INTRODUCTION : Clear and comprehensive documentation of ophthalmic findings is essential in the preparation of medicolegal reports that support the Family Court in making complex safeguarding decisions. Increasingly, courts are requesting clarification regarding the reliability of ophthalmic findings and whether documentation complies with recommendations issued by the Royal College of Ophthalmologists. Incomplete or inconsistent documentation may reduce the evidential weight of ophthalmic assessments and contribute to delays in judicial proceedings. The Royal College of Ophthalmologists guideline, Abusive Head Trauma and the Eye: 2024 Guidelines, was developed to support ophthalmologists in recording ocular findings in a standardised, reproducible, and clinically robust manner.

Abusive Head Trauma remains the leading cause of severe neurological morbidity and mortality in infancy. The annual incidence of inflicted head injury is estimated at 24.6 per 100,000 children under one year of age, with a median age at presentation of just over 8 weeks. Ophthalmologists are frequently asked to assess these infants for evidence of ocular injury, most commonly retinal haemorrhages and subconjunctival haemorrhages.

In 2009, WN, one of the authors and an Expert Witness in both criminal and family proceedings involving suspected child maltreatment, identified thirteen key elements of information that should reasonably be documented within the ophthalmic clinical record. An audit was subsequently undertaken to assess compliance with these standards, leading to recommendations including the introduction of a structured proforma. These findings were presented as a poster at the 2009 Annual Congress, followed by a re-audit in 2021.