Field Guides

Reference sets for event medical cover. All work offline — choose the one you need. The PGD suite is not included in this release.

Medicines Paramedic PGD Suite 2026 Unavailable Temporarily withdrawn. The PGD suite is unavailable in this release pending review — use JRCALC (or JRCALC Plus) and the current PGD on the Hub. Not in this release

Spark Medical & Mersey Medical Services Ltd ·Version 1.0 · September 2026

INDEX

Contents

Tap any card to open

Assessment & Reference

Lifesaving

Trauma

Medical

Environmental

Welfare & Medicines

Triage & Escalation

Records & Handover

Version 1.0 · September 2026 43 cards

STEP 1

Casualty Assessment

Primary Survey

Danger: Scene safety
Call for help
MOI: Trauma / Medical?

Non Time Critical

Time Critical

TIME

▼

Response:
Alert / Voice / Pain / Unresponsive

V P U

AVPU

▼

Severe Bleed

Control with: Direct Pressure · Indirect Pressure · Tourniquet

TIME
tourniquet applied

▼

Look / Clear / Secure

If P / U open airway:
Medical: Head Tilt / Chin Lift
Trauma: Jaw Thrust

Consider OP / NP / SGA / Suction

Record ▶

TICK

HT or JT

OP/NP/SGA

▼

Check breathing rate
10 seconds – and × 6

12, 18 or 24

0, 6, 30, 30+

Breathing · 6 / min or No Breathing

Begin CPR – Card 2

Find pulse, note rate
(Adult: neck or wrist · Child: arm)

Check central cap refill

Consider internal bleed
(chest, abdo, pelvis, long bones)
Apply pelvic splint if indicated

>42 <120

<42 >120

1s or 2s

>3s

Record ▶

CRT

TICK

Version 1.0 · September 2026

STEP 2

Casualty Assessment

Primary Survey

Trauma — if available administer oxygen at 15 l/min via mask
Medical — if Response = V, P or U, or Breathing Rate >30, or Pulse <42 or >120, if available administer oxygen at 15 l/min via mask

TICK

▼

Check Pupils

Visually check head

Consider FAST test
(Face / Arms / Speech / Time)

Pupils equal & reactive

Pupils not equal or reactive

FAST −ve

FAST +ve

SIZE

TICK

FAST

▼

Trauma • Expose and do head to toe • Keep warm • Record SAMPLE
Medical • Record SAMPLE • Examine as required

Sample recorded:TICK

▼

Evaluate Casualty

TIME CRITICAL

NON TIME CRITICAL

Treat and Evacuate
See treatment cards

Breathing Rate

10 seconds	0	1	2	3	4	5	6	7	8	9	10	11	12
1 minute	0	6	12	18	24	30	36	42	48	54	60	66	72

◀ CPR ▶ ◀——— 100% Oxygen Mask if oxygen indicated ———▶

Pulse Rate

10 seconds	5	6	7	8	9	10	11	12	13	14	15
1 minute	30	36	42	48	54	60	66	72	78	84	90

10 seconds	16	17	18	19	20	21	22	23	24	25	26
1 minute	96	102	108	114	120	126	132	138	144	150	156

Version 1.0 · September 2026

HISTORY

S.A.M.P.L.E.

Secondary Survey

Pain
Score

Signs and symptoms

Allergies

Medications

Past relevant medical history

Last oral intake

Events leading to incident

Return to assessment on completion of SAMPLE

Version 1.0 · September 2026

CARD 1

Unconscious Breathing Casualty

Lifesaving

Possible signs and symptoms:

Response P or U
Casualty is breathing

Trauma

Maintain airway using Jaw Thrust or Posture
Prepare suction

Attempt OP, NP or SGA
If available, give oxygen @15 l/min via mask

Treat traumatic injuries
Keep warm with blanket
Consider Glucose Gel applied onto gums by gloved finger

Monitor, evacuate and hand over to the ambulance service

Medical

Maintain airway using Head Tilt / Chin Lift
Prepare suction

Attempt OP, NP or SGA
If available, give oxygen @15 l/min via mask

Place in recovery position
Keep warm with blanket
Consider Glucose Gel applied onto gums by gloved finger

Monitor, evacuate and hand over to the ambulance service

Important

If you cannot maintain the airway in a trauma casualty choose life over limb and use head tilt / chin lift or the recovery position.
Place pregnant casualties on their left side. See Card 20

Version 1.0 · September 2026 1 / 39

CARD 2

Resuscitation

Lifesaving

Possible signs and symptoms:

Response U • Breathing Rate 0 or 6
Pale / blue colour

Child < 12 years

<2 Breaths in 10 secs or no breathing

Insert OP (or SGA if >10 years)
Prepare suction – paed catheter if < 8 years

5 breaths
Via pocket mask
If available: oxygen @15 l/min

15 compressions

2 breaths

Continue 15:2

If available and casualty >1 year old, connect AED and follow prompts

Adult > 12 years

<2 Breaths in 10 secs or no breathing

Insert OP, NP or SGA
Prepare suction

If drowned — 5 breaths
If available: oxygen @15 l/min via BVM / pocket mask / SGA

30 compressions

2 breaths
If available: oxygen @15 l/min via BVM / pocket mask / SGA

Continue 30:2

Connect AED and follow prompts

If possible, raise casualty's feet

Important

Always attempt CPR unless contraindicated. See Card 32
If Trauma: control bleeding, apply pelvic binder, straighten limbs.
Record CPR start & end time, shocks and ROSC. See Card 39

Version 1.0 · September 2026 2 / 39

CARD 3

External Bleeding

Lifesaving

Possible signs and symptoms:

Breathing >30 • Central Cap refill >3 secs • Pulse >120
No radial pulse • Pale • Cold and clammy
Reduced consciousness V-P-U

Keep injured casualties warm and handle gently

External Bleed

Sit or lie casualty down
Expose and examine wound

Apply direct finger pressure to site and elevate if possible

Apply trauma dressing

If in pain, See Card 28

If not giving Entonox, and casualty TIME CRITICAL, if available give oxygen @15 l/min via mask

If dressing bleeds through slowly apply second dressing on top

If bleeding not controlled, treat as Severe Bleed

Monitor, evacuate and hand over to the ambulance service

Severe Bleed

Apply immediate direct or indirect pressure

For limb bleeds use tourniquet

Dress wounds

If in pain, See Card 28

If not giving Entonox, and casualty TIME CRITICAL, if available give oxygen @15 l/min via mask

Do not release tourniquet

Note time of tourniquet application on cards / tourniquet / forehead

Request immediate ambulance back-up

Monitor, evacuate and hand over to the ambulance service

Important

If response = P or U See Card 1
Do not pull out embedded objects. Pad around objects or open fractures. Pack deep holes with gauze, then apply direct finger pressure.

Version 1.0 · September 2026 3 / 39

CARD 4

Internal Bleeding

Lifesaving

Possible signs and symptoms:

Breathing Rate >30 • Central Cap refill >3 secs • Pulse >120
No radial pulse • Reduced consciousness V-P-U
Pale, cold and clammy • Bruising, discolouration, swelling
Hardening in the abdomen

Keep injured casualties warm and handle gently

Examine 4 possible locations:
Chest / Abdomen / Pelvis / Limbs

If pelvis or limb fracture, apply relevant splints. If using pelvic splint, strap feet together before applying splint

Lie casualty head down. Raise feet if possible

If in pain, See Card 28

If not giving Entonox, and casualty TIME CRITICAL, if available give oxygen @15 l/min via mask

Keep warm and reassure

Monitor, evacuate and hand over to the ambulance service

Important

If response = P or U See Card 1
If casualty stops breathing See Card 2

Version 1.0 · September 2026 4 / 39

CARD 5

Choking

Lifesaving

Possible signs and symptoms:

Difficulty breathing • Wheezing or silent
Loss of consciousness V-P-U

Effective Cough?

YES ▶

Encourage casualty to cough

▼ NO

5 back blows – after each back blow check to see if obstruction has been relieved

5 abdominal thrusts (chest thrusts for infant) – after each thrust check to see if obstruction has been relieved

Repeat until resolved or unresponsive

If resolved – Full Reassessment

If casualty becomes unresponsive, See Card 2

Monitor, evacuate and hand over to the ambulance service

Important

If casualty stops breathing See Card 2

Version 1.0 · September 2026 5 / 39

CARD 6

Suspected Fractures / Crush / Dislocation

Trauma

Possible signs and symptoms:

Breathing Rate >30 • Central Cap refill >3 secs • Pulse >120
Pain • No radial pulse • Reduced consciousness V-P-U
Swelling, deformity, discolouration, possible wounds
Pale, cold and clammy

Keep injured casualties warm and handle gently

Control severe bleeding, if present

Remove watches / jewellery from affected limb

If in pain, See Card 28

If not giving Entonox, and casualty TIME CRITICAL, if available give oxygen @15 l/min via mask

Dress wounds, pack around bone ends but do not push back in

Apply relevant splints. If using pelvic splint, strap feet together before applying splint

Check cap refill beyond the injury. Compare to non-injured limb and record below. 2 or more seconds difference = TIME CRITICAL

Left s

Right s

Crushed limbs: Remove from crush as quickly as possible. Loosely apply tourniquet prior to release. Only tighten on release if severe bleed occurs or casualty loses consciousness.

Keep warm and reassure

Monitor, evacuate and hand over to the ambulance service

Important

If response = P or U See Card 1
If casualty stops breathing See Card 2

Version 1.0 · September 2026 6 / 39

CARD 7

Chest Injuries

Trauma

Possible signs and symptoms:

Breathing Rate >30 • Central Cap refill >3 secs • Pulse >120
Discolouration • Pale & sweaty • Deformity • Wounds • Pain

Never give Entonox
Keep injured casualties warm and handle gently

If TIME CRITICAL signs are present, if available give oxygen @15 l/min via mask

Expose whole chest

Pad around embedded objects. Do not pull out

If commercial chest seal available
Single wound: use chest seal
Multiple wounds: use chest seal and improvised dressings

If no commercial chest seal available
Single wound: leave open
Multiple wounds: dress wounds and leave one wound open per side

If conscious, position casualty in supported sitting

If unconscious, lie casualty on their back and maintain airway with Jaw Thrust

Monitor, evacuate and hand over to the ambulance service

Important

Wound size does not equal severity
If response = P or U See Card 1
If casualty stops breathing See Card 2

Version 1.0 · September 2026 7 / 39

CARD 8

Burns

Trauma

Possible signs and symptoms:

Breathing Rate >30 • Central Cap refill >3 secs • Pulse >120
Pale and sweaty • Reddening, blistering or charring
Soot around mouth / nose • Wheeze • Pain
Burnt facial hair • Eye irritation • Skin loss

Chemical Burn: Flush with copious amounts of cool / lukewarm running water for a min. of 20 mins. Do not dress burns with cling film

Facial Burn: suspect airway swelling, cool burns for 20 minutes

Smoke Inhalation: suspect all smoke inhalation casualties to have airway burns – request ambulance

Remove from cause
Remove watches / jewellery from affected area

Cool burns for 20 minutes
Do not allow casualty to become cold

If in pain, See Card 28

If not giving Entonox, and casualty TIME CRITICAL, if available give oxygen @15 l/min via mask

Dress thermal burns with cling film, use patchwork, do not wrap around limb or body. Wet dressing on facial burns. Maintain Airway

Avoid lying conscious casualty down if struggling to breathe

Monitor, evacuate and hand over to the ambulance service

Important

DO NOT burst blisters, or apply adhesive dressings.
DO NOT remove clothing stuck to a burn.
If response = P or U See Card 1 If casualty stops breathing See Card 2

Version 1.0 · September 2026 8 / 39

CARD 9

Spinal Injuries

Trauma

Possible signs and symptoms:

Breathing Rate 6 or >30 • Central Cap refill >3 secs
Incontinence • Loss of limb movement
Numbness • Pins and needles • Pain

Consider scene safety and need for immediate rescue

Reassure the casualty. Explain you will keep them safe. Use simple language.

Does the casualty understand instructions?

YES ▶

Ask casualty to try moving both legs

▼ NO

▼ NO YES ▼

Unable to move or
Casualty response = V / P / U

Place or minimal log roll casualty onto appropriate stretcher

Apply MILS if response = V/P/U

Watch for vomiting, maintain airway. Prepare suction

Able to move
Casualty response = A

Clear a route for casualty to move to place of safety with basic instructions

Make sure chair / stretcher is in place if required

Ask casualty to move to safe place. Provide support if required. Do not drag or lift casualty

If in pain, See Card 28, but be aware of masking pain

If not giving Entonox, and casualty TIME CRITICAL, if available give oxygen @15 l/min via mask

Monitor, evacuate and hand over to the ambulance service

Important

Consider head injury See Card 10
If response = P or U See Card 1 If casualty stops breathing See Card 2

Version 1.0 · September 2026 9 / 39

CARD 10

Head Injuries

Trauma

Possible signs and symptoms:

Breathing Rate 6 or >30 • Central cap refill >3 secs • Irritable
Reduced consciousness V-P-U • Confusion • Combative
Vomiting • Bleeding from ears or nose
Bruising around the eyes • Bruising behind the ears

Never give Entonox

Reassure, ask casualty to keep still
If standing, ask casualty to lie on appropriate stretcher

Apply MILS if response = V / P / U

Watch for vomiting, clear airway, prepare suction

If TIME CRITICAL if available give oxygen @15 l/min via mask

Dress head wound keeping head still

Consider if you have to move TIME CRITICAL / DANGER, or can you stabilise in location — Non Time Critical

If moving / extricating casualty allow conscious casualty to maintain own immobilisation See Card 9

Place or minimal log roll onto stretcher of choice

Secure the casualty to the stretcher, secure head
Position slightly head up

Monitor, evacuate and hand over to the ambulance service

Important

If V, P or U consider spinal injury See Card 9
Casualties have the potential to fit See Card 11
If response = P or U See Card 1 If casualty stops breathing See Card 2

Version 1.0 · September 2026 10 / 39

CARD 11

Fits, Seizures and Convulsions

Medical

Possible signs and symptoms:

Response U • Breathing Rate >30 • Rigid or violent shaking
In children (6 months – 6 years) may feel hot to touch

Consider reason for fitting

Reassure. Clear the area around the casualty and protect their head

When fit stops, full reassessment

If unconscious maintain airway
Trauma: Use Jaw Thrust
Medical: Use Head Tilt / Chin Lift
Prepare suction, attempt OP, NP, SGA

If TIME CRITICAL if available give oxygen @15 l/min via mask

Trauma: See Card 10

Monitor, evacuate and hand over to the ambulance service

Febrile Convulsion

Remove clothing and allow to cool

Reassure parents

Prompt parents to administer Paracetamol if appropriate See Card 28

Monitor, evacuate and hand over to the ambulance service

Version 1.0 · September 2026 11 / 39

CARD 12

Stings and Bites

Medical

Possible signs and symptoms:

Pain • Itching • Swelling • Rash • Redness
Puncture marks • Muscle cramps

Insect

Jellyfish

Portuguese Man-Of-War

Weever Fish

Snake

If stinger is embedded remove it by scraping

Scrape off any remaining tentacles, avoid rubbing

Immerse injured limb in warm water until pain eases

Keep casualty calm, minimise movement

Wash area with soap and water

If possible apply cold sea water

If possible apply warm sea water

Wash area with soap and water

Treat limb as fractured — immobilise with frac straps

Apply cold compress to ease pain and slow absorption

Avoid applying fresh water or cold packs — can increase pain

Avoid applying fresh water — can increase pain

Check and care for puncture wound

Do not use tourniquet or suck wound

Monitor for 30 minutes for allergic reaction See Card 15

Monitor, evacuate on stretcher, hand over to ambulance service

Version 1.0 · September 2026 12 / 39

CARD 13

Non-Traumatic Chest Pain

Medical

Possible signs and symptoms:

Pain; mild indigestion to vice-like chest pain • Nausea / vomiting
Pain radiating to jaw, neck and arms • Pale, cold and clammy

Sit casualty down in comfortable position, loosen clothing and reassure. Avoid lying down unless unconscious

If in pain, See Card 28. If not giving Entonox and TIME CRITICAL if available give oxygen @15 l/min via mask

Ascertain casualty has not taken Viagra or similar medication in last 24 hours, and has radial pulse, then

If available, encourage casualty to administer Glyceryl Trinitrate (GTN) spray or tablets in accordance with directions on pack. Record: Card 36

Check casualty is over 16, not allergic and has no severe liver disease, clotting disorder or GI bleed

If available, administer 300mg of Aspirin. Tablet to be swallowed, chewed or dispersed in water. Record: Card 36

If pain is still present, advise second dose of their GTN
Do not give until at least 5 minutes after the first dose
Do not give more than 2 doses in total Record: Card 36

If GTN has been taken, monitor blood pressure via radial pulse.

Monitor, evacuate and hand over to the ambulance service

Important

300mg Aspirin can still be given if the casualty has already taken a daily 75mg dose.
If casualty stops breathing See Card 2

Version 1.0 · September 2026 13 / 39

CARD 14

Breathing Difficulties

Medical

Possible signs and symptoms:

Breathing Rate >30 • Tripod position • Audible wheeze
Difficult or shallow breathing
Unable to complete a sentence

Pale, cold and clammy
Blue if severe

If Breathing Rate >36, or response is P or U, or casualty is unable to speak, inform ambulance service that condition is Immediately Life Threatening.

Reassure and remove from trigger if appropriate
Encourage casualty to slow / control breathing rate

Sit casualty in upright position or stand and lean forwards

If TIME CRITICAL if available give oxygen @15 l/min via mask

If patient is asthmatic and has their own inhaler, encourage them to use it. Record: Card 36

Monitor, evacuate and hand over to the ambulance service

Important

Take asthma seriously – it can kill
Avoid laying a conscious casualty down as this may aggravate breathing.
If casualty stops breathing See Card 2

Version 1.0 · September 2026 14 / 39

CARD 15

Severe Allergic Reaction

Medical

Possible signs and symptoms:

Breathing Rate >30 • Tripod position • Audible wheeze
Difficult or shallow breathing
Unable to complete a sentence

Red flushed and swollen with a rash
Central cap refill >3s

Reassure and remove from trigger if possible
Encourage casualty to slow / control breathing rate

Place casualty in a position of comfort, either sitting or lying down

If TIME CRITICAL, if available give oxygen @15 l/min via mask

If TIME CRITICAL administer Adrenaline Pen (called EpiPen, Emerade, Anapen or Jext Adrenalin) if they have their own. Record: Card 36

If no improvement and second adrenaline pen available, administer 5 minutes after the first pen. Record: Card 36

Monitor, evacuate and hand over to the ambulance service

Important

Continue treatment even if casualty shows improvement
Send used adrenaline pens to hospital with the casualty
If casualty stops breathing See Card 2

Version 1.0 · September 2026 15 / 39

CARD 16

Diabetes – Low Blood Sugar (Hypo)

Medical

Possible signs and symptoms:

Rapid loss of consciousness V-P-U • Aggressive
Breathing Rate >30
Pale, cold, clammy, sweaty • Mimics drunkenness or stroke
Casualty reports Blood Sugar <4 mmol/l / <72mg/dl

Never give Insulin – if given inappropriately it can kill

Casualty Unconscious P or U

Maintain airway using Head Tilt / Chin Lift
Prepare suction

Attempt OP, NP or SGA
If available, give oxygen @15 l/min via mask

Carefully administer small amounts of Glucose Gel onto the gums via a gloved finger until casualty is alert Record: Card 36

Place in recovery position, keep warm with blanket
Monitor, evacuate and hand over to the ambulance service

Casualty Conscious A or V

Sit the casualty down and reassure

Give sugary foods or drinks if possible, if not Glucose Gel Record: Card 36

If TIME CRITICAL, if available give oxygen @15 l/min via mask

Give sugary foods or drinks or up to 3 doses of Glucose Gel until casualty is alert Record: Card 36

Monitor, evacuate and hand over to the ambulance service

Important

For high blood sugar (hyper) treat as Unknown Illness See Card 21

Version 1.0 · September 2026 16 / 39

CARD 17

Dehydration

Medical

Possible signs and symptoms:

EARLY SIGNS: Thirst • Dark coloured urine • Dizziness • Headache • Tiredness • Dry lips, mouth and eyes
LATE SIGNS: Lethargy • Confusion • Not passing urine • Seizures • Pulse >90 • Central cap refill >2s • Reduced consciousness

Casualty Unconscious P or U

Maintain airway using Head Tilt / Chin Lift
Prepare suction

Attempt OP, NP or SGA
If available, give oxygen @15 l/min via mask

Consider administering small amounts of Glucose Gel onto the gums via a gloved finger Record: Card 36

Place in recovery position, keep warm with blanket

Monitor, evacuate and hand over to the ambulance service

Casualty Conscious A or V

Start oral rehydration
Small sips of water frequently
If available, commence oral rehydration solutions Record: Card 36

If nauseated, See Card 18

Record fluid volume intake Record: Card 36

Monitor, evacuate and hand over to the ambulance service

Important

At outdoor events consider heat illness alongside dehydration See Card 24
Alcohol and stimulant use markedly increase dehydration risk.

Version 1.0 · September 2026 17 / 39

CARD 18

Motion Sickness

Medical

Possible signs and symptoms:

EARLY SIGNS: Yawning • Pale and sweaty • Shivering • Retching • Vomiting
LATE SIGNS: Collapse • Incontinence • Lethargic, weak • Disorientated • Incapacitated

Casualty Unconscious P or U

Maintain airway using Head Tilt / Chin Lift
Prepare suction

Attempt OP, NP or SGA
If available, give oxygen @15 l/min via mask

Consider administering small amounts of Glucose Gel onto the gums via a gloved finger Record: Card 36

Place in recovery position, keep warm with blanket

Monitor, evacuate and hand over to the ambulance service

Casualty Conscious A or V

If available, administer anti-emetic tablet as per dosage guidelines on packet Record: Card 36

Tablet to be chewed or sucked and swallowed
Even if vomited, do not give second dose within 8 hours

Place the casualty in a well ventilated area
Keep warm

Encourage frequent sips of water. Encourage casualty to focus on the horizon or to sleep

If dehydrated See Card 17

Important

Applies to boat transfers, coach travel and fairground rides at events.
Rule out head injury, heat illness and intoxication before treating as motion sickness.

Version 1.0 · September 2026 18 / 39

CARD 19

Water & Dive Related

Medical

Possible signs and symptoms:

History of event • Breathing Rate >30
Difficult and shallow breathing • Skin rashes
Vision and speech problems • Pins and needles
Chest, sinus or joint pains • Confusion
Weakness, numbness or paralysis • Dizziness
Unable to complete a sentence • Frothy blood from mouth

Never give Entonox

Casualty Unconscious P or U

Maintain airway using Head Tilt / Chin Lift or Jaw Thrust if injured
Prepare suction

Attempt OP, NP or SGA
If available, give oxygen @15 l/min via mask

Place in recovery position, Keep warm

Contact Event Control with ATMIST info to pass on for dive advice

Monitor and rapidly evacuate, as level as possible. Prepare for CPR See Card 2

Casualty Conscious A or V

Ideally, lie the casualty down and minimise movement. Offer sips of water

If available give oxygen @15 l/min via mask

Contact Event Control with ATMIST info to pass on for dive advice

Protect from elements
Monitor and rapidly evacuate, as level as possible

Important

Continue treatment even if casualty shows improvement
Keep dive equipment for examination by authorities.
Evacuate dive computer and buddy with casualty.
For dive emergencies dial 999 and ask for the Coastguard, who will arrange specialist advice.

Version 1.0 · September 2026 19 / 39

CARD 20

Pregnant Casualties

Medical

1Conscious Breathing – Common Emergencies

Severe Vaginal Bleeding = TIME CRITICAL See Card 3 and 4
External pressure on external tears.
Rapidly evacuate and prepare for loss of consciousness Card 1

Seizures: TIME CRITICAL See Card 11
Unlikely to stop. Protect airway and rapidly evacuate casualty lying on their left side if any visible “bump”

Labour: waters breaking — consider TIME CRITICAL due to environment.
Use position of comfort on left side if comfortable. Keep warm.
Monitor, evacuate and hand over to the ambulance service

2Unconscious Breathing

TIME CRITICAL recovery position See Card 1
on casualty's left side if any visible “bump”

3Unconscious Not Breathing

TIME CRITICAL start CPR See Card 2
Manually displace fetus to casualty's left side if any visible “bump”

Two-handed displacement

One-handed displacement

Important

All other issues – treat in conjunction with this card.

Version 1.0 · September 2026 20 / 39

CARD 21

Unknown Illness

Medical

Consider F.A.S.T. for Stroke:

Face: Does the casualty's face droop on one side?
Arms: Can the casualty raise both arms and keep them there?
Speech: Is the casualty's speech slurred / altered?
Time: Record time of onset

If the casualty is FAST +ve with symptoms < 3 hours in duration, contact ambulance service for immediate back-up

1 Unconscious Not Breathing

TIME CRITICAL
Start CPR
See Card 2

2 Unconscious Breathing

TIME CRITICAL
See Card 1

3Conscious

If in pain, See Card 28
If not giving Entonox, TIME CRITICAL, if available give oxygen @15 l/min via mask

Consider blood glucose level and Glucose Gel administration Record: Card 36

Reassure and use position of comfort

Monitor, evacuate and hand over to the ambulance service

Version 1.0 · September 2026 21 / 39

CARD 22

Drowning / Immersion

Environmental

Possible signs and symptoms:

Agitation • Cough – may be frothy / bloody phlegm
Breathing Rate >30 • Unable to complete a sentence
Pale and cold • Reduced consciousness V-P-U

Casualty Unconscious P or U

Rapid evacuation from water

Complete full assessment

If breathing maintain airway See Card 1

If not breathing start CPR See Card 2

Casualty Conscious A or V

Rapid evacuation from water
Reassure

Complete full assessment

If TIME CRITICAL if available, give oxygen @15 l/min via mask

If appropriate, remove wet clothing, wrap in blankets and insulate from further heat loss

Monitor, evacuate and hand over to the ambulance service

Important

Always attempt CPR unless contraindicated See Card 32
Have suction ready, be ready to clear airway of water and vomit – vomiting is usual. Ignore foam / froth
Suspect casualty to also have hypothermia if immersion > 30 minutes.

Version 1.0 · September 2026 22 / 39

CARD 23

Cold and Hypothermia

Environmental

Possible signs and symptoms:

Cold: <30 mins immersion • Shivering • Conscious • Lucid
Hypothermia: >30 mins immersion • Loss of memory • Foetal position • Reduced consciousness • Shivering replaced by spasm

If immersed >30 mins, remove casualty carefully from the water / mud and lay down

Hypothermic TIME CRITICAL

If not breathing start CPR See Card 2

If unconscious maintain airway using Head Tilt, Chin Lift or place in recovery position. Prepare suction

Attempt OP, NP or SGA
If available, give oxygen @15 l/min via mask

Remove outer wet clothing, insulate from further heat loss and cover head

Monitor, evacuate and hand over to the ambulance service

Cold

Protect from elements and further cooling

If appropriate, remove wet clothing and wrap in blankets. Insulate from further heat loss and cover head

Give warm sweet drinks
Consider use of Glucose Gel Record: Card 36

Rational, shivering casualties can be rewarmed e.g. by sitting them in a warm shower

Monitor and evacuate

Important

Supervise rewarming at all times
Watch for post-rescue collapse, and if it occurs See Card 1 or 2
At camping events, consider overnight exposure in intoxicated or sleeping casualties.

Version 1.0 · September 2026 23 / 39

CARD 24

Heat Illness

Environmental

Possible signs and symptoms:

Mild / Moderate: Sweating • Thirst • Weakness • Headache • Nausea • Cramps
Severe: Hot, dry skin • Confused • Agitation / Aggression • Vomiting • Incontinence • Seizures • Reduced consciousness V-P-U

Severe TIME CRITICAL

If not breathing start CPR See Card 2

Stop activity and rest casualty in a cool area
Remove excess or tight clothing

If unconscious maintain airway using Head Tilt, Chin Lift or place in recovery position. Prepare suction

Attempt OP, NP or SGA
If available, give oxygen @15 l/min via mask

Rapidly cool casualty by any means possible until cool to touch

Monitor, evacuate rapidly and hand over to the ambulance service

Mild / Moderate

Stop activity and rest casualty in a cool area

Remove excess or tight clothing

Consider cool drink

Lie the casualty down and raise their legs

Cool and monitor
Should improve within 30 minutes

Monitor, evacuate and hand over to the ambulance service

Important

Common at summer events — consider stimulant use, alcohol and dense crowds as contributing factors.
Severe heat illness is a medical emergency. Cool first, transport second.

Version 1.0 · September 2026 24 / 39

CARD 25

Persons Threatening Self Harm

Welfare & Medicines

Request Police Assistance

Implement a Dynamic Risk Assessment using HoR and SASPI:
• Plan a safe approach and attempt to engage
• Always keep a reactionary gap >2m between rescuer and casualty
• Consider the positioning of other responders

• Give the casualty space
• Utilise SHUSH (next card)
• Don't creep
• Let the casualty vent
• Be patient, listen and gently persevere — even if they aren't engaging
• Maintain radio discipline

Casualty Compliant

Explain and implement the rescue plan with the casualty

Continue to build rapport
Consider casualty assessment

Casualty Non-Compliant
(unwilling to come to safe place)

Consider different approach or change rescuer

Don't advise
Don't make promises
Don't be sworn to secrecy
Don't give concessions

Don't be afraid to talk about suicide
Pass all info to Police; what's worked / hasn't worked, demands, third party approaches
Monitor and hand over to next level of care

Important

Always remember TRiM and post-incident support are available for any team members who feel support would be helpful following any incident
Please remember to check in on the welfare of your fellow team members

Version 1.0 · September 2026 25 / 39

CARD 26

SHUSH and DIST

Welfare & Medicines

Show you care

Focus on the person, turn radio down or off

Have patience

It may take time and several attempts before a person is ready to open up.
Listen to them and allow them to trust you

Use open Questions

Ask questions which need more than a yes or no. Follow up with “tell me more”. Open ended questions will help you to not jump in with your own ideas about how a person may be feeling.

Say it back

Check you've understood but don't interrupt or offer a solution. Repeating something back to somebody is a really good way to reassure them and show you understand.

Have courage

Don't be put off by a negative response and more importantly don't feel like you have to fill a silence.
Be prepared to ask difficult questions

Helpful Responses

“I am sorry to hear that you feel that way”
“From what I am hearing, it sounds like you really mean what you're saying”
“I really want you to keep talking to me”
“I will stay with you until.....”
“You were saying that you felt.....”
“Why today? Why here?”
“If you do this you eliminate all other options”
“I can't begin to understand what you are going through”
Emotional labelling – “You look / sound.....”

Version 1.0 · September 2026 26 / 39

CARD 27

Casualties Refusing Treatment

Welfare & Medicines

Immediate threat to life?

YES ▶

Perform initial rescue / treatment to preserve life, then continue this assessment

▼ NO

Can the casualty communicate?

NO ▶

Treat casualty in their best interests. Consider wishes of parent / guardian if applicable

▼ YES

Is there any doubt about the casualty's capacity to make a decision? e.g.

refuses treatment
makes no decision
decision adverse to interests

NO ▶

Seek consent to treat / rescue and do so to the extent of their permission. Casualties have the right to refuse or withdraw consent. Consider wishes of parent (child / adolescent).

Contact the Duty Medical Manager or on-call clinical lead for support if the situation is complex.

▼ YES

Is there impairment to mental function? If impairment suspected, consider the following factors:

Are they able to understand the relevant information?
Are they able to retain the information long enough to make the decision?
Are they able to weigh up the benefits / consequences of the decision?
Can they communicate the decision back to you?

Conditions which MAY impair mental function:

Dementia
Learning disabilities
Hypothermia
Hyperthermia
Head injury
Drugs & alcohol
Conditions associated with mental illness
Any other reason to suspect impaired mental function

Have all 4 criteria been met?

YES
NO

YES — casualty has capacity. Seek consent and treat only to the extent of their permission; they may refuse or withdraw consent at any time. Record the decision and escalate.
NO — treat in their best interests.

Version 1.0 · September 2026 27 / 39

CARD 28

Pain Management

Welfare & Medicines

Use positioning and immobilisation to reduce pain

No Pain 0

Mild 1–3

Moderate 4–6

Severe 7–10

No Hurt

Hurts Little Bit

Hurts Little More

Hurts Even More

Hurts Whole Lot

Hurts Worst

1Positional Pain Relief

Consider where appropriate; immobilisation, elevation, cooling, casualty position.

2Casualty's own Pain Relief Medication

If available and appropriate, allow casualty to administer their own pain relief within dosage limits, and in accordance with directions on the pack. Record: Card 36

3Pain Score 4 or above — use additional pain relief medication

Six “Rights” and double check Checks on Card 29

Step 1 – Paracetamol Liquid Checks on Card 30 & Record on Card 36

Step 2 – Inhaled Pain Relief (if available) Checks on Card 30 & Record on Card 36

Version 1.0 · September 2026 28 / 39

CARD 29

6 Rights

Welfare & Medicines

Six “Rights” and double check of medicines administration

Right Patient

Allergies or hypersensitivity to the medicine?
Casualty taking other medicines?

Right Reason

Medicine indicated by Check Cards?
Any Contraindications or Cautions?

Right Medicine

Always read the packet label
Correct medicine and strength?
Packaging intact and contents suitable for use?

Right Dose

Check dose according to Check Cards

Right to Refuse

Casualty consented to the medicine?

Right Documentation

Document drug, dose given, time given and by whom.
Document observations pre and post drug

Double Check

A second trained responder must double check the Six “Rights” prior to administration

When all Six “Rights” are met, progress to Card 30

Version 1.0 · September 2026 29 / 39

CARD 30

Medicines

Welfare & Medicines

Pain Score 4 or above — use additional pain relief medication

Six “Rights” and double check Checks on Card 29

Step 1 – Paracetamol Liquid Record on Card 36

Child 6–10 yrs	250mg = 1 sachet (5ml)
Child 10–12 yrs	500mg = 2 sachets (10ml)
Child 12–16 yrs	750mg = 3 sachets (15ml)
Adult 16+	1000mg = 4 sachets (20ml)

Step 2 – Inhaled Pain Relief (if available) Record on Card 36

Penthrox	Adult 18+ years and Trauma only
Entonox	All ages – Trauma and Medical

Do not use (where not mentioned on specific check card)

Paracetamol

Paracetamol containing medicine taken in last 6 hours
Severe liver failure

Entonox

Responsiveness = V, P or U
Severe head injuries with reduced conscious level
Violently disturbed psychiatric casualties
Scuba dived or caisson worked in last 24 hours
Intraocular injection of gas within the last 4 weeks
Abdominal pain where an obstruction is suspected
Chest injuries and any blunt injury to torso
Intoxicated casualties

Penthrox

<18 years old • non-trauma pain
Use in a confined space
V, P or U • no radial pulse • Pregnant
Sensitivity, Malignant Hyperthermia or Liver failure associated with an Anaesthetic
Penthrox inhaler used within last 24 hours (Max dose: 6mls / 2 inhalers in 24 hours)
Kidney or severe Liver failure

Version 1.0 · September 2026 30 / 39

CARD 31

Casualty Age Variations

Triage & Escalation

Age	Non-Time Critical	Time Critical
Breathing Rates / min	Adult (12+ yrs)	12 – 24	<12 or >24
Child (5–12 yrs)	15 – 30	<15 or >30
Child (1–4 yrs)	20 – 40	<20 or >40
Baby (0–1 yrs)	30 – 50	<30 or >50
Pulse Rates / min	Adult (12+ yrs)	42 – 120	<42 or >120
Child (5–12 yrs)	80 – 130	<80 or >130
Child (1–4 yrs)	90 – 140	<90 or >140
Baby (0–1 yrs)	110 – 150	<110 or >150
AED	All ages above 1 yr. If <8 yrs consider paediatric pads if available
BVM	12 yrs and over
OP Airway	Base on size; if <6 yrs do not rotate when inserting
NP Airway	12 yrs and over
SGA Airway	10 yrs and over – Size 3 (30–60 kg) 16 yrs and over – Size 4 (60–80 kg), Size 5 (>80 kg)
Suction	All ages. If <8 yrs consider paed catheter.

Age

Non-Time Critical

Time Critical

Breathing Rates / min

Adult (12+ yrs)

12 – 24

<12 or >24

Child (5–12 yrs)

15 – 30

<15 or >30

Child (1–4 yrs)

20 – 40

<20 or >40

Baby (0–1 yrs)

30 – 50

<30 or >50

Pulse Rates / min

Adult (12+ yrs)

42 – 120

<42 or >120

Child (5–12 yrs)

80 – 130

<80 or >130

Child (1–4 yrs)

90 – 140

<90 or >140

Baby (0–1 yrs)

110 – 150

<110 or >150

AED

All ages above 1 yr. If <8 yrs consider paediatric pads if available

BVM

12 yrs and over

OP Airway

Base on size; if <6 yrs do not rotate when inserting

NP Airway

12 yrs and over

SGA Airway

10 yrs and over – Size 3 (30–60 kg)
16 yrs and over – Size 4 (60–80 kg), Size 5 (>80 kg)

Suction

All ages. If <8 yrs consider paed catheter.

Version 1.0 · September 2026 31 / 39

CARD 32

Conditions Incompatible with Life

Triage & Escalation

Responders will not perform Basic Life Support when: (tick all relevant)

The scene is too dangerous
Unable to perform CPR and / or maintain it
There are injuries incompatible with life (see below)
A valid DNACPR form is present
If a doctor or other Health Care Professional stops the rescue

Decision not to commence BLS @ time:

Report to Event Control as soon as practical

Conditions Incompatible with Life: (tick all relevant)

Decapitation
Body cut in half
Massive skull & brain destruction
Decomposition or Putrefaction
Animals have picked at the body
Rigor Mortis
Whole body frozen (chest incompressible)
Submersion for >30 minutes in non-icy water
Submersion for >90 minutes in icy water (<6°C)
Incineration
Hypostasis (accumulation of blood in the lower parts of the body after death under the influence of gravity)

If you are in doubt at any time you
MUST commence BLS

Formal Verification of Death: This can only be assessed by two or more competent and trained people using your organisation's Verification of Death procedure, or by a Health Care Professional on scene.

Version 1.0 · September 2026 32 / 39

CARD 33

Ten Second Triage (TST)

Triage & Escalation

Walking

✔
YES

▼ ✘ NO

Severe Bleeding

✔
YES

Pressure · Tourniquet · Packing

▼ ✘ NO

Talking

✔
YES

Penetrating Injury?
front or back

P1 ✔ YES

P2 ✘ NO

▼ ✘ NO

BreathingOpen airway if able

✔
YES

Place in Recovery Position

✘
NO

Not BreathingCPR if resources allow

Version 1.0 · September 2026 33 / 39

CARD 34

Ten Second Triage (TST) Tally Chart

Triage & Escalation

Major Incident

Exact Location

Type of Incident

Hazards

Access

Number of Casualties

Emergency Services

Not Breathing

1234567891011121314151617181920

Version 1.0 · September 2026 34 / 39

CARD 35

Technique Reference

Records & Handover

QR CODE

Replace this panel with your organisation's technique-video QR code before printing.

Airway adjuncts – OP / NP / SGA

Bag-valve-mask & pocket mask

Tourniquet application

Wound packing & trauma dressings

Pelvic binder application

Chest seal application

Recovery position & log roll

Stretcher & scoop handling

AED pad placement

Paediatric CPR

Adrenaline pen administration

Entonox & Penthrox technique

Version 1.0 · September 2026 35 / 39

CARD 36

Medicines Record

Records & Handover

Six “Rights” and Double Check See Card 29 and 30

Drugs given		Dose	Time	Consent	Given by
Adrenaline	Intra-Muscular Injection			TICK
Aspirin	Tablet			TICK
Glucose	Gel tube			TICK
Glucose	Gel tube			TICK
GTN	Spray			TICK
Anti-emetic (state drug)	Tablet			TICK
Paracetamol	Sachet			TICK
Penthrox	Inhale			TICK
Entonox	Inhale			TICK
Oxygen (15 L/min)	BVM / SGA / FM			TICK
Patient's own medicines		Dose	Time	Route	Given by

Adverse events or reactions:

Version 1.0 · September 2026 36 / 39

CARD 37

Casualty Monitoring

Records & Handover

This card should be used after the treatment cards

TIME CRITICAL: re-assess every 2 minutes

NON TIME CRITICAL: re-assess every 5 minutes

Time

Airway Secure

Response

Breathing Rate

Central Cap Refill

Pulse Rate

PEARL

Pain Score

TC or NTC

✔

12, 18, 24

1 or 2 secs

>42 <120

✘

V P U

0, 6, 30+

3+ secs

<42 >120

Breathing Rate

10 seconds	0	1	2	3	4	5	6	7	8	9	10	11	12
1 minute	0	6	12	18	24	30	36	42	48	54	60	66	72

◀ CPR ▶ ◀——— 100% Oxygen Mask if oxygen indicated ———▶

Pulse Rate

10 seconds	5	6	7	8	9	10	11	12	13	14	15
1 minute	30	36	42	48	54	60	66	72	78	84	90

10 seconds	16	17	18	19	20	21	22	23	24	25	26
1 minute	96	102	108	114	120	126	132	138	144	150	156

Version 1.0 · September 2026 37 / 39

CARD 38

ATMIST

Records & Handover

Age and Name: Cover before photographing

Time of incident:

Mechanism of injury:

MEDICAL

TRAUMA

TIME CRITICAL

NON TIME CRITICAL

Injuries:

Signs and Symptoms:

	Initial TIME	Latest TIME
Response Level (AVPU)
Breathing (per minute)
Central Cap Refill (secs)
Pulse (per minute)
Pupils (reactive and size)
Pain Score

Treatment given:

Offer SAMPLE information Handover:TIMENAME OF SERVICE

Version 1.0 · September 2026 38 / 39

CARD 39

Notes and Key Timings Log

Records & Handover

Notes:

CPR Start Time:

CPR End Time:

Shocks Delivered: (Tally)

ROSC Time:
(Return of Spontaneous Circulation)

CASUALTY CARE CHECK CARDS © Spark Medical & Mersey Medical Services Ltd.
Clinical content adapted, with permission required, from the HM Coastguard Casualty Care Check Cards v2.0 (© HM Coastguard / Trident Training & Consultancy Ltd), originally conceived and produced by Paul Savage OBE.
No part of this publication may be reproduced or transmitted in any form without permission. Every effort is taken to ensure content is accurate; the publishers cannot take responsibility for any incorrect action taken, or not taken, due to errors or omissions.

Version 1.0 · September 2026 39 / 39

READ ME

Adaptation & Governance

Before You Print

Read before use. This card set is a visual redesign of the HM Coastguard Casualty Care Check Cards v2.0 (April 2025), © HM Coastguard / Trident Training & Consultancy Ltd. Written permission from the copyright holder is required before printing, distributing or using this set operationally.

Clinical governance. All content must be reviewed and signed off by the Spark Medical / Mersey Medical clinical lead against current JRCALC and Resuscitation Council UK guidance, and against each company's own PGDs and scope of practice, before issue.

What was adapted from the original

• “RCC” / “Ops Room” / “Duty SCOO” → Event Control / Duty Medical Manager
• “VHF” → radio; “CERCC trained CRO” → second trained responder
• “UKSAR Verification of Death form” → your organisation's VoD procedure
• Card 18 Seasickness → Motion Sickness (boat transfers, coach travel, rides)
• Card 19 Diving Related → Water & Dive Related, escalation via 999 / Coastguard
• Cards 17, 23, 24 gained event-specific notes (alcohol, stimulants, camping, crowds)
• Card 35 QR code replaced with a drop-in panel for your own technique library

Still to decide. Confirm whether your teams carry Entonox and Penthrox, and whether the Card 30 dosing table matches your PGDs. Amend or remove Cards 19 and 22 if you do not cover water-based events.

Do not print until

Copyright permission is in writing.
A named clinical lead has signed off every card.
Medicines tables match your current PGDs.

Version 1.0 · September 2026

IPC

Infection Prevention & Control — Field Guidance

Tap to open

Appendices — IPC equipment & procedure checklists

A–Z disease specific precautions

Version 1.0 · Adapted September 2026 51 diseases · 8 appendices

INTRO

Introduction & UK Legislation

Reference

Purpose of this manual

This manual provides Spark Medical and Mersey Medical personnel with a comprehensive, easy-to-reference guide to infection prevention and control (IPC) precautions for specific diseases and conditions encountered in the pre-hospital setting. It is designed to be carried on vehicles and used as a quick reference tool during patient care.

The A-Z disease entries provide standardised guidance on transmission routes, patient placement, personal protective equipment (PPE) requirements, vehicle cleaning protocols, clinical signs and identifying features, and additional precautions for each condition.

This manual should be used in conjunction with your employing organisation's IPC policies and standard operating procedures. Always follow local trust or service protocols where these differ from this general guidance.

How to use this guide

1Identify the condition — Look up the disease or condition in the A-Z index, or browse alphabetically.

2Check the Hazard Group — Each disease is colour-coded by Hazard Group (1-4) to indicate infection severity.

3Follow the guidance table — Each entry provides five categories: Transmission Route, Patient Placement, PPE Required, Vehicle Cleaning, and Additional Information.

4Clinical Signs — Each disease includes a Clinical Signs & Identifying Features box with presenting signs, key features, and clinical illustrations of rashes and skin changes where available.

5PPE Levels — Refer to the PPE Levels Quick Reference showing exactly what equipment is required at each level.

6HCID diseases — Diseases marked with the purple HCID badge require immediate escalation and HART team involvement. Follow your organisation's HCID protocol.

UK legislation & guidance references

Version 1.0 · Adapted September 2026 INTRO · p1/2

INTRO

Introduction & UK Legislation

Reference

Legislation / Guidance	Reference
Health and Safety at Work etc. Act 1974	Primary legislation for workplace health and safety in the UK
Control of Substances Hazardous to Health Regulations 2002 (COSHH)	SI 2002/2677 — Requires employers to control exposure to hazardous substances including biological agents
The Approved List of Biological Agents	HSE MISC208 — Classifies biological agents into Hazard Groups 1-4 under COSHH 2002
European Directive 2000/54/EC	Protection of workers from risks related to exposure to biological agents at work (retained EU law)
Health and Social Care Act 2008	Code of Practice on the Prevention and Control of Infections (The Hygiene Code)
National Infection Prevention and Control Manual	NHS England — Standard infection control precautions and transmission-based precautions
UKHSA Guidance	UK Health Security Agency — Disease-specific guidance and HCID protocols
Personal Protective Equipment at Work Regulations 1992	As amended 2022 — Requirements for provision and use of PPE
Management of Health and Safety at Work Regulations 1999	Risk assessment requirements for biological hazards
Hazardous Waste (England and Wales) Regulations 2005	Classification and disposal of clinical and infectious waste
HTM 01-01: Management and Decontamination of Surgical Instruments	Department of Health — Decontamination standards

Version 1.0 · Adapted September 2026 INTRO · p2/2

HAZARD

Hazard Group Classifications

Reference

HSE Approved List — biological agents classification

Under the Control of Substances Hazardous to Health Regulations 2002 (COSHH), the Health and Safety Executive (HSE) publishes the Approved List of Biological Agents (MISC208). This list classifies biological agents into four Hazard Groups based on their ability to cause human disease, the hazard they present to employees, whether the infection can spread to the community, and whether effective prophylaxis or treatment is available.

LOW

Unlikely to cause human disease.

MODERATE

Can cause human disease and may be a hazard to employees. It is unlikely to spread to the community and there is usually effective prophylaxis or treatment available.

HIGH

Can cause severe human disease and may be a serious hazard to employees. It may spread to the community, but there is usually effective prophylaxis or treatment available.

VERY HIGH

Causes severe human disease and is a serious hazard to employees. It is likely to spread to the community and there is usually NO effective prophylaxis or treatment available.

High Consequence Infectious Diseases (HCID)

High Consequence Infectious Diseases (HCIDs) are defined by the UK Health Security Agency (UKHSA) as acute infectious diseases which typically have a high case-fatality rate, may not have effective prophylaxis or treatment, are often difficult to recognise and detect rapidly, have the ability to spread in the community and within healthcare settings, and require an enhanced individual, population and system response.

Examples of HCIDs in this manual: MERS Coronavirus, Monkeypox (imported cases), Plague (Yersinia Pestis), Viral Haemorrhagic Fevers (Ebola, Marburg, Lassa Fever).

Action: Any suspected HCID case must be ESCALATED IMMEDIATELY through your organisation's HCID protocol. HART team involvement is required for confirmed or complex cases.

Aerosol Generating Procedures (AGPs)

Aerosol Generating Procedures (AGPs) are medical procedures that can generate small particle aerosols, increasing the risk of airborne transmission. When performing AGPs on patients with suspected or confirmed respiratory infections, staff must use Level 3 PPE (Airborne Precautions) as a minimum.

Common AGPs in pre-hospital care include: intubation/extubation, manual ventilation, open suctioning, nebuliser administration, CPAP/BiPAP, high-flow nasal oxygen, chest compressions (if airway not secured), and bronchoscopy.

Waste management

Version 1.0 · Adapted September 2026 HAZARD · p1/2

HAZARD

Hazard Group Classifications

Reference

Category	Bag Colour	Description
Category B	ORANGE BAG	Standard infectious waste stream. Used for most infectious waste generated during patient care.
Category A	DOUBLE YELLOW BAG	High-risk infectious waste. Used for HCID cases (e.g. VHF, imported Monkeypox). Requires specialist disposal.

Version 1.0 · Adapted September 2026 HAZARD · p2/2

PPE

PPE Levels Quick Reference

Reference

PPE Level	Also Known As	Components	When to Use
Level 1	Contact Precautions	Disposable nitrile gloves + yellow disposable apron	Routine patient care, handling body fluids, contaminated items
Level 2	Droplet Precautions	Gloves + apron + fluid-resistant surgical mask (FRSM) + eye protection (goggles or visor)	Within 2m of patients with suspected/confirmed respiratory infections transmitted by large droplets
Level 3	Airborne Precautions	Gloves + long-sleeved disposable gown + FFP3 respirator (fit-tested) + full-face visor	AGPs, or caring for patients with suspected/confirmed airborne diseases (e.g. measles, TB, COVID during AGP)
Level 4	HCID Ensemble	Full Tyvek-style coverall suit with integrated hood + double gloves + powered air-purifying respirator (PAPR) + sealed boot covers	High Consequence Infectious Diseases (HCID) with high mortality and transmissibility (e.g. Ebola, Lassa Fever, VHF)

Key PPE reminders

Hand hygiene — Perform hand hygiene BEFORE donning and AFTER doffing ALL PPE. Use soap and water for C. difficile and D&V cases.

FFP3 fit testing — All staff who may be required to wear FFP3 respirators MUST be fit-tested annually. Record results.

Donning and doffing — Follow your organisation's donning/doffing procedure. Use a buddy system where possible.

FRSM for patients — Where indicated, encourage patients to wear a fluid-resistant surgical mask to reduce droplet spread.

Waste disposal — All used PPE must be disposed of as clinical waste in the appropriate waste stream.

Version 1.0 · Adapted September 2026 PPE

CLEANING

Vehicle Cleaning Quick Reference

Reference

Standard between-patient clean

A standard between-patient clean must be performed after EVERY patient conveyance, regardless of the patient's infection status. This is a fundamental IPC requirement.

Step	Action	Detail
1	Don PPE	Disposable gloves and apron as minimum
2	Remove visible contamination	Remove any visible blood, body fluids or debris
3	Clean all surfaces	Wipe ALL patient-contact surfaces and equipment using approved broad-spectrum surface disinfectant and disposable paper
4	Clean floor	Mop floor with approved hygienic floor cleaner (if indicated)
5	Replace consumables	Replace linen, pillow covers, blankets and any used consumables
6	Dispose of waste	Dispose of all waste in appropriate clinical waste stream
7	Doff PPE and hand hygiene	Remove PPE, dispose as clinical waste, perform hand hygiene

Blood / body fluid spill procedure

Step	Action	Detail
1	Don PPE	Gloves and apron as minimum; eye protection if risk of splashing
2	Apply absorbent granules	Cover the spill with approved absorbent granules and allow to solidify
3	Scoop and dispose	Scoop solidified material into clinical waste bag
4	Clean surface	Clean the affected surface using approved broad-spectrum surface disinfectant
5	Doff PPE and hand hygiene	Remove PPE, dispose as clinical waste, perform hand hygiene

VOR (Vehicle Off Road) — deep clean triggers

A VOR deep clean removes the vehicle from service for thorough decontamination. The following situations require a VOR:

Trigger	Examples
Symptomatic D&V during conveyance	Campylobacter, C. difficile, Typhoid (if symptomatic)
Body fluid contamination of vehicle	Hepatitis B/C, HIV, Meningitis (bacterial/viral)
AGP performed on infectious patient	RSV, SARS-CoV-2, TB (after AGP)
Infestation	Fleas (isolate vehicle, remove all linen)
HCID patient conveyance	MERS, Monkeypox (HCID), Plague, VHF
Streptococcus Group A with body fluid contamination	GAS with wound exudate contamination

Cleaning products guidance

Always use your organisation's approved cleaning products. The following generic categories are referenced throughout this manual:

Version 1.0 · Adapted September 2026 CLEANING · p1/2

CLEANING

Vehicle Cleaning Quick Reference

Reference

Product Type	Use
Approved broad-spectrum surface disinfectant	Surface wipe for all patient-contact surfaces and equipment
Approved hygienic floor cleaner	Floor mopping post-transfer
Approved absorbent granules	Blood and body fluid spill management

Always check product compatibility with surfaces and equipment. Follow manufacturer's instructions for contact times and dilution rates. Ensure adequate ventilation when using cleaning products.

Version 1.0 · Adapted September 2026 CLEANING · p2/2

A–Z

Acinetobacter

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: VariableLevel 1 PPE ›

Can cause infections in the blood, urinary tract and lungs (pneumonia), or in wounds. It can also colonise a patient without causing infections or symptoms.

Transmission Route

Direct or indirect contact with a colonised or infected person. Environmental contamination of surfaces and equipment.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Mop floor with approved hygienic floor cleaner post transfer. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Acinetobacter is difficult to remove from surfaces; thorough decontamination post conveyance is IMPERATIVE.

Clinical signs & identifying features

Presenting signs

FeverSepsis/Septic shockDifficulty breathingProductive coughWound infection with purulent discharge

Key identifying features: The key identifying feature is the patient's recent history of hospitalization, particularly in an ICU setting, or residence in a long-term care facility. The presence of invasive devices (e.g., ventilators, catheters), recent surgery, or significant underlying comorbidities like diabetes or chronic lung disease are strong indicators.

Visible skin changes: Can present as cellulitis with an edematous 'peau d'orange' (orange peel) appearance, vesicles, and non-hemorrhagic bullae. In severe cases, it may manifest as necrotizing fasciitis with extensive purpura, ecchymosis, skin sloughing, and crepitus. Wound infections will show increasing erythema, swelling, and purulent discharge.

Version 1.0 · Adapted September 2026 1 / 51

A–Z

Adenovirus

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 5 – 12 DaysLevel 2 PPE ›

Common viruses that typically cause mild cold or flu-like illness. Can cause illness in people of all ages at any time of the year.

Transmission Route

Droplet transmission. Contact with secretions/lesions and contaminated equipment. Ingestion via faecal/oral route.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE). Encourage patient to wear FRSM.

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Mop floor post transfer. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Often resistant to common disinfectants; can remain infectious for long periods on surfaces. Thorough decontamination post conveyance is IMPERATIVE.

Clinical signs & identifying features

Presenting signs

FeverSore throatCoughConjunctivitisRunny nose

Key identifying features: The key distinguishing feature of adenovirus infection is the combination of upper respiratory tract symptoms (cough, sore throat, runny nose) with conjunctivitis (red, watery eyes). The presence of pharyngoconjunctival fever (fever, sore throat, and conjunctivitis) is highly suggestive of adenovirus. A maculopapular rash may also be present, but is less common.

Visible skin changes: The rash is typically a fine, maculopapular exanthem that can be morbilliform (measles-like). It often appears as erythematous (red) macules and papules, which may be blotchy. In some cases, particularly in immunocompromised patients, it can present as vesicle-like or keratotic papules, starting on the hands and feet before spreading.

Version 1.0 · Adapted September 2026 2 / 51

A–Z

Anthrax

HG 3 · HIGH

HG 3 · HIGHBacteria (spores)Incubation: 2 – 7 DaysLevel 1 PPE ›

A serious infectious disease occurring naturally in soil. Can cause severe illness in both humans and animals.

Transmission Route

Inhalation of spores, ingestion or direct contact with infected items. Person to person airborne transmission does NOT occur. Deliberate release: WITHDRAW and ESCALATE IMMEDIATELY.

Patient Placement

No isolation procedures required.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Any suspected deliberate release should be ESCALATED IMMEDIATELY.

Clinical signs & identifying features

Presenting signs

Painless skin lesion with black centerFeverDyspnoeaCoughProfound fatigue

Key identifying features: The key identifying feature of cutaneous anthrax is a painless skin lesion that progresses from a papule to a vesicle and then to a characteristic black necrotic eschar, often with surrounding non-pitting oedema. For inhalational anthrax, a key feature is a biphasic illness, with initial non-specific flu-like symptoms followed by a rapid deterioration into severe respiratory distress, often with a...truncated in source

Visible skin changes: The lesion begins as a small, itchy, and painless papule, which progresses over 1-2 days into a vesicle or ring of vesicles. This then ulcerates to form a painless, black, depressed eschar, often surrounded by significant swelling (oedema). The lesions are most commonly found on exposed areas such as the face, neck, arms, and hands.

Clinical illustration — Anthrax

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Antimicrobial Resistance (AMR)

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 1 – 11 DaysLevel 1 PPE ›

Antibiotic resistant strains including CRO/CPE/CRE, GRE, and VRE. Antibiotics are no longer routinely used to treat many infections as overuse leads to resistance.

Transmission Route

Ingestion via faecal/oral route. Indirect contact with contaminated items/surfaces.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE). STEP UP to Level 2 PPE if patient is ACTIVELY VOMITING or INCONTINENT OF FAECES.

Vehicle Cleaning

Additional Info

Thorough decontamination post conveyance is IMPERATIVE.

Clinical signs & identifying features

Presenting signs

Fever and chillsSigns of sepsis (tachycardia, hypotension, altered mental status)Symptoms specific to the infection site (e.g., painful urination for a UTI, redness and pus from a wound)General malaise and weakness

Key identifying features: The key identifying feature in a pre-hospital setting is the patient's history. Risk factors include recent or prolonged hospitalization, residence in a long-term care facility, recent antibiotic therapy, and the presence of indwelling medical devices (e.g., urinary catheters, central lines). The clinical presentation is indistinguishable from infections caused by non-resistant bacteria; the resis...truncated in source

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Campylobacter

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 1 – 11 DaysLevel 1 PPE ›

Bacterial infection from eating raw or undercooked meat (especially poultry), unpasteurised milk or untreated water.

Transmission Route

Ingestion transmission. If hygiene is poor, person to person spread is possible.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

NON-SYMPTOMATIC: between patient clean. SYMPTOMATIC during conveyance: VOR for deep clean.

Clinical signs & identifying features

Presenting signs

Diarrhea (often bloody)Abdominal pain and crampingFeverNausea and vomiting

Key identifying features: The key distinguishing feature is the acute onset of diarrheal illness, which is frequently bloody, accompanied by severe, cramping abdominal pain. The absence of a rash and the potential for symptoms to mimic acute appendicitis are also important diagnostic clues in a pre-hospital setting.

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Chickenpox (Varicella Zoster)

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 10 – 21 DaysLevel 3 PPE ›

An acute, infectious disease caused by VZV, commonly seen in children under 10. Can be more serious in adults, particularly pregnant women.

Transmission Route

Direct contact with infected lesions. Indirect contact with contaminated items. Droplet spread through respiratory tract.

Patient Placement

Single patient transport.

PPE Required

Airborne Precautions (Level 3 PPE) for general care and AGPs.

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Staff who do NOT know their immune status to VZV should NOT provide care to patients with chickenpox.

Clinical signs & identifying features

Presenting signs

FeverItchy vesicular rashMalaiseAnorexia

Key identifying features: The key identifying feature is the evolution of the rash in stages, with macules, papules, vesicles, and crusted lesions often present simultaneously. The rash typically has a centripetal distribution, starting on the trunk, face, and scalp before spreading to the limbs.

Visible skin changes: The rash begins as small, red macules that progress to papules, then to intensely itchy, fluid-filled vesicles on a red base ('dewdrop on a rose petal'). These vesicles then crust over. The rash appears in successive crops over several days, leading to lesions in all stages of development being present at once. It is most concentrated on the trunk and face.

Clinical illustration — Chickenpox (Varicella Zoster)

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Clostridium difficile

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 1 – 10 WeeksLevel 1 PPE ›

Bacterial infection, sometimes present in the bowel of healthy people, but may flourish following antibiotic treatment. Spore forming.

Transmission Route

Ingestion via faecal/oral route. Indirect contact from contaminated surfaces then ingested.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

NON-SYMPTOMATIC: between patient clean. SYMPTOMATIC during conveyance: VOR for deep clean.

Additional Info

Hand decontamination using SOAP AND WATER is required. Alcohol-based hand rubs are NOT effective at killing spores.

Clinical signs & identifying features

Presenting signs

Watery diarrheaAbdominal crampingFeverNauseaDehydration

Key identifying features: The key distinguishing feature of C. difficile infection is the recent history of antibiotic use, which disrupts the normal gut flora and allows C. diff to proliferate. The diarrhea is typically watery and has a characteristic foul odor. While most cases are non-bloody, the presence of blood may indicate a more severe infection.

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Creutzfeldt-Jakob Disease (CJD)

HG 3 · HIGH

HG 3 · HIGHPrionIncubation: Years to DecadesLevel 1 PPE ›

A rare, degenerative, fatal brain disorder caused by prion proteins.

Transmission Route

Direct contact with contaminated medical equipment into CNS. Ingestion of beef products from BSE infected cattle.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

Rapidly progressive dementiaMyoclonus (sudden, jerky movements)Ataxia (unsteady gait and poor coordination)Visual disturbancesBehavioral changes

Key identifying features: The key identifying feature of CJD is the extremely rapid progression of dementia and neurological symptoms, often over a period of weeks to months. This is in contrast to more common forms of dementia, which progress over years. The combination of rapidly progressing dementia with myoclonus and ataxia is highly suggestive of CJD.

Visible skin changes: Although not a common feature, CJD can be associated with skin manifestations such as a purplish, erythematous, and edematous lesion, a purpuric papular rash, or necrotizing cutaneous lesions associated with vasculitis.

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Cryptosporidium

HG 2 · MODERATE

HG 2 · MODERATEParasiteIncubation: 1 – 28 DaysLevel 1 PPE ›

Parasitic infection that can cause diarrhoea.

Transmission Route

Ingestion via faecal/oral route. Contact with infected animals.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean. If ACTIVE diarrhoea during conveyance: mop floor post transfer. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

Watery diarrheaAbdominal crampsNauseaVomitingDehydration

Key identifying features: The key feature is profuse, watery diarrhea that can last for weeks. This, combined with abdominal cramps and potential dehydration, in the absence of other common causes of gastroenteritis, should raise suspicion. It's particularly important to consider in patients with weakened immune systems, where the illness can be much more severe and prolonged.

Visible skin changes: While not a common symptom, there are isolated reports of urticaria (hives) associated with Cryptosporidium infection. This would present as raised, itchy welts on the skin. However, it is not a reliable diagnostic sign.

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Cytomegalovirus

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 3 – 12 WeeksLevel 1 PPE ›

A common virus that can infect people of all ages. Usually causes no symptoms but can be serious in immunocompromised patients.

Transmission Route

Direct contact with blood and bodily fluids.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

FeverFatigueSwollen lymph nodesSore throatMuscle aches

Key identifying features: CMV typically presents as a mild, self-limiting mononucleosis-like illness in healthy individuals, characterized by fever, fatigue, and lymphadenopathy. A key distinguishing feature is that the infection is often subclinical; however, in immunocompromised individuals, it can cause severe, organ-specific disease. The presence of a rash, which can be variable in appearance, may also be an indicator.

Visible skin changes: The rash associated with CMV is variable and can present as a morbilliform (measles-like) eruption, a petechial rash (small, non-blanching red or purple spots), or less commonly as ulcers, plaques, nodules, or vesiculobullous eruptions.

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Diarrhoea and/or Vomiting

HG 2 · MODERATE

HG 2 · MODERATEBacteria / VirusesIncubation: VariableLevel 1 PPE ›

Common causative organisms include campylobacter, S. aureus, E. coli O157, Salmonella spp, Shigella and Norovirus. Often referred to as gastroenteritis.

Transmission Route

Ingestion via faecal/oral route.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment. Mop floor post transfer. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Hand decontamination using SOAP AND WATER. Active diarrhoea and vomiting should be managed the same way regardless of cause.

Clinical signs & identifying features

Presenting signs

DiarrhoeaVomitingAbdominal crampsFeverDehydration

Key identifying features: The key features are the acute onset of watery diarrhoea and vomiting. Dehydration is a major concern, especially in the very young and elderly. The absence of blood in the stool and the self-limiting nature of the illness (typically 1-3 days) are also important distinguishing features.

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Diphtheria

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: Up to 10 DaysLevel 2 PPE ›

A serious bacterial infection that affects the mucous membranes of the throat and nose.

Transmission Route

Respiratory droplets and direct contact with respiratory secretions. Direct contact with discharge from cutaneous lesion.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE). Level 2 PPE if staff NOT vaccinated.

Vehicle Cleaning

Between patient clean. Remove any linen stored within the patient area. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

If staff uniform is SOILED despite PPE, it will require changing.

Clinical signs & identifying features

Presenting signs

Sore throatLow-grade feverSwollen glands in the neck (cervical lymphadenopathy)WeaknessA thick, gray coating in the back of the throat (pseudomembrane)

Key identifying features: The most prominent identifying feature of respiratory diphtheria is the 'pseudomembrane' – a thick, gray, adherent membrane on the tonsils and pharynx. Attempts to remove it cause bleeding. Another key sign is the 'bull's neck,' which is significant neck swelling due to cervical adenopathy and edema. For cutaneous diphtheria, the key feature is a chronic, non-healing ulcer with a gray, leathery me...truncated in source

Visible skin changes: Cutaneous diphtheria presents as one or more non-healing ulcers or shallow sores. The lesions are typically well-demarcated, may be painful, and are covered by a characteristic tough, gray to black, leathery pseudomembrane. The surrounding skin may be red and swollen.

Clinical illustration — Diphtheria

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Epstein-Barr Virus (Glandular Fever)

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 4 – 6 WeeksLevel 1 PPE ›

Viral infection causing weakness, headache, sore throat and enlargement of the lymph nodes and spleen.

Transmission Route

Direct contact with oral secretions.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

FeverSevere sore throatSwollen lymph nodes in the neckProfound fatigueHeadache

Key identifying features: The key distinguishing features are the combination of a severe sore throat with exudate, swollen posterior cervical lymph nodes, and profound fatigue. The presence of palatal petechiae (small red spots on the roof of the mouth) is also a strong indicator. A characteristic rash may develop, especially if the patient has been given amoxicillin.

Visible skin changes: A faint, generalized maculopapular rash may be present. More commonly, a bright, itchy maculopapular or morbilliform rash appears 7-10 days after starting antibiotics, particularly ampicillin or amoxicillin. This drug-induced rash is often widespread, affecting the trunk, limbs, and even palms and soles.

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ESBL (Extended Spectrum Beta-Lactamase)

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: VariableLevel 1 PPE ›

Antibiotic resistant strain of bacteria, usually Klebsiella or E. coli.

Transmission Route

Ingestion via faecal/oral route. Indirect contact from contaminated items.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

FeverAltered mental status (confusion/disorientation)Tachycardia and/or hypotension (signs of sepsis)Nausea and vomitingLocalized signs of infection (e.g., dysuria, wound drainage, productive cough)

Key identifying features: The primary distinguishing feature of an ESBL infection is the organism's resistance to many common antibiotics, which is determined by laboratory testing. In the pre-hospital setting, a key indicator is a patient with a known history of ESBL-colonization or infection, or a patient with significant risk factors such as recent or prolonged hospitalization, nursing home residency, or recent travel t...truncated in source

Visible skin changes: If a skin or soft tissue infection is present, the area may be red, swollen, warm to the touch, and painful. There may be pus or fluid drainage from a wound site. Some internal infections may cause a non-specific rash of red, raised bumps.

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Fleas

HG 2 · MODERATE

HG 2 · MODERATEParasiteIncubation: VariableLevel 1 PPE ›

Parasitic infestation that can be transmitted through direct or indirect contact.

Transmission Route

Direct skin to skin contact (requires prolonged periods). Indirect contact with contaminated environment.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE). Sleeve protectors if heavy infestation.

Vehicle Cleaning

VOR for deep clean. Isolate vehicle to contain infestation. Remove ALL linen and waste.

Additional Info

Post conveyance: DOFF PPE, return to base and change uniform. Uniform to be bagged and laundered at 60°C.

Clinical signs & identifying features

Presenting signs

Intensely pruritic (itchy) red papulesBites arranged in clusters or linear patternsLesions predominantly on lower legs, ankles, and feetVisible excoriation marks from scratching

Key identifying features: The key distinguishing features are the distribution of bites primarily on the lower limbs and the characteristic clustered or linear arrangement of the lesions. A history of pets in the household is a significant indicator. The lesions are typically small, papular, and intensely pruritic, often with a central hemorrhagic punctum.

Visible skin changes: Clusters of small, red, raised papules, typically 0.2-2 cm in diameter, often arranged in irregular groups or straight lines. A central hemorrhagic punctum (tiny bleeding point) may be visible within the center of the papule. In highly sensitized individuals, the reaction can be more severe, presenting as vesicles or bullae (fluid-filled blisters), a condition known as papular urticaria. The rash ...truncated in source

Clinical illustration — Fleas

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Gonococcal Conjunctivitis

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 3 – 25 DaysLevel 1 PPE ›

Ophthalmia neonatorum. Bacterial eye infection.

Transmission Route

Direct contact with conjunctival discharge.

Patient Placement

Single patient transport (see additional).

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

If 24 hours has passed since treatment began, the patient CAN be transported with other patients.

Clinical signs & identifying features

Presenting signs

Copious purulent eye dischargeSevere eyelid edemaMarked conjunctival redness and swelling (chemosis)Preauricular lymphadenopathy

Key identifying features: The key distinguishing feature of gonococcal conjunctivitis is its hyperacute onset with an extremely copious and continuous purulent discharge, which is far more pronounced than in other forms of bacterial conjunctivitis. The discharge often reaccumulates immediately after being wiped away, and the condition is frequently unilateral.

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Hand, Foot and Mouth Disease

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 3 – 5 DaysLevel 1 PPE ›

A common childhood illness that can affect adults. Usually clears up by itself in 7 to 10 days.

Transmission Route

Respiratory tract secretions and faeces.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

FeverSore throatMouth soresRash on hands and feet

Key identifying features: The key distinguishing features are the painful mouth sores, which begin as small red spots and then blister, in combination with a non-itchy maculopapular or vesicular rash on the palms of the hands and soles of the feet. The presence of lesions in all three locations (hand, foot, and mouth) is a strong indicator.

Visible skin changes: The rash presents as flat or slightly raised red spots, which can develop into blisters with a red base. It characteristically appears on the palms of the hands and soles of the feet, but can also be found on the buttocks, legs, and arms. The rash is typically not itchy.

Clinical illustration — Hand, Foot and Mouth Disease

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Hepatitis A

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 15 – 50 DaysLevel 1 PPE ›

A liver infection caused by a virus that spreads in the faeces of an infected person.

Transmission Route

Ingestion via faecal/oral route or ingestion of contaminated food or water.

Patient Placement

Single patient transport (if ACTIVE diarrhoea).

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean. If body fluid contamination: mop floor post transfer. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Vaccination available for staff who carry out exposure prone procedures (e.g. HART) and as a travel vaccination.

Clinical signs & identifying features

Presenting signs

JaundiceNausea and vomitingAbdominal pain (especially right upper quadrant)FeverMalaise

Key identifying features: The key identifying feature is the combination of jaundice (yellowing of the skin and eyes) with right upper quadrant abdominal pain and tenderness. This is often preceded by a prodromal phase of non-specific flu-like symptoms such as fever, fatigue, and nausea. Dark urine and pale, clay-colored stools are also highly indicative of hepatic dysfunction.

Visible skin changes: A non-specific, transient (evanescent) rash may be present in a minority of cases (up to 14%). It typically presents as a raised, itchy, red rash (urticaria/hives) that is not a primary diagnostic feature and may have resolved by the time of assessment.

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Hepatitis B and C

HG 3 · HIGH

HG 3 · HIGHVirusIncubation: 14 – 180 DaysLevel 1 PPE ›

Viral inflammation of the liver (WHICH CAN BE FATAL). 10% of those that recover become carriers and may develop cirrhosis or cancer of the liver.

Transmission Route

Direct blood to blood contact and per mucosal exposure to infective body fluids. Sexual contact (risk HIGHER with Hep B). Vertical transmission mother to baby.

Patient Placement

Single patient transport (if ACTIVELY bleeding or open sores).

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean. If body fluid contamination: VOR for deep clean. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Vaccination available and STRONGLY RECOMMENDED. Follow up inoculation injuries immediately.

Clinical signs & identifying features

Presenting signs

JaundiceDark urineAbdominal painFatigueNausea and vomiting

Key identifying features: In the acute phase, Hepatitis B and C are clinically indistinguishable. Key differentiating factors are the patient's history and risk factors, such as intravenous drug use, unprotected sexual contact, or occupation. Paramedics should focus on recognizing the signs of acute hepatitis and liver failure rather than trying to differentiate between the two viruses in the field.

Visible skin changes: A variety of rashes can occur, although they are not the most common presenting symptom. In acute Hepatitis B, this may present as hives (urticaria) or a widespread, flat, red rash (maculopapular). Chronic Hepatitis C infection can lead to blistering rashes on sun-exposed areas, though this is less common in the acute setting.

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Herpes Simplex

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 2 – 12 DaysLevel 1 PPE ›

Viral infection causing cold sores or genital lesions.

Transmission Route

Contact with saliva and fluid from lesions. Personal contact with another.

Patient Placement

Single patient transport (if 'wet' sores).

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Contagious when vesicles are 'WET'. Once lesions are 'DRY', single patient transport can be ceased.

Clinical signs & identifying features

Presenting signs

Painful, fluid-filled blistersTingling, itching, or burning sensation prior to rashFeverSwollen lymph nodes

Key identifying features: The primary identifying feature is the eruption of painful, fluid-filled vesicles (blisters) that rupture to form ulcers before crusting over. These lesions are often preceded by a prodromal phase of localized tingling, itching, or burning. The distribution of the rash, typically clustered around the mouth (oral herpes) or genitals (genital herpes), is a key diagnostic clue.

Visible skin changes: The rash consists of clusters of small, fluid-filled vesicles on an erythematous (red) base. These vesicles are typically painful, and they rupture to form shallow ulcers that may ooze clear or yellowish fluid before crusting over. The rash is most commonly distributed on or around the lips and mouth (orofacial) or on the genitals, buttocks, or inner thighs (genital).

Clinical illustration — Herpes Simplex

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HIV (Human Immunodeficiency Virus)

HG 3 · HIGH

HG 3 · HIGHVirusIncubation: Variable

A virus that damages the cells in your immune system and weakens your ability to fight everyday infections and disease.

Transmission Route

Direct contact to blood and body fluids. Inoculation or exposure injuries.

Patient Placement

Single patient transport (if ACTIVELY bleeding).

PPE Required

Contact Precautions for invasive procedures, blood or body fluid contamination.

Vehicle Cleaning

NON-SYMPTOMATIC: between patient clean. If body fluid contamination: VOR for deep clean. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

FeverMaculopapular rashSore throatSwollen lymph nodesFatigue

Key identifying features: The most common presentation is a flu-like or mononucleosis-like illness, which is non-specific and can be easily mistaken for other viral infections. The presence of a generalized maculopapular rash, often on the face and trunk, in conjunction with fever, pharyngitis, and lymphadenopathy, should raise suspicion of acute HIV infection.

Visible skin changes: The rash is typically a red, flattened maculopapular rash with small, raised bumps. It is non-itchy and commonly appears on the face, chest, and trunk, but can also be found on the hands and feet.

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Impetigo

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: VariableLevel 1 PPE ›

A bacterial skin infection that is VERY contagious but not usually serious. Common in young children. Clears in 7–10 days with treatment.

Transmission Route

Direct contact with exudate from skin lesions. Indirect contact through contaminated items.

Patient Placement

Single patient transport (if lesions are 'wet').

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Considered NON-INFECTIOUS if lesions are 'DRY' or if treatment carried out for 48 hours.

Clinical signs & identifying features

Presenting signs

Honey-colored crusted lesionsRed sores or blisters that ruptureItchingRegional lymphadenopathyLow-grade fever

Key identifying features: The key identifying feature is the characteristic honey-colored, cornflake-like crusted lesions that form after vesicles or bullae rupture. Two main forms exist: non-bullous, which is more common and typically appears around the nose and mouth, and bullous, which involves larger blisters and affects the trunk and extremities.

Visible skin changes: The rash begins as red macules that evolve into vesicles or pustules. These rupture easily, leaving a moist, erythematous base. The characteristic feature is the subsequent formation of thick, adherent, honey-colored or golden-brown crusts, often described as looking like 'cornflakes stuck to the skin'. In bullous impetigo, larger, flaccid bullae are present, which rupture to leave a thin, brown c...truncated in source

Clinical illustration — Impetigo

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Influenza

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 24 – 72 HoursLevel 2 PPE ›

Viral infection causing fever, fatigue, loss of appetite, headache, muscle and joint pains. Some strains can cause more serious illness in the elderly or immunocompromised.

Transmission Route

Droplet transmission. Indirect contact through contaminated items.

Patient Placement

1 metre distancing between patients. Patients to wear FRSM. Single patient transport if above cannot be achieved.

PPE Required

Droplet Precautions (Level 2 PPE). AGP: Level 3 PPE required.

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Encourage patient to wear FRSM. Vaccination available for healthcare staff.

Clinical signs & identifying features

Presenting signs

FeverCoughMuscle achesHeadacheSevere malaise

Key identifying features: The hallmark of influenza is the sudden onset of a combination of respiratory and constitutional symptoms. Unlike a common cold, which develops gradually, influenza symptoms appear rapidly over a few hours.

Visible skin changes: A faint, macular or maculopapular rash may occasionally be present, typically in children. It can manifest as red or purple spots on the face, torso, or limbs.

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Legionnaire's Disease

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 2 – 19 DaysLevel 1 PPE ›

A severe form of pneumonia caused by Legionella bacteria found in contaminated water sources.

Transmission Route

Inhalation of aerosolised bacteria from a contaminated water source.

Patient Placement

No restrictions required.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

NOT spread person to person.

Clinical signs & identifying features

Presenting signs

FeverCoughShortness of breathMyalgiaConfusion

Key identifying features: The key distinguishing feature of Legionnaires' Disease is the combination of an acute pneumonia with prominent extrapulmonary symptoms, particularly gastrointestinal issues like diarrhea and vomiting, and neurological changes such as confusion or ataxia. A history of recent travel with stays in hotels or on cruise ships, or exposure to hot tubs or large air conditioning systems, is also a signifi...truncated in source

Visible skin changes: Rashes are rare but can occur. Presentations are varied and may include maculopapular, petechial, or erythematous rashes. The rash is not a reliable diagnostic sign.

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Malaria (Plasmodium Vivax)

HG 2 · MODERATE

HG 2 · MODERATEProtozoaIncubation: 7 – 30 DaysLevel 1 PPE ›

A serious tropical disease spread by mosquitoes.

Transmission Route

Vector – through infected mosquito and insects. Transfusion of contaminated blood.

Patient Placement

No restrictions (if no bleeding). Single patient transport if blood contact likely.

PPE Required

Contact Precautions for invasive procedures or blood contact (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Person to person spread ONLY through inoculation injury or contaminated blood transfusion.

Clinical signs & identifying features

Presenting signs

FeverChillsSweatsHeadacheNausea and vomiting

Key identifying features: The key identifying feature of malaria is the cyclical nature of the fever, which occurs in paroxysms every 48 to 72 hours. This cycle consists of a cold stage with intense shivering, a hot stage with high fever, and a wet stage with profuse sweating. A recent travel history to a malaria-endemic region is also a critical diagnostic clue.

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A–Z

Measles

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 7 – 18 DaysLevel 2 PPE ›

A HIGHLY infectious viral illness that can lead to serious complications. Uncommon in the UK due to vaccination.

Transmission Route

Droplet transmission. Indirect contact from contaminated items.

Patient Placement

Single patient transport until rash present for at least 4 days.

PPE Required

Droplet Precautions (Level 2 PPE). AGP: Level 3 PPE required.

Vehicle Cleaning

Between patient clean. Mop floor post transfer. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Non-immune staff: refer to Occupational Health. MMR can be given as PEP within 72 hours. Request patient wears FRSM.

Clinical signs & identifying features

Presenting signs

High feverCoughCoryza (runny nose)ConjunctivitisKoplik spots

Key identifying features: The key identifying features of measles are the prodromal symptoms of high fever, cough, coryza (runny nose), and conjunctivitis, followed by the pathognomonic Koplik spots (tiny white spots on the buccal mucosa). The subsequent maculopapular rash, which starts on the face and spreads cephalocaudally, is also a classic sign.

Visible skin changes: A maculopapular rash that begins as flat red spots on the face at the hairline and spreads downward to the neck, trunk, arms, legs, and feet. Small raised bumps may also appear on top of the flat red spots, and the spots may become joined together as they spread. The rash is typically red or reddish-brown.

Clinical illustration — Measles

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A–Z

Meningitis – Bacterial

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 2 – 10 DaysLevel 2 PPE ›

An infection of the protective membranes surrounding the brain and spinal cord (meninges). Rarer but more serious than viral meningitis.

Transmission Route

Droplet transmission. Direct contact with oral and/or nasal secretions.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE). AGP: Level 3 PPE required.

Vehicle Cleaning

No body fluid contamination: between patient clean. If body fluid contamination or AGP: VOR for deep clean.

Additional Info

Considered NON-INFECTIOUS after 48 hours appropriate antibiotic treatment.

Clinical signs & identifying features

Presenting signs

FeverHeadacheStiff neck (nuchal rigidity)Altered mental status (confusion, lethargy)Photophobia (dislike of bright lights)

Key identifying features: The key distinguishing features of bacterial meningitis are the rapid onset of symptoms and the classic triad of fever, nuchal rigidity (stiff neck), and altered mental status. The presence of a non-blanching rash that does not fade under pressure (the 'glass test') is a critical sign of meningococcal septicaemia, which often accompanies bacterial meningitis.

Visible skin changes: The rash typically starts as small, red 'pinprick' spots (petechiae) that can spread quickly and develop into red or purple blotches (purpura). It is a non-blanching rash, meaning it does not fade when a glass is rolled over it. The rash can be found anywhere on the body and may be harder to see on darker skin, so paler areas like the palms of the hands and soles of the feet should be checked.

Clinical illustration — Meningitis – Bacterial

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A–Z

Meningitis – Viral

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: VariableLevel 2 PPE ›

Viral infection of the meninges. Generally less severe than bacterial meningitis.

Transmission Route

Droplet transmission. Direct contact with oral and/or nasal secretions.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE). AGP: Level 3 PPE required.

Vehicle Cleaning

No body fluid contamination: between patient clean. If body fluid contamination or AGP: VOR for deep clean.

Additional Info

Encourage patient to wear FRSM if possible.

Clinical signs & identifying features

Presenting signs

FeverHeadacheStiff neckNausea and vomitingPhotophobia

Key identifying features: Viral meningitis typically presents with classic signs of meningeal irritation, but is generally less severe than bacterial meningitis. A key distinguishing feature is the rash; while a rash is uncommon in viral meningitis, if present, it is typically a non-specific, maculopapular rash that blanches under pressure. This is in contrast to the characteristic non-blanching, petechial or purpuric rash...truncated in source

Visible skin changes: A non-specific, maculopapular rash may be present. This rash consists of flat, red areas on the skin with small, confluent bumps. It is typically blanching, meaning it fades when pressure is applied.

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MERS (Coronavirus)

HCID

HG 3 · HIGH

HG 3 · HIGHHCIDVirusIncubation: Up to 14 DaysLevel 4 PPE ›

Middle East Respiratory Syndrome Coronavirus – a RARE but SEVERE respiratory illness. Classified as HCID.

Transmission Route

Droplet transmission. Indirect contact through contaminated equipment.

Patient Placement

Single patient transport. HART transfer ONLY.

PPE Required

Level 4 PPE (HCID Ensemble). HART Level 3 PPE required.

Vehicle Cleaning

Airborne Precautions. VOR post transfer.

Additional Info

ESCALATE IMMEDIATELY. Encourage patient to wear FRSM. HIGH CONSEQUENCE INFECTIOUS DISEASE (HCID) — ESCALATE IMMEDIATELY — FOLLOW HART PROTOCOLS

Clinical signs & identifying features

Presenting signs

FeverCoughShortness of breathChillsMyalgia

Key identifying features: The key identifying features of MERS are the rapid progression from initial symptoms to severe respiratory distress, often within a week. A history of travel to the Arabian Peninsula or contact with dromedary camels is a significant epidemiological factor that can help differentiate it from other respiratory illnesses.

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Monkeypox (HCID – Imported)

HCID

HG 3 · HIGH

HG 3 · HIGHHCIDVirusIncubation: 5 – 21 DaysLevel 3 PPE ›

HCID for imported cases ONLY (travel history to West or Central Africa). Usually a mild, self-limiting disease.

Transmission Route

Vector from infected animals. Droplet. Direct contact through lesions. Indirect contact through contaminated surfaces/linen.

Patient Placement

ESCALATE IMMEDIATELY. HART transfer ONLY.

PPE Required

HCID PPE Ensemble (Level 4). Level 3 PPE required.

Vehicle Cleaning

Airborne Precautions. VOR post transfer. Category A waste (DOUBLE yellow bag).

Additional Info

Encourage patient to wear FRSM. HIGH CONSEQUENCE INFECTIOUS DISEASE (HCID) — ESCALATE IMMEDIATELY — FOLLOW HART PROTOCOLS

Clinical signs & identifying features

Presenting signs

FeverRashSwollen lymph nodesHeadacheMuscle aches

Key identifying features: The most reliable clinical sign differentiating mpox from smallpox and chickenpox is enlarged lymph nodes (lymphadenopathy), particularly in the submental, submandibular, and cervical regions. The rash has a centrifugal distribution, with more lesions on the extremities and face. The lesions are typically well- circumscribed, deep-seated, and often umbilicated.

Visible skin changes: The rash begins as flat, red macules that progress to raised papules, then fluid-filled vesicles, then pus-filled pustules, and finally crust over and scab. The lesions are typically 2-5mm in diameter, and can be painful or itchy. The rash often starts on the face and spreads to the rest of the body, including the palms of the hands and soles of the feet.

Clinical illustration — Monkeypox (HCID – Imported)

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Monkeypox (Non-HCID UK Cases)

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 5 – 21 DaysLevel 2 PPE ›

Usually a mild, self-limiting disease. Non-HCID UK cases: no recent travel to West or Central Africa.

Transmission Route

Vector from infected animals. Droplet. Direct contact through lesions. Indirect contact through contaminated surfaces/linen.

Patient Placement

Graded by presentation. Respiratory symptoms/weeping vesicles: ESCALATE IMMEDIATELY. Frontline 999 can convey. PTS: fixed bulkhead only.

PPE Required

Graded: Droplet (Level 2 PPE). Airborne (Level 3 PPE) if respiratory symptoms or weeping vesicles.

Vehicle Cleaning

VOR post transfer. Category B waste (orange bag).

Additional Info

Encourage patient to wear FRSM.

Clinical signs & identifying features

Presenting signs

FeverRashLymphadenopathyMyalgiaHeadache

Key identifying features: The key distinguishing feature of monkeypox from other rash illnesses like chickenpox is the presence of swollen lymph nodes (lymphadenopathy). The rash also has a characteristic progression, starting as flat lesions and developing into fluid-filled pustules before scabbing over.

Visible skin changes: The rash typically progresses through several stages. It begins with flat, red macules that become raised papules. These then develop into fluid- filled vesicles, which later become pus-filled pustules. Finally, the pustules crust over and form scabs, which eventually fall off to reveal new skin underneath. The lesions are often well-circumscribed, deep-seated, and may be umbilicated (have a centra...truncated in source

Clinical illustration — Monkeypox (Non-HCID UK Cases)

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A–Z

MRSA

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 4 – 10 DaysLevel 1 PPE ›

A type of bacteria resistant to several widely used antibiotics. Infections with MRSA can be harder to treat.

Transmission Route

Direct contact. Indirect contact through contaminated equipment and other items.

Patient Placement

Single patient transport (or COHORT with known infected/colonised). Do NOT place with patients who have open wounds, catheters or cannulas.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

Localised skin infection (boil or abscess)Cellulitis (red, swollen, warm skin)Pus or fluid drainage from the affected areaFever

Key identifying features: MRSA skin infections often begin as what looks like a spider bite, pimple or small boil, but can quickly develop into a deep, painful abscess. A key differentiating factor is a history of recent hospitalization, surgery, or living in a long-term care facility, although community-acquired MRSA is also prevalent.

Visible skin changes: The infection typically appears as a bump or infected area on the skin that is red, swollen, painful, and warm to the touch. It may present as a single boil or abscess, or as a cluster of lesions. The lesions are often filled with pus or other drainage and can be mistaken for spider bites in their early stages.

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Mumps

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 15 – 18 DaysLevel 1 PPE ›

A contagious viral infection that used to be common in children before the MMR vaccine.

Transmission Route

Direct contact with saliva or droplets of saliva from an infected person.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE). Droplet (Level 2 PPE) for NON-IMMUNE staff.

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Encourage patient to wear FRSM.

Clinical signs & identifying features

Presenting signs

Parotitis (unilateral or bilateral)FeverHeadacheMalaiseMyalgia

Key identifying features: The key identifying feature of mumps is the acute onset of tender, unilateral or bilateral swelling of the parotid glands, causing the characteristic 'hamster face' or 'chipmunk cheek' appearance. This is often preceded by a few days of non-specific symptoms such as fever, headache, and myalgia. Pain near the earlobe, exacerbated by chewing, is also a common early sign.

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Necrotising Fasciitis

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 1 – 5 DaysLevel 1 PPE ›

A rare but serious bacterial infection affecting tissue beneath the skin and surrounding muscles and organs.

Transmission Route

Direct contact with wound exudate. Indirect contact through contaminated surfaces and equipment.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

Intense painRedness and swellingHigh temperatureHeadacheVomiting and diarrhoea

Key identifying features: The most critical identifying feature is pain that is exceptionally severe and out of proportion to the visible signs of injury. The affected subcutaneous tissue may also feel hard and unyielding to the touch, often described as 'wooden'. The infection progresses with alarming speed.

Visible skin changes: The initial presentation is typically an area of erythema (redness) and swelling. This rapidly progresses to the formation of vesicles or bullae (blisters), followed by the development of dusky, purple, or black discoloration of the skin, which signifies tissue necrosis.

Clinical illustration — Necrotising Fasciitis

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A–Z

Parvovirus (Slapped Cheek)

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 4 – 20 DaysLevel 1 PPE ›

A common childhood viral infection causing a distinctive red rash on the cheeks.

Transmission Route

Direct contact with respiratory secretions. Vertical transmission from mother to fetus.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE). Droplet (Level 2 PPE) if patient coughing.

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Pregnant staff should contact Occupational Health if exposed.

Clinical signs & identifying features

Presenting signs

FeverBright red facial rash ('slapped cheeks')General malaise or lethargyA secondary, lace-like rash on the bodyHeadache

Key identifying features: The most prominent distinguishing feature is the characteristic 'slapped cheek' rash, which is a bright red, confluent erythema on both cheeks, often with noticeable paleness around the mouth (circumoral pallor). This is frequently followed a few days later by a secondary maculopapular rash on the trunk and limbs that fades into a distinctive lacy or reticular pattern. The presence of this rash pr...truncated in source

Visible skin changes: The initial rash is a fiery red, confluent erythema on the cheeks, creating the classic 'slapped cheek' appearance, with sparing of the nasal bridge and the area around the mouth (circumoral pallor). Several days later, a second rash emerges on the trunk and extensor surfaces of the limbs. This secondary rash is maculopapular and evolves into a characteristic lacy, reticular (net-like) pattern as ...truncated in source

Clinical illustration — Parvovirus (Slapped Cheek)

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A–Z

Pinworm / Threadworm

HG 2 · MODERATE

HG 2 · MODERATEParasiteIncubation: 4 – 20 DaysLevel 1 PPE ›

Parasitic infection causing peri-anal itching (Enterobiasis).

Transmission Route

Ingestion via faecal/oral route. Indirect contact through contaminated surfaces and equipment.

Patient Placement

Individual transport not required.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Educate patient on good hygiene. Eggs remain infective on linen/clothing – decontaminate at 60°C for 2 hours.

Clinical signs & identifying features

Presenting signs

Intense perianal itching (especially nocturnal)Restlessness and insomniaIrritabilityVisible thread-like worms in perianal area

Key identifying features: The most distinguishing feature is intense itching around the anus, which is characteristically worse at night and often disrupts sleep. Direct visualization of tiny, white, thread-like worms (8-13 mm for females) in the perianal region or on feces is diagnostic, though not always observed.

Visible skin changes: No true rash is present. Skin changes are secondary to intense scratching and include perianal erythema (redness), inflammation, and linear excoriations. In some cases, a secondary bacterial infection can cause localized cellulitis with increased warmth and tenderness.

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Plague (Yersinia Pestis)

HCID

HG 3 · HIGH

HG 3 · HIGHHCIDBacteriaIncubation: 1 – 6 DaysLevel 3 PPE ›

Bacterial infection presenting with swollen glands, haemorrhagic rash, cough, haemoptysis or meningitis. Classified as HCID.

Transmission Route

Vector – bites from infected fleas. Droplet. Direct contact with blood/body fluids. Indirect contact through contaminated surfaces.

Patient Placement

Single patient transport. ESCALATE IMMEDIATELY. HART transfer ONLY.

PPE Required

Airborne Precautions (Level 3 PPE).

Vehicle Cleaning

Airborne Precautions. VOR post transfer.

Additional Info

Encourage patient to wear FRSM. HIGH CONSEQUENCE INFECTIOUS DISEASE (HCID) — ESCALATE IMMEDIATELY — FOLLOW HART PROTOCOLS

Clinical signs & identifying features

Presenting signs

FeverHeadacheChillsExtreme weaknessA single, very painful, swollen lymph node (bubo)

Key identifying features: The key distinguishing feature of bubonic plague is the 'bubo,' a very painful, swollen lymph node, typically in the groin, armpit, or neck. For pneumonic plague, it is the rapid onset of severe pneumonia with coughing up blood (hemoptysis). Septicemic plague is distinguished by overwhelming sepsis, shock, and disseminated intravascular coagulation, leading to bleeding into the skin (purpura) and ...truncated in source

Visible skin changes: In septicemic plague, patients may develop purpuric lesions (purple or black spots) due to bleeding into the skin. This can progress to acral gangrene, where the skin and deep tissues on the fingers, toes, and nose die and turn black.

Clinical illustration — Plague (Yersinia Pestis)

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A–Z

Psittacosis (Parrot Fever)

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 7 – 28 DaysLevel 1 PPE ›

A bacterial infection transmitted from infected birds.

Transmission Route

Vector – from infected birds (secretions and dust).

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Person to person transmission is RARE. Encourage patient to wear FRSM.

Clinical signs & identifying features

Presenting signs

FeverHeadacheDry CoughMyalgiaChills

Key identifying features: The most critical identifying feature is the patient's history of exposure to birds (parrots, parakeets, cockatiels, or poultry). The clinical presentation is a non-specific febrile illness, so this epidemiological link is crucial for differentiation from other causes of atypical pneumonia.

Visible skin changes: A faint, macular rash known as 'Horder spots' may be present on the face. This rash resembles the rose spots seen in typhoid fever. Erythema nodosum has also been reported.

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A–Z

Rabies

HG 3 · HIGH

HG 3 · HIGHVirusIncubation: Variable

Viral inflammation of the brain causing fever, headache, neck stiffness, anxiety and disorientation.

Transmission Route

Vector – bites from infected animals.

Patient Placement

Individual transport not required.

PPE Required

Standard IPC precautions. Contact Precautions only if exposure to blood/body fluids.

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Person to person transmission DOES NOT occur.

Clinical signs & identifying features

Presenting signs

AgitationConfusionHallucinationsHypersalivationHydrophobia

Key identifying features: The most characteristic features of rabies are the two distinct clinical presentations: furious and paralytic. Furious rabies, the more common form, involves agitation, hyperactivity, and episodes of bizarre behavior, often with hydrophobia (fear and avoidance of water) and aerophobia (fear of drafts of air). Paralytic rabies is characterized by ascending muscle weakness and paralysis, which can b...truncated in source

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A–Z

Ringworm (Tinea Corporis)

HG 2 · MODERATE

HG 2 · MODERATEFungusIncubation: 1 – 10 DaysLevel 1 PPE ›

A common fungal skin infection causing a ring-shaped rash.

Transmission Route

Direct contact with lesions. Indirect contact through contaminated surfaces and equipment.

Patient Placement

Individual transport not required.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

Annular (ring-shaped), erythematous (red) rashRaised, scaly border (active edge)Central clearing within the rashPruritus (itching)Single or multiple lesions

Key identifying features: The key feature is the characteristic annular lesion with a raised, scaly, active border and central clearing, which helps distinguish it from other skin conditions like eczema or psoriasis. The rash is typically well-demarcated.

Visible skin changes: Colour: Erythematous (red) on light skin; can be hyperpigmented (grey or brown) on darker skin tones. Distribution: Can occur on any part of the body, including the trunk, limbs, scalp (tinea capitis), groin (tinea cruris), and feet (tinea pedis). Pattern: Presents as a classic circular or oval patch or plaque. The border is raised and scaly, while the central area flattens and clears, creating a ...truncated in source

Clinical illustration — Ringworm (Tinea Corporis)

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A–Z

RSV (Respiratory Syncytial Virus)

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 1 – 10 DaysLevel 2 PPE ›

A common respiratory virus. Usually causes mild, cold-like symptoms but can be serious in infants and older adults.

Transmission Route

Droplet transmission. Indirect contact through contaminated surfaces.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE). AGP: Level 3 PPE required.

Vehicle Cleaning

Between patient clean. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant. If AGP performed: VOR post transfer.

Additional Info

Encourage patient to wear FRSM.

Clinical signs & identifying features

Presenting signs

CoughRunny or blocked noseHigh temperatureShortness of breathWheezing

Key identifying features: RSV is a common respiratory virus that typically causes cold-like symptoms but can lead to severe lower respiratory tract infections, such as bronchiolitis and pneumonia, particularly in infants and older adults. Pre-hospital, it is distinguished by the presence of significant respiratory distress (wheezing, tachypnoea, retractions) in a patient with an initial upper respiratory tract infection.

Visible skin changes: A rare, non-pruritic maculopapular rash may occur. It typically appears as small, flat or raised red or pink spots, starting on the trunk and potentially spreading to the limbs. The rash usually develops 1-3 days after the onset of respiratory symptoms and resolves within a week.

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A–Z

Rubella / German Measles

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: 14 – 21 DaysLevel 2 PPE ›

A viral infection causing a red rash. Generally mild but can be serious in pregnant women.

Transmission Route

Droplet transmission. Indirect contact through contaminated surfaces and equipment.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Encourage patient to wear FRSM.

Clinical signs & identifying features

Presenting signs

Low-grade feverFine, pinkish-red rashSwollen lymph nodes behind the ears and neckHeadacheRunny or stuffy nose

Key identifying features: The key distinguishing features of Rubella are the characteristic fine, pinkish-red rash that starts on the face and spreads downwards, and the presence of swollen and tender lymph nodes behind the ears and at the base of the skull. Unlike measles, the fever is typically low-grade, and the overall illness is milder.

Visible skin changes: The rash is a fine, pink or red maculopapular rash that starts on the face and spreads to the torso and then to the arms and legs. The spots may merge to form evenly colored patches. On darker skin, the rash may be harder to see but may feel rough or bumpy.

Clinical illustration — Rubella / German Measles

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A–Z

SARS-CoV-2 (COVID-19)

HG 3 · HIGH

HG 3 · HIGHVirusIncubation: 3 – 5 DaysLevel 2 PPE ›

Viral infection causing fever, fatigue, headache, loss of taste and smell. Can cause more serious illness in the elderly or immunocompromised.

Transmission Route

Droplet transmission. Indirect contact through contaminated surfaces and equipment.

Patient Placement

Can be cohorted with other SARS-CoV-2 cases. Patients to wear FRSM. Single patient transport if above cannot be achieved.

PPE Required

Droplet Precautions (Level 2 PPE). AGP: Level 3 PPE required.

Vehicle Cleaning

Between patient clean. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant. If AGP performed: VOR post transfer.

Additional Info

Encourage patient to wear FRSM. Vaccination/boosters available for healthcare staff.

Clinical signs & identifying features

Presenting signs

FeverCoughShortness of breathMuscle or body achesFatigue

Key identifying features: A key distinguishing feature of COVID-19 is the diverse and sometimes non-specific presentation. Unlike typical respiratory infections, a significant number of patients may be afebrile upon assessment. The presence of skin manifestations, such as 'COVID toes', in conjunction with other symptoms, can also be an important diagnostic clue.

Visible skin changes: COVID-19 can cause several types of rashes. The most common are maculopapular (a flat, red rash with small bumps), urticarial (hives), and chilblain-like lesions on the extremities, often referred to as 'COVID toes'. These chilblain-like lesions appear as red or purple, swollen areas on the fingers or toes and can be painful.

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A–Z

Scabies

HG 2 · MODERATE

HG 2 · MODERATEMiteIncubation: Up to 8 WeeksLevel 1 PPE ›

Parasitic skin infestation causing INTENSE itching.

Transmission Route

Direct transmission; prolonged skin to skin contact required.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Clinical signs & identifying features

Presenting signs

Intense itching, especially at nightPimple-like rashBurrows in the skin

Key identifying features: The key identifying features are the characteristic burrows, which appear as thin, wavy, and slightly raised lines on the skin, and the intense itching that is typically worse at night. The distribution of the rash in adults (e.g., between fingers, on wrists, elbows, and around the waist) is also a key feature.

Visible skin changes: The rash appears as small, red, pimple-like bumps (papules). The burrows are thin, wavy, greyish-white or skin-colored lines. The rash is most commonly found in the webbing between the fingers, the skin folds of the wrist, elbow, knee, or armpit, and on the penis, nipples, waist, buttocks, and shoulder blades. In infants and young children, the rash is often on the head, face, neck, palms, and sol...truncated in source

Clinical illustration — Scabies

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A–Z

Scarlet Fever (Group A Strep)

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: Up to 7 DaysLevel 2 PPE ›

A bacterial infection caused by Group A Streptococcus, causing a distinctive red rash, sore throat and fever.

Transmission Route

Droplet transmission.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Encourage patient to wear FRSM.

Clinical signs & identifying features

Presenting signs

FeverSore throatSwollen neck glandsHeadacheNausea

Key identifying features: The key identifying features of scarlet fever are the abrupt onset of fever and sore throat, followed by a characteristic fine, red rash that feels like sandpaper to the touch. Another distinguishing sign is the 'strawberry tongue,' where the tongue appears red and bumpy, often initially covered with a white coating.

Visible skin changes: The rash is a fine, erythematous, papular rash that blanches on pressure and has a 'sandpaper' texture. It typically begins on the neck, chest, axillae, and groin before spreading to the rest of the body. A key diagnostic sign is the presence of Pastia's lines, which are linear petechial markings in the antecubital and axillary folds. The face may also be flushed with circumoral pallor.

Clinical illustration — Scarlet Fever (Group A Strep)

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A–Z

Shingles (Varicella Zoster)

HG 2 · MODERATE

HG 2 · MODERATEVirusIncubation: Years (reactivation)Level 1 PPE ›

Viral infection caused by reactivation of Varicella-Zoster Virus which causes chickenpox.

Transmission Route

Direct contact with 'wet' lesions.

Patient Placement

Single patient transport if lesions are 'wet'.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Staff NOT IMMUNE to chickenpox CAN contract chickenpox from shingles. Contact Occupational Health if exposed.

Clinical signs & identifying features

Presenting signs

Unilateral vesicular rashSevere neuropathic pain (burning, tingling, or stabbing)HeadacheMalaisePhotophobia

Key identifying features: The most prominent identifying feature of shingles is the unilateral, dermatomal distribution of the vesicular rash, meaning it is confined to one side of the body and does not cross the midline. This rash is almost always preceded by neuropathic pain (burning, tingling, or stabbing sensations) in the same area by 2-3 days.

Visible skin changes: The rash begins as red patches (erythematous macules) that quickly progress to fluid-filled blisters (vesicles) on a red base. These vesicles appear in clusters in a distinct line or band along a single dermatome. The blisters will then weep, ulcerate, and finally crust over in 7-10 days. The rash is typically red, though this can be harder to discern on darker skin tones.

Clinical illustration — Shingles (Varicella Zoster)

Version 1.0 · Adapted September 2026 46 / 51

A–Z

Streptococcus Group A (GAS)

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 1 – 3 DaysLevel 1 PPE ›

A serious bacterial infection that can cause necrotising fasciitis and gangrene.

Transmission Route

Droplet transmission. Direct contact with infected lesions. Indirect contact through contaminated surfaces.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE). Droplet (Level 2 PPE) if respiratory symptoms.

Vehicle Cleaning

No body fluid contamination: between patient clean. If body fluid contamination: VOR post transfer.

Additional Info

Encourage patient to wear FRSM.

Clinical signs & identifying features

Presenting signs

FeverSevere painRedness at a wound siteHypotensionConfusion

Key identifying features: iGAS is a severe, rapidly progressing infection. Key features that differentiate it are the severity of the symptoms and the potential for necrotizing fasciitis (flesh-eating disease) and streptococcal toxic shock syndrome (STSS). The presence of a wound infection that is rapidly worsening is a strong indicator. STSS is characterized by a sudden drop in blood pressure and signs of organ damage.

Visible skin changes: A diffuse erythematous 'sandpaper' rash, often starting on the neck and chest and spreading to the body, sometimes with a flushed face and a pale area around the mouth. The rash is more prominent in skin folds.

Version 1.0 · Adapted September 2026 47 / 51

A–Z

Tuberculosis – Open (Pulmonary / MDR-TB)

HG 3 · HIGH

HG 3 · HIGHBacteriaIncubation: 2 – 10 WeeksLevel 2 PPE ›

A bacterial infection spread through inhaling tiny droplets from the coughs or sneezes of an infected person.

Transmission Route

Droplet transmission.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE). AGP or MDR-TB: Level 3 PPE required.

Vehicle Cleaning

Between patient clean. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant. If body fluid, AGP or drug resistant TB: VOR post transfer.

Additional Info

Prolonged close contact (over 8 hours) required for transmission.

Clinical signs & identifying features

Presenting signs

Persistent cough (>3 weeks)FeverNight sweatsUnexplained weight lossHaemoptysis (coughing up blood)

Key identifying features: The key identifying feature is the combination of a chronic cough with constitutional symptoms such as fever, night sweats, and weight loss. Haemoptysis is a significant finding. Consider TB in patients with these symptoms, especially if they have risk factors like known exposure, homelessness, or compromised immunity.

Visible skin changes: Cutaneous TB is uncommon but can present in several forms. Look for 'Lupus vulgaris', which appears as reddish-brown plaques, or 'Scrofuloderma', which are firm, painless subcutaneous nodules that can ulcerate, often seen around the neck. Another form, 'Tuberculosis verrucosa cutis', presents as a purplish, warty growth.

Version 1.0 · Adapted September 2026 48 / 51

A–Z

Typhoid

HG 3 · HIGH

HG 3 · HIGHBacteriaIncubation: 7 – 14 DaysLevel 1 PPE ›

A serious bacterial infection spread through contaminated food and water.

Transmission Route

Ingestion via faecal/oral route.

Patient Placement

Single patient transport.

PPE Required

Contact Precautions (Level 1 PPE).

Vehicle Cleaning

NON-SYMPTOMATIC: between patient clean. SYMPTOMATIC during conveyance: VOR post transfer.

Additional Info

Prolonged close contact (over 8 hours) required for transmission.

Clinical signs & identifying features

Presenting signs

Sustained high feverHeadacheAbdominal painWeaknessConstipation or diarrhea

Key identifying features: Typhoid fever presents with a gradual onset of a high, sustained, and often progressively rising 'stepwise' fever. A key differentiating feature is often a history of recent travel to an endemic area, as it is a major risk factor. Relative bradycardia in the presence of high fever can also be a suggestive, though not universal, sign.

Visible skin changes: Faint, salmon-colored, blanching macules, 2-4 mm in diameter, known as 'rose spots'. The rash typically appears on the chest, abdomen, and back, often in sparse crops, and is seen in up to 30% of patients.

Version 1.0 · Adapted September 2026 49 / 51

A–Z

Viral Haemorrhagic Fever (VHF)

HCID

HG 4 · VERY HIGH

HG 4 · VERY HIGHHCIDVirusIncubation: 7 – 14 DaysLevel 4 PPE ›

VHFs include Ebola, Marburg, Lassa Fever and Yellow Fever. They affect many organs, damage blood vessels and affect the body's ability to regulate itself. Some cause SEVERE disease and DEATH. Classified as HCID.

Transmission Route

Direct contact with blood or body fluids from an infected person.

Patient Placement

Single patient transport. ESCALATE IMMEDIATELY. HART transfer ONLY.

PPE Required

Level 4 PPE MINIMUM required for decontamination.

Vehicle Cleaning

Between patient clean. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant. VOR post transfer.

Additional Info

Remove ALL surplus kit from vehicle and cupboards. Category A waste (DOUBLE yellow bag). HIGH CONSEQUENCE INFECTIOUS DISEASE (HCID) — ESCALATE IMMEDIATELY — FOLLOW HART PROTOCOLS

Clinical signs & identifying features

Presenting signs

FeverSevere headacheMuscle painVomitingDiarrhoea

Key identifying features: The most critical identifying feature in a pre-hospital setting is the combination of a febrile illness with a relevant travel or contact history. The initial symptoms are non-specific and mimic other tropical diseases like malaria. Unexplained bleeding or bruising, if present, is a strong indicator but is often a late sign.

Visible skin changes: A non-itchy, maculopapular rash may appear between 2 and 7 days after symptom onset. The rash typically starts on the trunk and can spread to other parts of the body.

Clinical illustration — Viral Haemorrhagic Fever (VHF)

Version 1.0 · Adapted September 2026 50 / 51

A–Z

Whooping Cough (Bordetella Pertussis)

HG 2 · MODERATE

HG 2 · MODERATEBacteriaIncubation: 7 – 20 DaysLevel 2 PPE ›

Bacterial infection of early childhood causing an exhausting cough. Adults are not normally infected.

Transmission Route

Droplet transmission. Indirect contact through contaminated surfaces and equipment.

Patient Placement

Single patient transport.

PPE Required

Droplet Precautions (Level 2 PPE).

Vehicle Cleaning

Between patient clean: all surfaces and equipment using approved broad-spectrum surface disinfectant. Blood/body fluid spill: use approved absorbent granules followed by surface disinfectant.

Additional Info

Vaccination available. Non-immune staff: discuss vaccination or PEP with Occupational Health. Encourage patient to wear FRSM.

Clinical signs & identifying features

Presenting signs

Severe, uncontrollable coughing fitsHigh-pitched inspiratory 'whoop'Vomiting after coughingApnoea or cyanosis in infants

Key identifying features: The key distinguishing feature of pertussis is the progression from initial mild, cold-like symptoms to severe, paroxysmal coughing fits. The characteristic high-pitched inspiratory 'whoop' after a coughing bout is a classic sign, though it may be absent in very young infants, who might present with apnoea instead.

Version 1.0 · Adapted September 2026 51 / 51

APPENDIX A

Donning & Doffing Nitrile Gloves

Appendix

Donning & Doffing Nitrile Gloves — Infection Prevention & Control Checklist
SM-IPC-001 · 2.0 · March 2025

Purpose & Scope

Disposable nitrile gloves are a critical component of standard infection prevention and control (IPC) precautions. They provide a protective barrier between the clinician’s hands and potentially infectious materials including blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. This checklist covers the correct technique for donning (putting on) and doffing (removing) nitrile gloves to prevent cross-contamination.

KEY PRINCIPLE
Gloves are NOT a substitute for hand hygiene. Hands MUST be cleaned before donning and immediately after doffing gloves. Failure to perform hand hygiene negates the protective benefit of gloves.

Fig. 1: Blue nitrile examination gloves — dispenser box and glove pair

Equipment: Nitrile Examination Gloves

Factor	Guidance
Material	Nitrile (latex-free) — standard for EMS
Size	Select correct size (XS, S, M, L, XL) — snug but not tight
Powdered	Powder-free preferred (reduces allergic reactions)
Sterile vs Non-sterile	Non-sterile for standard precautions; sterile for aseptic procedures
Double gloving	Consider for high-risk procedures (sharps, heavy contamination)
Allergy	Nitrile is latex-free; safe for latex-allergic patients/staff

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APPENDIX A

Donning & Doffing Nitrile Gloves

Appendix

When to Wear Gloves

Situation	Gloves Required?
Direct contact with blood or body fluids	YES — Always
Contact with mucous membranes (mouth, eyes)	YES — Always
Contact with non-intact skin (wounds, rashes)	YES — Always
Handling contaminated equipment or waste	YES — Always
Cannulation, venepuncture, injections	YES — Always
Wound care and dressing changes	YES — Always
Suctioning (oral/tracheal)	YES — Always
Patient assessment (no body fluid risk)	Not routinely required
Taking blood pressure, pulse, temperature	Not routinely required
Handling clean equipment	Not routinely required

Fig. 2: Donning nitrile gloves — Step 1: Wash hands. Step 2: Remove glove from box by cuff. Step 3: Pull onto hand. Step 4: Take second glove. Step 5: Pull on avoiding skin contact. Step 6: Adjust fit.

Version 1.0 · Adapted September 2026 1 / 8 · p2/5

APPENDIX A

Donning & Doffing Nitrile Gloves

Appendix

Donning Procedure (Putting On)

1Perform hand hygiene — wash with soap and water for 20+ seconds OR use ABHR

2Allow hands to dry completely — wet hands tear gloves and reduce barrier integrity

3Select correct size from dispenser box — check for visible damage or tears

4Remove first glove from box — touch only the cuff edge

5Pull glove onto hand — pull by the cuff, ensuring fingers seat correctly

6Remove second glove from box with ungloved hand

7Pull second glove on — avoid touching bare skin with the already-gloved hand

8Adjust fit — interlock fingers to seat gloves; ensure snug fit at fingertips

9Inspect for integrity — check for holes, tears, or thin spots; replace if damaged

10Extend cuffs over uniform sleeves or gown cuffs if wearing additional PPE

CONTAMINATION RISK
The outside of used gloves is contaminated. Incorrect removal is the most common cause of self-contamination. Follow the technique below precisely.

Fig. 3: Doffing nitrile gloves — Step 1: Grasp outside at wrist. Step 2: Peel inside-out. Step 3: Hold in gloved palm. Step 4: Slide finger under cuff. Step 5: Peel over first glove. Step 6: Dispose in clinical waste.

Version 1.0 · Adapted September 2026 1 / 8 · p3/5

APPENDIX A

Donning & Doffing Nitrile Gloves

Appendix

Doffing Procedure (Removal) — CRITICAL

1Grasp the outside of one glove at the wrist area with the opposite gloved hand

2Peel the glove away from the body, turning it inside out as you remove it

3Hold the removed glove in the palm of the still-gloved hand

4Slide ungloved finger under the wrist of the remaining glove — skin to skin only

5Peel second glove off, turning it inside out over the first glove (creating a “bag”)

6Dispose immediately into clinical waste (orange/yellow bag)

7Perform hand hygiene IMMEDIATELY — soap and water or ABHR

REMEMBER
Glove-to-glove, skin-to-skin — the gloved hand only touches the outside of the other glove; the bare hand only touches the inside (clean side) of the remaining glove.

Common Errors to Avoid

#	Error	Risk
1	Not performing hand hygiene before donning	Contaminates inside of gloves and patient
2	Not performing hand hygiene after doffing	Hands contaminated from micro-perforations
3	Touching face/phone/equipment with gloves on	Spreads contamination to clean surfaces
4	Wearing same gloves between patients	Cross-contamination between patients
5	Snapping gloves off carelessly	Aerosolises contaminants; splashes
6	Wrong size gloves (too loose)	Reduced dexterity; glove may slip off
7	Wrong size gloves (too tight)	Tears easily; hand fatigue
8	Using damaged/torn gloves	No barrier protection
9	Wearing gloves unnecessarily	Waste; false sense of security; cross-contamination
10	Reusing disposable gloves	Barrier integrity compromised; infection risk

Version 1.0 · Adapted September 2026 1 / 8 · p4/5

APPENDIX A

Donning & Doffing Nitrile Gloves

Appendix

Key Rules

#	Rule
1	ALWAYS perform hand hygiene before and after glove use
2	CHANGE gloves between patients — no exceptions
3	CHANGE gloves between dirty and clean tasks on the same patient
4	NEVER wash or reuse disposable gloves
5	NEVER touch clean surfaces with contaminated gloves
6	DISPOSE of gloves immediately into clinical waste
7	REPORT any glove tears, punctures, or allergic reactions
8	SELECT correct size for proper fit and dexterity

References

WHO Guidelines on Hand Hygiene in Health Care (2009); NICE CG139 Infection Prevention and Control; Health and Social Care Act 2008 Code of Practice; AACE IPC Guidelines; HSE Personal Protective Equipment Regulations 2002; EN 455 Medical Gloves Standard; RCEM Infection Control Guidelines

Spark Medical Services — Donning & Doffing Nitrile Gloves Checklist — SM-IPC-001 v2.0

Version 1.0 · Adapted September 2026 1 / 8 · p5/5

APPENDIX B

Level 3 PPE for EMS Staff

Appendix

Level 3 PPE for EMS Staff — Infection Prevention & Control Checklist
SM-IPC-003 · 2.0 · March 2025

Purpose & When to Use

Level 3 PPE is the highest level of personal protective equipment for ambulance staff. It is required when performing or present during aerosol generating procedures (AGPs) on patients with suspected or confirmed respiratory infections. Level 3 provides protection against airborne, droplet, and contact transmission.

MANDATORY FOR ALL AGPs
Level 3 PPE MUST be worn whenever any aerosol generating procedure is performed on a patient with suspected or confirmed respiratory infection. There are NO exceptions.

Aerosol Generating Procedures (AGPs)

Procedure	Risk Level
Intubation / extubation / tracheostomy	HIGH
Manual ventilation (BVM)	HIGH
Open suctioning (oral / tracheal)	HIGH
CPR (chest compressions)	HIGH
Nebuliser administration	MODERATE
CPAP / BiPAP / NIV	HIGH
High-flow oxygen >15 L/min	MODERATE
Induction of sputum	HIGH
Bronchoscopy	HIGH

Fig. 1: Level 3 PPE components — double nitrile gloves, long-sleeved fluid-repellent gown, FFP3 respirator, full-face visor

Version 1.0 · Adapted September 2026 2 / 8 · p1/5

APPENDIX B

Level 3 PPE for EMS Staff

Appendix

Level 3 PPE Components

Component	Type	Standard
Gloves	Blue nitrile, powder-free — DOUBLE GLOVING	EN 455
Gown	Long-sleeved, fluid-repellent, disposable isolation gown	EN 13795
Respirator	FFP3 (face-fit tested for the specific make/model)	EN 149:2001+A1:2009
Eye/Face	Full-face visor/shield (covers entire face over FFP3)	EN 166

Level 2 vs Level 3 Comparison

Component	Level 2	Level 3
Gloves	Single pair nitrile	Double pair nitrile
Body	Disposable plastic apron	Long-sleeved gown
Respiratory	FRSM Type IIR	FFP3 respirator
Eye	Safety spectacles	Full-face visor
When	No AGPs	AGPs being performed

Paramedic in Full Level 3 PPE

Fig. 2: UK ambulance paramedic wearing complete Level 3 PPE — FFP3 respirator, full-face visor, long-sleeved gown, double nitrile gloves

DONNING ORDER IS CRITICAL
A buddy system is strongly recommended for Level 3. Both clinicians should check each other’s PPE before entering the patient zone.

Version 1.0 · Adapted September 2026 2 / 8 · p2/5

APPENDIX B

Level 3 PPE for EMS Staff

Appendix

Fig. 3: Level 3 PPE donning sequence — 1. Hand hygiene, 2. Gown (tie at back), 3. FFP3 respirator, 4. Fit check, 5. Full-face visor, 6. Double gloves over cuffs

Donning Procedure (Putting On)

1Perform hand hygiene — ABHR or soap and water; allow to dry completely

2Don long-sleeved gown — arms through sleeves; tie at neck and waist behind back; ensure full coverage

3Don FFP3 respirator — cup in hand; position over nose and mouth; pull bottom strap over head to nape of neck; pull top strap over head to crown

4Mould nose clip — press with both index fingers; adjust for seal

5Perform fit check — cover front with both hands; exhale sharply (positive pressure); inhale sharply (negative pressure); no air leaks at edges

6Don full-face visor — place headband over forehead; adjust for comfort and full face coverage over FFP3

7Don first pair of gloves (inner) — standard technique

8Don second pair of gloves (outer) — extend cuffs over gown sleeves

9Buddy check — confirm all components secure; no gaps; no exposed skin; FFP3 seal intact

HIGHEST CONTAMINATION RISK
Level 3 doffing is the most dangerous stage. The outside of ALL items is heavily contaminated. Use a buddy system. Perform hand hygiene between EVERY step. NEVER rush doffing.

Version 1.0 · Adapted September 2026 2 / 8 · p3/5

APPENDIX B

Level 3 PPE for EMS Staff

Appendix

Fig. 4: Level 3 PPE doffing sequence — 1. Remove outer gloves, 2. Untie gown, 3. Peel gown off inside-out, 4. Remove visor from behind, 5. Remove FFP3 by straps, 6. Final hand hygiene

Doffing Procedure (Removal) — CRITICAL

1Remove outer gloves — peel off using glove-to-glove technique; dispose in clinical waste

2Perform hand hygiene (over inner gloves)

3Remove gown — untie/break ties; peel gown forward off shoulders; turn inside-out; roll into bundle; dispose

4Remove inner gloves — peel off; dispose

5Perform hand hygiene

6Remove visor — grasp headband from behind; lift forward and away; dispose or decontaminate

7Perform hand hygiene

8Remove FFP3 — grasp bottom strap first, pull over head; then top strap; lean forward; let respirator fall away from face; DO NOT touch front

9Dispose of FFP3 into clinical waste

10Perform FINAL hand hygiene — soap and water preferred

KEY PRINCIPLE
Remove most contaminated items first (outer gloves, gown) and FFP3 last. The FFP3 protects your airway — it comes off last. Hand hygiene between EVERY step.

Version 1.0 · Adapted September 2026 2 / 8 · p4/5

APPENDIX B

Level 3 PPE for EMS Staff

Appendix

Key Safety Rules

#	Rule
1	NEVER perform an AGP without Level 3 PPE
2	ALWAYS use a buddy system for donning and doffing
3	MUST have a valid face-fit test for the FFP3 make/model
4	ALWAYS perform a fit check every time you don an FFP3
5	DOUBLE GLOVE — inner pair under gown, outer pair over gown cuffs
6	NEVER touch your face during use or doffing
7	NEVER rush the doffing procedure
8	REPLACE any PPE that becomes damaged, wet, or soiled
9	DISPOSE of all waste into clinical waste (orange/yellow bags)
10	REPORT any PPE breaches or exposure incidents via Datix/IR1

References

AACE Level 3 PPE Donning & Doffing Guide (HSG53); UK Gov COVID-19 Guidance for Ambulance Trusts; PHE Recommended PPE for Ambulance Staff; INDG479 FFP3 Fit Testing; EN 149:2001+A1:2009; EN 13795; EN 455; EN 166; NICE CG139; Health and Social Care Act 2008; COSHH Regulations 2002

Spark Medical Services — Level 3 PPE Checklist — SM-IPC-003 v2.0

Version 1.0 · Adapted September 2026 2 / 8 · p5/5

APPENDIX C

Eye Protection for EMS Staff

Appendix

Eye Protection for EMS Staff — Infection Prevention & Control Checklist
SM-IPC-006 · 2.0 · March 2025

Purpose & Overview

Eye protection is a critical component of personal protective equipment for EMS staff. The eyes are a direct mucous membrane route for infection transmission through splashes, sprays, droplets, and aerosols of blood and body fluids. Eye protection is mandatory during any procedure where there is a risk of splash or spray to the face.

MANDATORY
Eye protection MUST be worn during ALL patient contacts where there is a risk of exposure to blood, body fluids, secretions, or excretions, and during ALL aerosol generating procedures (AGPs).

Types of Eye Protection

Type	Standard	Protection Level	PPE Level
Safety Spectacles	EN 166	Front & side splash	Level 2
Safety Goggles	EN 166	Sealed, all-round splash	Level 2/3
Full-Face Visor	EN 166	Full face coverage	Level 3
Over-Spectacles	EN 166	Front & side (over Rx)	Level 2

Version 1.0 · Adapted September 2026 3 / 8 · p1/6

APPENDIX C

Eye Protection for EMS Staff

Appendix

Safety Spectacles — Correctly Worn

Feature	Requirement
Fit	Snug on bridge of nose, no gaps
Side shields	Must provide lateral protection
Arms	Secure over ears, no slipping
Vision	Clear, unobstructed forward view
Anti-fog	Anti-fog coating preferred
Compatibility	Must fit with mask/respirator

Fig. 2: UK ambulance paramedic wearing safety spectacles correctly — snug fit, side shields, secure arms

Version 1.0 · Adapted September 2026 3 / 8 · p2/6

APPENDIX C

Eye Protection for EMS Staff

Appendix

When Eye Protection is Required

Scenario	Minimum Eye Protection
Cannulation / venepuncture	Safety spectacles
Wound care / dressing changes	Safety spectacles
Suctioning (oral/tracheal)	Safety spectacles / goggles
Intubation / airway management	Full-face visor (Level 3)
CPR / chest compressions	Safety spectacles minimum
Nebuliser administration	Full-face visor (AGP)
CPAP / BiPAP application	Full-face visor (AGP)
Childbirth / obstetric emergency	Full-face visor
Major trauma / haemorrhage	Safety spectacles / goggles
Patient vomiting / coughing	Safety spectacles
Suspected infectious disease	As per PPE level guidance

PRESCRIPTION GLASSES
Standard prescription glasses do NOT provide adequate splash protection. Staff who wear prescription glasses must use over-spectacles, goggles, or a full-face visor over their glasses.

Full-Face Visor — Level 3 PPE

The full-face visor is required for Level 3 PPE during aerosol generating procedures. It provides complete face coverage from forehead to below chin and is worn over the FFP3 respirator.

Feature	Detail
Coverage	Forehead to below chin
Headband	Foam-padded, adjustable
Strap	Elastic, around back of head
Worn with	FFP3 respirator underneath
Type	Single-use or reusable

Version 1.0 · Adapted September 2026 3 / 8 · p3/6

APPENDIX C

Eye Protection for EMS Staff

Appendix

Fig. 3: UK ambulance paramedic wearing full-face visor with FFP3 respirator (Level 3 PPE)

Donning & Doffing Procedure

Fig. 4: Eye protection donning (steps 1–3) and doffing (steps 4–6) sequence

Version 1.0 · Adapted September 2026 3 / 8 · p4/6

APPENDIX C

Eye Protection for EMS Staff

Appendix

Donning (Putting On)

1Perform hand hygiene before handling eye protection

2Hold by arms/temples only — do not touch the lens surface

3Position on face — sit on bridge of nose, arms over ears

4Adjust for secure fit — no gaps at sides, comfortable, clear vision

5Check compatibility with mask/respirator — no interference

Doffing (Removing)

1Grasp arms/temples from behind — do NOT touch the front lens

2Lift away from face by the arms, tilting forward

3Dispose or decontaminate — disposable into clinical waste; reusable into decontamination container

4Perform hand hygiene immediately after removal

CONTAMINATED FRONT
The front surface of eye protection is considered contaminated. NEVER touch the front lens during use or removal. Always handle by the arms, temples, or headband only.

Reusable vs Disposable

Feature	Reusable	Disposable
Decontamination	Clean with detergent wipe, then disinfect	Single use — dispose after each patient
Disposal	When scratched, damaged, or cloudy	Clinical waste (orange bag)
Storage	Clean, dry location; in protective case	N/A
Inspection	Before each use for damage	Before use for defects

Version 1.0 · Adapted September 2026 3 / 8 · p5/6

APPENDIX C

Eye Protection for EMS Staff

Appendix

Key Safety Rules

#	Rule
1	ALWAYS wear eye protection when risk of splash/spray exists
2	NEVER touch the front lens during use or removal
3	REMOVE eye protection by grasping arms/temples from behind
4	USE full-face visor for all AGPs (Level 3 PPE)
5	PRESCRIPTION GLASSES are NOT adequate — use over-spectacles or visor
6	REPLACE if scratched, damaged, or vision impaired
7	DECONTAMINATE reusable eye protection between patients
8	DISPOSE of single-use items into clinical waste immediately
9	REPORT any splash exposure to eyes via Datix/IR1 immediately
10	IRRIGATE eyes immediately with saline/water if splash occurs

Eye Splash Exposure — Immediate Action

1Irrigate affected eye(s) with sterile saline or clean running water for minimum 20 minutes

2Do NOT rub the eyes

3Report immediately to Clinical Team Leader / line manager

4Complete Datix/IR1 incident report

5Attend Occupational Health / A&E for risk assessment

References

PPE at Work Regulations 1992 (as amended); EN 166 Personal Eye Protection; COSHH Regulations 2002; HSE INDG174 — PPE Guidance; AACE PPE Guidance; PHE Recommended PPE for Ambulance Staff; Health and Safety at Work Act 1974

Spark Medical Services — Eye Protection Checklist — SM-IPC-006 v2.0

Version 1.0 · Adapted September 2026 3 / 8 · p6/6

APPENDIX D

Correct Handwashing Techniques

Appendix

Correct Handwashing Techniques — Infection Prevention & Control Checklist
SM-IPC-005 · 2.0 · March 2025

Purpose & Overview

Hand hygiene is the single most important measure to prevent the spread of healthcare-associated infections (HCAIs). Effective hand decontamination reduces microbial load by up to 99.9% and is a fundamental requirement for all EMS staff at every patient contact.

MANDATORY
⚠ MANDATORY: Hand hygiene MUST be performed at the WHO 5 Moments. Failure to comply is a patient safety incident and may constitute a disciplinary matter.

WHO 5 Moments for Hand Hygiene

Moment	When
1. Before patient contact	Before touching the patient
2. Before aseptic task	Before cannulation, injection, wound care, catheterisation
3. After body fluid exposure	After contact with blood, vomit, urine, saliva, wound drainage
4. After patient contact	After touching the patient or their immediate surroundings
5. After touching surroundings	After touching stretcher, monitor, equipment near patient

Soap & Water Technique
USE SOAP & WATER WHEN: Hands are visibly soiled or contaminated; after contact with body fluids; after caring for patients with diarrhoea/vomiting (C. difficile, norovirus); after using the toilet; before eating.

Fig. 1: Soap and water handwashing procedure — 1. Wet hands, 2. Apply soap, 3. Lather & rub, 4. Rinse thoroughly, 5. Dry hands, 6. Turn off tap & dispose

Version 1.0 · Adapted September 2026 4 / 8 · p1/5

APPENDIX D

Correct Handwashing Techniques

Appendix

1Wet hands thoroughly under running water

2Apply soap — one full pump of liquid soap to palm

3Lather and rub using the 7-step technique (see Fig. 3) for minimum 20 seconds

4Rinse thoroughly under running water

5Dry with single-use paper towel — pat dry, do not rub

6Turn off tap using the paper towel (avoid recontamination)

7Dispose of paper towel in waste bin without touching lid

ABHR (Alcohol Hand Rub) Technique
USE ABHR WHEN: Hands are NOT visibly soiled; as the primary method between patient contacts in the field; when soap and water is not immediately available. ABHR is NOT effective against C. difficile spores or norovirus.

Fig. 3: WHO 7-step hand hygiene technique — 1. Palm to palm, 2. Palm over dorsum, 3. Fingers interlaced, 4. Backs of fingers, 5. Thumbs, 6. Fingertips, 7. Wrists

Version 1.0 · Adapted September 2026 4 / 8 · p2/5

APPENDIX D

Correct Handwashing Techniques

Appendix

The 7-Step Hand Hygiene Technique

Step	Action	Duration
1	Palm to palm	5 rotations
2	Right palm over left dorsum (and vice versa)	5 rotations each
3	Palm to palm, fingers interlaced	5 rotations
4	Backs of fingers to opposing palms (interlocked)	5 rotations
5	Rotational rubbing of thumbs (clasped)	5 rotations each
6	Rotational rubbing of fingertips in palm	5 rotations each
7	Rotational rubbing of wrists	5 rotations each

Commonly Missed Areas

Area	Risk	Addressed by Step
Fingertips / nail beds	HIGH	Step 6
Thumbs	HIGH	Step 5
Between fingers	HIGH	Steps 2, 3
Back of hands	MODERATE	Step 2
Wrists	MODERATE	Step 7
Palms	LOW	Step 1

Version 1.0 · Adapted September 2026 4 / 8 · p3/5

APPENDIX D

Correct Handwashing Techniques

Appendix

Fig. 2: ABHR technique — 1. Dispense gel, 2. Palm to palm, 3. Palm over dorsum, 4. Fingers interlaced, 5. Thumbs, 6. Fingertips

1Dispense a palmful of ABHR gel (minimum 3ml)

2Rub palm to palm to distribute gel

3Right palm over left dorsum with interlaced fingers, and vice versa

4Palm to palm, fingers interlaced

5Rotational rubbing of thumbs

6Rotational rubbing of fingertips in opposing palm

7Continue rubbing until hands are completely dry (minimum 20 seconds)

DO NOT
⚠ DO NOT wipe or rinse ABHR off — allow to air dry completely. Do not apply to wet hands.

Version 1.0 · Adapted September 2026 4 / 8 · p4/5

APPENDIX D

Correct Handwashing Techniques

Appendix

Soap & Water vs ABHR — When to Use

Scenario	Method
Hands visibly soiled / contaminated	Soap & water
After body fluid exposure	Soap & water
C. difficile / norovirus patient	Soap & water (ABHR ineffective)
Between patient contacts (clean hands)	ABHR
Before aseptic procedure	ABHR (or soap & water)
After removing gloves	ABHR (or soap & water)
Before/after eating	Soap & water
After using toilet	Soap & water

Key Safety Rules for EMS Staff

#	Rule
1	ALWAYS perform hand hygiene at the WHO 5 Moments
2	MINIMUM 20 seconds for both soap & water and ABHR
3	REMOVE all jewellery, watches, and rings before hand hygiene
4	KEEP nails short, clean, and free of nail polish or extensions
5	COVER cuts and abrasions with waterproof dressings
6	USE soap & water when hands are visibly soiled
7	ALLOW ABHR to dry completely — never wipe off
8	CARRY personal ABHR on your person at all times on duty
9	ALWAYS wash hands after removing gloves
10	USE emollient hand cream to maintain skin integrity

References

References: WHO Guidelines on Hand Hygiene in Health Care (2009); NICE CG139 — Healthcare-Associated Infections; Health and Social Care Act 2008 — Code of Practice; PHE Hand Hygiene Guidance; NHS England National IPC Manual; EN 1500 (ABHR); EN 1499 (Handwash)

Spark Medical Services — Handwashing Techniques Checklist — SM-IPC-005 v2.0

Version 1.0 · Adapted September 2026 4 / 8 · p5/5

APPENDIX E

FFP3 Respirator Use

Appendix

FFP3 Respirator Use — Infection Prevention & Control Checklist
SM-IPC-004 · 2.0 · March 2025

Purpose & Overview

The FFP3 respirator (Filtering Face Piece class 3) provides the highest level of respiratory protection available in disposable respirator form. It filters at least 99% of airborne particles and is mandatory for UK ambulance staff during aerosol generating procedures (AGPs) on patients with suspected or confirmed respiratory infections.

MANDATORY REQUIREMENT
⚠ MANDATORY REQUIREMENT: All staff who may need to wear an FFP3 MUST have a valid face-fit test for the specific make and model of FFP3 they will use. An untested FFP3 provides NO guaranteed protection.

FFP3 Respirator — Product

Specification	Detail
Classification	FFP3 NR D
Standard	EN 149:2001+A1:2009
Filtration	≥99% airborne particles
Inward Leakage	≤2% (nominal)
Type	Fold-flat / cup-shaped
Straps	Two elastic head straps
Nose Clip	Adjustable aluminium
Use	Single-use, single-session

Fig. 1: FFP3 fold-flat respirator with nose clip and head straps

Version 1.0 · Adapted September 2026 5 / 8 · p1/5

APPENDIX E

FFP3 Respirator Use

Appendix

Common UK EMS FFP3 Models

Make/Model	Type	Valve
3M Aura 1863+	Fold-flat	No (unvalved)
3M Aura 9332+	Fold-flat	Yes
3M 8833	Cup-shaped	Yes
Moldex 3405	Cup-shaped	Yes
Alpha Solway 3030V	Fold-flat	Yes
Honeywell Superone 3208	Cup-shaped	Yes

IMPORTANT
⚠ IMPORTANT: You are ONLY fit-tested for specific make/model combinations. You CANNOT use a different model without a new face-fit test, even from the same manufacturer.

FFP3 Correctly Worn

Fig. 2: UK ambulance paramedic with FFP3 respirator correctly fitted — nose clip moulded, top strap at crown, bottom strap at nape, full nose/mouth/chin coverage

Face-Fit Testing Requirements

Requirement	Detail
Method	Qualitative (Bitrex/saccharin) or Quantitative (Portacount)
Frequency	Every 2 years minimum; sooner if face shape changes
Retest triggers	Weight change >7kg, dental work, facial surgery, scarring
Clean-shaven	MANDATORY — facial hair in the seal zone invalidates the fit
Record	Certificate must state make, model, and size tested

Version 1.0 · Adapted September 2026 5 / 8 · p2/5

APPENDIX E

FFP3 Respirator Use

Appendix

FACIAL HAIR
⚠ FACIAL HAIR: Any stubble, beard, or sideburns in the seal zone between the mask edge and the face will break the seal and render the FFP3 ineffective. Staff MUST be clean-shaven in the seal zone.

Fig. 3: FFP3 donning sequence — 1. Cup in hands, 2. Position over nose/mouth, 3. Bottom strap to nape, 4. Top strap to crown, 5. Mould nose clip, 6. Perform seal check

Donning Procedure

1Perform hand hygiene before handling the respirator

2Open and cup the FFP3 in one hand with nosepiece at fingertips; hold by edges only

3Position the respirator over nose and mouth; nosepiece at the bridge of the nose

4Pull bottom strap over head to rest at the nape of the neck (below ears)

5Pull top strap over head to rest at the crown of the head (above ears)

6Mould nose clip — use both index fingers to press and shape the aluminium clip firmly to the bridge of the nose

7Adjust straps for a snug, comfortable fit — no gaps at cheeks, nose, or chin

8Perform fit check (see below)

Version 1.0 · Adapted September 2026 5 / 8 · p3/5

APPENDIX E

FFP3 Respirator Use

Appendix

Fig. 4: FFP3 fit check — 1. Positive pressure (exhale), 2. Pass (no leak), 3. Negative pressure (inhale), 4. Fail (air leak detected — refit)

Fit Check Procedure — EVERY TIME

Check	Method	Expected Result
Positive Pressure	Cup both hands over front; exhale sharply	Slight pressure build-up inside; NO air escaping at edges
Negative Pressure	Cup both hands over front; inhale sharply	Mask collapses slightly inward against face; no air drawn in at edges

IF FIT CHECK FAILS
⚠ IF FIT CHECK FAILS: Reposition the respirator, readjust straps and nose clip, and repeat the check. If it fails again, try a different size or model for which you have been fit-tested. DO NOT proceed with a failed fit check.

Doffing Procedure (Removal)

1Grasp the BOTTOM strap at the nape of the neck and pull forward over the head

2Grasp the TOP strap at the crown and pull forward over the head

3Lean forward and allow the respirator to fall away from the face

4DO NOT touch the front of the respirator — it is contaminated

5Dispose immediately into clinical waste (orange bag)

6Perform hand hygiene immediately

KEY PRINCIPLE
KEY PRINCIPLE: The FFP3 is always the LAST item removed during Level 3 PPE doffing. It protects your airway — keep it on until all other PPE is removed.

Version 1.0 · Adapted September 2026 5 / 8 · p4/5

APPENDIX E

FFP3 Respirator Use

Appendix

Key Safety Rules

#	Rule
1	MUST have a valid face-fit test for the specific make/model
2	MUST be clean-shaven in the seal zone
3	ALWAYS perform a fit check every time you don an FFP3
4	NEVER proceed with a failed fit check
5	NEVER touch the front of the respirator during use or removal
6	SINGLE USE ONLY — dispose after each patient encounter
7	REMOVE bottom strap first, then top strap during doffing
8	REPLACE immediately if damaged, wet, soiled, or breathing becomes difficult
9	STORE in original packaging until use; do not crush or fold
10	REPORT any fit test failures or exposure incidents via Datix/IR1

References

References: HSE INDG479 — FFP3 Fit Testing; EN 149:2001+A1:2009; COSHH Regulations 2002; HSE RPE at Work Guide (HSG53); AACE PPE Guidance; PHE Recommended PPE for Ambulance Staff; UK Gov COVID-19 Guidance for Ambulance Trusts

Spark Medical Services — FFP3 Respirator Checklist — SM-IPC-004 v2.0

Version 1.0 · Adapted September 2026 5 / 8 · p5/5

APPENDIX F

Correct Handwashing Techniques

Appendix

Correct Handwashing Techniques — Infection Prevention & Control Checklist
SM-IPC-005 · 2.0 · March 2025

Purpose & Overview

MANDATORY
⚠ MANDATORY: Hand hygiene MUST be performed at the WHO 5 Moments. Failure to comply is a patient safety incident and may constitute a disciplinary matter.

WHO 5 Moments for Hand Hygiene

Moment	When
1. Before patient contact	Before touching the patient
2. Before aseptic task	Before cannulation, injection, wound care, catheterisation
3. After body fluid exposure	After contact with blood, vomit, urine, saliva, wound drainage
4. After patient contact	After touching the patient or their immediate surroundings
5. After touching surroundings	After touching stretcher, monitor, equipment near patient

Version 1.0 · Adapted September 2026 6 / 8 · p1/5

APPENDIX F

Correct Handwashing Techniques

Appendix

1Wet hands thoroughly under running water

2Apply soap — one full pump of liquid soap to palm

3Lather and rub using the 7-step technique (see Fig. 3) for minimum 20 seconds

4Rinse thoroughly under running water

5Dry with single-use paper towel — pat dry, do not rub

6Turn off tap using the paper towel (avoid recontamination)

7Dispose of paper towel in waste bin without touching lid

Version 1.0 · Adapted September 2026 6 / 8 · p2/5

APPENDIX F

Correct Handwashing Techniques

Appendix

The 7-Step Hand Hygiene Technique

Step	Action	Duration
1	Palm to palm	5 rotations
2	Right palm over left dorsum (and vice versa)	5 rotations each
3	Palm to palm, fingers interlaced	5 rotations
4	Backs of fingers to opposing palms (interlocked)	5 rotations
5	Rotational rubbing of thumbs (clasped)	5 rotations each
6	Rotational rubbing of fingertips in palm	5 rotations each
7	Rotational rubbing of wrists	5 rotations each

Commonly Missed Areas

Area	Risk	Addressed by Step
Fingertips / nail beds	HIGH	Step 6
Thumbs	HIGH	Step 5
Between fingers	HIGH	Steps 2, 3
Back of hands	MODERATE	Step 2
Wrists	MODERATE	Step 7
Palms	LOW	Step 1

Version 1.0 · Adapted September 2026 6 / 8 · p3/5

APPENDIX F

Correct Handwashing Techniques

Appendix

1Dispense a palmful of ABHR gel (minimum 3ml)

2Rub palm to palm to distribute gel

3Right palm over left dorsum with interlaced fingers, and vice versa

4Palm to palm, fingers interlaced

5Rotational rubbing of thumbs

6Rotational rubbing of fingertips in opposing palm

7Continue rubbing until hands are completely dry (minimum 20 seconds)

DO NOT
⚠ DO NOT wipe or rinse ABHR off — allow to air dry completely. Do not apply to wet hands.

Version 1.0 · Adapted September 2026 6 / 8 · p4/5

APPENDIX F

Correct Handwashing Techniques

Appendix

Soap & Water vs ABHR — When to Use

Scenario	Method
Hands visibly soiled / contaminated	Soap & water
After body fluid exposure	Soap & water
C. difficile / norovirus patient	Soap & water (ABHR ineffective)
Between patient contacts (clean hands)	ABHR
Before aseptic procedure	ABHR (or soap & water)
After removing gloves	ABHR (or soap & water)
Before/after eating	Soap & water
After using toilet	Soap & water

Key Safety Rules for EMS Staff

#	Rule
1	ALWAYS perform hand hygiene at the WHO 5 Moments
2	MINIMUM 20 seconds for both soap & water and ABHR
3	REMOVE all jewellery, watches, and rings before hand hygiene
4	KEEP nails short, clean, and free of nail polish or extensions
5	COVER cuts and abrasions with waterproof dressings
6	USE soap & water when hands are visibly soiled
7	ALLOW ABHR to dry completely — never wipe off
8	CARRY personal ABHR on your person at all times on duty
9	ALWAYS wash hands after removing gloves
10	USE emollient hand cream to maintain skin integrity

References

Spark Medical Services — Handwashing Techniques Checklist — SM-IPC-005 v2.0

Version 1.0 · Adapted September 2026 6 / 8 · p5/5

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

Dräger X-plore 8500 PAPR — Healthcare Respirator Checklist
v1.0 · January 2026

FOR USE WITH APPROPRIATE HEALTHCARE FILTERS (P3/TH3P) FOR BIOLOGICAL AGENT PROTECTION

DEVICE OVERVIEW

The Dräger X-plore 8500 is a battery-operated Powered Air-Purifying Respirator (PAPR) designed for healthcare settings requiring enhanced respiratory protection against biological agents including HCID pathogens. The PAPR draws ambient air through a high-efficiency P3 filter and delivers clean, filtered air via a breathing hose to a headpiece (hood, helmet, or full-face mask). Key advantage: No breathing resistance — continuous positive airflow reduces user fatigue during extended patient care.

Fig. 1: Dräger X-plore 8500 System Components — labelled components: 1 Dräger X-plore 8500 Blower Unit; 2 P3 Particle Filter Cartridge; 3 Lithium-ion Battery Pack; 4 Breathing Hose; 5 Hood with Visor; 6 Waist Belt/Carrying System; 7 Splash Guard Lid.

SYSTEM COMPONENTS CHECKLIST

Blower unit (X-plore 8500 main body)

Lithium-Ion battery (standard or high-capacity)

P3 particle filter (healthcare grade)

Splash guard lid (protects filter)

Carrying system (harness with comfort pad)

Breathing hose (connects blower to headpiece)

Headpiece (hood, helmet, or full-face mask)

Battery charger (single or multi-bay)

Belt extension (if required)

Version 1.0 · Adapted September 2026 7 / 8 · p1/9

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

TECHNICAL SPECIFICATIONS

Parameter	Specification
Dimensions	250 × 84 × 235 mm (including splash guard)
Weight (blower unit only)	908 g
Weight (with battery & splash guard)	1,400 g
IP Rating	IP65 (dust-tight and water-jet resistant)
Certification	EN 12941 / EN 12942
Standard Battery Life	4 hours (at 210 L/min with P3 filter)
High-Capacity Battery Life	8 hours (at 210 L/min with P3 filter)
Charging Time	Approx. 4 hours (standard charger)
Flow Rate	Adjustable; auto-set to minimum for connected headpiece
Self-Test	Automatic on start-up (battery, filter, airflow)

BATTERY STATUS INDICATORS

LED Display	Status	Action
4 segments	>75% capacity	Ready for use
3 segments	>50% capacity	Ready for use
2 segments	>25% capacity	Plan to recharge soon
1 segment	<25% capacity	RECHARGE BEFORE USE

Charging LEDs: Green solid = fully charged • Green flashing = charging • Red flashing = malfunction — contact equipment manager.

HEALTHCARE FILTER SELECTION

For protection against biological agents, the P3 particle filter MUST be used.

HEALTHCARE FILTER SELECTION

Filter Type	Class	Details
P3 Particle	TH3P / TM3P	Highest particulate protection. Efficiency >99.95% for particles ≥0.3µm.
Hood use	TH3P	Turbo Hood class 3 — loose-fitting, no fit-testing required.
Mask use	TM3P	Turbo Mask class 3 — tight-fitting, requires fit-testing.

WARNING
WARNING: Gas/combination filters are NOT required for biological agent protection. Use P3 particle filter ONLY unless chemical exposure is also present.

Version 1.0 · Adapted September 2026 7 / 8 · p2/9

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

1. BATTERY INSERTION

1Check battery charge by pressing blue button on battery. Check LED segments (4 segments = >75%).

2If required, charge battery before use. Green flashing LED = charging; Green solid = fully charged.

3Insert battery into compartment with blue locking button pointing upwards and contacts pointing towards device.

4Press battery firmly until you hear an audible click confirming secure engagement.

2. FILTER INSTALLATION

5Remove splash guard lid by pressing the blue filter locking button.

6Place P3 particle filter into the splash guard lid.

7Insert both (filter + lid) at an angle into the blower unit.

8Fold towards device until lid audibly clicks into place.

3. CARRYING SYSTEM & BREATHING HOSE

9Take harness and attach comfort pad to strap if needed.

10Position connecting plate with top edge at angle into blower unit. Push until it audibly clicks.

11Plug hose connector onto coupling of blower unit. Slightly turn until it audibly clicks.

12Connect other end of hose to headpiece coupling. Turn until audible click.

ASSEMBLY VERIFICATION CHECKLIST

Battery fully charged and securely clicked in

P3 filter correctly seated with splash guard locked

Carrying system securely attached to blower

Breathing hose connected to blower (click)

Breathing hose connected to headpiece (click)

No visible damage to any component

Version 1.0 · Adapted September 2026 7 / 8 · p3/9

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

WEARING THE DEVICE

1Put on the carrying system like a rucksack. Blower unit should sit at the lower back.

2Close the waist buckle and tighten all straps for a secure, comfortable fit.

3Ensure the breathing hose runs freely and is not kinked or trapped.

SWITCHING ON & SELF-TEST

4Press the green button on the control panel to switch on.

5The device performs an automatic self-test (battery, filter capacity, airflow).

6GREEN indicator lights = device operating correctly. If RED or no lights — DO NOT USE.

7Unit auto-sets minimum flow rate for connected headpiece. Adjust (+/−) if needed.

IF SELF-TEST FAILS OR RED INDICATORS APPEAR — DO NOT USE — REPORT TO EQUIPMENT MANAGER

Version 1.0 · Adapted September 2026 7 / 8 · p4/9

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

HOOD DONNING (Preferred for HCID — No Fit-Testing Required)

1Adjust head circumference and height using the support ring inside the hood.

2Ensure breathing hose is connected to hood coupling (audible click).

3Put hood on using the fitting loops. Ensure visor is centred over face.

4Tuck the inner bib layer into protective clothing (coverall or gown).

HELMET DONNING

1Adjust headband height and width using 4 fastening points.

2Connect breathing hose to helmet. Stretch sealing cuff and put on.

3Adjust air outlet at front and ratchet at back.

4Pull sealing cuff under chin and tighten strap.

FULL-FACE MASK DONNING (Requires Fit-Testing)

1Connect mask to breathing hose. Open all straps fully.

2Insert chin into chin piece. Fit harness over head.

3Tighten neck straps, then temple straps, then front strap.

4Perform positive and negative pressure seal checks.

Version 1.0 · Adapted September 2026 7 / 8 · p5/9

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

PRE-USE SAFETY CHECKS

Visual inspection: Check all components for visible damage, cracks, or wear

Filter check: P3 filter correctly installed, splash guard lid locked, no damage to filter media

Battery check: Press blue button — minimum 2 segments (>25%) required for use

Hose check: No kinks, cracks, or blockages in breathing hose

Headpiece check: Visor/lens clear, seals intact, no tears in hood/sealing cuff

Self-test: Switch on — all indicator lights GREEN after self-test

Airflow check: Feel positive airflow at headpiece — air should flow continuously

Seal check: No air leaks at hose connections or headpiece seal

Alarm test: Confirm audible alarm sounds during self-test sequence

Version 1.0 · Adapted September 2026 7 / 8 · p6/9

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

DOFFING PROCEDURE

1Move to designated doffing area (Amber zone if HCID).

2Remove headpiece carefully — avoid touching outer contaminated surfaces.

3Disconnect breathing hose from headpiece.

4Switch off blower unit (press and hold green button).

5Remove carrying system and place on designated clean surface.

6Perform hand hygiene immediately after doffing.

7Decontaminate all reusable components before storage (see Cleaning page).

DURING USE — IMPORTANT REMINDERS

Monitor battery LED display regularly during use

If audible alarm sounds, exit contaminated area immediately

Do not remove headpiece in contaminated area

Ensure breathing hose remains unkinked at all times

If airflow feels reduced, exit and check filter/battery

Always have a buddy present during HCID patient care

POST-USE CLEANING PROCEDURE

1Don PPE (gloves and apron) before handling contaminated equipment.

2Remove battery: Push down blue lock tab on reverse, fold out battery.

3Remove filter: Press blue locking button, remove splash guard and filter. Dispose of used P3 filter as clinical waste.

4Disconnect hose: Separate breathing hose from blower and headpiece.

5Clean blower unit: Wipe all external surfaces with approved chlorine-based disinfectant wipe.

6Clean breathing hose: Flush interior with approved disinfectant solution. Rinse and air dry.

7Clean headpiece: Wipe visor/lens. Clean all seals and inner surfaces.

8Dry all components thoroughly before reassembly or storage.

9Recharge battery: Place in charger. Confirm green flashing LED.

Version 1.0 · Adapted September 2026 7 / 8 · p7/9

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

ROUTINE INSPECTION SCHEDULE

Frequency	Action Required
Before every use	Visual inspection. Battery charge check. Self-test on start-up.
After every use	Full cleaning and decontamination. Battery recharge.
Weekly	Functional test even if not used. Check battery. Inspect filter sealing surfaces.
Monthly	Full system inspection: hose integrity, headpiece seals, harness buckles.
Annually	Full service by authorised Dräger service partner. Calibration check.

FILTER REPLACEMENT & STORAGE

Replace the P3 particle filter when: breathing resistance increases • filter exposed to blood/body fluid • visible damage or contamination • self-test indicates filter issue • after each HCID patient encounter (mandatory). Storage: Clean, dry location away from sunlight • Store disassembled for long-term storage • Keep filters sealed until required • Recharge battery every 3 months if stored • Store headpiece in protective bag.

TROUBLESHOOTING GUIDE

Problem	Possible Cause	Action
Self-test fails	Low battery, filter blockage, or system fault	Check battery. Replace filter. If persists, remove from service.
Reduced airflow	Filter clogged, hose kinked, or low battery	Replace filter. Check hose. Recharge battery.
Audible alarm	Battery low, filter resistance high	Exit contaminated area. Replace battery or filter.
No power	Battery not inserted or flat	Reinsert battery (check click). Recharge.
Visor fogging	Low airflow, blocked filter	Increase flow rate. Replace filter if needed.

IF ANY FAULT CANNOT BE RESOLVED — REMOVE DEVICE FROM SERVICE — REPORT TO EQUIPMENT MANAGER AND TAG AS DEFECTIVE

EMERGENCY PROCEDURES — PAPR FAILURE DURING PATIENT CONTACT

1Immediately hold your breath and move away from the patient.

2Exit the Red Zone to the Amber/doffing area.

3If FFP3 mask is available, don it immediately as backup respiratory protection.

4Inform your doffing buddy and senior staff immediately.

5Complete doffing procedure as normal. Report incident and complete incident form.

6Seek occupational health review if exposure suspected.

Version 1.0 · Adapted September 2026 7 / 8 · p8/9

APPENDIX G

Dräger X-plore 8500 PAPR

Appendix

REFERENCES

Dräger X-plore 8500 Instructions for Use (IFU)
Dräger X-plore 8000 Donning Poster (9045091-en)
EN 12941 / EN 12942 — Powered filtering devices
UKHSA HCID Programme — PPE Guidance
HSE PPE at Work Regulations 1992 (amended 2022)

TRAINING REQUIREMENTS

Device training (assembly, donning, doffing)

Pre-use safety checks and self-test

Post-use cleaning and decontamination

Emergency procedures (device failure)

Practical assessment signed off

Refresh annually.

DOCUMENT CONTROL

Version	Date	Status
v1.0	January 2026	Issued

Based on Dräger manufacturer instructions and UKHSA HCID guidance. For use by Spark Medical personnel only.

Version 1.0 · Adapted September 2026 7 / 8 · p9/9

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

Level 4 PPE — HCID Ensemble — with Dräger X-plore 8500
v1.0 · January 2026

LEVEL 4 PPE IS REQUIRED FOR SUSPECTED OR CONFIRMED HIGH CONSEQUENCE INFECTIOUS DISEASES (HCID) ONLY TO BE USED BY STAFF TRAINED AND ASSESSED AS COMPETENT

WHEN TO USE LEVEL 4 PPE

Level 4 PPE is required when managing patients with suspected or confirmed:

Viral Haemorrhagic Fevers (Ebola, Marburg, Lassa, Crimean-Congo)
SARS / MERS (novel coronavirus with HCID designation)
Avian Influenza (H5N1, H7N9 with HCID designation)
Plague (pneumonic)
Monkeypox (Clade I — if designated HCID)
Any pathogen designated as HCID by UKHSA

Always confirm HCID status with UKHSA before donning Level 4.

CRITICAL SAFETY RULES

NEVER enter Red Zone without complete PPE ensemble
NEVER doff without a trained buddy observing
NEVER step back into Amber/Red zone after entering Green
Change outer gloves between care events in Red Zone
Report any PPE breach immediately to senior staff
If PAPR alarm sounds, exit Red Zone immediately

ZONE MANAGEMENT OVERVIEW

Zone	Description
RED ZONE	High-contamination patient area — full Level 4 PPE required
AMBER ZONE	Doffing / transitional area — controlled removal of PPE
GREEN ZONE	Clean area — no PPE permitted

Zones must be clearly marked with physical barriers. Movement between zones follows strict one-way protocols.

THIS ENSEMBLE USES

Dräger X-plore 8500 PAPR with TH3P hood provides continuous positive-pressure filtered air. No FFP3 fit-testing required when using PAPR hood. Sealed Tyvek-type impermeable coverall provides full-body fluid barrier protection, replacing the standard surgical gown. Refer to Dräger X-plore 8500 PAPR Checklist (Appendix G) for assembly & pre-use checks.

Version 1.0 · Adapted September 2026 8 / 8 · p1/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

MANDATORY EQUIPMENT CHECKLIST

Wellington boots — 2 sizes larger than normal (new pair each entry)

Dräger X-plore 8500 PAPR — assembled, battery charged, self-test passed

PAPR TH3P hood — connected to breathing hose, sealing cuff intact

Sealed impermeable coverall (Tyvek or equivalent) — correct size, no tears or defects

Nitrile short-cuff gloves (inner) — 1 pair, first layer against skin

Nitrile long-cuff gloves (middle) — 1 pair, taped to coverall cuffs

Nitrile short-cuff gloves (outer) — multiple pairs for changing during care

Micropore tape — for sealing glove-to-coverall interface

High-grade long-length apron — plastic, with breakable neck loop

Full-face visor — splash protection (optional with PAPR hood visor)

PRE-DONNING REQUIREMENTS

Ensure you are hydrated and have used the toilet

Confirm you feel well enough to enter patient area

Remove ID badges, jewellery, watches, lanyards

Tie long hair back securely

Change into surgical scrubs

Wash hands thoroughly (WHO 7-step technique)

Cover any cuts with waterproof dressing

Identify your doffing buddy before entering

THREE-GLOVE SYSTEM

Layer	Type	Purpose
Inner (1st)	Short-cuff nitrile	Base protection against skin
Middle (2nd)	Long-cuff nitrile	Taped to coverall for sealed interface
Outer (3rd)	Short-cuff nitrile	Patient contact — change between care events

Version 1.0 · Adapted September 2026 8 / 8 · p2/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

LEVEL 4 HCID PPE — EQUIPMENT LAYOUT. Numbered layout showing: 1 wellington boots; 2 Dräger blower unit with breathing hose; 3 PAPR TH3P hood with visor; 4 sealed impermeable coverall; 5 short-cuff nitrile gloves (inner); 6 long-cuff nitrile gloves (middle); 7 short-cuff nitrile gloves (outer); 8 micropore tape; 9 high-grade long-length apron; 10 full-face visor (OPTIONAL). Fig. 1: Level 4 PPE Equipment Layout — HCID Ensemble

DONNING TAKES PLACE IN THE GREEN ZONE — ALL EQUIPMENT LAID OUT AND CHECKED BEFORE STARTING

STEP 1: WELLINGTON BOOTS

1Put on wellington boots (preferably 2 sizes larger than normal to allow coverall overlap). Use a new pair for each entry into the Red Zone.

STEP 2: FIRST PAIR OF GLOVES (INNER)

2Put on first pair of standard nitrile short-cuff gloves (inner layer). These sit directly against skin.

STEP 3: SEALED IMPERMEABLE COVERALL

3aStep into the Tyvek-type sealed impermeable coverall. Ensure correct size — should allow full range of movement without being baggy.

3bPull coverall up over torso and insert arms into sleeves.

3cZip up the front fully. Ensure the storm flap covers the zip completely.

3dSeal the storm flap with the adhesive strip or tape provided.

3eEnsure coverall cuffs fully overlap inner gloves. Tuck cuffs over glove cuffs.

Version 1.0 · Adapted September 2026 8 / 8 · p3/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

STEP 4: CHECK COVERALL-BOOT OVERLAP

4aCheck for ≥10–15 cm overlap between boot top and coverall leg.

4bIf coverall too long, trim legs to avoid trip hazard.

4cIf unable to achieve >10 cm overlap — do NOT proceed. Inform senior staff.

STEP 5: SECOND PAIR OF GLOVES (LONG CUFF)

5aPut on long-cuff nitrile gloves over coverall cuffs.

5bTape gloves to coverall using 4 strips of micropore tape placed lengthways around each wrist.

5cEnsure there are no gaps between glove and coverall cuff — this creates a sealed interface.

STEP 6: APRON

6aTake high-grade long-length plastic apron. Break the head loop at the back of neck (for easy removal during doffing).

6bPut on apron, tying at top behind neck and bottom around waist. Achieve a ‘high fit’ over chest area.

STEP 7: DRÄGER X-PLORE 8500 PAPR

7aDon PAPR carrying system (belt or harness) over coverall.

7bSwitch on blower unit. Confirm self-test passes (all green LEDs).

7cDon PAPR TH3P hood. Tuck inner bib layer into coverall neckline.

7dConfirm positive airflow at face. Ensure visor is centred.

STEP 8: SEAL COVERALL HOOD

8aPull coverall hood up over the PAPR hood if coverall has an integrated hood.

8bIf no integrated hood, ensure PAPR hood bib fully overlaps coverall neckline with no gaps.

8cTape the coverall-to-PAPR hood junction if required for a complete seal.

STEP 9: THIRD PAIR OF GLOVES (OUTER)

9Put on 3rd pair of standard nitrile short-cuff gloves (outer layer). These are the patient contact gloves — change between care events.

Version 1.0 · Adapted September 2026 8 / 8 · p4/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

STEP 10: BUDDY CHECK

10aBuddy runs through each step to verify all items correctly in place.

10bCheck for gaps, exposed skin, or defects in any PPE item.

10cIf any issues cannot be corrected — inform senior staff, do NOT enter Red Zone.

DONNING COMPLETE — BUDDY CONFIRMS CLEAR TO ENTER RED ZONE RECORD TIME OF ENTRY

DONNING VERIFICATION CHECKLIST

Wellington boots on, coverall overlap ≥10 cm

Coverall zipped, storm flap sealed

PAPR self-test passed, green LEDs, positive airflow

PAPR hood fitted, bib tucked, no skin visible

Inner gloves on under coverall cuffs

Long-cuff gloves taped to coverall with micropore

Apron on with high fit, neck loop pre-broken

Outer gloves on as outermost layer

No exposed skin visible anywhere

Breathing hose not kinked

Version 1.0 · Adapted September 2026 8 / 8 · p5/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

LEVEL 4 HCID PPE DONNING PROCEDURE: 12-STEP SEQUENCE. Panel captions: 1. Put on wellington boots (oversized). 2. Put on FFP3 mask and perform fit check. 3. Put on hood, fasten Velcro tabs, check fit around face. 4. Put on first pair of short nitrile gloves. 5. Put on reinforced surgical gown, secure Velcro at neck, tie at side. 6. Check 10-15cm overlap between gown and boot tops. 7. Put on long-cuff gloves over gown cuffs, tape with micropore tape (4 strips). 8. Break head loop of apron. 9. Don apron high over chest, tie at neck and waist. 10. Put on visor, ensure band overlaps hood, no skin showing. 11. Put on third pair of short nitrile gloves. 12. Buddy check - verify all items in place, no gaps. Fig. 2: Level 4 PPE Donning Sequence — 12-Step Process

DOFFING IS THE HIGHEST-RISK PHASE — A TRAINED DOFFING BUDDY IS MANDATORY FOLLOW THEIR INSTRUCTIONS THROUGHOUT THE ENTIRE PROCEDURE

PRE-DOFFING CHECKS

Doffing buddy identified and in position in Green Zone

Amber ‘Doffing Area’ is clear of other personnel

Clinical waste bins available and not overfull

Alcohol gel available at Green Zone boundary

Mirror available for hood removal

STEP 1: REMOVE APRON (AMBER ZONE)

1aBreak the pre-broken neck loop by pulling forward from front of apron.

1bRoll dirty side inward, keeping hold of inner ‘clean’ side.

1cPlace in clinical waste bin. Do NOT push down.

Version 1.0 · Adapted September 2026 8 / 8 · p6/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

STEP 2: REMOVE OUTER GLOVES (AMBER ZONE)

2Remove outer (3rd) gloves using ‘pinch and pull’ technique. Do not contaminate the middle gloves below. Place in bin.

STEP 3: REMOVE PAPR HOOD (AMBER ZONE)

3aRemove PAPR hood carefully, avoiding touching outer contaminated surfaces.

3bDisconnect breathing hose from hood.

3cSwitch off blower unit (press and hold green button).

3dRemove carrying system. Place PAPR on designated clean surface for decontamination.

STEP 4: REMOVE COVERALL (AMBER ZONE)

4aUnseal the storm flap and unzip the coverall from top to bottom.

4bPeel coverall off shoulders, rolling dirty side inward as you go.

4cContinue rolling down over hips and legs, turning coverall inside-out.

4dThe taped long-cuff (middle) gloves should come off with the coverall sleeves.

4eStep out of coverall legs. Place in bin — DO NOT push down.

STEP 5: REMOVE INNER GLOVES (AMBER ZONE)

5Remove inner gloves using ‘pinch and pull’ technique. Do not contaminate bare hands. Place in bin.

STEP 6: HAND DECONTAMINATION (TRANSITION TO GREEN)

6aBuddy dispenses alcohol gel into your hands at Green Zone boundary.

6bDecontaminate using WHO 7-step technique.

6cEnsure gel is completely dry before proceeding.

STEP 7: REMOVE BOOTS (GREEN ZONE)

7aMove toward Green Zone boundary.

7bStep out of boots directly into Green Zone.

7cDO NOT step back into Amber area.

Version 1.0 · Adapted September 2026 8 / 8 · p7/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

STEP 8: DISPOSE OF BOOTS

8Pinch inner surfaces together, place in designated bin. Do NOT touch outer surfaces. If unable to safely reach from Green Zone, leave boots where they are.

STEP 9: WASH HANDS

9Immediately wash hands using WHO 7-step technique at nearest sink. Do not touch anything first.

DOFFING COMPLETE — RECORD TIME OF EXIT REPORT ANY PPE BREACHES OR INCIDENTS IMMEDIATELY

DURING USE — IMPORTANT REMINDERS

Monitor PAPR battery LED display regularly

If audible alarm sounds, exit Red Zone immediately

Do not remove PAPR hood in contaminated area

Keep breathing hose unkinked at all times

Always have a buddy present during HCID care

Change outer gloves between care events

Version 1.0 · Adapted September 2026 8 / 8 · p8/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

Doffing sequence chart in three columns — RED ZONE (Contaminated Area), AMBER ZONE (Doffing Area), GREEN ZONE (Clean Area). Panel captions: Step 1: Remove Apron — Pull forward to break, roll dirty side in, bin. Step 2: Remove Outer Gloves — Using pinch-and-pull technique. Step 3: Unfasten Gown Side Tie — Unfasten gown side tie. Step 4: Remove Gown — Grab shoulders, pull down, taped gloves come off with gown, bin. Step 5: Remove Visor — Reach behind head, close eyes, lift band upwards, do NOT bend forward. Step 6: Remove Hood — Locate tabs, pull apart, close eyes, bend forward from waist, lift over head. Step 7: Remove Inner Gloves — Using pinch-and-pull. Step 8: Decontaminate Hands — With alcohol gel (WHO 7 steps). Step 9: Remove FFP3 Mask — Reach behind, lift strings over head, let mask fall away. Step 10: Remove Boots — Step out into clean zone. Step 11: Place Wellies in Designated Bin — Place wellies in designated bin. Step 12: Wash Hands Thoroughly — At nearest sink. Fig. 3: Level 4 PPE Doffing Sequence — Red/Amber/Green Zones

WELLINGTON BOOT MANAGEMENT

Boots can be decontaminated by autoclave or approved methods
If autoclave not available, boots remain in bins until HCID results known
Results negative: clean and return to use
Results positive: destroy as clinical waste

RED ZONE — PATIENT AREA PROTOCOLS

Full Level 4 PPE must be worn at all times
Change outer gloves between care events
Remain vigilant of your own and others’ PPE integrity
Report any PPE breach immediately
Minimise time in Red Zone where possible
All clinical waste remains in Red Zone bins
If PAPR alarm sounds — exit to Amber Zone immediately

Version 1.0 · Adapted September 2026 8 / 8 · p9/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

AMBER ZONE — DOFFING AREA PROTOCOLS

Only one person doffing at a time
Doffing buddy must observe from Green Zone
Follow buddy’s instructions throughout
Use stick to compress bin items if full (do not use hands)
Do NOT enter Green Zone wearing any PPE
Mirror must be available for hood removal

GREEN ZONE — CLEAN AREA PROTOCOLS

No PPE items permitted in Green Zone
Doffing buddy position for observation
Alcohol gel and handwashing facilities available
Staff welfare checks after each Red Zone entry
Document entry/exit times and any incidents

PAPR DECONTAMINATION AFTER USE

1Don PPE (gloves & apron) before handling contaminated PAPR.

2Remove battery (push blue lock tab, fold out).

3Remove & dispose of P3 filter as clinical waste.

4Separate breathing hose from blower and headpiece.

5Wipe all external surfaces with approved chlorine-based disinfectant.

6Flush breathing hose interior with approved disinfectant. Rinse & air dry.

7Clean hood visor/lens and inner surfaces.

8Dry all components thoroughly. Recharge battery.

9Reassemble with new P3 filter before next use.

CLINICAL WASTE MANAGEMENT

All PPE items disposed of as Category A clinical waste
Double-bag in orange clinical waste bags
Seal bags with cable ties or approved closures
Label with date, time, and HCID designation
Store in designated locked area pending collection
PAPR reusable components — decontaminate, do NOT dispose

Version 1.0 · Adapted September 2026 8 / 8 · p10/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

INCIDENT REPORTING

Report immediately if any of the following occur:

PPE breach (tear, puncture, or gap in ensemble)
Needlestick or sharps injury
Splash exposure to mucous membranes
PAPR failure or alarm during patient contact
Incorrect doffing sequence
Feeling unwell during or after Red Zone entry

Immediate actions:

1Exit Red Zone safely.

2Decontaminate affected area immediately.

3Report to senior clinician on scene.

4Complete Datix / incident report form.

5Seek occupational health review.

6Follow local post-exposure prophylaxis protocol.

TRAINING REQUIREMENTS

All staff using Level 4 PPE must have completed:

HCID awareness training

Level 4 PPE donning & doffing practical assessment

Dräger X-plore 8500 device training

Post-use cleaning & decontamination procedure

Emergency procedures (device failure)

Practical assessment signed off by competent assessor

Refresh annually or when equipment/procedures change.

Version 1.0 · Adapted September 2026 8 / 8 · p11/12

APPENDIX H

Level 4 PPE — HCID Ensemble

Appendix

REFERENCES

UKHSA HCID Programme — PPE Guidance
NHS England — HCID Operational Framework
HCID Training Programme — Donning & Doffing Assessment
Dräger X-plore 8500 Instructions for Use (IFU)
HSE PPE at Work Regulations 1992 (amended 2022)
COSHH Regulations 2002
Health and Safety at Work etc. Act 1974

DOCUMENT CONTROL

Version	Date	Status
v1.0	January 2026	Issued

For use by Spark Medical personnel only.

THIS DOCUMENT DOES NOT REPLACE FORMAL HCID PPE TRAINING STAFF MUST BE ASSESSED AS COMPETENT BEFORE USE

Version 1.0 · Adapted September 2026 8 / 8 · p12/12

SAFEGUARDING

Safeguarding Bulletins & NICE Best Practice

See something · Say something · Do something

This section carries every Spark Medical safeguarding bulletin plus a reference set on NICE best practice for ambulance services, checked against nice.org.uk in September 2026. Each bulletin is six screens — cover, why and law, statistics and types, signs and rapid reference, pattern recognition and actions, helplines and reporting. Swipe or use the arrows; the Contents button returns here from anywhere.
Start at NICE 1 if you want the guidance picture first — it says plainly which bulletins NICE covers and which it does not.

IF A CHILD OR ADULT IS IN IMMEDIATE DANGER

Call 999. Ensure the person is taken to a place of safety, then follow the Spark reporting procedure and contact the Spark Safeguarding On-Call. Do not wait for the end of the shift.

NICE best practice for ambulance servicesverified September 2026

Child abuse & neglect3

Family & household risk4

Peer & digital harm2

Exploitation5

Harmful practices & radicalisation3

Adults at risk4

Capacity, communication & the law2

Professional duty1

Safeguarding Bulletins · V1.0 · Spark Medical 24 bulletins

NICE 1

What NICE Actually Says — and Where It Is Silent

NICE best practice

Two NICE guidelines carry the child safeguarding recognition rules, and they are complementary, not sequential.

CG89 — what you see on the body

Bruises, bites, lacerations, burns, fractures, head and spinal injury, poisoning, submersion. Updated 3 December 2025.

NG76 — what you see in the room

Behaviour, family interaction, neglect, disclosure, vulnerability factors — plus what to do next. Published 2017, never updated.

NG76 itself says at 1.3: “Note that physical injuries and other clinical indicators are covered in the NICE guideline on child maltreatment” — that is CG89. Neither replaces the other.

The one that names us

QS116 (Domestic violence and abuse) is the only NICE document that puts ambulance staff on the frontline roster for safeguarding. If you need a single NICE citation to justify this module to a commissioner or to CQC, it is QS116 statements 1 and 2.

Where NICE is silent — do not badge these as NICE

NICE has no guideline or quality standard on child criminal exploitation, county lines, cuckooing, or Prevent / radicalisation. Bulletins 10, 11, 12 and 16 must be cited to their real sources — Working Together to Safeguard Children, the Home Office county lines guidance, the Care Act 2014 s.42, and the Prevent duty guidance. Claiming NICE authority for those cards would be the easiest way to lose credibility in an audit.

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 11

NICE 2

Consider · Suspect · Exclude — the Framework

NICE best practice

The three levels (CG89 wording)

CONSIDERMaltreatment is one possible explanation for the alerting feature, or is included in the differential diagnosis.

SUSPECTA serious level of concern about the possibility of child maltreatment — but not proof of it.

EXCLUDEMaltreatment is ruled out when a suitable explanation is found for the alerting features.

What each level obliges you to do (NG76)

SUSPECTDiscuss the need for a referral with children's social care using local multi-agency safeguarding procedures.

CONSIDERLook for additional corroborating alerting features in the history, presentation or family interactions. Gather information from other agencies and explain to the family why. Review periodically — and escalate to a referral if concern rises to suspect.

IMMEDIATE
DANGERRefer to children's social care and / or the police. Do not wait.

An unsuitable explanation is one that is implausible, inadequate or inconsistent with: the child's presentation; their normal activities; their medical condition; their age and developmental stage; the accounts given by the child and by the carers; the accounts given between carers; or the accounts given over time.

CG89: “At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment.” It moves in both directions — a concern you raised and which was then explained is not a mistake.

Safeguarding Bulletins · V1.0 · Spark Medical 2 / 11

NICE 3

Child Physical Injury — CG89 §1.1

NICE best practice

NEW — December 2025. CG89 now defines “independently mobile”. It governs recommendations 1.1.2, 1.1.5, 1.1.6 and 1.1.9 — bruising, lacerations, burns and fractures.

A child should be considered independently mobile if they can do any of the following: crawl, bottom shuffle, pull themself up into a standing position using an object (for example, furniture), move into a standing position unaided, cruise (that is, move from place to place holding onto an object), climb (for example onto furniture or stairs), walk using a push-along walker, or walk unaided.

CG89, added 3 December 2025

“Children under 12 weeks typically lack the muscle strength, coordination and neurological maturity needed for independent mobility. However, age alone should not be used to determine whether a child is independently mobile.” Assess the child in front of you — do not assume from a date of birth.

This change came from a 2024 exceptional surveillance review, triggered by the Child Safeguarding Practice Review Panel report Bruising in non-mobile infants (September 2022). The undefined term had produced real variation in how maltreatment was being classified.

SUSPECT — bruising (1.1.1–1.1.2)

Bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement
Bruising or petechiae with no medical cause and an unsuitable explanation, including any of the following:
bruising in a child who is not independently mobile
multiple bruises, or bruises in clusters
bruises of similar shape and size
bruises on any non-bony part of the body or face, including eyes, ears and buttocks
bruises on the neck that look like attempted strangulation
bruises on ankles and wrists that look like ligature marks

SUSPECT — burns and scalds (1.1.6)

Explanation absent or unsuitable; or the child is not independently mobile
On soft tissue that would not be expected to come into contact with a hot object
In the shape of an implement — a cigarette, an iron
Forced immersion: scalds to buttocks, perineum and lower limbs; scalds to limbs in a glove or stocking distribution; symmetrical scalds to limbs; scalds with sharply delineated borders

Safeguarding Bulletins · V1.0 · Spark Medical 3 / 11 · p1/2

NICE 3

Child Physical Injury — CG89 §1.1

NICE best practice

SUSPECT — other injury

Rec	Injury	Suspect when
1.1.3	Human bite mark	Thought unlikely to have been caused by a young child
1.1.5	Lacerations, abrasions, scars	Unsuitable explanation and: child not independently mobile; multiple with symmetrical distribution; on areas usually covered by clothing (back, chest, abdomen, axilla, genital area); on eyes, ears, sides of face; on neck, ankles or wrists resembling ligature marks
1.1.9	Fractures	One or more fractures with no predisposing condition, or explanation absent or unsuitable. Includes fractures of different ages and occult fractures
1.1.10	Intracranial injury	Absent major confirmed accidental trauma or known medical cause, where: explanation absent or unsuitable; child under 3 years; retinal haemorrhages; rib or long-bone fractures; other inflicted injuries; multiple subdural haemorrhages ± subarachnoid haemorrhage
1.1.12	Spinal injury	Absent major confirmed accidental trauma. Cervical injury with inflicted head injury; thoracolumbar injury with focal neurology or unexplained kyphosis
1.1.13	Intra-abdominal / intrathoracic	Absent major confirmed accidental trauma, where explanation is absent or unsuitable or there is a delay in presentation
1.1.20	Poisoning	Reported deliberate administration of inappropriate substances; unexpected blood levels of non-prescribed drugs; evidence of ingestion of toxic substances; the child could not access the substance independently; repeated presentations of ingestion in the child or others in the household
1.1.18	Apparent life-threatening events	Repeated ALTEs with onset witnessed only by one parent or carer, and no medical explanation

1.1.24 — CONSIDER maltreatment on an “unusual pattern of presentation to and contact with healthcare providers, or frequent presentations or reports of injuries.” This is the recommendation that covers repeat callers and repeat event attendances — the pattern is itself an alerting feature, even when each individual job looked ordinary.

Safeguarding Bulletins · V1.0 · Spark Medical 3 / 11 · p2/2

NICE 4

Neglect, Behaviour & Fabricated Illness

NICE best practice

SUSPECT — neglect

CG89 1.4.12 / NG76 1.3.40 — the one most likely to be triggered on an ambulance job: parents or carers fail to seek medical advice to the extent that the child's health is compromised, including ongoing pain
Child is persistently smelly and dirty — especially at times of day when there has been no opportunity to become dirty (NG76 1.3.25)
Repeated observation or reports of a poor standard of hygiene that affects the child's health; inadequate provision of food; a living environment unsafe for the child's developmental stage
Child repeatedly scavenges, steals, hoards or hides food with no medical explanation (CG89 1.5.13 / NG76 1.3.23)

NICE states plainly that it is difficult to distinguish between neglect and material poverty. That difficulty is not a reason to withhold a concern — it is a reason to record what you observed rather than what you concluded, and to let social care make the assessment.

CONSIDER — neglect

Severe persistent infestations (1.4.1)Consistently inappropriate clothing or footwear (1.4.2)Faltering growth from inadequate diet (1.4.6)Injury explanation suggesting lack of supervision (1.4.7)Carer unable to provide adequate care (1.4.8)Failure to administer essential prescribed treatment (1.4.9)Repeated failure to attend essential follow-up (1.4.10)Untreated dental caries (1.4.11)

CG89 1.4.5: “Abandoning a child is a form of maltreatment.”

Safeguarding Bulletins · V1.0 · Spark Medical 4 / 11 · p1/2

NICE 4

Neglect, Behaviour & Fabricated Illness

NICE best practice

Behavioural and emotional alerting features

Level	Feature
SUSPECT	Emotional abuse or emotional neglect where the harmful interactions at 1.5.1 / 1.5.4 are persistent. Those interactions are: negativity or hostility; rejection or scapegoating; developmentally inappropriate expectations, threats or discipline; exposure to frightening or traumatic experiences, including domestic abuse; using the child to meet adult needs; failure to promote socialisation
SUSPECT	Sexualised behaviour that is indiscriminate, precocious or coercive; a pre-pubertal child with repeated or coercive sexualised behaviour, or unusual sexualised behaviours (1.5.16–1.5.17)
CONSIDER	Current or past maltreatment — particularly sexual, physical or emotional abuse — where a child is deliberately self-harming (1.5.12)
CONSIDER	The child has run away from home or care, or is living in alternative accommodation without the full agreement of parents or carers (1.5.18). This is the CG89 anchor for the exploitation bulletins.
CONSIDER	The child responds to health examination in an unusual, unexpected or developmentally inappropriate way — extreme passivity, resistance or refusal (1.5.11)
CONSIDER	A parent or carer refuses to allow the child to speak to a healthcare professional on their own when that is necessary for assessment (1.5.19)

Fabricated or induced illness (CG89 1.3.1–1.3.2)

CONSIDER where the history, presentation or findings show a discrepancy with the recognised clinical picture. SUSPECT where that discrepancy is present plus one or more of: symptoms or signs only appear when the parent or carer is present; symptoms are only observed by the parent or carer; an inexplicably poor response to treatment; new symptoms reported as soon as the previous ones resolve; a biologically unlikely history; multiple disputed opinions sought; normal daily activities compromised, or aids such as wheelchairs used more than expected.

Safeguarding Bulletins · V1.0 · Spark Medical 4 / 11 · p2/2

NICE 5

Domestic Abuse — QS116 & PH50

NICE best practice

QS116 names ambulance staff. Frontline staff — listed as nurses, GPs, mental health professionals, midwives, prison staff and ambulance staff — are expected to meet statements 1 and 2.

STATEMENT 1People presenting to frontline staff with indicators of possible domestic violence or abuse are asked about their experiences in a private discussion.

STATEMENT 2People experiencing domestic violence and abuse receive a response from level 1 or 2 trained staff.

STATEMENT 3People experiencing domestic violence or abuse are offered referral to specialist support services.

STATEMENT 4People who disclose that they are perpetrating domestic violence or abuse are offered referral to specialist services.

“Any incident or pattern of incidents of controlling behaviour, coercive behaviour or threatening behaviour, violence or abuse between those aged 16 or over who are family members or who are, or have been, intimate partners. This includes psychological, physical, sexual, financial and emotional abuse. It also includes ‘honour’-based violence and forced marriage.”

QS116 scope — note the clause about ex-partners

Two things follow. First, coercive control is inside QS116's own definition — everything on this card applies to bulletin 23, without needing a separate authority. Second, “or have been” extends it to ex-partners, which is the population most at risk after separation. QS116's wording predates the Domestic Abuse Act 2021, whose section 1 definition is the one with legal force today; the criminal offence of controlling or coercive behaviour is Serious Crime Act 2015 s.76.

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 11 · p1/3

NICE 5

Domestic Abuse — QS116 & PH50

NICE best practice

QS116 statement 1 — the indicators to recognise

Depression, anxiety, PTSD, sleep disturbanceSelf-harm or suicidal ideationSubstance misuseUnexplained chronic pain or GI problemsGynaecological symptoms or reproductive complicationsUrinary tract problemsNeurological symptoms — headaches, cognitive problemsRepeated injuries with unclear explanationsMultiple health consultations with no diagnosisAn intrusive “other person” in consultations

PH50 Rec 6 — how to ask

Ensure frontline staff in all services are trained to recognise the indicators of domestic violence and abuse and can ask relevant questions to help people disclose their past or current experiences.

PH50 recommendation 6

Enquiry must be in private, one-to-one, in an environment where the person feels safe, and in a kind, sensitive manner. Staff must ensure people can be seen on their own — NICE's stated reason is that “a person may have multiple abusers and friends or family members may be colluding in the abuse.” For event medical, this is a treatment-tent layout question before it is a clinical one: can you separate a patient from the person who came in with them?

Rec 7 — information sharing. Read this twice.

ADULT victim — consent-led

Share only with the person's consent, unless they are at serious risk, and within agreed multi-agency protocols. NICE: “Information sharing without consent risks losing trust and may endanger a person's safety.”

A CHILD is affected — share

“Information sharing without consent, or where consent is not given, is necessary when children's safety is at risk.” The adult's wishes do not govern here.

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 11 · p2/3

NICE 5

Domestic Abuse — QS116 & PH50

NICE best practice

Rec 15 — the four training levels

Level	Can do	NICE's examples
1	Respond to a disclosure sensitively and safely, and direct people to specialist services	Physiotherapists, dentists, care assistants, receptionists
2	Ask about domestic violence and abuse in a way that makes it easier to disclose	Nurses, A&E doctors, GPs, midwives, health visitors, mental health professionals
3	Risk identification and assessment, safety planning, continued liaison with specialist services	Child safeguarding social workers, safeguarding nurses
4	Give expert advice and support	Domestic violence advocates, IDVAs

Where Spark crews sit. PH50's own level lists do not name ambulance staff — but QS116 does, and places them on the frontline roster for statements 1 and 2. Statement 2 requires level 1 or 2; level 2 staff assess immediate safety and offer referrals. In practice event-medical crews should be trained to level 2 — trained to ask, not only to receive.

One caution on citation. It could not be confirmed that PH50 or QS116 name MARAC anywhere in their recommendation text — IDVAs are named, MARAC is not. Do not attribute MARAC to NICE without checking the source first.

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 11 · p3/3

NICE 6

Adults at Risk — NG189

NICE best practice

NG189 is scoped to care homes, not to pre-hospital care. It is nonetheless the only NICE adult safeguarding guideline that exists, and its indicator logic, immediate actions and confidentiality rules transfer to a scene without strain. Cite it as guidance you have adopted, not as guidance written for you.

The combination rule (§1.4): if there are multiple indicators, and at least one is a “suspect” indicator, you should suspect abuse or neglect.

Six categories of abuse, with indicators

Neglect (1.4.7–1.4.9)Physical (1.4.10–1.4.12)Sexual (1.4.14–1.4.17)Psychological (1.4.18–1.4.19)Financial and material (1.4.20–1.4.22)Discriminatory (1.4.23–1.4.24)Organisational (§1.12)

Under physical abuse, “suspect” includes multiple or repeated marks or injuries and injuries that are very unlikely to be accidental.

Immediate actions at scene (1.6.1–1.6.13)

1If danger exists — call 999 and stay with the person at risk until help arrives.

2Document what happened, when, where, and who was involved.

3Use simple, open questions, asked in a non-leading way.

4Do not investigate the situation yourself — NICE's stated reason is that doing so “could cause problems for police or other investigations” (1.6.5–1.6.10).

5Preserve evidence (1.1.4, 1.6.10).

6Report to a senior member of staff and to the safeguarding lead as soon as is practical (1.6.13).

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NICE 6

Adults at Risk — NG189

NICE best practice

Confidentiality on disclosure (1.6.11–1.6.12)

Tell the person of your reporting responsibility. Tell them who you will report to, why, and when. And: do not agree to keep secrets or make promises you cannot keep.

NG189 — the clearest statement of this rule in the NICE set

Wishes do not override the duty (1.4.4). Even if the person does not want any safeguarding action taken, if you suspect abuse or neglect you must still refer. Their preference shapes how you act — Making Safeguarding Personal — not whether you act.

Thresholds and principles

The local authority must decide as quickly as possible whether a concern meets the legal criteria for a section 42 safeguarding enquiry (1.7.9). Where it is uncertain whether abuse exists, NICE is explicit that safeguarding leads should discuss it with the local authority first rather than defaulting to not referring (1.7.1–1.7.4). On capacity, follow Making Safeguarding Personal and the NICE guideline on decision making and mental capacity (1.4.2, 1.8.3–1.8.4).

EmpowermentPreventionProportionalityProtectionPartnershipsAccountability

The six statutory principles of adult safeguarding. Cuckooing (bulletin 16) has no NICE coverage at all — the term does not appear in NICE guidance. Route it through this card: NG189 §1.4 indicators, then a Care Act 2014 s.42 referral.

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NICE 7

Documentation, Consent & Information Sharing

NICE best practice

Your notes may be the only contemporaneous record that ever exists. NICE sets an auditable standard for them — and it is the child's words, not your paraphrase.

Children and young people who have experienced abuse or neglect have their words accurately represented in notes summarising their conversations with practitioners.

QS179 quality statement 3

Produce a record of conversations using their actual words unless there is a good reason not to — and check that they have understood and agree with what is recorded.

NG76 recommendation 1.1.6

What to record (CG89 process step 3)

“Record in the child or young person's clinical record exactly what is observed and heard, from whom and when. Record why this is of concern.” Then, after you act: “Record all actions taken and the outcome.”

Consent and what you must explain

Rec	Obligation
NG76 1.1.3	During conversations about abuse or neglect, explain confidentiality and when you might need to share specific information, and with whom
NG76 1.1.5	Before any physical contact, explain what you are going to do and ask for consent
NG76 1.4.1	Communicate directly with the child without the parent or carer present — with the parent or carer's consent
NG76 1.4.5	Communicate your concerns honestly to families, to avoid increasing the risk of harm
NG189 1.6.11	On disclosure, tell the person who you will report to, why, and when. Do not agree to keep secrets
NG55 1.1.9–1.1.12	Collect and share information as set out in the Caldicott Guardian information standards

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NICE 7

Documentation, Consent & Information Sharing

NICE best practice

The five-step process — CG89

1Identify the source — history given, disclosure, appearance, behaviour or demeanour, symptom, physical sign, investigation result, or parent–child interaction. NICE: “It is standard practice to refer to children's social services when a child makes a disclosure of maltreatment, even though it may not be precise in every detail.”

2Seek an explanation from both the parent or carer and the child, openly and non-judgementally. Note the warning on disability: “Alerting features of maltreatment in children with disabilities may also be features of the disability, making identification more difficult.”

3Document — exactly what you observed and heard, from whom, when, and why it concerns you.

4Gather and consult — look for other alerting features; discuss with a more experienced colleague, a community paediatrician, a CAMHS colleague, or a named or designated safeguarding professional.

5Refer and record — refer to children's social care following local multi-agency arrangements, then record every action taken and the outcome.

FGM is different. NG76 1.3.8 — regulated professionals have a mandatory statutory duty to report FGM in an under-18 to the police. This is the only hard reporting duty in the NICE safeguarding set. It is not a referral decision and it is not discretionary.

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NICE 8

Mental Capacity — NG108, and the DoLS / LPS Position

NICE best practice

CORRECTION TO BULLETIN 22. That bulletin describes Liberty Protection Safeguards as the “successor” to DoLS. LPS has never been brought into force. DoLS is the framework that applies today.

LPS was created by the Mental Capacity (Amendment) Act 2019, delayed in April 2023 “beyond the life of this Parliament”, and is still not in force. It has not been abandoned either — on 18 October 2025 DHSC and the Ministry of Justice announced a consultation on LPS implementation to run in the first half of 2026. So do not tell a crew LPS applies, and do not tell them it is dead. Today: DoLS. Verified September 2026; check before this guide is reissued.

NICE has no guideline or quality standard on DoLS or LPS — the term appears only in passing in NG108's and NG189's scope documents. Everything below is NG108, which is what NG189 cross-refers to for capacity.

NG108 — capacity is decision-specific

ASSUME
CAPACITY1.1.4 — assume capacity unless there is evidence to suggest an assessment is required. The starting point is not neutral; it is in the person's favour.

PROPORTIONATE1.1.54 — the assessment and its recording should be proportionate to the complexity and significance of the decision. A decision about a lift home is not a decision about surgery.

SUPPORT
FIRST1.1.12 find out how the person wants to be supported to decide · 1.1.21 support them to communicate so they can take part · 1.1.24 allow sufficient time.

The two-stage test — the direction matters

1.1.74 — record what impairment or disturbance of the mind or brain has been identified, and confirm that the inability to decide is a direct consequence of it. The impairment must cause the inability. An impairment that merely co-exists with an unwise decision is not incapacity — and an unwise decision is not, by itself, evidence of anything.

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NICE 8

Mental Capacity — NG108, and the DoLS / LPS Position

NICE best practice

Best interests — and the emergency carve-outs

Rec	What it says
1.1.78	A capacity assessment and a finding of incapacity must be recorded before a best-interests decision — “except in emergency situations.”
1.1.55	The expectation that you already know something of the person applies “except in emergencies or where services have had no previous contact.”
1.1.90	Find out the person's wishes and feelings, and document your reasons where the decision does not accord with them.
1.1.92	Explore less restrictive options that will meet the person's needs.
1.1.44	Review advance care plans while the person has capacity, and amend as necessary.

Those two carve-outs are the ones that matter to a crew: NG108 was written knowing that emergency care cannot always pause for paperwork. They excuse the recording sequence and the prior knowledge — they do not excuse the duty to assume capacity, to support the person to decide, or to choose the least restrictive option.

Safeguarding Bulletins · V1.0 · Spark Medical 8 / 11 · p2/2

NICE 9

Learning Disability & Diagnostic Overshadowing

NICE best practice

Diagnostic overshadowing is the failure mode that kills people with a learning disability: a new, treatable problem gets written off as part of the disability.

Diagnostic overshadowing — “the tendency to attribute all behavioural, emotional, physical and social issues to a person's learning disability or a pre-existing condition, while overlooking the possibility that they could be symptoms of other conditions or difficulties.”

NG96 — NICE's formal definition

NG96 1.7.3 puts the duty in the positive: assess people's changing needs, and do not assume that any new problem is due to their learning disability when it could be a symptom of something else. NG54 1.8.4 describes the same trap from the other side — a physical health condition, or a sensory or cognitive impairment, may mask an underlying mental health problem.

Reasonable adjustments — this one is a “must”

NG96 1.1.3 — providers and commissioners must make reasonable adjustments to ensure services are fully accessible, in line with the Equality Act 2010. NICE writes “must”, not “should”: this is a legal duty being restated, not a recommendation.

What that means at a scene

NG54 1.3.1 — use clear, straightforward and unambiguous language; assess whether communication aids, an advocate, or someone familiar with the person's communication methods are needed; adjust for sensory impairments
NG96 1.1.5 — communication support per the NHS Accessible Information Standard: independent interpreters, extended time, Easy Read, visual aids, advocacy
NG54 1.8.2 — speak to the person on their own to find out if they have any concerns, including safeguarding concerns. On a job with a carer present, this is the single most useful line on this card
NG54 1.8.18 — risk assessment should cover vulnerability to exploitation, and whether safeguarding protocols should be implemented
NG96 1.1.6 — the person should be given accessible information on how to raise a safeguarding concern themselves

A caution on scope. None of these is a safeguarding guideline — they are care and mental-health guidelines that happen to contain safeguarding lines. For recognising abuse in a person with a learning disability, NICE is not your authority: route to the Care Act 2014 and local safeguarding procedures. Codes are easily confused — NG96 is growing older with learning disabilities; NG54 is mental health problems in people with learning disabilities.

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Guidance Register & Status

NICE best practice

Every code, date and status below was checked against nice.org.uk in September 2026. NICE reviews its guidance continually — re-verify before this guide is reissued. One item could not be resolved: the NICE safeguarding topic page reports counters for new and in-development quality standards but renders its list in JavaScript, so the codes behind those counters could not be read. Open that page in a browser before signing this section off.

CG89Child maltreatment: when to suspect maltreatment in under 18sPublished 22 Jul 2009 · Last updated 3 Dec 2025 · live · nice.org.uk/guidance/cg89The clinical / injury alerting features. Updated Dec 2025 with a definition of independently mobile.
NG76Child abuse and neglect: recognising, assessing and respondingPublished 9 Oct 2017 · Last updated never · live · nice.org.uk/guidance/ng76The behavioural, relational and response features — and what to do next.
QS179Child abuse and neglect (quality standard)Published 12 Feb 2019 · Last updated none · live · nice.org.uk/guidance/qs179Five quality statements. Statement 3 is the documentation standard.
QS116Domestic violence and abuse (quality standard)Published 29 Feb 2016 · Last updated none · live · nice.org.uk/guidance/qs116The only NICE document that names ambulance staff in a safeguarding role. Four quality statements.
PH50Domestic violence and abuse: how services can respond effectivelyPublished 26 Feb 2014 · Last updated none · live · nice.org.uk/guidance/ph5017 recommendations. Recs 5, 6, 7, 8, 10 and 15 are frontline.
NG189Safeguarding adults in care homesPublished 26 Feb 2021 · Last updated none · live · nice.org.uk/guidance/ng189Scoped to care homes, but the only NICE adult safeguarding guideline. Its indicators and immediate actions transfer to a scene.
NG55Harmful sexual behaviour among children and young peoplePublished 20 Sep 2016 · Last updated unverified · live · nice.org.uk/guidance/ng55Rec 1.2.1 — inform the named safeguarding lead immediately.
NG108Decision-making and mental capacityPublished 3 Oct 2018 · Last updated Oct 2018 (minor) · live · nice.org.uk/guidance/ng108The guideline NG189 cross-refers to for capacity. Carries two explicit emergency carve-outs a crew will rely on.
NG96Care and support of people growing older with learning disabilitiesPublished Apr 2018 · Last updated none · live · nice.org.uk/guidance/ng96Carries NICE's formal definition of diagnostic overshadowing (1.7.3) and the Equality Act “must” on reasonable adjustments (1.1.3).
NG54Mental health problems in people with learning disabilitiesPublished 14 Sep 2016 · Last updated 2024 (exact date not published) · live · nice.org.uk/guidance/ng541.3.1 on communication adjustments and 1.8.2 on speaking to the person alone are the two that transfer to a scene.
DoLS / LPSDeprivation of Liberty Safeguards · Liberty Protection SafeguardsPublished — · Last updated — · no NICE guidance · see NICE 8NICE has no guideline on either. LPS has never been brought into force — DoLS remains the operative framework. See NICE 8.
NG205Looked-after children and young peoplePublished 20 Oct 2021 · Last updated none · live · nice.org.uk/guidance/ng205Rec 1.4.5 is the closest NICE comes to a county lines / CCE recommendation.
NG232Head injury: assessment and early managementPublished 18 May 2023 · Last updated see NICE · live · cross-link · nice.org.uk/guidance/ng232Not a safeguarding guideline, but suspected non-accidental head injury sits between NG232 and CG89 1.1.10.
NG94 / QS174Emergency and acute medical care in over 16sPublished 2018 · Last updated — · no safeguarding content · nice.org.uk/guidance/ng94Verified negative. QS174 statement 1 is titled “Ambulance services” but concerns advanced paramedic practitioners, not safeguarding.

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ROUTING

Which Bulletin Maps to Which Guidance

NICE best practice

Four of these bulletins have no NICE anchor at all. Badge them by their real statutory source — not by NICE.

NICE covers thisPartial — definition or a vulnerability factor onlyNo NICE coverage — cite the real source

Child physical abuseCG89 §1.1 · NG76 §1.3
Child neglectCG89 §1.4 · NG76 1.3.23–1.3.28, 1.3.40
Safeguarding the unborn babyNo specific NICE guidance. NG76 1.2.3 (parental vulnerability factors) · PH50 Rec 6 (routine antenatal enquiry)
Parental substance misuseNG76 1.2.3 — parental substance misuse is a named vulnerability factor. No dedicated guideline.
Parental mental ill-healthNG76 1.2.3 — “mental health problems significantly impacting parenting”. No dedicated guideline.
Domestic abuseQS116 (names ambulance staff) · PH50 Recs 5–10, 15
BullyingNG76 defines it — “persistent intentional behaviour causing physical or emotional harm” — but gives no recognition recommendations.
Online abuse & digital harmsThin. NG76 CSE definition (abuse “through technology”) · NG55 1.2.1 (sexting, age-inappropriate pornography) · NG205 1.2.12 (unmonitored online contact)
Child sexual exploitationDefinition and behavioural features only: NG76 Terms, 1.3.20–1.3.22, 1.2.6 · CG89 1.5.16–1.5.17
Child criminal exploitationNICE does not define criminal exploitation. Closest: NG205 1.4.5 · NG76 1.8.3 · CG89 1.5.18. Cite Working Together to Safeguard Children, not NICE.
County linesNo NICE coverage. As above — cite Working Together and the Home Office county lines guidance.
Prevent & radicalisationNo NICE anchor exists. Radicalisation is not mentioned anywhere in NG76's recognition recommendations. Cite the Prevent duty guidance and KCSIE.
Female genital mutilationNG76 1.3.8 — the mandatory duty to report FGM in an under-18 to the police. The only hard statutory reporting duty in the NICE safeguarding set. Also NG205 1.5.11.
Forced marriage & HBAMentioned, not developed: NG76 1.3.45–1.3.46 (trafficking for forced marriage) · NG76 1.8.3 (“honour-based abuse”)
Modern slavery & traffickingNG76 1.3.45–1.3.47 — including referral to the National Referral Mechanism and interpreter continuity.
CuckooingThe term does not appear in NICE guidance. Adult safeguarding route only: NG189 §1.4 indicators and a Care Act 2014 s.42 referral.
Adult neglect & acts of omissionNG189 1.4.7–1.4.9 neglect indicators — written for care homes, adopted here. Statutory route: Care Act 2014 s.42.
Self-neglectNICE has no guidance on self-neglect, and NG189 does not treat it as a distinct category. Cite the Care Act 2014 s.42 and chapter 14 of the Care and Support Statutory Guidance. Capacity sits at the centre — see NICE 8.
Elder physical abuseNG189 1.4.10–1.4.12 — “suspect” includes multiple or repeated marks or injuries and injuries very unlikely to be accidental.
Financial abuseNG189 1.4.20–1.4.22, financial and material abuse. One of the six NG189 categories; no dedicated NICE guideline.
Learning disabilitiesNG96 1.7.3 defines diagnostic overshadowing and 1.1.3 makes reasonable adjustments an Equality Act must. NG54 1.3.1 on communication, 1.8.2 on speaking to the person alone. See NICE 9.
Mental Capacity & DoLSNG108 — decision-making and mental capacity, including two emergency carve-outs. No NICE guidance on DoLS or LPS. See NICE 8 — and read the correction there before using bulletin 22.
Coercive & controlling behaviourQS116's own scope definition names it: “controlling behaviour, coercive behaviour”. So the whole of NICE 5 applies. Statutory: Serious Crime Act 2015 s.76, Domestic Abuse Act 2021 s.1.
Whistleblowing & speaking upOutside NICE's remit entirely — zero results on nice.org.uk. Cite PIDA 1998, the National Guardian / Freedom to Speak Up, CQC Regulation 20 (statutory duty of candour), and HCPC standards — HCPC, not GMC/NMC, is the regulator for paramedics.

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BULLETIN 01

Child Physical Abuse

Safeguarding

SAFEGUARDING BULLETIN 01

PROTECT THE CHILD.

A single accurate concern raised early can prevent a serious injury — or a death.

Every Spark Medical member of staff has a personal duty under UK law.

You may be the only professional a child sees after an incident.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG01 · August 2026 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 01

Child Physical Abuse

Safeguarding

Why vigilance matters

Child physical abuse is one of the most under-recognised forms of harm in front-line healthcare. Spark Medical staff are often the first professional a child will see after an incident — whether in an emergency, at an event, or during patient transfer. What we see, record and act on can be decisive. A single accurate concern raised early has the power to prevent life-changing injury or death. Every member of staff has a personal and professional responsibility under UK law to safeguard children.

Definition

Physical abuse is any act by an adult, or an older child, that intentionally causes physical harm to a child under the age of 18. This includes hitting, slapping, punching, kicking, shaking, throwing, poisoning, burning, scalding, biting, drowning, or otherwise deliberately injuring a child. Physical abuse also includes fabricated or induced illness — where a parent or carer fabricates symptoms, or deliberately causes ill health in a child.

Physical abuse can occur in isolation but is frequently associated with other categories of harm — neglect, emotional abuse, domestic abuse in the household, or parental substance misuse. Any single presentation should be considered in the context of the whole family picture.

Legal & policy framework

Children Act 1989 — defines 'significant harm' and gives local authorities the duty to investigate under Section 47 where a child is suspected of suffering, or likely to suffer, significant harm.
Children Act 2004, Section 11 — places a statutory duty on NHS bodies (including Integrated Care Boards and NHS trusts) and other listed agencies to make arrangements to safeguard and promote the welfare of children.
Working Together to Safeguard Children (2023) — statutory guidance from HM Government setting out the multi-agency arrangements for safeguarding.
Children and Social Work Act 2017 — introduced safeguarding partners and the duty to review serious child safeguarding cases.

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BULLETIN 01

Child Physical Abuse

Safeguarding

Key statistics

1 in 14children in the UK have experienced physical abuse

< 1 yrthe age group at highest risk of fatal injury

~50%of serious case reviews involve physical injury

Risingreferrals for suspected non-accidental injury post-pandemic

Sources: NSPCC, Department for Education • Working Together to Safeguard Children (2023)

Types & presentations

ImpactHitting, slapping, punching, kicking

ShakingEspecially dangerous in infants — abusive head trauma

BurnsScalds, contact burns, cigarette burns

FabricatedInduced illness, false symptoms

PoisoningDrugs, chemicals, over-medication

Any deliberately-caused injury is physical abuse — pattern, site and history matter

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BULLETIN 01

Child Physical Abuse

Safeguarding

Signs to watch for

Bruises

Any bruise on a non-mobile baby
Clustered or patterned bruising
Ears, neck, buttocks, torso
Bruises of different ages
Bruises shaped like an implement

Presentation red flags

Story does not fit the injury
Explanation changes between accounts
Delayed presentation
Injury blamed on a sibling or pet
Child unusually quiet or watchful

Serious injuries

Any fracture in a non-mobile baby
Torn frenulum
Retinal haemorrhage
Burns or scalds — particularly gloved / stocking pattern
Unexplained collapse or apnoea

Baby / under 5

Any bruise before independent mobility
Fracture, especially rib or long-bone
Head injury with no clear history
Bite marks
Failure to thrive plus injury

Figure 1: Recognising the signs of child physical abuse. Adapted from NSPCC guidance (nspcc.org.uk).

Clinician rapid reference

THE CHILD

Mobile? Non-mobile baby = high suspicion
Undress and body-map all injuries
Behaviour — fearful, frozen, over-compliant
Disclosure — record verbatim

THE INJURY

Site — ears, neck, torso, buttocks are concerning
Pattern — clustered, symmetrical, implement-shaped
Age — injuries of different ages

THE STORY

Does the mechanism fit the injury?
Does the story change?
Was there a delay in seeking help?
Consider siblings and household

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BULLETIN 01

Child Physical Abuse

Safeguarding

Pattern recognition

GREEN

Mobile child, plausible mechanism
Injury site fits story
Single minor injury, prompt help-seeking
Child interacts normally
Consistent history across carers

AMBER

Slightly delayed presentation
Minor inconsistency in story
Parent stressed or under pressure
Repeated minor injuries
Child quiet or watchful

RED

Any bruise or fracture on a non-mobile baby
Story does not fit injury
Story changes between accounts
Delayed presentation with serious injury
Disclosure of physical harm

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Body-map every injury.

2ASK

Age-appropriate questions to the child and to the carer.

3RECORD

Contemporaneous notes — site, size, colour, shape.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Record contemporaneously, in your own words, exactly what you saw, heard and did. Include verbatim quotes where possible, body-map any injuries, note the time of each observation and each action, and record who else was present. Objective language only — no opinion, no diagnosis. Your notes may be the only record a safeguarding lead sees.

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BULLETIN 01

Child Physical Abuse

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

IF YOU ARE A YOUNG PERSON

Childline — free, confidential

0800 1111

Sources & further reading

NSPCC — Physical Abuse
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/physical-abuse/
NSPCC Learning — Definitions and signs of child abuse
https://learning.nspcc.org.uk/research-resources/briefings/definitions-signs-child-abuse
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Children Act 2004 — Section 11
https://www.legislation.gov.uk/ukpga/2004/31/section/11
RCPCH — Child protection resources
https://www.rcpch.ac.uk/resources/child-protection-resources
NICE guideline NG76 — Child abuse and neglect
https://www.nice.org.uk/guidance/ng76
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 02

Child Neglect

Safeguarding

SAFEGUARDING BULLETIN 02

EVERY CHILD DESERVES CARE.

Neglect is the most common category on child protection plans.

It is chronic, cumulative and often invisible on a single visit.

You may be the first professional to notice.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG02 · August 2026 · Spark Medical

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BULLETIN 02

Child Neglect

Safeguarding

Why vigilance matters

Child neglect is the most common form of safeguarding concern seen in front-line healthcare, yet the hardest to recognise on a single call-out. Neglect harms cumulatively: a cold home, a missed clinic, an unmanaged medical need, an unwashed child — each detail alone is easily explained away, but together they are the single strongest predictor of serious harm. Spark Medical staff enter homes, schools and public places every day and see what other professionals do not. What you notice, record and share can save a child's life.

Definition

Neglect is the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. It includes failure to provide adequate food, clothing and shelter (including exclusion from home or abandonment); failure to protect from physical and emotional harm or danger; failure to ensure adequate supervision (including inadequate care-givers); or failure to ensure access to appropriate medical care or treatment.

Neglect may also include neglect of, or unresponsiveness to, a child's basic emotional needs. It is often chronic and can begin before birth (for example when a pregnant woman does not engage with antenatal care). It commonly co-exists with domestic abuse, parental substance misuse, and parental mental ill-health.

Legal & policy framework

Children Act 1989, Section 47 — duty on local authorities to investigate where a child is suspected of suffering, or likely to suffer, significant harm through neglect.
Children Act 2004, Section 11 — statutory duty on NHS bodies and other agencies to safeguard and promote the welfare of children.
Working Together to Safeguard Children (2023) — statutory guidance including specific expectations around identifying and responding to neglect.
Children and Young Persons Act 1933, Section 1 — the criminal offence of cruelty (including neglect) to a person under 16.

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BULLETIN 02

Child Neglect

Safeguarding

Key statistics

~50%of children on protection plans are there for neglect

1 in 10children in the UK have experienced neglect

Under 5the age group at highest risk of serious harm

Chroniccumulative harm — recognise early, act early

Sources: Department for Education, NSPCC • Working Together to Safeguard Children (2023)

Types & presentations

PhysicalFood, clothing, hygiene, shelter

EmotionalWarmth, affection, responsiveness

MedicalMissed care, unmanaged conditions

EducationalPersistent non-attendance

SupervisoryLeft alone, unsafe environments

Any single category can constitute neglect — patterns confirm the picture

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BULLETIN 02

Child Neglect

Safeguarding

Signs to watch for

Physical signs

Persistent hunger, thirst or poor growth
Poor hygiene, ingrained dirt, head lice
Inappropriate clothing for weather
Untreated medical or dental problems
Recurrent minor infections

Presentation red flags

Missed clinic, immunisation or A&E follow-up
Home cold, damp, dirty or unsafe
Little or no food in the home
Multiple children on scene, unsupervised
Delayed help-seeking

Behavioural signs

Fearful, watchful or 'frozen' child
Overly self-reliant or parentified for age
Language or developmental delay
Poor peer relationships
Attachment difficulties

Baby / under 5

Failure to thrive, low weight-for-age
Missed immunisations or checks
Severe nappy rash, dental caries
Persistent unwell presentation
Poorly responsive or 'flat' baby

Figure 1: Recognising the signs of child neglect. Adapted from NSPCC guidance (nspcc.org.uk).

Clinician rapid reference

THE CHILD

Poor hygiene, ingrained dirt
Inappropriate or dirty clothing
Low weight-for-age, failure to thrive
Unmanaged medical or dental needs

THE HOME

Cold, damp, no food in fridge
Unsafe environment (waste, drugs, weapons)
Sleeping arrangements inadequate

THE FAMILY

Missed appointments, chaotic engagement
Parental substance misuse or MH crisis
Domestic abuse in the household

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BULLETIN 02

Child Neglect

Safeguarding

Pattern recognition

GREEN

Child looks well cared-for
Home warm, clean, food available
Parent engaged and responsive
Appointments kept
Age-appropriate development

AMBER

Occasional missed appointment
Home slightly chaotic but safe
Parent under stress or unwell
Minor hygiene concerns
Delayed help-seeking

RED

Multiple missed appointments
Home unsafe, squalid or freezing
Child hungry, dirty or 'flat'
Parent under influence or absent
Failure to thrive

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at child, home and family.

2ASK

Ask the child (age-appropriate) and the carer. Open questions.

3RECORD

Contemporaneous notes. Home environment, hygiene, weight.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 02

Child Neglect

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

IF YOU ARE A YOUNG PERSON

Childline — free, confidential

0800 1111

Sources & further reading

NSPCC — Neglect
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/neglect/
NSPCC Learning — Recognising neglect
https://learning.nspcc.org.uk/child-abuse-and-neglect/neglect
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Children Act 2004 — Section 11
https://www.legislation.gov.uk/ukpga/2004/31/section/11
Children and Young Persons Act 1933 — Section 1
https://www.legislation.gov.uk/ukpga/Geo5/23-24/12/section/1
RCPCH — Child protection resources
https://www.rcpch.ac.uk/resources/child-protection-resources
NICE guideline NG76 — Child abuse and neglect
https://www.nice.org.uk/guidance/ng76
Action for Children — Neglect
https://www.actionforchildren.org.uk/what-we-do/protecting-children-from-harm/neglect/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 03

Safeguarding the Unborn Baby

Safeguarding

SAFEGUARDING BULLETIN 03

SAFEGUARDING BEGINS BEFORE BIRTH.

The unborn baby is one of the most vulnerable people in UK law.

Concerns identified antenatally allow protection to be planned before birth.

You may be the only professional who sees the whole family.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG03 · September 2026 · Spark Medical

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BULLETIN 03

Safeguarding the Unborn Baby

Safeguarding

Why vigilance matters

The unborn baby is one of the most vulnerable people Spark Medical staff will ever meet. Concerns identified during pregnancy allow protection to be planned before the child is born — including pre-birth conferences, safety plans, and, where necessary, care proceedings from the moment of birth. Recognising risk in pregnancy is one of the single most powerful safeguarding interventions available. Whenever we transport a pregnant woman, attend a maternity or perinatal call, or see a household where a pregnancy is disclosed, we are also safeguarding the child.

Definition

Safeguarding the unborn baby means recognising and responding to concerns about a pregnancy where the child, once born, is likely to suffer significant harm or neglect. Concerns may arise from the mother's circumstances, the wider household, or from previous children who have been removed or harmed. UK statutory guidance requires professionals to make a referral to children's social care where a pre-birth assessment may be needed — typically no later than the 20-week scan, and always as soon as concerns emerge.

The unborn baby has no legal personhood before birth, but children's social care can and does carry out pre-birth planning under Working Together to Safeguard Children (2023). Where the risk is high (for example previous children removed, ongoing domestic abuse, or severe parental substance misuse), a pre-birth conference must be held and a plan agreed before birth.

Legal & policy framework

Children Act 1989, Section 47 — duty to investigate applies to a child from birth; pre-birth planning uses this framework in anticipation.
Children Act 2004, Section 11 — statutory duty to safeguard and promote welfare, includes unborn children in pre-birth planning.
Working Together to Safeguard Children (2023) — statutory guidance explicitly covers pre-birth assessment and multi-agency planning.
HCPC / GMC / NMC professional codes — duty to raise concerns about an unborn baby where risk is identified during clinical contact.

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BULLETIN 03

Safeguarding the Unborn Baby

Safeguarding

Key statistics

~20 wksthe typical trigger point for pre-birth referral

30–40%of maternal deaths involve domestic abuse in some form

2 xrisk of stillbirth in families known to safeguarding services

Everypregnancy in a high-risk household warrants referral

Sources: MBRRACE-UK, NSPCC, Working Together to Safeguard Children (2023)

Types & presentations

Prev. removalAny previous child removed from parent(s)

DAOngoing or historical domestic abuse

SubstancesAlcohol or drug misuse in pregnancy

MH crisisSerious perinatal mental illness

HouseholdSchedule 1 offender / MAPPA in home

Antenatal referral is the strongest protective act available for the unborn baby

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BULLETIN 03

Safeguarding the Unborn Baby

Safeguarding

Signs to watch for

The mother

Late booking or non-engagement with antenatal care
Domestic abuse disclosed or suspected
Substance misuse in pregnancy
Serious perinatal mental illness
Under 18 or care-experienced

The pregnancy

Concealed or denied pregnancy
Repeated non-attendance at scans
Injuries to abdomen — assault in pregnancy
Unexplained bleeding or presentations
Refusal of maternity care

The household

Schedule 1 offender in household
Ongoing domestic abuse in the home
Parental substance misuse
Chaotic, unsafe or overcrowded home
MAPPA / criminal exploitation

The history

Previous child(ren) removed
Previous serious case review or protection plan
Family history of infant harm
Learning disability affecting parenting capacity
No engagement with pre-birth plan

Figure 1: Recognising antenatal safeguarding risk. Adapted from NSPCC and RCM guidance.

Clinician rapid reference

MOTHER

Late booking / non-attendance at scans
DA disclosed or suspected
Substance misuse in pregnancy
Serious perinatal mental illness

PREGNANCY

Concealed or denied pregnancy
Injuries to abdomen (any mechanism)
Unexplained bleeding, refusal of care

HISTORY / HOUSEHOLD

Previous children removed
Schedule 1 offender in household
MAPPA / criminal exploitation

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BULLETIN 03

Safeguarding the Unborn Baby

Safeguarding

Pattern recognition

GREEN

Booked in early, attends antenatal care
Household stable, no DA
No substance misuse
No previous safeguarding concerns
Engaged with maternity team

AMBER

Late booking, some missed appointments
Historical DA (now separated)
Recent life stressor
Mild parental MH concerns
Family under social care assessment

RED

No antenatal engagement or concealed pregnancy
Ongoing domestic abuse
Alcohol / drug misuse in pregnancy
Previous child(ren) removed
Schedule 1 offender in household

Any red flag — refer today. Two or more amber — escalate for review.

See it, act on it

1NOTICE

Any risk factor in a pregnant household — pause and consider.

2ASK

Ask sensitively about DA, substances, previous children.

3RECORD

Document mother, partner, household, history. Verbatim disclosures.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 03

Safeguarding the Unborn Baby

Safeguarding

Helplines & signposting

WORRIED ABOUT AN UNBORN BABY?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

DOMESTIC ABUSE IN PREGNANCY

National DA Helpline — Refuge, 24/7

0808 2000 247

Sources & further reading

NSPCC — Protecting babies from harm
https://learning.nspcc.org.uk/child-abuse-and-neglect/protecting-babies-from-harm
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Children Act 2004 — Section 11
https://www.legislation.gov.uk/ukpga/2004/31/section/11
Royal College of Midwives — Safeguarding position statement
https://www.rcm.org.uk/publications/
Royal College of Obstetricians and Gynaecologists — Domestic abuse in pregnancy
https://www.rcog.org.uk/for-the-public/browse-our-patient-information/domestic-violence/
MBRRACE-UK — Confidential enquiries into maternal deaths
https://www.npeu.ox.ac.uk/mbrrace-uk
RCPCH — Child protection resources
https://www.rcpch.ac.uk/resources/child-protection-resources
NICE guideline NG76 — Child abuse and neglect
https://www.nice.org.uk/guidance/ng76
Refuge — National Domestic Abuse Helpline (24/7) — 0808 2000 247 | nationaldahelpline.org.uk
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 04

Parental Substance Misuse

Safeguarding

SAFEGUARDING BULLETIN 04

BEHIND CLOSED DOORS, A CHILD IS WATCHING.

Parental substance misuse is a factor in a large share of child protection cases.

Children often become carers, secret-keepers or bystanders to chaos.

You may be the only professional who sees inside the home.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG04 · September 2026 · Spark Medical

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BULLETIN 04

Parental Substance Misuse

Safeguarding

Why vigilance matters

Spark Medical staff attend homes at all hours, often unannounced, and see what clinics and schools cannot: the paraphernalia on a table, the parent who cannot be roused, the child who has learned to manage alone. Parental substance misuse rarely presents as a standalone concern — it is usually discovered while responding to something else. Your vantage point inside the home, at the moment of crisis, makes you uniquely placed to notice when a child is living alongside chaotic or dependent drug or alcohol use.

Definition

Parental substance misuse refers to the use of drugs or alcohol by a parent or carer in a way that impairs their ability to meet a child's needs, as recognised in Working Together to Safeguard Children (2023) as one of the three most common features of cases where children suffer significant harm, alongside domestic abuse and parental mental ill-health. It can affect supervision, routine, emotional availability and home safety.

Substance misuse does not automatically mean a child is unsafe — many parents manage dependency while maintaining safe, loving care. The safeguarding concern arises from the impact on parenting capacity: chaotic use, relapse, intoxication during care-giving hours, or a home environment where drugs or drug-related items are accessible to children.

Legal & policy framework

Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm.
Children Act 2004, Section 11 — statutory duty on NHS bodies to safeguard and promote children's welfare.
Working Together to Safeguard Children (2023) — identifies parental substance misuse as a key indicator of household stress associated with significant harm.
Children and Young Persons Act 1933, Section 1 — offence of cruelty to a person under 16, including exposure to danger.
Care Act 2014, Section 42 — duty to make enquiries where an adult with care needs, including a substance-misusing parent, may be at risk.

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BULLETIN 04

Parental Substance Misuse

Safeguarding

Key statistics

~30%of child protection cases feature parental substance misuse

2.5m+children in the UK live with a parent who drinks hazardously

1 in 3serious case reviews cite parental substance misuse as a factor

Hidden harmchildren often conceal the problem to protect their parent

Sources: Department for Education, Advisory Council on the Misuse of Drugs • Working Together to Safeguard Children (2023)

Types & presentations

Chaotic useUnpredictable care, missed routines

IntoxicationImpaired supervision during care hours

Neglect overlapBasic needs unmet due to dependency

Exposure riskParaphernalia, substances accessible

Antenatal riskSubstance use in pregnancy

Impact on the child — not the substance itself — is the safeguarding concern

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BULLETIN 04

Parental Substance Misuse

Safeguarding

Signs to watch for

Physical signs

Child looks unkempt, hungry or tired
Injuries consistent with lack of supervision
Poor school attendance or persistent lateness
Untreated medical or dental needs
Signs of self-care beyond the child's years

Behavioural signs

Anxious, withdrawn or hyper-vigilant child
Child minimises or covers for the parent
Acting as carer for parent or siblings
Reluctance to bring friends home
Secretive or evasive when asked about home life

Environmental signs

Drug or alcohol paraphernalia visible or accessible
Chaotic, unsafe or unhygienic home
Unknown adults present, drug-related activity
Money or valuables missing, signs of debt
Evidence of dealing or cuckooing

Parent presentation

Intoxicated, sedated or unresponsive at visit
Erratic mood, aggression or withdrawal symptoms
Missed antenatal or health appointments
Reluctant to allow access to the home

Figure 1: Recognising the impact of parental substance misuse. Adapted from NSPCC guidance (nspcc.org.uk).

Clinician rapid reference

THE PARENT

Level of intoxication or impairment now
History of dependency, treatment engagement
Capacity to respond to the child's needs
Willingness to accept support

THE HOME

Paraphernalia or substances accessible to children
General safety, hygiene and warmth
Presence of unknown or concerning adults

THE CHILD

Visible wellbeing, affect and behaviour
Evidence of a caring or protective role
Direct, age-appropriate conversation if safe to do so

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BULLETIN 04

Parental Substance Misuse

Safeguarding

Pattern recognition

GREEN

Parent engaged with treatment or support
Home safe, substances stored securely
Child appears settled and cared for
Appointments and routines maintained
Family has protective support network

AMBER

Occasional missed appointments
Parent under stress, early signs of relapse
Child showing mild anxiety or withdrawal
Home mildly chaotic but not unsafe
Some reluctance to engage with services

RED

Parent intoxicated or unresponsive during care hours
Paraphernalia accessible to young children
Child acting as primary carer
Home unsafe, evidence of dealing or cuckooing
Pregnant parent using substances without engagement

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at parent, home and child.

2ASK

Ask calmly and non-judgementally. Open questions to parent and child.

3RECORD

Contemporaneous notes. Presentation, environment, child's demeanour.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 04

Parental Substance Misuse

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

IF YOU ARE A YOUNG PERSON

Childline — free, confidential

0800 1111

Sources & further reading

NSPCC — Parental substance misuse
https://www.nspcc.org.uk/keeping-children-safe/support-for-parents/alcohol-drug-abuse/
NSPCC Learning — Hidden harm
https://learning.nspcc.org.uk/child-abuse-and-neglect/parental-substance-misuse
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Children Act 2004 — Section 11
https://www.legislation.gov.uk/ukpga/2004/31/section/11
NICE guideline NG76 — Child abuse and neglect
https://www.nice.org.uk/guidance/ng76
RCPCH — Child protection resources
https://www.rcpch.ac.uk/resources/child-protection-resources
Research in Practice — Parental substance misuse
https://www.researchinpractice.org.uk/
Action for Children — Supporting families affected by substance misuse
https://www.actionforchildren.org.uk/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

Safeguarding Bulletins · V1.0 · Spark Medical 6 / 6

BULLETIN 05

Parental Mental Ill-Health

Safeguarding

SAFEGUARDING BULLETIN 05

A STRUGGLING PARENT NEEDS YOU TO SEE.

Parental mental ill-health is a feature in a large share of serious case reviews.

Children often mask their own distress to protect a struggling parent.

Your visit may be the first chance anyone has had to notice.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG05 · October 2026 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 05

Parental Mental Ill-Health

Safeguarding

Why vigilance matters

Spark Medical staff often attend households at moments of crisis, when a parent's mental health has visibly deteriorated and there is no one else present to notice. You see the home as it really is: unopened post, an unresponsive parent, a child quietly managing alone. Parental mental ill-health can profoundly affect a parent's capacity to care, and the child's welfare is easily overlooked in the urgency of responding to the adult. Your dual vantage — assessing the parent while observing the child — is a safeguard many other professionals do not have.

Definition

Parental mental ill-health becomes a safeguarding concern when a parent or carer's mental health condition impairs their capacity to meet a child's needs, as recognised in Working Together to Safeguard Children (2023) as one of the three parental risk factors most commonly present in cases of significant harm to children, alongside domestic abuse and substance misuse. It can affect supervision, emotional availability, routine and the child's own emotional wellbeing.

Most parents living with mental illness care for their children safely and well. The safeguarding concern is not the diagnosis itself but its impact: severity, acute crisis, non-engagement with treatment, or a home where the child has taken on inappropriate caring responsibilities for the parent or siblings.

Legal & policy framework

Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm.
Children Act 2004, Section 11 — statutory duty on NHS bodies to safeguard and promote children's welfare.
Working Together to Safeguard Children (2023) — identifies parental mental ill-health as a key indicator of household stress associated with significant harm.
Mental Health Act 1983 (as amended) — governs assessment and treatment of the parent; consider the impact of any detention on dependent children.
Care Act 2014, Section 42 — duty to make enquiries where an adult with care and support needs may be at risk of abuse or neglect.

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BULLETIN 05

Parental Mental Ill-Health

Safeguarding

Key statistics

~50%of serious case reviews cite parental mental ill-health as a factor

1 in 5children live with a parent experiencing a common mental disorder

Perinatal riskmental illness in pregnancy carries specific safeguarding risk

Hidden strugglemany parents fear disclosure will lead to child removal

Sources: NSPCC, Royal College of Psychiatrists • Working Together to Safeguard Children (2023)

Types & presentations

Emotional unavailabilityReduced warmth, responsiveness

Inconsistent routineMissed meals, school, appointments

Role reversalChild becomes carer for parent

Crisis exposureChild witnesses acute mental health crisis

Perinatal illnessRisk to unborn or newborn baby

Impact on the child — not the diagnosis itself — is the safeguarding concern

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BULLETIN 05

Parental Mental Ill-Health

Safeguarding

Signs to watch for

Physical signs

Child looks unkempt, hungry or tired
Missed medical, dental or school appointments
Poor school attendance or persistent lateness
Signs of self-care beyond the child's years
Sleep disruption or exhaustion in the child

Behavioural signs

Anxious, withdrawn or hyper-vigilant child
Child minimises or covers for the parent
Acting as carer for parent or siblings
Reluctance to leave the parent alone
Low mood or expressions of worry beyond their years

Environmental signs

Home neglected, unopened post, disorder
Evidence parent is not managing daily tasks
Unsafe items accessible (medication, sharp objects)
Isolation — few visitors, little support network

Parent presentation

Low mood, flat affect or agitation at visit
Signs of psychosis, confusion or acute crisis
Expressions of hopelessness or self-harm risk
Non-engagement with treatment or services

Figure 1: Recognising the impact of parental mental ill-health. Adapted from NSPCC guidance (nspcc.org.uk).

Clinician rapid reference

THE PARENT

Current presentation and risk to self
History of illness, treatment engagement
Capacity to respond to the child's needs
Willingness to accept support

THE HOME

General safety, hygiene and functioning
Access to medication or hazards
Presence of a support network

THE CHILD

Visible wellbeing, affect and behaviour
Evidence of a caring or protective role
Direct, age-appropriate conversation if safe to do so

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BULLETIN 05

Parental Mental Ill-Health

Safeguarding

Pattern recognition

GREEN

Parent engaged with treatment or support
Home functioning, routines maintained
Child appears settled and cared for
Appointments kept, support network present
Parent able to prioritise child's needs

AMBER

Occasional missed appointments
Parent under stress, early signs of relapse
Child showing mild anxiety or low mood
Home mildly neglected but not unsafe
Some reluctance to engage with services

RED

Parent in acute crisis, unresponsive to care needs
Hazards accessible to young children
Child acting as primary carer
Expressions of harm to self or child
Pregnant parent with untreated severe mental illness

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at parent, home and child.

2ASK

Ask calmly and non-judgementally. Open questions to parent and child.

3RECORD

Contemporaneous notes. Presentation, environment, child's demeanour.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 05

Parental Mental Ill-Health

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

CONCERNED ABOUT A PARENT?

Samaritans — free, confidential, 24/7

116 123

Sources & further reading

NSPCC — Parental mental health problems
https://www.nspcc.org.uk/keeping-children-safe/support-for-parents/mental-health/
NSPCC Learning — Parental mental ill-health
https://learning.nspcc.org.uk/child-abuse-and-neglect/parental-mental-health
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Children Act 2004 — Section 11
https://www.legislation.gov.uk/ukpga/2004/31/section/11
Royal College of Psychiatrists — Parental mental illness
https://www.rcpsych.ac.uk/
NICE guideline NG76 — Child abuse and neglect
https://www.nice.org.uk/guidance/ng76
Mind — Supporting a parent with mental illness
https://www.mind.org.uk/
Samaritans — 24/7 support
https://www.samaritans.org/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

Safeguarding Bulletins · V1.0 · Spark Medical 6 / 6

BULLETIN 06

Domestic Abuse

Safeguarding

SAFEGUARDING BULLETIN 06

CHILDREN HEAR EVERYTHING.

Domestic abuse is a feature in the majority of serious case reviews.

Children experiencing domestic abuse are victims in their own right.

Your presence in the home may be the only outside witness.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG06 · October 2026 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 06

Domestic Abuse

Safeguarding

Why vigilance matters

Spark Medical staff enter homes at moments of crisis, often called for an entirely different reason, and see the household as it truly is: a tense atmosphere, a partner who will not leave the room, injuries with an unconvincing explanation, a child frozen and watchful. Domestic abuse thrives in secrecy, and victims — adult and child alike — are frequently unable to disclose while the perpetrator is present. Your unscheduled, in-home vantage point makes you one of the few professionals able to notice the signs that a clinic appointment would never reveal.

Definition

Domestic abuse is defined under the Domestic Abuse Act 2021 as any incident or pattern of incidents of controlling, coercive, threatening, degrading or violent behaviour, including sexual violence, between people aged 16 or over who are personally connected. A child who sees, hears or experiences the effects of domestic abuse, and is related to the victim or perpetrator, is legally recognised as a victim of domestic abuse in their own right.

Domestic abuse is not limited to physical violence — it includes coercive control, economic abuse, emotional abuse, and threats. It occurs across all communities regardless of income, ethnicity or background, and can continue or escalate after separation, including through child contact arrangements.

Legal & policy framework

Domestic Abuse Act 2021 — statutory definition of domestic abuse; recognises children as victims in their own right.
Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm.
Children Act 2004, Section 11 — statutory duty on NHS bodies to safeguard and promote children's welfare.
Working Together to Safeguard Children (2023) — identifies domestic abuse as a key indicator of household risk to children.
Serious Crime Act 2015, Section 76 — criminal offence of controlling or coercive behaviour in an intimate or family relationship.

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BULLETIN 06

Domestic Abuse

Safeguarding

Key statistics

1 in 5children in the UK have been exposed to domestic abuse

2.1madults experienced domestic abuse in the past year

~60%of serious case reviews feature domestic abuse

Children are victimsnot witnesses — recognised in law since 2021

Sources: Office for National Statistics, SafeLives • Domestic Abuse Act 2021

Types & presentations

Physical abuseViolence, restraint, physical harm

Coercive controlIsolation, monitoring, restriction

Emotional abuseDegradation, threats, humiliation

Economic abuseControlling money, work, resources

Sexual abuseNon-consensual sexual acts within the relationship

Any single category can constitute domestic abuse — patterns confirm the picture

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BULLETIN 06

Domestic Abuse

Safeguarding

Signs to watch for

Physical signs

Injuries inconsistent with the explanation given
Injuries to areas typically covered by clothing
Delayed presentation for injuries
Signs of old and new injuries together
Pregnancy-related injuries (abuse often escalates in pregnancy)

Behavioural signs

Victim appears fearful, anxious or evasive
Partner answers for the victim or won't leave the room
Victim minimises or denies obvious concerns
Social isolation, reluctance to seek help
Sudden changes in mood or presentation

Environmental signs

Damage to property, holes in walls or doors
Signs of restricted access to money or phone
Children's toys or belongings damaged or absent
Evidence of alcohol or substance use escalating tension

Impact on children

Watchful, 'frozen' or hyper-vigilant presentation
Aggression, anxiety or regression in younger children
Acting as a protector, mediator or go-between
Reluctance to discuss home life

Figure 1: Recognising the signs of domestic abuse and its impact on children. Adapted from Refuge and SafeLives guidance (refuge.org.uk, safelives.org.uk).

Clinician rapid reference

THE VICTIM

Ask alone, away from the suspected abuser
Injury pattern, history and explanation
Safety of leaving, and any safety plan in place
Impact on and safety of any children

THE HOME

Signs of control, restriction or damage
Presence and demeanour of the alleged perpetrator
Access to weapons or means of harm

THE CHILDREN

Direct observation of demeanour and behaviour
Evidence of exposure to abuse (seeing, hearing, effects)
Consider unborn children — risk often escalates in pregnancy

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BULLETIN 06

Domestic Abuse

Safeguarding

Pattern recognition

GREEN

Both adults calm, able to speak freely
No signs of control or restriction
Children appear settled and unafraid
Consistent, plausible explanations for any injury
Victim has independent access to support

AMBER

Some tension or reluctance to speak freely
Minor inconsistency in explanations
Child appears subdued or watchful
Some signs of restricted independence
History of past incidents, currently stable

RED

Victim fearful, unable to speak without partner present
Injuries inconsistent with explanation, non-accidental pattern
Children witnessing or directly caught up in incidents
Escalating severity, strangulation, weapons involved
Pregnant victim with signs of current abuse

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at atmosphere, injuries and the children.

2ASK

Ask the victim alone, away from the suspected abuser. Open questions.

3RECORD

Contemporaneous notes. Injuries, explanations, demeanour, children present.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 06

Domestic Abuse

Safeguarding

Helplines & signposting

EXPERIENCING DOMESTIC ABUSE?

Refuge — Freephone National Domestic Abuse Helpline, 24/7

0808 2000 247

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

Sources & further reading

Refuge — Recognising domestic abuse
https://www.refuge.org.uk/i-need-help-now/what-is-domestic-abuse/
SafeLives — Domestic abuse and children
https://www.safelives.org.uk/
Domestic Abuse Act 2021
https://www.legislation.gov.uk/ukpga/2021/17/contents
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Serious Crime Act 2015 — Section 76
https://www.legislation.gov.uk/ukpga/2015/9/section/76
Women's Aid — Impact of domestic abuse on children
https://www.womensaid.org.uk/
NSPCC — Domestic abuse
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/domestic-abuse/
Respect Men's Advice Line
https://www.respectphoneline.org.uk/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

Safeguarding Bulletins · V1.0 · Spark Medical 6 / 6

BULLETIN 07

Bullying

Safeguarding

SAFEGUARDING BULLETIN 07

SILENCE ISN'T ALWAYS PEACE.

Bullying is one of the most common reasons children contact Childline.

It can occur face-to-face, online, or both at once.

A child's reluctance to talk may be the clearest sign of all.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG07 · November 2026 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 07

Bullying

Safeguarding

Why vigilance matters

Spark Medical staff often see children away from school and peer settings — at home, at appointments, in unguarded moments — where the mask children wear for classmates can slip. Bullying frequently goes unreported because children fear it will make things worse, or feel ashamed. A change in mood, a reluctance to attend school, or an unexplained injury noticed during a routine visit may be the first indication that a child is being bullied. Your position outside the school gate gives you a chance to notice what teachers and peers do not see.

Definition

Bullying is defined by the Department for Education as behaviour by an individual or group, usually repeated over time, that intentionally hurts another individual or group either physically or emotionally, often motivated by prejudice against particular groups, and can take many forms including physical, verbal, and online (cyberbullying).

Bullying is not the same as occasional childhood conflict — it involves a repeated pattern, an imbalance of power, and intent to cause distress. It can occur between peers, within families, or in institutional settings, and frequently overlaps with online abuse when it continues via social media or messaging apps.

Legal & policy framework

Children Act 1989, Section 17 — duty to safeguard and promote the welfare of children in need, which can include children experiencing severe or persistent bullying.
Education Act 2002, Section 175 — duty on schools to safeguard and promote the welfare of pupils, including preventing and responding to bullying.
Working Together to Safeguard Children (2023) — recognises bullying, including online bullying, as a form of peer-on-peer abuse requiring a safeguarding response.
Equality Act 2010 — relevant where bullying is motivated by a protected characteristic such as race, disability, or sexual orientation.
Malicious Communications Act 1988 — criminal offence where bullying involves threatening or grossly offensive electronic communications.

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BULLETIN 07

Bullying

Safeguarding

Key statistics

1 in 5children report being bullied in the last year

Top concernbullying remains a leading reason children contact Childline

Overlapa large share of bullying now involves an online element

Under-reportedmany children never tell an adult what is happening

Sources: Childline, Anti-Bullying Alliance • Department for Education

Types & presentations

PhysicalHitting, pushing, damaging belongings

VerbalName-calling, threats, mockery

RelationalExclusion, spreading rumours, isolation

CyberbullyingAbuse via messaging, social media, gaming

Prejudice-basedTargeting race, disability, sexuality, faith

Bullying is repeated and intentional — it is not the same as one-off conflict

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BULLETIN 07

Bullying

Safeguarding

Signs to watch for

Physical signs

Unexplained bruises, scratches or injuries
Damaged or 'lost' belongings, clothing or equipment
Headaches, stomach aches with no medical cause
Changes in eating or sleeping patterns
Bedwetting or regression in younger children

Behavioural signs

Reluctance or refusal to attend school or clubs
Sudden drop in confidence or mood
Becoming withdrawn, anxious or tearful
Asking for extra money or 'losing' money often
Uncharacteristic aggression or acting out

Environmental signs

Taking unusual routes to school or avoiding places
Reluctance to go online or excessive secrecy about devices
Few or no friends mentioned, sudden loss of friend group
Not being invited to social events previously attended

Online-specific signs

Anxious or upset after using phone or social media
Sudden change in online activity or platforms used
Reluctance to discuss messages or notifications
Deleting accounts or avoiding devices altogether

Figure 1: Recognising the signs of bullying. Adapted from Childline and Anti-Bullying Alliance guidance (childline.org.uk).

Clinician rapid reference

THE CHILD

Mood, confidence and demeanour compared to baseline
Unexplained injuries or somatic complaints
Willingness to talk about school or peer relationships
Impact on sleep, appetite and attendance

THE CONTEXT

Setting — school, online, community, sibling or family
Duration and frequency — one-off or repeated pattern
Power imbalance — age, size, social status, numbers

THE RESPONSE

Has the child or family told anyone already?
What action, if any, has the school or platform taken?
Does the child feel safe now?

Safeguarding Bulletins · V1.0 · Spark Medical 4 / 6

BULLETIN 07

Bullying

Safeguarding

Pattern recognition

GREEN

Child engaged with school and friends as usual
No unexplained injuries or missing belongings
Confident, open when discussing peer relationships
Sleep, appetite and mood within normal range
Supportive network of friends and family

AMBER

Occasional reluctance to attend school or clubs
Some drop in mood or confidence
Vague explanations for minor injuries or losses
Increased secrecy around phone or social media
One-off reported incident, currently resolving

RED

Persistent refusal to attend school
Repeated unexplained injuries or significant distress
Expressions of hopelessness, self-harm or suicidal ideation
Severe online harassment or threats
Complete social withdrawal or isolation

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at mood, injuries and routine changes.

2ASK

Ask the child privately and calmly. Open, non-leading questions.

3RECORD

Contemporaneous notes. What was said, seen, and by whom.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 07

Bullying

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

IF YOU ARE A YOUNG PERSON

Childline — free, confidential

0800 1111

Sources & further reading

Childline — Bullying and cyberbullying
https://www.childline.org.uk/info-advice/bullying-abuse-safety/types-bullying/bullying-cyberbullying/
NSPCC — Bullying and cyberbullying
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/bullying-and-cyberbullying/
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Education Act 2002 — Section 175
https://www.legislation.gov.uk/ukpga/2002/32/section/175
Equality Act 2010
https://www.legislation.gov.uk/ukpga/2010/15/contents
Malicious Communications Act 1988
https://www.legislation.gov.uk/ukpga/1988/27/contents
Department for Education — Preventing and tackling bullying
https://www.gov.uk/government/publications/preventing-and-tackling-bullying
Young Minds — Bullying and mental health
https://www.youngminds.org.uk/
Internet Matters — Cyberbullying advice
https://www.internetmatters.org/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

Safeguarding Bulletins · V1.0 · Spark Medical 6 / 6

BULLETIN 08

Online Abuse & Digital Harms

Safeguarding

SAFEGUARDING BULLETIN 08

THE DANGER IS IN THEIR POCKET.

Most children now own a smartphone before secondary school.

Online abuse can happen inside an otherwise safe, loving home.

A child's device may hold the only evidence of what is happening.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG08 · November 2026 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 08

Online Abuse & Digital Harms

Safeguarding

Why vigilance matters

Spark Medical staff see children in their own bedrooms and homes, often alongside the very devices through which online abuse occurs. A parent may have no idea their child is being groomed, harassed or exposed to harmful content through a phone sitting on the bedside table. Because online harm leaves few physical signs, your observations of a child's mood, secrecy around devices, or unexplained distress after using their phone can be the first indication that something is wrong in a space adults rarely see.

Definition

Online abuse, as defined by the NSPCC and reflected in Working Together to Safeguard Children (2023), is any type of abuse that happens on the internet, facilitated through technology such as social media, messaging apps, gaming platforms and text, and includes cyberbullying, grooming, sexual abuse, sexual exploitation, and exposure to harmful or age-inappropriate content.

Online abuse frequently overlaps with offline harm — a child groomed online may go on to be abused in person, and bullying that starts at school often continues online out of hours. The Online Safety Act 2023 places new duties on platforms, but professionals remain the key safety net for spotting harm that platforms miss.

Legal & policy framework

Online Safety Act 2023 — places duties on online platforms to protect children from illegal and harmful content.
Sexual Offences Act 2003, Section 15A — offence of sexual communication with a child, covering online grooming.
Protection of Children Act 1978 — offences relating to indecent images of children, including those generated or shared online.
Working Together to Safeguard Children (2023) — recognises online abuse as a distinct safeguarding category requiring specific response.
Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm.

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BULLETIN 08

Online Abuse & Digital Harms

Safeguarding

Key statistics

97%of children aged 12–15 in the UK go online daily

1 in 3children report an unwanted online contact experience

Risingreports of self-generated indecent imagery continue to increase

Under-reportedmany children do not tell an adult what happened online

Sources: Ofcom, Internet Watch Foundation, CEOP • Working Together to Safeguard Children (2023)

Types & presentations

GroomingBuilding trust to enable abuse

CyberbullyingHarassment via messaging or social media

Sexual abuse materialIndecent images, sextortion

Harmful contentSelf-harm, violent or age-inappropriate material

Live-streamed abuseReal-time exploitation via webcam or app

Online harm often overlaps with offline abuse — treat every disclosure seriously

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BULLETIN 08

Online Abuse & Digital Harms

Safeguarding

Signs to watch for

Behavioural signs

Secretive or anxious behaviour around devices
Sudden change in mood after using phone or gaming
Reluctance to discuss who they talk to online
New, unexplained gifts, money or items
Withdrawal from family or previous friendships

Device-related signs

Multiple devices or hidden accounts
Excessive or unusual times spent online, especially at night
Switching screens or closing apps when approached
Sexual knowledge or language beyond their years

Environmental signs

Unrestricted or unsupervised device access at a young age
No parental controls or filters in place
Household unaware of platforms the child uses
Evidence of contact with unknown adults online

Grooming-specific signs

Talk of an older or unfamiliar online 'friend'
Requests to keep a relationship or messages secret
Pressure to share images or move to private platforms
Sudden possession of a new phone or SIM card

Figure 1: Recognising the signs of online abuse and digital harm. Adapted from CEOP and Internet Watch Foundation guidance (thinkuknow.co.uk, iwf.org.uk).

Clinician rapid reference

THE CHILD

Mood and behaviour around device use
Willingness to talk about online contacts and platforms
Any disclosure of unwanted contact or images
Sleep and routine disruption linked to device use

THE DEVICE

Do not search the device yourself — preserve as evidence
Note which platforms and apps are in use
Presence or absence of parental controls

THE RESPONSE

Has any image or message been shared or requested?
Has the family reported to CEOP or the platform?
Does the child feel safe now?

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BULLETIN 08

Online Abuse & Digital Harms

Safeguarding

Pattern recognition

GREEN

Open communication with parents about online life
Age-appropriate platforms with parental controls in place
Child comfortable discussing online friends and content
No secrecy around devices or notifications
Balanced online and offline activity

AMBER

Increasing secrecy around a specific app or contact
Mild anxiety linked to device notifications
Unfamiliar online contact mentioned casually
Some unsupervised or unrestricted device use
Minor decline in mood coinciding with online activity

RED

Disclosure or evidence of grooming or sexual contact
Possession of, or requests for, indecent images
Severe distress, self-harm or suicidal ideation linked to online abuse
Contact with an adult seeking to meet in person
Evidence of sextortion or financial exploitation online

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at mood, secrecy and device behaviour.

2ASK

Ask the child calmly and without judgement about online contacts.

3RECORD

Contemporaneous notes. Preserve devices — do not search or delete.

4REPORT

Follow Spark reporting procedure. Report to CEOP if imagery or grooming suspected.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 08

Online Abuse & Digital Harms

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD ONLINE?

CEOP — report grooming or abuse

thinkuknow.co.uk

IF YOU ARE A YOUNG PERSON

Childline — free, confidential

0800 1111

Sources & further reading

CEOP — Thinkuknow
https://www.thinkuknow.co.uk/
Internet Watch Foundation — Reporting
https://report.iwf.org.uk/
NSPCC — Online abuse
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/online-abuse/
Online Safety Act 2023
https://www.legislation.gov.uk/ukpga/2023/50/contents
Sexual Offences Act 2003 — Section 15A
https://www.legislation.gov.uk/ukpga/2003/42/section/15A
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Internet Matters — Online safety advice
https://www.internetmatters.org/
Childline — Staying safe online
https://www.childline.org.uk/info-advice/bullying-abuse-safety/online-mobile-safety/
UK Safer Internet Centre
https://www.saferinternet.org.uk/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

Safeguarding Bulletins · V1.0 · Spark Medical 6 / 6

BULLETIN 09

Child Sexual Exploitation

Safeguarding

SAFEGUARDING BULLETIN 09

IT NEVER LOOKS LIKE A CRIME.

Child sexual exploitation can affect any child, of any background.

Perpetrators deliberately build trust before abuse begins.

Many children do not recognise themselves as victims.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG09 · December 2026 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 09

Child Sexual Exploitation

Safeguarding

Why vigilance matters

Spark Medical staff often meet young people in homes, at odd hours, or in the aftermath of a crisis — exactly the moments when signs of exploitation surface. A teenager with unexplained gifts, an older 'boyfriend', or injuries they will not explain may be showing you the only visible trace of a hidden and coercive relationship. Because exploitation is built on manipulation and fear, young people rarely self-identify as victims. Your outside perspective, away from the relationships that control them, can be the first step toward safety.

Definition

Child sexual exploitation is defined in Working Together to Safeguard Children (2023) as a form of child sexual abuse in which an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child into sexual activity, in exchange for something the victim needs or wants, and/or for the financial advantage or increased status of the perpetrator. The victim may have been sexually exploited even if the activity appears consensual.

Child sexual exploitation can occur without physical contact, including online, and does not always involve an obvious exchange of money — it may involve gifts, drugs, alcohol, accommodation, affection or status. Victims are frequently groomed to believe they are in a genuine relationship, and boys and young men are exploited as well as girls.

Legal & policy framework

Sexual Offences Act 2003 — defines offences of sexual activity with a child and abuse of a position of trust.
Modern Slavery Act 2015 — relevant where exploitation involves trafficking or exploitation for gain.
Working Together to Safeguard Children (2023) — sets out the statutory definition and multi-agency response to CSE.
Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm.
Serious Crime Act 2015, Section 68 — offence of sexual communication with a child.

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BULLETIN 09

Child Sexual Exploitation

Safeguarding

Key statistics

Any childcan be targeted, regardless of background or family circumstance

Under-identifiedmany victims do not recognise themselves as being exploited

Both girls and boysaffected — exploitation is not limited by gender

Grooming is gradualtrust-building can take weeks or months before abuse begins

Sources: NSPCC, Barnardo's • Working Together to Safeguard Children (2023)

Types & presentations

Boyfriend modelCoercive 'relationship' used to control victim

Peer exploitationYoung people recruiting other young people

Online exploitationGrooming, images and coercion via technology

Trafficking for sexMovement of a child for sexual exploitation

Exchange-based abuseSex exchanged for gifts, drugs, money or status

A child cannot consent to their own exploitation — apparent willingness does not remove risk

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BULLETIN 09

Child Sexual Exploitation

Safeguarding

Signs to watch for

Physical signs

Unexplained injuries, particularly to intimate areas
Sexually transmitted infections or pregnancy in a young person
Signs of drug or alcohol use beyond their years
Fatigue, dishevelment after unexplained absences

Behavioural signs

Secretive or evasive about relationships and whereabouts
Sexualised behaviour or language beyond developmental age
Sudden change in appearance, mood or friendship group
Aggression or hostility when questioned about a relationship
Self-harm or suicidal ideation

Environmental signs

Unexplained gifts, money, phones or new clothing
Association with older individuals or multiple unknown adults
Going missing repeatedly, or returning at unusual hours
Travel to hotels, unfamiliar addresses or other towns

Grooming-specific signs

Older 'boyfriend' or 'girlfriend' with controlling behaviour
Being picked up or dropped off by unknown adults or cars
Multiple phones or secretive online accounts
Fear or reluctance to discuss a particular relationship

Figure 1: Recognising the signs of child sexual exploitation. Adapted from NSPCC and Barnardo's guidance (nspcc.org.uk, barnardos.org.uk).

Clinician rapid reference

THE CHILD

Physical presentation — injuries, STIs, substance use
Emotional state — fear, secrecy, sexualised behaviour
Willingness to talk about relationships and whereabouts
History of missing episodes

THE RELATIONSHIP

Age gap and power imbalance with associate(s)
Evidence of control, coercion or exchange for gifts/money
Multiple young people linked to the same adult or group

THE CONTEXT

Locations, transport and unfamiliar addresses involved
Online activity and communication with the exploiter
Prior agency involvement or missing-person reports

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BULLETIN 09

Child Sexual Exploitation

Safeguarding

Pattern recognition

GREEN

Relationships age-appropriate and known to family
No unexplained gifts, money or absences
Open communication about friendships and whereabouts
No signs of coercion, secrecy or fear
Stable mood, attendance and behaviour

AMBER

New relationship with some secrecy
Occasional unexplained gift or late return home
Mild change in mood or friendship group
Some reluctance to discuss a specific person
One missing episode, resolved without concern

RED

Older, controlling 'boyfriend' or exploiter identified
Repeated missing episodes, travel to unfamiliar locations
Unexplained possession of money, drugs or multiple phones
Disclosure or evidence of sexual exploitation
Signs of trafficking or movement between addresses

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at relationships, gifts and absences.

2ASK

Ask calmly and without judgement. Avoid assumptions about consent.

3RECORD

Contemporaneous notes. Names, descriptions, locations, timings.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 09

Child Sexual Exploitation

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

REPORT EXPLOITATION

Fearless / Crimestoppers — 100% anonymous

0800 555 111

Sources & further reading

Barnardo's — Child sexual exploitation
https://www.barnardos.org.uk/what-we-do/tackling-child-sexual-exploitation
NSPCC — Child sexual exploitation
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/child-sexual-exploitation/
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Sexual Offences Act 2003
https://www.legislation.gov.uk/ukpga/2003/42/contents
Modern Slavery Act 2015
https://www.legislation.gov.uk/ukpga/2015/30/contents
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
CEOP — Thinkuknow
https://www.thinkuknow.co.uk/
Fearless — Report exploitation anonymously
https://www.fearless.org/
Missing People — Missing and exploitation links
https://www.missingpeople.org.uk/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

Safeguarding Bulletins · V1.0 · Spark Medical 6 / 6

BULLETIN 10

Child Criminal Exploitation

Safeguarding

SAFEGUARDING BULLETIN 10

THEY CALL IT A CHOICE. IT ISN'T.

Child criminal exploitation can affect any child, of any background.

Debt, threats and manipulation — not free choice — drive involvement.

A young person may present as an offender when they are a victim.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2026-SG10 · December 2026 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 10

Child Criminal Exploitation

Safeguarding

Why vigilance matters

Spark Medical staff often meet young people at moments of crisis — an injury, a missing episode, a household in turmoil — exactly when the signs of criminal exploitation surface. A teenager with unexplained cash, unfamiliar injuries, or repeated unexplained absences may be caught in a coercive relationship built on debt and fear rather than choice. Because these young people are often treated as offenders rather than victims, your willingness to look beneath the presenting behaviour can be the difference between punishment and protection.

Definition

Child criminal exploitation is defined in Working Together to Safeguard Children (2023) as occurring where an individual or group takes advantage of an imbalance of power to coerce, control, manipulate or deceive a child into any criminal activity in exchange for something the victim needs or wants, and/or for the financial or other advantage of the perpetrator. The victim may have been criminally exploited even if the activity appears consensual, and it can include children being forced to commit crimes such as drug trafficking.

Child criminal exploitation frequently overlaps with county lines drug trafficking, but also includes exploitation for theft, fraud, cannabis cultivation and other offences. Victims are often controlled through debt bondage, violence, or threats to their family, and may not recognise themselves as exploited because they believe they chose to become involved.

Legal & policy framework

Modern Slavery Act 2015 — covers exploitation for forced criminality and provides statutory defences for exploited children.
Working Together to Safeguard Children (2023) — sets out the statutory definition and multi-agency response to CCE.
Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm.
Serious Crime Act 2015, Section 45 — statutory defence for victims of slavery or trafficking compelled to commit an offence.
Psychoactive Substances Act 2016 — relevant where exploitation involves drug supply offences.

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BULLETIN 10

Child Criminal Exploitation

Safeguarding

Key statistics

Any childcan be targeted, regardless of background or family circumstance

Debt-drivencoercion through manufactured debt is a common control tactic

Victim, not offendermany exploited children are first identified through arrest

Cross-borderexploitation often involves travel between towns and counties

Sources: Children's Society, Barnardo's • Working Together to Safeguard Children (2023)

Types & presentations

County linesDrug trafficking between urban and other areas

Debt bondageManufactured debt used to force compliance

CuckooingHome taken over to store or sell drugs

Weapons involvementCoerced carrying or use of weapons

Forced theft or fraudCompelled shoplifting, scams or ATM fraud

A child cannot consent to their own criminal exploitation — apparent willingness does not remove risk

Safeguarding Bulletins · V1.0 · Spark Medical 3 / 6

BULLETIN 10

Child Criminal Exploitation

Safeguarding

Signs to watch for

Physical signs

Unexplained injuries, particularly consistent with assault
Signs of drug or alcohol use beyond their years
Fatigue or dishevelment after unexplained absences
Injuries the young person is reluctant to explain

Behavioural signs

Secretive or evasive about relationships and whereabouts
Sudden change in friendship group, attitude or language
Carrying more than one phone or frequently changing numbers
Increased aggression, anxiety or fearfulness
Truancy or sudden disengagement from school

Environmental signs

Unexplained money, expensive items or new clothing
Going missing repeatedly, or returning at unusual hours
Travel to unfamiliar towns or addresses, often by taxi or train
Unknown or older individuals visiting or waiting outside the home

Exploitation-specific signs

Talk of 'owing' money or being unable to leave a situation
Evidence of home being used to store drugs or weapons (cuckooing)
Association with known gang or organised crime activity
Previous exploitation or missing-person history

Figure 1: Recognising the signs of child criminal exploitation. Adapted from Barnardo's and the Children's Society guidance (barnardos.org.uk, childrenssociety.org.uk).

Clinician rapid reference

THE CHILD

Physical presentation — injuries, substance use, fatigue
Emotional state — fear, secrecy, defensiveness
Willingness to talk about relationships and whereabouts
History of missing episodes or police contact

THE CONTROL

Evidence of debt, threats or coercion
Age gap and power imbalance with associate(s)
Multiple young people linked to the same adult or group

THE CONTEXT

Locations, transport and unfamiliar addresses involved
Signs of cuckooing at the family home
Prior agency, police or youth-justice involvement

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BULLETIN 10

Child Criminal Exploitation

Safeguarding

Pattern recognition

GREEN

Relationships and friendships known to family
No unexplained money, items or absences
Open communication about whereabouts and activities
No signs of coercion, secrecy or fear
Stable mood, attendance and behaviour

AMBER

New friendship group with some secrecy
Occasional unexplained item or late return home
Mild change in mood, language or attitude
Some reluctance to discuss a specific person or place
One missing episode, resolved without concern

RED

Evidence of debt bondage or threats of violence
Repeated missing episodes, travel to unfamiliar locations
Unexplained possession of drugs, weapons or large sums of cash
Disclosure or evidence of forced criminal activity
Signs of cuckooing or organised exploitation at the home

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at relationships, money and absences.

2ASK

Ask calmly and without judgement. Treat the young person as a possible victim.

3RECORD

Contemporaneous notes. Names, descriptions, locations, timings.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 10

Child Criminal Exploitation

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

REPORT EXPLOITATION

Fearless / Crimestoppers — 100% anonymous

0800 555 111

Sources & further reading

Children's Society — Child criminal exploitation
https://www.childrenssociety.org.uk/what-we-do/our-work/child-exploitation
Barnardo's — Child criminal exploitation
https://www.barnardos.org.uk/what-we-do/tackling-child-exploitation
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Modern Slavery Act 2015
https://www.legislation.gov.uk/ukpga/2015/30/contents
Serious Crime Act 2015 — Section 45
https://www.legislation.gov.uk/ukpga/2015/9/section/45
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Psychoactive Substances Act 2016
https://www.legislation.gov.uk/ukpga/2016/2/contents
Fearless — Report exploitation anonymously
https://www.fearless.org/
Missing People — Missing and exploitation links
https://www.missingpeople.org.uk/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 11

County Lines

Safeguarding

SAFEGUARDING BULLETIN 11

EVERY CHILD IS A VICTIM, NOT A CRIMINAL.

County lines exploitation moves children across force boundaries to sell drugs.

Victims are often invisible to services until crisis point.

You may see the signs before anyone else does.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG11 · January 2027 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 11

County Lines

Safeguarding

Why vigilance matters

Spark Medical staff attending homes, hostels and street-based call-outs are often the first to see the physical and situational markers of county lines exploitation — unexplained injuries, unfamiliar adults in a young person's life, or a child found far from home with no clear reason. Because exploitation is deliberately hidden by perpetrators and often normalised by victims themselves, your independent, cross-household vantage point is critical to spotting the pattern before it escalates into serious violence.

Definition

County lines is defined by the Home Office as a police term for urban gangs supplying drugs to suburban areas, market and coastal towns using dedicated mobile phone lines, exploiting children and vulnerable adults to move and store drugs and money. It is a form of child criminal exploitation as recognised in Working Together to Safeguard Children (2023), and typically involves debt bondage, coercion and the crossing of police force boundaries.

A common misconception is that county lines only affects children already known to services. In reality, exploitation increasingly targets children with no prior safeguarding history, using grooming tactics such as gifts, status and manufactured 'debt'. Criminalisation of the child is never an appropriate first response.

Legal & policy framework

Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm through exploitation.
Modern Slavery Act 2015, Section 45 — statutory defence for victims of trafficking or exploitation compelled to commit certain offences.
Working Together to Safeguard Children (2023) — statutory guidance defining child criminal exploitation and county lines indicators.
Children and Young Persons Act 1933, Section 1 — offence of cruelty to a child, relevant where exploitation causes harm.
Serious Crime Act 2015, Section 76 — relevant where controlling or coercive behaviour features in exploitation of older adolescents.

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BULLETIN 11

County Lines

Safeguarding

Key statistics

>2,000county lines identified across England and Wales

14average age at which children are first exploited

1 in 4county lines victims referred to the NRM are children

Cross-forceexploitation often crosses police force boundaries

Sources: Home Office, National Crime Agency • Working Together to Safeguard Children (2023)

Types & presentations

Debt bondageManufactured 'debt' used to coerce

CuckooingLocal vulnerable adult's home taken over

RunnersChildren used to transport drugs/cash

ViolenceThreats or violence to enforce control

GroomingGifts, status and false relationships

Exploitation is rarely a single event — look for the pattern over time

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BULLETIN 11

County Lines

Safeguarding

Signs to watch for

Physical signs

Unexplained injuries, bruising or cuts
Signs of physical assault or restraint
Poor hygiene or self-neglect while carrying cash/items
Signs of substance use or supply
Exhaustion from repeated travel

Behavioural signs

Secretive about journeys, associates or phones
Sudden change in friendship group or attitude
Reluctance to engage with services or professionals
Anxiety when a particular phone rings
Aggressive or fearful when questioned

Environmental signs

Repeated travel to unfamiliar towns, especially by train
Multiple mobile phones or SIM cards
Unexplained amounts of cash or new possessions
Association with older individuals or vehicles
Presence at addresses linked to drug activity

Population-specific

Looked-after children and those in care homes
Children with school exclusions or missing episodes
Vulnerable adults whose homes may be 'cuckooed'
Children previously known to youth justice services

Figure 1: Recognising the signs of county lines exploitation. Adapted from NSPCC guidance (nspcc.org.uk).

Clinician rapid reference

THE YOUNG PERSON

Unexplained injuries or restraint marks
Multiple phones, unexplained cash
Secretive, anxious or fearful demeanour
Reluctant to explain travel or associates

THE ADDRESS

Adults present who are not known relatives
Signs of drug activity or paraphernalia
Vulnerable resident with unfamiliar visitors (cuckooing)

THE PATTERN

Repeated missing episodes or unexplained travel
Association with known exploitation networks
Escalating debt, threats or violence disclosed

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BULLETIN 11

County Lines

Safeguarding

Pattern recognition

GREEN

Young person accounted for and safe
Consistent, verifiable explanation for travel
No unexplained cash, phones or injuries
Engaged positively with services
Stable, known peer group

AMBER

Occasional unexplained absence
New peer group or phone, plausible explanation
Minor unexplained injury, explained inconsistently
Reluctance to discuss whereabouts
Single missing episode

RED

Repeated missing episodes across force boundaries
Multiple phones, unexplained large sums of cash
Unexplained or patterned injuries, signs of restraint
Disclosure or evidence of debt bondage or threats
Presence of exploitative adults or cuckooed address

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at injuries, phones, cash and associates.

2ASK

Ask the young person alone if safe. Open, non-judgemental questions.

3RECORD

Contemporaneous notes. Travel, injuries, associates, disclosures.

4REPORT

Follow Spark reporting procedure. Consider NRM referral. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 11

County Lines

Safeguarding

Helplines & signposting

WORRIED ABOUT A CHILD?

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

REPORT ANONYMOUSLY

Fearless / Crimestoppers — free, anonymous

0800 555 111

Sources & further reading

NSPCC — County lines
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/child-exploitation/county-lines/
Home Office — Criminal exploitation of children and vulnerable adults: county lines guidance
https://www.gov.uk/government/publications/criminal-exploitation-of-children-and-vulnerable-adults-county-lines
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Modern Slavery Act 2015 — Section 45
https://www.legislation.gov.uk/ukpga/2015/30/section/45
Children and Young Persons Act 1933 — Section 1
https://www.legislation.gov.uk/ukpga/Geo5/23-24/12/section/1
Fearless — County lines
https://www.fearless.org/en/a-z/county-lines
Barnardo's — Child criminal exploitation
https://www.barnardos.org.uk/what-we-do/protecting-children/child-exploitation
Missing People — County lines and missing children
https://www.missingpeople.org.uk/
NSPCC Helpline (24/7) — 0808 800 5000 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 12

Prevent & Radicalisation

Safeguarding

SAFEGUARDING BULLETIN 12

EARLY WORDS CAN CHANGE A PATH.

Radicalisation is a process, not an event — it can be interrupted early.

Vulnerability, not ideology, is often the first sign.

You may be the trusted adult who notices the change.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG12 · January 2027 · Spark Medical

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BULLETIN 12

Prevent & Radicalisation

Safeguarding

Why vigilance matters

Spark Medical staff build trusted relationships with individuals and families in their homes over time, placing them in a unique position to notice gradual changes in behaviour, beliefs or associations that may indicate vulnerability to radicalisation. Because this is a slow, often hidden process, isolated observations can seem insignificant — but a pattern of withdrawal, new ideological language or secrecy noticed early can open the door to support before harm occurs to the individual or others.

Definition

Radicalisation is defined in the Prevent Duty Guidance as the process by which a person comes to support terrorism and forms of extremism. Prevent is one of four strands of the government's counter-terrorism strategy (CONTEST) and is a safeguarding approach, not a criminal justice response, aimed at supporting people before they become involved in terrorism, as set out under the Counter-Terrorism and Security Act 2015.

A common misconception is that Prevent targets a particular faith, ethnicity or political view. In fact, Prevent covers all forms of extremism, including far-right, Islamist and single-issue ideologies, and applies equally to adults and children. Referral to Channel is voluntary support, not a criminal sanction.

Legal & policy framework

Counter-Terrorism and Security Act 2015, Section 26 — statutory Prevent duty on specified authorities to have due regard to preventing people being drawn into terrorism.
Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm through radicalisation.
Working Together to Safeguard Children (2023) — statutory guidance recognising radicalisation as a safeguarding issue requiring multi-agency response.
Care Act 2014 — relevant where an adult at risk is vulnerable to radicalisation and meets safeguarding adults criteria.
Human Rights Act 1998, Article 10 — balances the right to freedom of expression against the duty to prevent harm from radicalisation.

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BULLETIN 12

Prevent & Radicalisation

Safeguarding

Key statistics

>6,000Prevent referrals recorded across the UK annually

Under 18age group accounting for a large share of referrals

Channelvoluntary, multi-agency support panel for those at risk

Risingproportion of referrals linked to online radicalisation

Sources: Home Office Prevent statistics • Counter-Terrorism and Security Act 2015

Types & presentations

Far-rightEthno-nationalist or white supremacist ideology

IslamistExtremist interpretations used to justify violence

Single-issueExtreme views on a specific cause

Online groomingRecruitment via gaming, forums or social media

Mixed/unstableUnclear or shifting ideological influences

Ideology varies but the vulnerability pathway is often similar — notice the process

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BULLETIN 12

Prevent & Radicalisation

Safeguarding

Signs to watch for

Behavioural signs

Withdrawal from family, friends or usual activities
Sudden change in appearance, dress or routine
Increased secrecy, especially around online activity
Expressing 'us vs them' or grievance-based views
Glorifying violence or extremist figures

Language red flags

Talk of martyrdom, retribution or 'the cause'
Dehumanising language about a group of people
Repeating conspiracy narratives or propaganda phrases
Absolutist, black-and-white worldview
Reluctance to discuss where views originated

Environmental signs

New unfamiliar online contacts or group memberships
Extremist material found in the home
Association with known extremist individuals or groups
Unexplained travel to conflict regions
Isolation from previously supportive networks

Population-specific

Young people experiencing identity or belonging crisis
Individuals recently bereaved, traumatised or excluded
Adults with mental health needs targeted by recruiters
Care leavers or those with limited support networks

Figure 1: Recognising vulnerability to radicalisation. Adapted from Prevent Duty guidance (gov.uk).

Clinician rapid reference

THE INDIVIDUAL

Withdrawal, secrecy or sudden ideological language
Grievance narratives or 'us vs them' framing
Glorification of violence or extremist figures
Recent identity crisis, trauma or isolation

THE ENVIRONMENT

Extremist material present in the home
Unfamiliar online contacts or group activity
Association with known extremist networks

THE RESPONSE

Non-judgemental, open conversation — avoid confrontation
Record concerns factually and verbatim where possible
Consider voluntary Channel referral via Spark procedure

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BULLETIN 12

Prevent & Radicalisation

Safeguarding

Pattern recognition

GREEN

Engaged with family, friends and usual activities
Open to discussing views without hostility
No extremist material or contacts identified
Stable identity and support network
No grievance-based or absolutist language

AMBER

Some withdrawal or secrecy, plausible explanation
Occasional grievance language, open to challenge
New online contacts, nature unclear
Recent life stressor (bereavement, exclusion)
Curiosity about extreme content without endorsement

RED

Significant withdrawal and secrecy
Repeated glorification of violence or extremist figures
Extremist material or symbols found in the home
Confirmed association with known extremist individuals
Expressed intent to act or travel for extremist purposes

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look for changes in behaviour, language and contacts.

2ASK

Ask open, non-judgemental questions. Avoid confrontation or

3RECORD

Contemporaneous notes. Language used, material seen, contacts described.

4REPORT

Follow Spark reporting procedure. Consider Channel referral. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 12

Prevent & Radicalisation

Safeguarding

Helplines & signposting

WORRIED ABOUT RADICALISATION?

Prevent — via Spark reporting procedure

Follow Spark report

REPORT TERRORISM CONCERNS

Anti-Terrorist Hotline — ACT Early

0800 789 321

Sources & further reading

GOV.UK — Prevent duty guidance
https://www.gov.uk/government/publications/prevent-duty-guidance
GOV.UK — Channel guidance
https://www.gov.uk/government/publications/channel-guidance
Counter-Terrorism and Security Act 2015 — Section 26
https://www.legislation.gov.uk/ukpga/2015/6/section/26
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Children Act 1989 — Section 47
https://www.legislation.gov.uk/ukpga/1989/41/section/47
Care Act 2014 — statutory guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance
Human Rights Act 1998 — Article 10
https://www.legislation.gov.uk/ukpga/1998/42/schedule/1/part/I/chapter/6
NSPCC — Radicalisation and extremism
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/radicalisation/
Research in Practice — Prevent and safeguarding
https://www.researchinpractice.org.uk/
Anti-Terrorist Hotline — 0800 789 321

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 13

Female Genital Mutilation

Safeguarding

SAFEGUARDING BULLETIN 13

EVERY GIRL HAS THE RIGHT TO SAY NO.

FGM is a form of child abuse and violence against women and girls.

It is illegal in the UK regardless of consent, culture or belief.

You may be the professional a girl or family trusts first.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG13 · February 2027 · Spark Medical

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BULLETIN 13

Female Genital Mutilation

Safeguarding

Why vigilance matters

Spark Medical staff visiting homes and communities may be among the few professionals to see a family in an unguarded setting, hear conversations about travel plans, or notice a girl's reluctance to discuss a forthcoming trip abroad. Because FGM is hidden by design and often framed within families as protective or cultural, your ability to notice subtle situational cues — not just physical signs — is critical to preventing harm before it happens.

Definition

Female genital mutilation is defined under the Female Genital Mutilation Act 2003 as all procedures involving partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons. It is recognised in Working Together to Safeguard Children (2023) as a form of child abuse and violence against women and girls, with no medical justification and significant physical and psychological harm.

A common misconception is that FGM only affects girls travelling abroad. Procedures can also take place in the UK, and a girl may be at risk from birth if she belongs to a community that practises FGM. There is no religious requirement for FGM in any major faith, despite cultural justifications sometimes given.

Legal & policy framework

Female Genital Mutilation Act 2003 (as amended) — makes FGM and taking a girl abroad for FGM a criminal offence, and creates FGM Protection Orders.
Serious Crime Act 2015, Section 74 — introduces mandatory reporting duty for regulated health, social care and teaching professionals where FGM is discovered in a girl under 18.
Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm through FGM.
Working Together to Safeguard Children (2023) — statutory guidance on identifying and responding to FGM risk and disclosure.
Human Rights Act 1998, Article 3 — prohibition of torture and inhuman or degrading treatment, engaged by FGM.

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BULLETIN 13

Female Genital Mutilation

Safeguarding

Key statistics

>130,000women and girls in England and Wales are estimated to be affected

Under 15the age group most girls are at risk before

Mandatoryreporting duty for regulated professionals under UK law

IllegalFGM is a criminal offence in the UK regardless of consent

Sources: NHS Digital FGM enhanced dataset, NSPCC • Serious Crime Act 2015

Types & presentations

Type 1Clitoridectomy — partial or total removal

Type 2Excision of the clitoris and labia minora

Type 3Infibulation — narrowing of the vaginal opening

Type 4Other harmful procedures for non-medical reasons

Risk stagePre-procedure risk in girls not yet cut

All types constitute abuse under UK law — risk must be acted on before it occurs

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BULLETIN 13

Female Genital Mutilation

Safeguarding

Signs to watch for

Physical signs

Difficulty walking, sitting or standing
Frequent urinary, menstrual or infection problems
Prolonged absence from school or clinic
Reluctance to undergo normal medical examination
Signs of pain or distress in the genital area

Pre-procedure indicators

Talk of a 'special procedure' or 'becoming a woman'
A trip abroad planned, especially in school holidays
Female relative recently visited or is visiting from abroad
Family belongs to a community known to practise FGM
Older sibling has already undergone FGM

Behavioural signs

Anxiety or reluctance about an upcoming trip
Whispered conversations about a ceremony or ritual
Withdrawal from friends or usual activities
Asking for help or hinting at a problem indirectly

Population-specific

Girls aged 0–15 from FGM-practising communities
Families with a history of FGM in older female relatives
Girls whose mothers have undergone FGM
Recently arrived families from higher-prevalence countries

Figure 1: Recognising the signs and risk factors of FGM. Adapted from NHS and NSPCC guidance (nhs.uk, nspcc.org.uk).

Clinician rapid reference

THE GIRL

Physical signs of pain, infection or difficulty walking
Anxiety about an upcoming trip abroad
Verbal disclosure or hints of a planned procedure
Reluctance to discuss the topic directly

THE FAMILY

Community or family history of FGM practice
Recent or planned travel to a practising country
Older female relatives who have undergone FGM

THE DUTY

Mandatory reporting duty if FGM is disclosed or observed in under-18s
FGM Protection Orders can be sought to prevent travel
Report via Spark reporting procedure without delay

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BULLETIN 13

Female Genital Mutilation

Safeguarding

Pattern recognition

GREEN

No planned travel to higher-prevalence countries
Family expresses clear opposition to FGM
No physical signs or symptoms present
Girl engaged, confident and unconcerned
Open, positive family communication

AMBER

Planned trip abroad, purpose unclear
Vague or reluctant answers about the trip
Older female relative recently visited from abroad
Girl slightly withdrawn or anxious
Family belongs to a practising community, no other risk noted

RED

Explicit talk of a 'special procedure' or ceremony
Girl discloses fear of an upcoming procedure
Physical signs of FGM already present
Imminent travel booked with no reasonable explanation
Older sibling known to have undergone FGM

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look for physical signs and pre-procedure indicators.

2ASK

Ask the girl alone if safe. Open, sensitive, non-judgemental questions.

3RECORD

Contemporaneous notes. Travel plans, disclosures, family context, verbatim wording.

4REPORT

Follow Spark reporting procedure without delay. Mandatory reporting duty applies.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 13

Female Genital Mutilation

Safeguarding

Helplines & signposting

WORRIED ABOUT FGM?

NSPCC FGM Helpline — 24 hours a day, 7 days a week

0800 028 3550

HONOUR-BASED ABUSE SUPPORT

Karma Nirvana — confidential support

0800 5999 247

Sources & further reading

NHS — Female genital mutilation (FGM)
https://www.nhs.uk/conditions/female-genital-mutilation-fgm/
NSPCC — Female genital mutilation (FGM)
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/female-genital-mutilation-fgm/
GOV.UK — Female Genital Mutilation: multi-agency statutory guidance
https://www.gov.uk/government/publications/multi-agency-statutory-guidance-on-female-genital-mutilation
Female Genital Mutilation Act 2003
https://www.legislation.gov.uk/ukpga/2003/31/contents
Serious Crime Act 2015 — Section 74
https://www.legislation.gov.uk/ukpga/2015/9/section/74
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
28 Too Many — FGM research and resources
https://www.28toomany.org/
RCOG — Female genital mutilation
https://www.rcog.org.uk/for-the-public/browse-our-patient-information/female-genital-mutilation-fgm/
Karma Nirvana
https://www.karmanirvana.org.uk/
NSPCC FGM Helpline (24/7) — 0800 028 3550 | help @ nspcc.org.uk

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 14

Forced Marriage & HBA

Safeguarding

SAFEGUARDING BULLETIN 14

MARRIAGE MUST ALWAYS BE A CHOICE.

Forced marriage is a crime and a form of honour-based abuse in the UK.

Victims are often isolated from services until it is too late to intervene.

You may be the only professional a victim can safely speak to.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG14 · February 2027 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 14

Forced Marriage & HBA

Safeguarding

Why vigilance matters

Spark Medical staff visiting homes often see family dynamics that other professionals never witness — sudden restrictions on a young person's movement, talk of an upcoming trip abroad, or visible fear around certain relatives. Because forced marriage and honour-based abuse are hidden within family and community structures and victims are often too afraid to disclose openly, your ability to notice situational cues in the home may be the only chance to intervene before a victim is taken abroad or married against their will.

Definition

Forced marriage is defined under the Anti-social Behaviour, Crime and Policing Act 2014 as a marriage without the free and full consent of one or both parties, where pressure or abuse is used to force the marriage to take place. Honour-based abuse, as recognised in Working Together to Safeguard Children (2023) and Home Office statutory guidance, is a form of violence committed to protect or defend the perceived honour of a family or community, often linked to forced marriage.

A common misconception is that forced marriage is the same as arranged marriage. Arranged marriage, where both parties freely consent, is lawful and common across many cultures. Forced marriage involves coercion — physical, emotional, financial or psychological — and is a crime regardless of the age of the victim or the cultural context.

Legal & policy framework

Anti-social Behaviour, Crime and Policing Act 2014, Sections 121-122 — makes forced marriage a criminal offence and enables Forced Marriage Protection Orders.
Forced Marriage (Civil Protection) Act 2007 — established Forced Marriage Protection Orders to prevent a marriage taking place or provide protection.
Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm through forced marriage.
Working Together to Safeguard Children (2023) — statutory guidance on identifying and responding to forced marriage and honour-based abuse.
Care Act 2014 — relevant where an adult at risk is subject to forced marriage or honour-based abuse and meets safeguarding adults criteria.

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BULLETIN 14

Forced Marriage & HBA

Safeguarding

Key statistics

>300cases handled by the Forced Marriage Unit annually

1 in 3victims contacting the Forced Marriage Unit are under 18

Both sexesaffected, though the majority of victims are female

Hiddencrime — most victims never formally report

Sources: Home Office / Foreign, Commonwealth & Development Office Forced Marriage Unit • Karma Nirvana

Types & presentations

Forced marriageMarriage without free and full consent

RestrictionControl of movement, education or dress

ThreatsThreats of violence, abandonment or disownment

Physical abuseViolence to enforce family 'honour'

IsolationRemoval from friends, school or support networks

Honour-based abuse can escalate quickly — recognise the pattern early

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BULLETIN 14

Forced Marriage & HBA

Safeguarding

Signs to watch for

Physical signs

Unexplained bruising, injuries or self-harm
Signs of depression, anxiety or suicidal ideation
Signs of restraint or being kept indoors
Sudden withdrawal from healthcare or contraception services

Behavioural signs

Sudden announcement of engagement or marriage
Reluctance or fear when discussing family plans
Requests for help that are indirect or coded
Withdrawal from school, college or work
Truancy or a drop in academic performance

Environmental signs

Passport or documents removed or confiscated
One-way ticket or unexplained trip abroad planned
Extended absence from school reported as 'family reasons'
Family surveillance — accompanied everywhere, phone monitored
Un-registered or informal marriage ceremony discussed

Population-specific

Young people from communities where HBA is more prevalent
Individuals with siblings previously forced into marriage
LGBT+ individuals fearing family reaction to their identity
Adults with disabilities at risk of forced marriage

Figure 1: Recognising the signs of forced marriage and honour-based abuse. Adapted from Home Office guidance (gov.uk).

Clinician rapid reference

THE INDIVIDUAL

Fear, anxiety or reluctance to discuss family plans
Signs of restraint, self-harm or depression
Passport, phone or documents removed
Indirect or coded requests for help

THE FAMILY

Sudden engagement or marriage announcement
History of forced marriage in siblings or relatives
Overt surveillance or control of movement

THE RESPONSE

Speak to the person alone, never with family present
Never contact family to 'verify' concerns
Report via Spark reporting procedure without delay

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BULLETIN 14

Forced Marriage & HBA

Safeguarding

Pattern recognition

GREEN

Free to discuss relationships and future plans openly
No restriction on movement, school or social contact
No pressure regarding marriage or engagement
Confident, open communication when alone
Passport and documents in the person's own control

AMBER

Some reluctance to discuss family expectations
Planned trip abroad, purpose unclear
Recent reduction in social contact
Vague talk of a future engagement, no immediate date
Mild anxiety about family reaction to personal choices

RED

Passport or documents confiscated
One-way ticket booked or imminent travel abroad
Explicit disclosure of forced marriage plans or threats
Signs of physical restraint, violence or self-harm
Total withdrawal from school, friends and services

Any single red flag warrants urgent senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look for restriction, fear and travel plans.

2ASK

Ask the person alone, never with family present. Open, safe questions.

3RECORD

Contemporaneous notes. Disclosures, travel plans, verbatim wording.

4REPORT

Follow Spark reporting procedure urgently. Never involve the family.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 14

Forced Marriage & HBA

Safeguarding

Helplines & signposting

WORRIED ABOUT FORCED MARRIAGE?

Karma Nirvana — confidential support

0800 5999 247

FORCED MARRIAGE UNIT

Foreign, Commonwealth & Development Office

020 7008 0151

Sources & further reading

GOV.UK — Forced marriage
https://www.gov.uk/stop-forced-marriage
GOV.UK — Multi-agency practice guidelines: forced marriage
https://www.gov.uk/government/publications/forced-marriage
Anti-social Behaviour, Crime and Policing Act 2014 — Sections 121–122
https://www.legislation.gov.uk/ukpga/2014/12/section/121
Forced Marriage (Civil Protection) Act 2007
https://www.legislation.gov.uk/ukpga/2007/20/contents
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Care Act 2014 — statutory guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance
Karma Nirvana
https://www.karmanirvana.org.uk/
NSPCC — Forced marriage
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/forced-marriage/
Equality and Human Rights Commission — Forced marriage
https://www.equalityhumanrights.com/
Karma Nirvana Helpline (24/7) — 0800 5999 247

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 15

Modern Slavery & Human Trafficking

Safeguarding

SAFEGUARDING BULLETIN 15

NO ONE IS PROPERTY TO BE SOLD.

Modern slavery affects adults and children of all nationalities in the UK.

Victims are often hidden in plain sight — in homes, farms and businesses.

You may be the only outsider a victim ever encounters.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG15 · March 2027 · Spark Medical

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BULLETIN 15

Modern Slavery & Human Trafficking

Safeguarding

Why vigilance matters

Spark Medical staff attending addresses across communities may be the only outsiders to enter premises where victims of modern slavery are held — cramped living conditions, multiple unrelated occupants, or a person who seems fearful, controlled or unable to speak for themselves. Because trafficking victims are deliberately isolated from services and often coached to give a false account, your independent observation of the environment and the individual's demeanour may be the only opportunity to identify exploitation.

Definition

Modern slavery is defined under the Modern Slavery Act 2015 as encompassing slavery, servitude, forced or compulsory labour, and human trafficking. Trafficking involves the recruitment, movement or receipt of a person through deception, coercion or abuse of vulnerability for the purpose of exploitation, as further defined by the Council of Europe Convention on Action against Trafficking in Human Beings, which underpins the UK's National Referral Mechanism.

A common misconception is that modern slavery only involves people trafficked from abroad. UK nationals, including children, are also victims of internal trafficking and forced labour. A victim's apparent compliance does not indicate consent — control through debt, fear, isolation and confiscated documents is central to exploitation.

Legal & policy framework

Modern Slavery Act 2015 — consolidates offences of slavery, servitude, forced labour and human trafficking, and creates the National Referral Mechanism.
Modern Slavery Act 2015, Section 45 — statutory defence for victims compelled to commit certain offences as a result of their exploitation.
Children Act 1989, Section 47 — duty to investigate where a child is suspected of suffering, or likely to suffer, significant harm through trafficking.
Working Together to Safeguard Children (2023) — statutory guidance recognising trafficking and modern slavery as child protection concerns.
Care Act 2014 — relevant where an adult at risk of modern slavery meets safeguarding adults criteria.

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BULLETIN 15

Modern Slavery & Human Trafficking

Safeguarding

Key statistics

>17,000potential victims referred to the NRM annually

1 in 4referrals to the NRM are children

Labour exploitationthe most commonly recorded exploitation type

All nationalitiesUK nationals are among the most referred groups

Sources: Home Office National Referral Mechanism statistics • Modern Slavery Act 2015

Types & presentations

Labour exploitationForced work in agriculture, car washes, construction

Sexual exploitationForced involvement in the sex trade

Domestic servitudeForced unpaid labour within a household

Criminal exploitationForced involvement in crime, including county lines

Organ harvestingCoerced or deceived removal of organs

Victims may experience more than one type of exploitation simultaneously

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BULLETIN 15

Modern Slavery & Human Trafficking

Safeguarding

Signs to watch for

Physical signs

Signs of malnutrition, dehydration or poor hygiene
Untreated injuries or signs of physical abuse
Exhaustion consistent with excessive working hours
Signs of restraint or confinement

Behavioural signs

Fearful, anxious or unable to speak for themselves
Rehearsed or inconsistent personal account
Reluctance to make eye contact or speak when others present
Unfamiliarity with their own home address or surroundings
Distrust of authorities or reluctance to engage

Environmental signs

Overcrowded, makeshift or unsafe living conditions
Multiple unrelated occupants at one address
Passports or ID documents held by a third party
Signs of controlled finances — no personal bank account or wages
Vehicles or equipment associated with forced labour on-site

Population-specific

Recently arrived migrants with limited English
Children exploited through county lines or domestic servitude
Adults with care needs exploited within their own home
Individuals with debts to a recruiter or 'agent'

Figure 1: Recognising the signs of modern slavery and trafficking. Adapted from GOV.UK statutory guidance.

Clinician rapid reference

THE PERSON

Signs of malnutrition, injury or exhaustion
Fearful or unable to speak freely when others present
Rehearsed, inconsistent or unfamiliar personal details
No control over own documents, wages or movement

THE ADDRESS

Overcrowded or unsafe living conditions
Multiple unrelated occupants
Signs of forced labour or makeshift workspace

THE RESPONSE

Speak to the person alone with an independent interpreter
Never use a family member or associate as interpreter
Report via Spark reporting procedure; consider NRM referral

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BULLETIN 15

Modern Slavery & Human Trafficking

Safeguarding

Pattern recognition

GREEN

Person speaks freely and confidently when alone
Consistent, verifiable personal account
Controls own documents, wages and movements
Living conditions safe and appropriate
No signs of injury, malnutrition or exhaustion

AMBER

Some hesitation discussing living or working arrangements
Overcrowded but not obviously unsafe accommodation
Limited English requiring interpreter support
Mild inconsistency in personal account
Recently arrived with limited independent support

RED

Signs of malnutrition, injury or severe exhaustion
Documents confiscated by a third party
Fearful, controlled or coached responses
Overcrowded, unsafe living conditions with forced labour signs
Explicit disclosure of exploitation, debt bondage or threats

Any single red flag warrants urgent senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at the person, the address and who controls what.

2ASK

Ask the person alone with an independent interpreter. Open, safe questions.

3RECORD

Contemporaneous notes. Living conditions, account given, verbatim wording.

4REPORT

Follow Spark reporting procedure. Consider NRM referral. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 15

Modern Slavery & Human Trafficking

Safeguarding

Helplines & signposting

WORRIED ABOUT MODERN SLAVERY?

Modern Slavery Helpline — 24 hours a day, 7 days a week

08000 121 700

SUPPORT FOR TRAFFICKED CHILDREN

NSPCC Helpline — 24 hours a day, 7 days a week

0808 800 5000

Sources & further reading

GOV.UK — Modern slavery: statutory guidance
https://www.gov.uk/government/publications/modern-slavery-statutory-guidance
GOV.UK — National Referral Mechanism guidance
https://www.gov.uk/government/publications/human-trafficking-victims-referral-and-assessment-forms
Modern Slavery Act 2015
https://www.legislation.gov.uk/ukpga/2015/30/contents
Modern Slavery Act 2015 — Section 45
https://www.legislation.gov.uk/ukpga/2015/30/section/45
Working Together to Safeguard Children 2023 (statutory guidance)
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2
Care Act 2014 — statutory guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance
Unseen UK — Modern slavery
https://www.unseenuk.org/
NSPCC — Child trafficking
https://www.nspcc.org.uk/what-is-child-abuse/types-of-abuse/child-trafficking/
Modern Slavery Helpline
https://www.modernslaveryhelpline.org/
Modern Slavery Helpline (24/7) — 08000 121 700

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 16

Cuckooing

Safeguarding

SAFEGUARDING BULLETIN 16

THEIR HOME IS NOT YOURS TO TAKE.

Cuckooing sees vulnerable people's homes taken over for criminal exploitation.

Victims often feel unable to refuse or report due to fear or dependency.

You may be the only visitor who notices the takeover.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG16 · March 2027 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 16

Cuckooing

Safeguarding

Why vigilance matters

Spark Medical staff attending home visits regularly enter properties belonging to vulnerable adults and may be the only professionals to notice when an address no longer feels like it belongs to its resident — unfamiliar visitors, drug paraphernalia, or a resident who seems frightened or diminished in their own home. Because cuckooing thrives on isolation and the victim's reluctance to report due to fear, dependency or shame, your independent observation of the property and its occupant may be the first sign anyone notices.

Definition

Cuckooing is a form of criminal exploitation, recognised in Home Office county lines guidance and under the Care Act 2014 safeguarding framework, in which a person's home is taken over by individuals — often involved in drug supply — who use the property to deal drugs, store weapons or exploit the resident. Victims are frequently older adults, people with substance misuse issues, learning disabilities or mental health needs, targeted for their vulnerability and isolation.

A common misconception is that cuckooing victims have consented to or benefit from the arrangement. In reality, victims are often coerced, threatened or manipulated, and many are unable to leave their own home or refuse entry to exploiters without fear of violence or losing their only source of company or drugs.

Legal & policy framework

Care Act 2014 — defines adults at risk of abuse or neglect, including exploitation such as cuckooing, and sets duties for local authority safeguarding response.
Modern Slavery Act 2015, Section 45 — relevant statutory defence where a victim is compelled to commit offences as part of their exploitation.
Anti-social Behaviour, Crime and Policing Act 2014 — provides for Closure Orders and Community Protection Notices used to tackle cuckooed properties.
Serious Crime Act 2015, Section 76 — controlling or coercive behaviour offence, relevant where the victim and exploiter have a personal connection.
Human Rights Act 1998, Article 8 — right to respect for private and family life and the home, engaged when a property is taken over against the resident's will.

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BULLETIN 16

Cuckooing

Safeguarding

Key statistics

Widespreadcuckooing is linked to the majority of county lines operations

Vulnerable adultsthe most commonly targeted victim group

Closure Ordersa key police power used to disrupt cuckooed addresses

Under-reportedmany victims never come to the attention of services

Sources: Home Office county lines guidance, National Crime Agency • Care Act 2014

Types & presentations

Drug storageHome used to store or deal drugs

Weapon storageProperty used to conceal weapons

Sexual exploitationHome used to exploit the resident or visitors

Financial exploitationResident's money or benefits taken

Coercive controlResident controlled, threatened or isolated

Cuckooing is often linked to county lines and modern slavery networks

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BULLETIN 16

Cuckooing

Safeguarding

Signs to watch for

Physical signs

Unexplained injuries, bruising or physical decline in the resident
Signs of poor self-care or neglect of usual needs
Resident appears frightened, sedated or withdrawn
Weight loss or deteriorating health without explanation

Behavioural signs

Resident reluctant to discuss visitors or who is staying
Resident anxious, evasive or fearful in their own home
Reduced contact with previously regular services or family
Resident appears to defer to or fear a third party present

Environmental signs

Increased visitors, especially at unusual times of day or night
Drug paraphernalia, weapons or unexplained quantities of cash
Damage to doors, windows or locks
Windows covered, curtains permanently drawn
Unfamiliar vehicles or individuals repeatedly at the address

Population-specific

Older adults living alone with reduced family contact
Adults with substance misuse or mental health needs
Adults with learning disabilities living independently
Care leavers or single tenants recently moved into an area

Figure 1: Recognising the signs of cuckooing. Adapted from Home Office county lines guidance (gov.uk).

Clinician rapid reference

THE RESIDENT

Fearful, withdrawn or physically declined presentation
Reluctance to discuss visitors or living arrangements
Signs of coercion, threats or financial exploitation
Reduced control over their own home and choices

THE PROPERTY

Increased or unfamiliar visitors, unusual hours
Drug paraphernalia, weapons or damage present
Windows covered, appearance changed from baseline

THE RESPONSE

Speak to the resident alone wherever possible
Do not challenge exploiters directly — assess safety first
Report via Spark reporting procedure; consider Care Act referral

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BULLETIN 16

Cuckooing

Safeguarding

Pattern recognition

GREEN

Resident controls who enters their own home
No unfamiliar or unexplained visitors
Resident engaged, confident and physically well
Home clean, safe and unchanged from baseline
Regular contact maintained with family or services

AMBER

Occasional unfamiliar visitor, plausible explanation
Resident slightly withdrawn or anxious
Minor changes to the home noted since last visit
Some reduction in contact with usual services
Resident vague about a new acquaintance

RED

Resident fearful, coerced or unable to speak freely
Drug paraphernalia, weapons or unexplained cash present
Frequent unfamiliar visitors at unusual hours
Resident's physical health has markedly declined
Resident's finances or benefits are being controlled by others

Any single red flag warrants urgent senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at the resident, the property and the visitors.

2ASK

Ask the resident alone if safe. Open, non-judgemental questions.

3RECORD

Contemporaneous notes. Visitors, property changes, verbatim disclosures.

4REPORT

Follow Spark reporting procedure. Consider Care Act safeguarding referral.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 16

Cuckooing

Safeguarding

Helplines & signposting

WORRIED ABOUT A VULNERABLE ADULT?

Ann Craft Trust — safeguarding advice

0115 951 5400

REPORT COUNTY LINES / CUCKOOING

Fearless / Crimestoppers — free, anonymous

0800 555 111

Sources & further reading

GOV.UK — Criminal exploitation of children and vulnerable adults: county lines guidance
https://www.gov.uk/government/publications/criminal-exploitation-of-children-and-vulnerable-adults-county-lines
GOV.UK — Care Act statutory guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance
Care Act 2014
https://www.legislation.gov.uk/ukpga/2014/23/contents
Anti-social Behaviour, Crime and Policing Act 2014
https://www.legislation.gov.uk/ukpga/2014/12/contents
Serious Crime Act 2015 — Section 76
https://www.legislation.gov.uk/ukpga/2015/9/section/76
Human Rights Act 1998 — Article 8
https://www.legislation.gov.uk/ukpga/1998/42/schedule/1/part/I/chapter/8
Ann Craft Trust — Cuckooing
https://www.ann-craft-trust.org/
SCIE — Safeguarding adults and cuckooing
https://www.scie.org.uk/
Fearless — County lines and cuckooing
https://www.fearless.org/en/a-z/county-lines
Ann Craft Trust Helpline — 0115 951 5400

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 17

Adult Neglect & Acts of Omission

Safeguarding

SAFEGUARDING BULLETIN 17

EVERY ADULT DESERVES DIGNIFIED CARE.

Adult neglect is a leading category of safeguarding concern referred to local authorities.

It is often the result of omission by carers, not deliberate cruelty.

You may be the first professional to notice a decline in care.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG17 · April 2027 · Spark Medical

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BULLETIN 17

Adult Neglect & Acts of Omission

Safeguarding

Why vigilance matters

Spark Medical staff attending home visits see adults with care and support needs in their own environment, often revealing far more than a single clinic appointment ever could — an unkempt home, missed medication, or a carer who seems overwhelmed or absent. Because neglect accumulates gradually and is frequently unintentional, isolated observations can seem minor, but your pattern of visits over time may be the clearest evidence that an adult's basic needs are not being met.

Definition

Neglect and acts of omission are defined under the Care Act 2014 statutory guidance as a form of abuse including ignoring medical, emotional or physical care needs, failure to provide access to appropriate health, social care or educational services, and withholding the necessities of life such as medication, adequate nutrition and heating. It applies to adults with care and support needs who are unable to protect themselves from the neglect or the risk of it.

A common misconception is that neglect only occurs in care homes or through malicious intent. In reality, neglect frequently occurs in a person's own home, including through self-neglect or an overwhelmed family carer, and often results from a lack of support, training or respite rather than deliberate harm.

Legal & policy framework

Care Act 2014, Section 42: — duty on local authorities to make enquiries where an adult with care and support needs is at risk of abuse or neglect.
Care Act 2014 (statutory guidance): — defines neglect and acts of omission as a recognised category of abuse for safeguarding adults purposes.
Mental Capacity Act 2005: — relevant where capacity to consent to care or refuse support must be assessed alongside neglect concerns.
Human Rights Act 1998, Article 3: — prohibition of inhuman or degrading treatment, engaged in severe neglect cases.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 13: — duty on regulated providers to safeguard service users from abuse and improper treatment.

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BULLETIN 17

Adult Neglect & Acts of Omission

Safeguarding

Key statistics

~10%of safeguarding adults concerns relate to neglect or acts of omission

Over 65sthe age group most frequently affected

Carer straina leading contributing factor in unintentional neglect

Chroniccumulative harm — recognise early, act early

Sources: NHS Digital Safeguarding Adults Collection, SCIE • Care Act 2014 statutory guidance

Types & presentations

PhysicalFood, clothing, hygiene, shelter

MedicalMissed medication, unmanaged conditions

EmotionalIsolation, lack of stimulation or contact

EnvironmentalUnsafe, unheated or unsanitary home

Carer omissionFailure by paid or family carer to provide care

Any single category can constitute neglect — patterns confirm the picture

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BULLETIN 17

Adult Neglect & Acts of Omission

Safeguarding

Signs to watch for

Physical signs

Pressure sores, poor hygiene or ingrained dirt
Weight loss, dehydration or malnutrition
Inappropriate clothing for weather or condition
Untreated medical or dental problems
Unexplained deterioration in mobility or health

Presentation red flags

Missed medication, appointments or care visits
Home cold, damp, dirty or unsafe
Little or no food in the home
Delayed help-seeking by the person or carer
Repeated hospital admissions for preventable issues

Behavioural signs

Withdrawn, anxious or reluctant to discuss care
Confusion about medication or care arrangements
Reluctance to allow professionals into the home
Signs of depression or loss of interest in surroundings

Carer / environment signs

Carer appears exhausted, overwhelmed or absent
Lack of aids or equipment needed for care
Evidence of carer's own substance misuse or ill health
Isolation from family, friends or support services

Figure 1: Recognising the signs of adult neglect. Adapted from SCIE and Care Act guidance (scie.org.uk).

Clinician rapid reference

THE PERSON

Poor hygiene, pressure sores, weight loss
Missed medication or unmanaged conditions
Inappropriate or dirty clothing
Signs of withdrawal, confusion or distress

THE HOME

Cold, damp, unsafe or unsanitary environment
No food, water or heating available
Lack of care equipment or aids

THE CARER

Signs of carer strain, exhaustion or absence
Lack of training, support or respite
Consider capacity and consent under the Mental Capacity Act

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BULLETIN 17

Adult Neglect & Acts of Omission

Safeguarding

Pattern recognition

GREEN

Person looks well cared-for and engaged
Home warm, clean, food available
Carer present, responsive and coping
Appointments and medication kept up to date
Person able to express their wishes freely

AMBER

Occasional missed appointment or medication dose
Home slightly chaotic but safe
Carer under stress or showing early signs of strain
Minor hygiene or nutrition concerns
Delayed help-seeking

RED

Multiple missed appointments or medication doses
Home unsafe, squalid or freezing
Person dehydrated, malnourished or with pressure sores
Carer absent, incapacitated or refusing access
Rapid, unexplained deterioration in health

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Trust your instinct. Look at the person, the home and the carer.

2ASK

Ask the person and, separately, the carer. Open questions.

3RECORD

Contemporaneous notes. Home environment, hygiene, weight, medication.

4REPORT

Follow Spark reporting procedure. On-call if unsure.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 17

Adult Neglect & Acts of Omission

Safeguarding

Helplines & signposting

WORRIED ABOUT AN ADULT AT RISK?

Local authority safeguarding adults team — via Spark reporting procedure

Follow Spark reporting procedure

SAFEGUARDING ADVICE

Ann Craft Trust — safeguarding adults advice line

0115 951 5400

Sources & further reading

SCIE — Safeguarding adults
https://www.scie.org.uk/safeguarding/adults
GOV.UK — Care Act statutory guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance
Care Act 2014 — Section 42
https://www.legislation.gov.uk/ukpga/2014/23/section/42
Mental Capacity Act 2005
https://www.legislation.gov.uk/ukpga/2005/9/contents
Human Rights Act 1998 — Article 3
https://www.legislation.gov.uk/ukpga/1998/42/schedule/1/part/I/chapter/3
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 — Regulation 13
https://www.legislation.gov.uk/uksi/2014/2936/regulation/13
CQC — Safeguarding adults
https://www.cqc.org.uk/guidance-providers/adult-social-care/safeguarding-adults
Ann Craft Trust
https://www.ann-craft-trust.org/
Age UK — Safeguarding older people from abuse and neglect
https://www.ageuk.org.uk/
Ann Craft Trust Advice Line — 0115 951 5400

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 18

Self-Neglect

Safeguarding

SAFEGUARDING BULLETIN 18

NOTICING WHEN SOMEONE STOPS COPING.

Self-neglect is one of the most frequent categories of adult safeguarding concern.

It often develops slowly, hidden behind a closed front door.

Home visits give Spark staff a unique vantage point to notice change.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG18 · April 2027 · Spark Medical

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BULLETIN 18

Self-Neglect

Safeguarding

Why vigilance matters

Self-neglect develops gradually and privately, often behind a closed front door where no one else looks in. Spark Medical staff who attend home visits, community clinics and welfare checks are frequently the only professionals who see inside a person's daily life — the state of their home, their hygiene, their medication management, and whether they are eating or engaging with care. A single visit can reveal a pattern that has been building for months. What you notice and report may be the first step towards support for someone who has stopped being able to care for themselves.

Definition

Self-neglect covers a wide range of behaviour: neglecting to care for one's personal hygiene, health or surroundings, and includes behaviour such as hoarding, as defined in the Care Act 2014 statutory guidance. It applies whether or not the person has mental capacity to understand the risks, and safeguarding duties apply if the local authority reasonably suspects an adult with care and support needs is at risk of harm as a result, and is unable to protect themselves because of those needs.

Self-neglect is unique among safeguarding categories because there may be no third-party perpetrator. It is easy to wrongly assume that because someone chooses their lifestyle, no action is needed — but capacity, coercion and the impact of mental ill-health or cognitive decline must always be actively considered before accepting a person's stated wishes at face value.

Legal & policy framework

Care Act 2014, Section 42: — duty on local authorities to make enquiries where an adult with care and support needs may be at risk of self-neglect and unable to protect themselves.
Care Act 2014 Statutory Guidance: — confirms self-neglect, including hoarding, as a distinct safeguarding category requiring a proportionate, person-centred response.
Mental Capacity Act 2005: — requires a capacity assessment for specific decisions before assuming a person lacks capacity to make lifestyle choices.
Human Rights Act 1998, Article 8: — balances the right to respect for private and family life against the duty to protect life and wellbeing (Article 2/3).
Care and Support Statutory Guidance (updated): — emphasises multi-agency, proportionate responses that respect autonomy while managing risk.

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BULLETIN 18

Self-Neglect

Safeguarding

Key statistics

Top 3self-neglect is among the most common adult safeguarding concern types

~1 in 20older adults show signs of self-neglect at some point

Hoardinga recognised and distinct form of self-neglect

Multi-agencyresponse usually needed — health, housing, social care

Sources: SCIE, Care Act 2014 Statutory Guidance

Types & presentations

Personal careHygiene, nutrition, dress neglected

EnvironmentalHome unsafe, unclean or unheated

HoardingAccumulation preventing safe living

MedicalRefusing or missing essential treatment

BehaviouralWithdrawal, isolation, refusal of support

Self-neglect can occur with or without mental capacity — never assume, always assess

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BULLETIN 18

Self-Neglect

Safeguarding

Signs to watch for

Physical signs

Unkempt appearance, poor hygiene
Weight loss or malnutrition
Untreated wounds, pressure sores or infections
Inappropriate clothing for weather
Poor mobility due to unmanaged conditions

Environmental signs

Home cluttered, hoarded or unsafe
No heating, lighting or working utilities
Infestation or accumulated waste
Fire hazards — blocked exits, faulty wiring
Pets neglected alongside the person

Behavioural signs

Refusing help or visits from services
Social withdrawal and isolation
Loss of interest in appearance or activities
Disorientation or confusion
Missed medication or appointments

Risk-heightened groups

Living alone with limited support network
Recent bereavement or major life change
Untreated mental illness or dementia
History of trauma or substance use
Recent hospital discharge without follow-up

Figure 1: Recognising the signs of self-neglect. Adapted from SCIE guidance (scie.org.uk).

Clinician rapid reference

THE PERSON

Hygiene, weight, untreated conditions
Mood, orientation, insight into risk
Engagement with offered support
Evidence of capacity or fluctuating capacity

THE HOME

Heating, lighting, working utilities
Hoarding, hazards, infestation
Food availability and storage

THE NETWORK

Family, neighbours or carers involved
History with GP and social care
Prior safeguarding referrals

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BULLETIN 18

Self-Neglect

Safeguarding

Pattern recognition

GREEN

Person clean, appropriately dressed
Home warm, safe, reasonably maintained
Engages with GP, carers or family
Medication managed appropriately
Stable mood and orientation

AMBER

Some decline in home standards
Occasional missed appointments
Mild withdrawal or low mood
Minor hygiene lapses
Reluctant but not refusing help

RED

Home unsafe, hoarded or unsanitary
Severe self-neglect of hygiene or nutrition
Refusing all help despite clear risk
Untreated wounds or serious health decline
Evidence of impaired capacity or exploitation

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Look at the person, the home and change over time.

2ASK

Ask about coping, support and capacity. Open, non-judgemental questions.

3RECORD

Contemporaneous notes on presentation, environment and engagement.

4REPORT

Follow Spark reporting procedure. Escalate urgently if life at risk.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 18

Self-Neglect

Safeguarding

Helplines & signposting

WORRIED ABOUT AN ADULT?

Contact your local authority adult safeguarding team

Via Spark reporting

NEED SUPPORT OR ADVICE?

Ann Craft Trust — adult safeguarding advice

0115 951 5400

Sources & further reading

SCIE — Self-neglect
https://www.scie.org.uk/safeguarding/adults/introduction/self-neglect/
Care Act 2014 — Section 42
https://www.legislation.gov.uk/ukpga/2014/23/section/42
Care and Support Statutory Guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guida
SCIE — Hoarding and self-neglect
https://www.scie.org.uk/self-neglect/
NICE — Older people: independence and mental wellbeing
https://www.nice.org.uk/guidance/ng32
Social Work England / SCIE practice guidance
https://www.scie.org.uk/safeguarding/adults/practice/
Age UK — Safeguarding older people
https://www.ageuk.org.uk/information-advice/care/safeguarding/
Research in Practice for Adults — Self-neglect resources
https://www.researchinpractice.org.uk/adults/
Ann Craft Trust — Adult safeguarding helpline — 0115 951 5400

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 19

Elder Physical Abuse

Safeguarding

SAFEGUARDING BULLETIN 19

EVERY BRUISE DESERVES A QUESTION.

Physical abuse of older adults is under-reported and often hidden.

Bruising patterns and unexplained injury are frequently dismissed as 'just falls'.

Spark staff attending homes and care settings can spot what others miss.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG19 · May 2027 · Spark Medical

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BULLETIN 19

Elder Physical Abuse

Safeguarding

Why vigilance matters

Physical abuse of older adults is easily mistaken for the ordinary frailty of ageing — a bruise explained as a fall, a fracture explained as an accident. Spark Medical staff who attend homes, care homes and community settings see older people in their everyday environment and often build a picture over multiple visits that a single hospital attendance cannot. An unexplained injury, an inconsistent account, or a carer who will not leave the room may be the only clue that abuse is occurring. Your observations, properly recorded, can be the trigger for protection.

Definition

Physical abuse is defined within the Care Act 2014 safeguarding framework as including hitting, slapping, pushing, misuse of medication, inappropriate restraint or sanctions, and includes any act which causes physical harm or pain to an adult with care and support needs. Safeguarding duties apply where the local authority reasonably suspects the adult is at risk of such abuse and is unable to protect themselves because of their care and support needs.

Physical abuse of older people commonly occurs alongside other forms of abuse, including financial exploitation and psychological control, and is not limited to institutional settings — most abuse of older people occurs within the family home. Injuries in multiple stages of healing, or inconsistent with the explanation given, should always raise concern.

Legal & policy framework

Care Act 2014, Section 42: — duty to make enquiries where an adult with care and support needs may be experiencing or at risk of physical abuse.
Mental Capacity Act 2005: — relevant where an older adult's capacity to consent to care, contact or reporting is in question.
Human Rights Act 1998, Article 3: — prohibition of inhuman or degrading treatment, engaged in cases of serious physical abuse.
Domestic Abuse Act 2021: — applies where the perpetrator is a partner or family member, recognising abuse of older people within intimate or family relationships.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 13: — duty on care providers to safeguard service users from abuse.

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BULLETIN 19

Elder Physical Abuse

Safeguarding

Key statistics

1 in 6people aged 65+ globally experience some form of abuse annually

~500,000older people are believed to experience abuse in the UK each year

Under-reportedmost cases are never disclosed to authorities

Home settingmost physical abuse occurs within family homes, not care homes

Sources: Hourglass, World Health Organization, Care Act 2014 Statutory Guidance

Types & presentations

Hitting/slappingDirect physical assault

RestraintInappropriate physical or chemical restraint

Medication misuseOver- or under-medicating deliberately

Rough handlingDuring care, moving or personal care tasks

Withholding careDenying mobility aids, food or comfort

Physical abuse often co-occurs with financial or psychological abuse — look at the whole picture

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BULLETIN 19

Elder Physical Abuse

Safeguarding

Signs to watch for

Physical signs

Bruising in unusual sites (upper arms, torso, thighs)
Injuries at different stages of healing
Fractures inconsistent with account given
Burns, cuts or grip marks
Signs of restraint (rope or strap marks)

Behavioural signs

Fearfulness, flinching or watchfulness around carer
Reluctance to be examined or undress
Withdrawal, depression or agitation
Contradictory or evasive account of injury
Sudden change in mood in carer's presence

Environmental signs

Carer will not leave the person alone with staff
Signs of neglect alongside injury
Home shows evidence of conflict or restraint devices
Medication stored or administered inappropriately
Isolation from friends, family or community

Care/institutional settings

Pattern of injuries across residents
Delayed or absent reporting by staff
Untrained or overstretched care staff
High staff turnover and poor culture
Reluctance to allow unannounced visits

Figure 1: Recognising the signs of elder physical abuse. Adapted from Hourglass guidance (wearehourglass.org).

Clinician rapid reference

THE INJURY

Location, pattern, stage of healing
Consistency with explanation given
Evidence of restraint or grip marks
Untreated or hidden injuries

THE PERSON

Fearfulness or watchfulness
Capacity to describe events
Isolation from others

THE CARER

Reluctance to leave person alone
Hostility or evasiveness
History of previous concerns

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BULLETIN 19

Elder Physical Abuse

Safeguarding

Pattern recognition

GREEN

Injury consistent with plausible accidental cause
Person relaxed and open when questioned alone
Carer supportive and welcomes scrutiny
Consistent, coherent account given
No prior safeguarding history

AMBER

Minor bruising with vague explanation
Some hesitancy discussing home life
Carer present throughout, mildly protective
Occasional missed check-ups
Historic but resolved concerns

RED

Injuries inconsistent with explanation
Multiple injuries at different healing stages
Person fearful or flinches around carer
Carer refuses to allow private conversation
Signs of restraint or repeated injury pattern

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Examine injuries carefully. Look at pattern and history.

2ASK

Speak to the person alone where possible. Open questions.

3RECORD

Contemporaneous notes and body-map any injuries.

4REPORT

Follow Spark reporting procedure. Escalate urgently if unsafe.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 19

Elder Physical Abuse

Safeguarding

Helplines & signposting

WORRIED ABOUT AN OLDER PERSON?

Hourglass Helpline — 24 hours a day, 7 days a week

0808 808 8141

NEED SAFEGUARDING ADVICE?

Ann Craft Trust — adult safeguarding advice line

0115 951 5400

Sources & further reading

Hourglass — Recognising abuse of older people
https://www.hourglass.org/get-help/recognising-abuse
Care Act 2014 — Section 42
https://www.legislation.gov.uk/ukpga/2014/23/section/42
Care and Support Statutory Guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance
SCIE — Physical abuse of adults
https://www.scie.org.uk/safeguarding/adults/introduction/types-and-indicators-of-abuse/
CQC — Safeguarding adults
https://www.cqc.org.uk/guidance-providers/adult-social-care/safeguarding-adults
Age UK — Safeguarding older people
https://www.ageuk.org.uk/information-advice/care/safeguarding/
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
https://www.legislation.gov.uk/uksi/2014/2936/regulation/13
Domestic Abuse Act 2021
https://www.legislation.gov.uk/ukpga/2021/17/contents
Hourglass Helpline (24/7) — 0808 808 8141

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 20

Financial Abuse

Safeguarding

SAFEGUARDING BULLETIN 20

A LIFETIME'S SAVINGS STOLEN IN SILENCE.

Financial abuse is one of the fastest-growing forms of adult abuse.

Victims are often isolated from friends, family and their own money.

Spark staff visiting homes may be the only outsider to see the warning signs.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG20 · May 2027 · Spark Medical

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BULLETIN 20

Financial Abuse

Safeguarding

Why vigilance matters

Financial abuse leaves no physical mark, yet can devastate an older or vulnerable person's security and independence more completely than almost any other form of harm. Spark Medical staff who enter homes see details others do not: unpaid bills beside unopened letters, a 'new friend' who controls access to bank cards, or a person who is suddenly unable to afford essentials they previously managed easily. These small observations, taken together, can reveal exploitation that is otherwise invisible to professionals who never see inside the home.

Definition

Financial or material abuse is defined within the Care Act 2014 safeguarding framework as including theft, fraud, exploitation, pressure in connection with wills, property, inheritance or financial transactions, and the misuse or misappropriation of property, possessions or benefits. Safeguarding duties apply where the local authority reasonably suspects an adult with care and support needs is at risk of such abuse and unable to protect themselves as a result of those needs.

Financial abuse frequently occurs alongside other forms of abuse, particularly where a family member or carer has gained control over a vulnerable person's finances under the guise of 'helping'. It is a common misconception that lasting power of attorney automatically prevents misuse — attorneys and deputies can and do abuse their position of trust.

Legal & policy framework

Care Act 2014, Section 42: — duty to make enquiries where an adult with care and support needs may be at risk of financial or material abuse.
Mental Capacity Act 2005: — governs lasting power of attorney and deputyship, and the safeguards against their misuse.
Fraud Act 2006: — creates criminal offences of fraud by false representation, failing to disclose information, or abuse of position.
Theft Act 1968: — covers theft and dishonest appropriation of property, applicable to misappropriation of an adult's funds.
Office of the Public Guardian safeguarding powers: — enables investigation and removal of attorneys or deputies who abuse their position.

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BULLETIN 20

Financial Abuse

Safeguarding

Key statistics

~1 in 5safeguarding concerns for older adults involve financial abuse

£billions lost annually to fraud and financial exploitation of older people

Trustedmost perpetrators are family members or trusted carers

Under-reportedshame and dependency prevent many victims disclosing

Sources: Action on Elder Abuse / Hourglass, Age UK, Office of the Public Guardian

Types & presentations

TheftCash, cards or possessions taken

Fraud/scamsDeception for financial gain

CoercionPressure over wills or property

Misuse of POAAttorney or deputy abusing position

Withholding fundsDenying access to own money

Financial abuse often accompanies isolation and control — look at the wider picture

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BULLETIN 20

Financial Abuse

Safeguarding

Signs to watch for

Financial signs

Unpaid bills despite adequate income
Unexplained withdrawals or missing possessions
Sudden changes to a will or beneficiaries
New or unexplained named account signatories
Inability to explain financial arrangements

Behavioural signs

Anxiety or evasiveness when discussing money
Reluctance to speak in front of a carer or relative
Confusion about recent financial decisions
Fear of losing accommodation or care
Signs of coercion or intimidation

Environmental signs

Home in poor repair despite apparent means
Essentials lacking — heating, food, care products
Post redirected or intercepted by another person
Unusual visitors coinciding with financial requests
Property recently transferred or remortgaged

Relationship red flags

New 'friend' or carer controlling access to money
Family member isolating person from others
Attorney or deputy avoiding scrutiny of accounts
Person pressured to change legal or financial documents
Carer benefiting disproportionately from person's assets

Figure 1: Recognising the signs of financial abuse. Adapted from Age UK guidance (ageuk.org.uk).

Clinician rapid reference

THE PERSON

Capacity to manage own finances
Awareness of own financial situation
Signs of anxiety, fear or coercion
Standard of living versus known income

THE FINANCES

Unpaid bills or unexplained withdrawals
Recent changes to will or property
Attorney/deputy arrangements in place

THE RELATIONSHIP

Who controls access to money and post
New or unusually involved third parties
Isolation from independent family or friends

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BULLETIN 20

Financial Abuse

Safeguarding

Pattern recognition

GREEN

Person manages or understands own finances
Bills paid, home maintained appropriately
Open discussion of money without anxiety
Attorney/deputy transparent and accountable
No unexplained changes to legal documents

AMBER

Some confusion about recent transactions
Minor unpaid bills or missed payments
New person recently involved in finances
Reluctance to discuss money in detail
Slight decline in living standards

RED

Significant unexplained loss of funds or assets
Person fearful or coerced when discussing money
Essentials unaffordable despite known income
Sudden, unexplained changes to will or property
Named individual actively blocking access or scrutiny

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Look at living standards, post and financial control.

2ASK

Ask about money matters sensitively and in private if possible.

3RECORD

Contemporaneous notes — amounts, dates, named individuals.

4REPORT

Follow Spark reporting procedure. Escalate urgently if coercion suspected.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 20

Financial Abuse

Safeguarding

Helplines & signposting

WORRIED ABOUT FINANCIAL ABUSE?

Hourglass Helpline — 24 hours a day, 7 days a week

0808 808 8141

CONCERNED ABOUT AN ATTORNEY/DEPUTY?

Office of the Public Guardian safeguarding unit

Via Spark reporting

Sources & further reading

Age UK — Financial abuse
https://www.ageuk.org.uk/information-advice/care/safeguarding/financial-abuse/
Care Act 2014 — Section 42
https://www.legislation.gov.uk/ukpga/2014/23/section/42
Care and Support Statutory Guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guida
Fraud Act 2006
https://www.legislation.gov.uk/ukpga/2006/35/contents
Theft Act 1968
https://www.legislation.gov.uk/ukpga/1968/60/contents
Office of the Public Guardian — Report concerns about an attorney or deputy
https://www.gov.uk/report-concern-about-attorney-deputy-guardian
SCIE — Financial abuse of adults
https://www.scie.org.uk/safeguarding/adults/introduction/types-and-indicators-of-abuse/
Hourglass — Recognising financial abuse
https://www.hourglass.org/get-help/recognising-abuse
Hourglass Helpline (24/7) — 0808 808 8141

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 21

Safeguarding Adults with Learning Disabilities

Safeguarding

SAFEGUARDING BULLETIN 21

EVERY VOICE DESERVES TO BE HEARD.

Adults with learning disabilities face significantly higher rates of abuse.

Communication differences can mask or delay disclosure of harm.

Spark staff can adapt how they ask, listen and observe to hear what matters.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG21 · June 2027 · Spark Medical

Safeguarding Bulletins · V1.0 · Spark Medical 1 / 6

BULLETIN 21

Safeguarding Adults with Learning Disabilities

Safeguarding

Why vigilance matters

Adults with learning disabilities are amongst the most vulnerable people Spark Medical staff will encounter, and among the least likely to have concerns believed or acted upon. Communication differences, dependency on carers for daily life, and a history of not being listened to can all combine to hide abuse in plain sight. Staff attending homes, supported living settings and day services are often the only visitors from outside a person's usual circle of carers — uniquely placed to notice a change in wellbeing, an unexplained injury, or a carer who speaks over the person rather than to them.

Definition

A learning disability is defined by the Department of Health and Social Care as a significant, lifelong condition affecting intellectual and adaptive functioning that started before adulthood, with lasting effect on development. Adults with learning disabilities are entitled to the same safeguarding protections as any other adult under the Care Act 2014, and additional reasonable adjustments must be made to ensure they can participate in decisions about their own safety.

A common misconception is that a learning disability itself implies lack of capacity — capacity must always be assessed decision-by-decision under the Mental Capacity Act 2005, and many adults with learning disabilities can and should be supported to make their own choices, including about safeguarding responses.

Legal & policy framework

Care Act 2014, Section 42 — duty to make enquiries where an adult with care and support needs, including learning disability, may be at risk of abuse.
Mental Capacity Act 2005 — requires decision-specific capacity assessment and best-interests decisions where capacity is lacking.
Equality Act 2010 — requires reasonable adjustments to ensure adults with learning disabilities can access services and communicate safeguarding concerns.
Human Rights Act 1998 — protects the right to private and family life, liberty and freedom from inhuman or degrading treatment.
Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) — relevant where restrictive care arrangements are in place.

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BULLETIN 21

Safeguarding Adults with Learning Disabilities

Safeguarding

Key statistics

~1.5 millionpeople in the UK have a learning disability

Higher riskadults with learning disabilities are significantly more likely to experience abuse

Under-reportedcommunication barriers mean many cases go unrecognised

Reasonable adjustmentsa legal requirement, not an optional extra

Sources: Mencap, NHS England, Care Act 2014 Statutory Guidance

Types & presentations

PhysicalHitting, rough handling, misuse of restraint

FinancialBenefits or money misused by others

SexualNon-consensual contact, exploitation

NeglectCare needs unmet by paid or family carers

DiscriminatoryHate-motivated harassment or exclusion

Dependency on carers can increase both risk and difficulty disclosing abuse

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BULLETIN 21

Safeguarding Adults with Learning Disabilities

Safeguarding

Signs to watch for

Physical signs

Unexplained bruising or injury
Poor hygiene or unkempt appearance
Weight loss or signs of malnutrition
Untreated medical or dental conditions
Signs of over-medication or restraint

Behavioural signs

Sudden withdrawal or increased aggression
Fear of a particular carer or setting
Self-harming behaviour
Regression in skills previously held
Reluctance to be alone with a specific person

Environmental signs

Home or setting unsafe or poorly maintained
Restrictive practices used inappropriately
Lack of privacy or personal possessions
Isolation from family, friends or community
Carer answers for the person routinely

Communication-specific

Person given no time or means to respond
Communication aids withheld or unavailable
Distress expressed only through behaviour
Carer dismisses attempts to communicate concern
Person appears frightened to disagree with carer

Figure 1: Recognising abuse of adults with learning disabilities. Adapted from Mencap guidance (mencap.org.uk).

Clinician rapid reference

THE PERSON

Communication style and preferred method
Behaviour change from baseline
Physical signs of harm or neglect
Capacity for the specific decision in question

THE CARER

Speaks for the person constantly
Restricts access or private conversation
History of previous concerns

THE SETTING

Safety and cleanliness of environment
Use of restrictive practices
Access to community and relationships

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BULLETIN 21

Safeguarding Adults with Learning Disabilities

Safeguarding

Pattern recognition

GREEN

Person communicates freely with carer present
Carer allows time and space to respond
Home or setting safe and personalised
Consistent engagement with health services
Stable mood and behaviour

AMBER

Some hesitancy communicating in carer's presence
Minor unexplained marks or injuries
Occasional missed appointments
Carer sometimes answers on person's behalf
Mild behaviour change noted

RED

Person appears fearful of a specific carer
Unexplained injuries or signs of restraint
Carer blocks private conversation entirely
Significant regression or self-harming behaviour
Evidence of financial or sexual exploitation

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Observe behaviour change and the caring relationship.

2ASK

Use the person's preferred communication method. Allow time.

3RECORD

Contemporaneous notes, including how the person communicated.

4REPORT

Follow Spark reporting procedure. Escalate urgently if unsafe.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

Safeguarding Bulletins · V1.0 · Spark Medical 5 / 6

BULLETIN 21

Safeguarding Adults with Learning Disabilities

Safeguarding

Helplines & signposting

WORRIED ABOUT AN ADULT?

Mencap Direct — advice and support

0808 808 1111

NEED SAFEGUARDING ADVICE?

Ann Craft Trust — adult safeguarding advice line

0115 951 5400

Sources & further reading

Mencap — Safeguarding
https://www.mencap.org.uk/advice-and-support/safeguarding
Care Act 2014 — Section 42
https://www.legislation.gov.uk/ukpga/2014/23/section/42
Care and Support Statutory Guidance
https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-support-statutory-guidance
Mental Capacity Act 2005
https://www.legislation.gov.uk/ukpga/2005/9/contents
Equality Act 2010 — reasonable adjustments
https://www.legislation.gov.uk/ukpga/2010/15/contents
NHS England — Learning disability services
https://www.england.nhs.uk/learning-disabilities/
SCIE — Safeguarding adults with learning disabilities
https://www.scie.org.uk/safeguarding/adults/
Dimensions UK — Safeguarding resources
https://www.dimensions-uk.org/
Mencap Direct Helpline — 0808 808 1111

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 22

Mental Capacity & DoLS

Safeguarding

SAFEGUARDING BULLETIN 22

ASSUME NOTHING. ASSESS EVERYTHING.

Capacity must be assessed for each decision, not assumed from a diagnosis.

Unlawful restriction of liberty is a safeguarding matter, not just a paperwork issue.

Spark staff make capacity-relevant observations on every home visit.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG22 · June 2027 · Spark Medical

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BULLETIN 22

Mental Capacity & DoLS

Safeguarding

Why vigilance matters

Questions of mental capacity arise on almost every Spark Medical visit involving an adult with cognitive impairment, learning disability or mental ill-health, yet capacity is one of the most frequently misunderstood areas of practice. Staff who see a person in their own home, over repeated visits, are well placed to notice fluctuating capacity, restrictive practices disguised as care, or decisions being made 'for' someone rather than 'with' them. Getting capacity right protects both the person's autonomy and their safety — getting it wrong can mean either unlawful restriction or unmet need going unaddressed.

Definition

The Mental Capacity Act 2005 states that a person must be assumed to have capacity unless it is established that they lack it, and a person is not to be treated as unable to make a decision unless all practicable steps to help them have been taken without success. Deprivation of Liberty Safeguards (DoLS), and their successor the Liberty Protection Safeguards, provide the legal framework for authorising care arrangements that restrict a person's liberty when they lack capacity to consent to them.

Capacity is decision-specific and time-specific — a person may lack capacity for one decision (for example, managing finances) while retaining capacity for another (for example, choosing what to wear). Capacity can also fluctuate, particularly in conditions such as dementia or delirium, and must be reassessed rather than assumed to be permanent.

Legal & policy framework

Mental Capacity Act 2005, Section 1 — sets out the five statutory principles, including the presumption of capacity and the right to make unwise decisions.
Mental Capacity Act 2005, Sections 2-3 — defines the two-stage test for lack of capacity (diagnostic and functional).
Deprivation of Liberty Safeguards (DoLS) / Liberty Protection Safeguards — require lawful authorisation before liberty is restricted for someone lacking capacity to consent to their care arrangements.
Care Act 2014, Section 42 — safeguarding duties apply where unlawful restriction or coercion is identified alongside care and support needs.
Human Rights Act 1998, Article 5 — protects the right to liberty, engaged whenever a person's freedom of movement is restricted.

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BULLETIN 22

Mental Capacity & DoLS

Safeguarding

Key statistics

300,000+DoLS applications are made in England annually

2-stagetest for capacity: diagnostic and functional

Decision-specificcapacity must be assessed per decision, not globally

Least restrictiveoption is a legal requirement, not a preference

Sources: NHS Digital, Mental Capacity Act 2005 Code of Practice

Types & presentations

No assessment doneCapacity assumed rather than tested

Restrictive practiceRestraint or restriction without authority

Fluctuating capacityMissed reassessment over time

Best interests bypassedDecisions made without proper process

Unlawful deprivationLiberty restricted without DoLS authorisation

Capacity is decision-specific and time-specific — never assume, always assess

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BULLETIN 22

Mental Capacity & DoLS

Safeguarding

Signs to watch for

Assessment red flags

No documented capacity assessment for a major decision
Capacity assumed from diagnosis alone
No attempt to support decision-making before concluding incapacity
Assessment not decision-specific
No reassessment despite known fluctuation

Restrictive practice signs

Locked doors or gates preventing free movement
Continuous supervision beyond clinical need
Medication used primarily to sedate
Restraint used without documented authorisation
Removal of mobility aids or communication devices

Best-interests concerns

Family or carer making decisions unilaterally
Person's wishes and feelings not recorded
No consultation with person or advocate
Decision not the least restrictive option available
No independent mental capacity advocate (IMCA) involved where required

Setting-specific

Care home unable to evidence DoLS authorisation
Hospital ward restricting visits or discharge unlawfully
Supported living restricting access to community
Repeated urgent authorisations without standard review
High turnover of staff unfamiliar with the person's needs

Figure 1: Recognising capacity and DoLS concerns. Adapted from SCIE guidance (scie.org.uk).

Clinician rapid reference

THE DECISION

Is it decision-specific and time-specific?
Has the two-stage test been applied?
Has support to decide been offered first?
Is the outcome the least restrictive option?

THE PERSON

Wishes, feelings and history recorded
Fluctuating capacity considered
Advocate or IMCA involved where required

THE AUTHORISATION

DoLS / Liberty Protection Safeguards in place
Authorisation current and not overdue for review
Restrictions proportionate to assessed risk

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BULLETIN 22

Mental Capacity & DoLS

Safeguarding

Pattern recognition

GREEN

Capacity assessed for the specific decision
Person supported to be involved as far as possible
Restrictions proportionate and authorised
Wishes and feelings documented and considered
Regular review of fluctuating capacity

AMBER

Assessment present but not fully decision-specific
Some restriction with informal justification only
Limited involvement of person in decision
Review overdue but not significantly
Family view prioritised over person's own wishes

RED

No capacity assessment for a significant decision
Liberty restricted with no DoLS authorisation
Person's wishes never sought or recorded
Restraint or sedation used without authority
Capacity assumed permanently despite known fluctuation

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Look for restriction, assumption of incapacity, or exclusion.

2ASK

Ask what assessment has been done and what the person wants.

3RECORD

Contemporaneous notes on capacity, restriction and involvement.

4REPORT

Follow Spark reporting procedure. Escalate urgently if unlawfully restricted.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 22

Mental Capacity & DoLS

Safeguarding

Helplines & signposting

NEED CAPACITY OR DoLS ADVICE?

Local authority DoLS / safeguarding team

Via Spark reporting

NEED WIDER SAFEGUARDING ADVICE?

Ann Craft Trust — adult safeguarding advice line

0115 951 5400

Sources & further reading

Mental Capacity Act 2005
https://www.legislation.gov.uk/ukpga/2005/9/contents
SCIE — Mental Capacity Act
https://www.scie.org.uk/mca/
Mental Capacity Act 2005 Code of Practice (GOV.UK)
https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice
SCIE — Deprivation of Liberty Safeguards
https://www.scie.org.uk/mca/dols/
Care Act 2014 — Section 42
https://www.legislation.gov.uk/ukpga/2014/23/section/42
NICE — Decision-making and mental capacity (NG108)
https://www.nice.org.uk/guidance/ng108
CQC — Mental Capacity Act guidance
https://www.cqc.org.uk/guidance-providers/adult-social-care/mental-capacity-act
Social Care Institute for Excellence — Best interests
https://www.scie.org.uk/mca/practice/best-interests
Ann Craft Trust Helpline — 0115 951 5400

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 23

Coercive & Controlling Behaviour

Safeguarding

SAFEGUARDING BULLETIN 23

CONTROL LEAVES NO BRUISE.

Coercive control is a pattern of behaviour, not a single incident.

It is a criminal offence in its own right under UK law.

Spark staff visiting homes can notice controlling dynamics others never see.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG23 · July 2027 · Spark Medical

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BULLETIN 23

Coercive & Controlling Behaviour

Safeguarding

Why vigilance matters

Coercive control is deliberately invisible to outsiders — there may be no bruise, no broken bone, and no single incident to point to, yet the cumulative effect on a victim's freedom and wellbeing can be devastating. Spark Medical staff who visit homes see a fuller picture than a single consultation ever could: a partner who insists on being present for every conversation, a person who must check in constantly, or someone who has no access to money, transport or their own phone. Recognising the pattern, not just a single moment, is essential to identifying coercive control.

Definition

Controlling or coercive behaviour is defined as an act or pattern of acts of assault, threats, humiliation and intimidation, or other abuse used to harm, punish or frighten the victim, as set out under Section 76 of the Serious Crime Act 2015, which created the criminal offence of controlling or coercive behaviour in an intimate or family relationship. It includes isolating a person from friends and family, controlling their finances, monitoring their time, and depriving them of independence.

Coercive control does not require physical violence to be present, and can occur without a single identifiable incident. It is a common misconception that a victim who appears to comply, or defends their partner, is not being controlled — compliance and loyalty are often survival strategies rather than evidence of a healthy relationship.

Legal & policy framework

Serious Crime Act 2015, Section 76 — creates the offence of controlling or coercive behaviour in an intimate or family relationship.
Domestic Abuse Act 2021 — provides the first statutory definition of domestic abuse, explicitly including controlling and coercive behaviour and economic abuse.
Care Act 2014, Section 42 — safeguarding duties apply where an adult with care and support needs is subject to coercive control and unable to protect themselves.
Human Rights Act 1998, Article 8 — the right to private and family life, engaged where control restricts personal autonomy.
Children Act 1989 — relevant where children are living in a household affected by coercive control, given the recognised impact on child welfare.

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BULLETIN 23

Coercive & Controlling Behaviour

Safeguarding

Key statistics

~43,000coercive control offences recorded by police in England and Wales annually

2015the year coercive control became a specific criminal offence

No bruisesmany victims show no physical signs of abuse

Highest riskcoercive control is strongly linked to serious harm and homicide

Sources: Office for National Statistics, SafeLives, Serious Crime Act 2015

Types & presentations

IsolationCutting off friends, family, support

Economic abuseControlling money, work, resources

MonitoringTracking phone, movements, contacts

IntimidationThreats, humiliation, degradation

Micro-regulationControlling daily routines and choices

It is the pattern, not a single act, that constitutes the offence

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BULLETIN 23

Coercive & Controlling Behaviour

Safeguarding

Signs to watch for

Behavioural signs

Anxious or fearful when partner is mentioned
Constantly checking in or seeking permission
Apologetic or minimising about partner's behaviour
Sudden personality change from previously known self
Reluctant to speak freely in partner's presence

Isolation signs

Lost contact with previously close friends or family
No independent social life or activities
Partner present at all appointments and conversations
Restricted or monitored phone and internet use
Dependent entirely on partner for transport

Economic signs

No access to own bank account or money
Unaware of household finances
Prevented from working or studying
Allowance-style control over spending
Debts run up in victim's name without consent

Environmental signs

Home rules dictate movement or visitors
Surveillance equipment in the home
Victim unable to answer door or phone independently
Partner answers questions on victim's behalf
Signs of intimidation — damaged property, threats

Figure 1: Recognising coercive control. Adapted from SafeLives guidance (safelives.org.uk).

Clinician rapid reference

THE PERSON

Freedom to speak without partner present
Anxiety, fearfulness or over-compliance
Access to own money, phone and transport
Contact maintained with friends and family

THE RELATIONSHIP

Partner speaks for or over the person
History of jealousy, monitoring or threats
Pattern of escalating restriction

THE RISK

Recent separation or threat to leave
Escalating frequency or severity
Access to weapons or history of violence

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BULLETIN 23

Coercive & Controlling Behaviour

Safeguarding

Pattern recognition

GREEN

Person speaks freely, including alone
Independent access to money and transport
Maintains friendships and family contact
Makes own day-to-day decisions
No signs of fear or intimidation

AMBER

Partner present at most appointments
Some reduction in social contact
Mild anxiety discussing relationship
Limited but not absent financial independence
Occasional deference to partner's wishes

RED

Never able to speak without partner present
No independent access to money or phone
Isolated entirely from friends and family
Visible fear or intimidation in partner's presence
History of escalating threats or violence

Any single red flag warrants senior review. Any pattern of amber — refer.

See it, act on it

1NOTICE

Look at freedom, finances and relationships over time.

2ASK

Ask to speak to the person alone. Use open, safe questions.

3RECORD

Contemporaneous notes on pattern and specific incidents.

4REPORT

Follow Spark reporting procedure. Escalate urgently if high risk.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 23

Coercive & Controlling Behaviour

Safeguarding

Helplines & signposting

WORRIED ABOUT SOMEONE?

Refuge — Freephone 24hr National Domestic Abuse Helpline

0808 2000 247

MEN AFFECTED BY ABUSE?

Respect Men's Advice Line

0808 8010327

Sources & further reading

SafeLives — Coercive control
https://safelives.org.uk/policy-evidence/about-domestic-abuse/coercive-control
Serious Crime Act 2015 — Section 76
https://www.legislation.gov.uk/ukpga/2015/9/section/76
Domestic Abuse Act 2021
https://www.legislation.gov.uk/ukpga/2021/17/contents
Care Act 2014 — Section 42
https://www.legislation.gov.uk/ukpga/2014/23/section/42
Refuge — Recognising domestic abuse
https://www.refuge.org.uk/i-need-help-now/what-is-domestic-abuse/
Respect Phoneline — for men experiencing abuse
https://www.respectphoneline.org.uk/
Mankind Initiative — support for male victims
https://www.mankind.org.uk/
Women's Aid — Coercive control
https://www.womensaid.org.uk/information-support/what-is-domestic-abuse/coercive-control/
Refuge Helpline (24/7) — 0808 2000 247

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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BULLETIN 24

Whistleblowing & Speaking Up

Safeguarding

SAFEGUARDING BULLETIN 24

SPEAKING UP PROTECTS EVERYONE.

Whistleblowers are legally protected when raising genuine concerns.

Colleagues are often the first to notice poor or unsafe practice.

Spark staff have a professional duty, not just a right, to speak up.

SEE SOMETHING · SAY SOMETHING · DO SOMETHING

CB-2027-SG24 · July 2027 · Spark Medical

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BULLETIN 24

Whistleblowing & Speaking Up

Safeguarding

Why vigilance matters

Safeguarding failures are not only caused by families and strangers — sometimes the greatest risk to a vulnerable person comes from within the very services meant to protect them. Spark Medical staff work alongside colleagues, agency workers and other professionals in homes, care settings and clinics, and are often the first to notice unsafe practice, poor culture or a colleague crossing a line. Speaking up is uncomfortable, but silence allows harm to continue. Every member of staff has both a professional duty and legal protection to raise a genuine concern.

Definition

Whistleblowing is defined under the Public Interest Disclosure Act 1998 as the disclosure of information by a worker who reasonably believes it shows one or more specific types of wrongdoing, including that a person's health or safety has been, is being, or is likely to be endangered. A worker who makes such a protected disclosure is legally protected from being dismissed or subjected to detriment as a result.

Whistleblowing is distinct from a routine complaint or grievance — it is specifically about wrongdoing that affects others, such as patient or service-user safety, rather than a personal employment dispute. A common misconception is that raising a concern internally first is required before protection applies; protection can also extend to disclosures made to a prescribed regulator.

Legal & policy framework

Public Interest Disclosure Act 1998 (as amended by the Employment Rights Act 1996) — provides legal protection for workers making protected disclosures in the public interest.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20 — the statutory duty of candour requiring openness when things go wrong.
Care Act 2014, Section 42 — safeguarding duties apply where whistleblowing reveals abuse or neglect of an adult with care and support needs.
NHS England's Freedom to Speak Up policy — requires every provider to have a Freedom to Speak Up Guardian and clear local reporting routes.
Working Together to Safeguard Children (2023) — requires organisations to have clear whistleblowing procedures where child safeguarding concerns arise.

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BULLETIN 24

Whistleblowing & Speaking Up

Safeguarding

Key statistics

1998the year statutory whistleblower protection was introduced in UK law

~1 in 5NHS staff say they would not feel safe raising a concern

Duty of candoura legal requirement to be open when things go wrong

Protectedworkers cannot lawfully be dismissed for genuine disclosures

Sources: NHS Staff Survey, NHS England Freedom to Speak Up, Public Interest Disclosure Act 1998

Types & presentations

Unsafe practiceCare shortcuts risking harm

Abuse or neglectBy a colleague, carer or provider

Poor cultureConcerns dismissed or discouraged

Cover-upsIncidents hidden or minimised

Fraud/malpracticeDishonesty affecting care or funds

If in doubt, raise it — you do not need to be certain to speak up

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BULLETIN 24

Whistleblowing & Speaking Up

Safeguarding

Signs to watch for

Practice red flags

Care plans or protocols routinely ignored
Medication administered incorrectly or unrecorded
Repeated near-misses never investigated
Records falsified or backdated
Equipment or safety checks skipped

Cultural red flags

Colleagues speak contemptuously of service users
New staff told 'not to make waves'
Concerns raised previously were ignored or punished
High staff turnover with no clear cause addressed
Management discourages incident reporting

Safeguarding-specific

A colleague behaves inappropriately with a vulnerable person
Injuries or incidents not properly recorded or reported
A service user or their family are frightened of a staff member
Restraint or restrictive practice used without authorisation
Safeguarding referrals suppressed or discouraged

Organisational red flags

No visible whistleblowing or Freedom to Speak Up policy
No identifiable Freedom to Speak Up Guardian
Retaliation against those who have previously raised concerns
Financial irregularities affecting care provision
External inspection findings dismissed internally

Figure 1: Recognising when to speak up. Adapted from NHS Freedom to Speak Up guidance (england.nhs.uk).

Clinician rapid reference

WHAT TO RAISE

Unsafe or unlawful practice
Risk to health, safety or dignity
Abuse, neglect or cover-up
Concerns about culture or leadership

HOW TO RAISE IT

Follow Spark reporting procedure first where safe
Use the Freedom to Speak Up Guardian if available
Escalate externally to a regulator if unresolved

YOUR PROTECTION

Legal protection under PIDA 1998
Right to remain anonymous where possible
Protection from dismissal or detriment

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BULLETIN 24

Whistleblowing & Speaking Up

Safeguarding

Pattern recognition

GREEN

Concerns raised are welcomed and acted on
Clear, known reporting routes exist
Staff feel safe speaking up
Incidents investigated openly and promptly
Leadership models honesty about mistakes

AMBER

Reporting routes exist but are underused
Some reluctance to raise minor concerns
Inconsistent follow-up on reported issues
Mixed messages from management about speaking up
Concerns raised informally rather than formally

RED

Concerns actively discouraged or punished
No functioning reporting route available
Repeated safety incidents never addressed
Retaliation against those who have spoken up
Evidence of deliberate cover-up

Any single red flag warrants senior review. Any pattern of amber — raise it.

See it, act on it

1NOTICE

Notice unsafe practice, poor culture or a colleague's conduct.

2ASK

Ask questions where safe to do so. Clarify before assuming.

3RECORD

Contemporaneous notes — what, when, who was present.

4REPORT

Follow Spark reporting procedure or your Freedom to Speak Up Guardian.

IF UNCERTAIN — CONTACT THE SPARK SAFEGUARDING ON-CALL

Documentation

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BULLETIN 24

Whistleblowing & Speaking Up

Safeguarding

Helplines & signposting

NEED CONFIDENTIAL ADVICE?

Protect — independent whistleblowing charity

020 3117 2520

NHS STAFF?

Freedom to Speak Up Guardian — your local service

Via Spark reporting

Sources & further reading

NHS England — Freedom to Speak Up
https://www.england.nhs.uk/ournhspeople/freedom-to-speak-up/
Public Interest Disclosure Act 1998 (GOV.UK guidance)
https://www.gov.uk/whistleblowing
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20
https://www.legislation.gov.uk/uksi/2014/2936/regulation/20
CQC — Duty of candour
https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-20-duty-candour
Care Act 2014 — Section 42
https://www.legislation.gov.uk/ukpga/2014/23/section/42
GMC — Raising and acting on concerns
https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/raising-and-acting-on-concerns-about-patient-safety
NMC — Raising concerns guidance
https://www.nmc.org.uk/standards/guidance/raising-concerns-guidance-for-nurses-and-midwives/
HCPC — Guidance on raising concerns
https://www.hcpc-uk.org/standards/meeting-our-standards/raising-concerns/
Protect — Whistleblowing advice line — 020 3117 2520

REPORTING — EVERY CONCERN, EVERY TIME

For all safeguarding concerns — follow the Spark reporting procedure.
If there is an immediate safety issue — call 999 and ensure the patient is taken to a place of safety.
If you are uncertain — contact the Spark Safeguarding On-Call for advice before you leave the scene.

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