Editor's note: we apologise to Dr Hussain and to our readers that this letter was not printed in its entirety in BDJ 2006; 200 : 475.

Sir, I write to you with the hope and possibility that you may raise this awareness through the columns and letters section of the BDJ with regard to problems I have had with a suspected case of abuse of a family of four children.

I had been seeing a family with four children for several years and over the last few years had noticed that the children had become very, very withdrawn and not connecting socially on their visits to see me. I had further noticed and observed that the father had an alcoholic problem and had seen him around the area of my practice on several occasions in a clearly drunken state. On two occasions he came to appointments with a distinct smell of alcohol on his breath.

When I recently saw some of his children for treatment I began to worry about their state of withdrawal and decided to alert Social Services, having observed this. I was aware of the fact that all professionals have a duty to inform the appropriate authorities if there is a concern about the welfare of children but was not aware that we can make this awareness known and maintain our anonymity when making a referral. However, in this case when I made an initial enquiry with the Social Services, the family were known by the Social Services and was on a monitoring register. I was promised that they would maintain my anonymity as they said they would just re-open the case and visit the children to see how they were.

I was horrified some two months later when one of my practice staff informed me while I was away that the father had made an approach to the practice and was very verbally abusive and aggressive to them (I hadn't informed any of my staff of this referral). This seriously worried me as the father had been aggressive and abusive in the past and I was worried about the security of my practice staff. I immediately contacted Social Services who informed me that they'd had to tell the parents who had initiated the referral and therefore my anonymity was blown and it compromised the security of my staff as well as myself. I was informed by Social Services that the health and wellbeing of a child is far and above the welfare and security of a practitioner or his staff and premises and because of this they'd had to inform the parents who had made the referral. I was shocked to hear this and had I known this in advance I would have made another approach to the Services to try and maintain my anonymity and the welfare of my staff.

Would you kindly raise awareness through your columns that, if there is concern about the wellbeing of children, before making any referral, practitioners need to realise the implications of what happens when you make referrals under the Child Protection Act in abuse cases and that there must be some form of avenue where we can make referrals without compromise.

Professor Tim Newton and Dr Elizabeth Bower offer some guidance: The incident described by Dr Hussain demonstrates the complexity and difficulty of the management of suspected instances of abuse or neglect. General dental practitioners faced with a situation such as this will need to consider the welfare of the children involved, their personal safety and that of their staff. Clearly there is a moral imperative to protect the children at risk. Guidance on what to do in cases of suspected abuse is relatively clear; 1, 2 practitioners can phone up and ask whether a child is on the child protection register (and if the child is on the register, the social worker will be informed of the enquiry) and/or discuss the case of a child with Social Services without disclosing the child's name. However, if they make a referral (even if this is relatively 'informal'), it is suggested that the practitioner obtains the parent's consent unless it is judged that discussing concerns with the parents would place the child at risk of significant harm. Sharing information after refusal of consent is only appropriate if the child's welfare overrides the need to keep the information confidential. Of course it can be difficult to judge the harm that may arise from speaking to a parent, and it is not a pleasant task, however a parent who is asked about their children's social withdrawal may respond differently to one who finds that they have been referred to social services without their knowledge.

Balancing the risk of harm to the child and the risk to the staff of the practice again requires the practitioner to enter in discussions which are probably outside the normal range of general practice. Dentists and staff working in the practice will be protected by the law on assault, and practices should develop guidance on the management of threatening behaviour. A key element is communication within the team, and the development of clear guidance on dealing with problems of this nature. 2 In a busy practice setting, it is easy to hope that what are, thankfully, relatively uncommon occurrences can be managed as and when they occur. However the development of protocols for handling difficult situations can ensure that a response, when needed, maximizes the beneficial outcomes and reduces the risks.