Home Volume: 2, Issue: Supplement 1
International Journal of Healthcare Simulation
Adi Health+Wellness
Testing the system: infant ‘abduction’
DOI:10.54531/FSVP7999, Volume: 2, Issue: Supplement 1, Pages: A54-A54
Article Type: Editorial, Article History





Infant abductions from hospital are rare events but make headline news. A US study examined 247 infant abductions between 1983–2006 and found nearly half were abducted from healthcare settings [1]. Abduction risk reduction strategies are also considered during the Care Quality Commission’s inspection of each maternity unit [2]. The baby tagging system was updated in our hospital in April 2020, training undertaken and subsequently reinforced with e-learning. In our hospital, many families have safeguarding concerns. These are considered the highest potential risk for infant abduction so it is essential the system and processes provide protection. The aim of this simulation was to test the processes currently in place for a tagged baby abduction from an inpatient ward to highlight good practices and identify system failures.


An activated tag was assigned to a manikin on the transitional care unit. The manikin was removed, in a carrier bag, by a faculty member (‘the abductor’) tailgating a leaving staff member thus preventing the ward doors from automatically locking when the tag is near the sensor. The ‘abductor’ took the lift to the ground floor and walked out of the main entrance within three minutes. Faculty members were placed in transitional care (TC), the main entrance, and another tracking the tag’s location. A timeline of events was recorded and analysed. Simulation participants were debriefed, including staff directly involved, parents on TC, front of house staff, and senior managers.


It was evident from the debriefing that this caused significant distress to some staff members who felt helpless and uncertain when faced with this scenario. It highlighted how quick and easy it is to leave the hospital with a baby. Important human factors were identified including discrepancies between emergency call requests and responses, and poor knowledge about the abduction of baby policy. System problems were found: hospital ‘lockdown’ locked internal doors preventing responder actions but not all external doors; and the tagging system did not respond as expected – locking the doors to the ward and an inaccurate final tag location.


Multiple deficiencies in the system were found so an action plan has subsequently commenced. New external doors have been added to automatic lockdown and a new main entrance door system proposed. Tagging engineers are addressing the automatic locking of internal doors and tag location, switchboard calls are to be standardised, and the standard operating procedure is being reviewed and recirculated.


1. Burgess AW, Carr KE, Nahirny C, Rabun JB Jr. Nonfamily infant abductions, 1983–2006. Am J Nurs. 2008 Sep;108(9):32–8. doi: 10.1097/01.NAJ.0000334972.82359.58. PMID: 18756155.

2. Care Quality Commission NHS IH Maternity core service framework v7 (2018)