
NEO-SOP-002	Weight-based medicine dosing for neonates and infants
NEO-SOP-003	Family information and presence in the neonatal unit
NEO-POL-001	Neonatal level of care
NEO-FRM-001	Neonatal level of care assessment record
INC-SOP-001	Root cause analysis of serious incidents

18. Evidence

This SOP is based on the reference sources listed below, the requirement of criterion 37.4 of the ASF standards, and the facility's safeguarding policy, which must be checked at each review.

E-learning for this document

• No course linked yet. Request a child safeguarding and identification course from the academy (see the Standard 37 request list).

References

1. United Nations. Convention on the Rights of the Child, Articles 19 and 34. 1989.
2. HM Government. Working Together to Safeguard Children. Current edition (UK statutory guidance; replace with the national equivalent where applicable).
3. The Lullaby Trust. Safer sleep guidance for babies. Current edition.
4. World Health Organization. Patient identification and safety guidance. Current edition.
5. Facility safeguarding policy and national neonatal service requirements (to be inserted by the unit at adoption).

Change history

Version	Date	Change
0.1	2026-10-26	First draft for review. Not yet approved by the ASF Expert Committee.