Records, Information Sharing, Capacity, and Learning

Safeguarding records should be factual, timely, clear and respectful. They should state what was seen, heard, said, decided and done.

Good records include the patient's own words, observed injuries or behaviour, who was present, explanations given, advice sought, referrals made and the reasons for decisions. Avoid vague labels such as "dodgy family" or "difficult patient". Distinguish facts from professional concern: for example, "Child said..." and "I was concerned because..." are both useful when clearly recorded.

Teams often hesitate about information sharing. Data protection law does not prevent proportionate sharing for safeguarding. It does require judgement: share what is relevant, with the right people, for a safeguarding purpose, and record why you shared. For adults, mental capacity affects decision-making. If an adult lacks capacity for a specific safeguarding decision, or is subject to coercion, the team may need advice about best interests, advocacy and lawful information sharing.

• Write notes as soon as possible after the concern.
• Use exact words where they matter.
• Record who was informed and when.
• Document advice and referral outcomes.
• Reflect and learn after safeguarding events.

"GDPR" should not be used as a reason to ignore or delay a genuine safeguarding concern.

Mental Capacity and Adults At Risk