Primary and Secondary Healthcare Department

STANDARD OPERATING PROCEDURES

CODE PINK:
SUSPECTED INFANT/CHILD ABDUCTION PROCEDURE

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DOCUMENT PREPARATION /APPROVAL AUTHORITIES:

Prepared & Reviewed By:

Sr # Name
1. Dr. Shafqat Ali
MBBS, DPH
Senior Health Consultant
Project Management Unit, P&SHD, Lahore
2. Dr. Ibtsam Ijaz
MBBS, MCPS
Project Manager Technical, PMU, P&SHD Govt. of the Punjab

Design & Formatting

1. Mr. Imran Hameed
Project Management Unit
P&SHD Govt. of the Punjab

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Please note that this is a first draft, and may be subject to revisions. All information and content in this
Material is provided in good faith by Project Management Unit, Primary & Secondary Healthcare
Department and is based on sources believed to be reliable and accurate at the time of development.

Copyright © 2019, Project Management Unit

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in
any form or by any means, including photocopying, recording, or other electronic or mechanical
methods, without the prior written permission of the publisher, except in the case of brief
quotations embodied in critical reviews and certain other noncommercial uses permitted by
copyright law. For permission requests, write to the PMU, addressed “Attention: Permissions
Coordinator,” at the address below.

PROJECT MANAGEMENT UNIT

31-E/1, Shahra-e-Immam Hussain,
Qaddafi Stadium
Lahore

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REVISION SHEET

Page # Rev. # Date Reason of Change Signature

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TABLE OF CONTENTS
1 ABBREVIATIONS ............................................................................................................................. 6
2 PURPOSE ………………………………………………………………………………………………………………………………… 7
3 DEFINITIONS .................................................................................................................................... 7
4 RESPONSIBILITY............................................................................................................................. 7
5 POLICY ………………………………………………………………………………………………………………………………… 8
6 PREVENTION .................................................................................................................................... 9
7 INFANT ABDUCTION RESPONSE PLAN .................................................................................. 13
8 RECOVERY ……………………………………………………………………………………………………………………………… 15
9 SUPPORTIVE DATA ...................................................................................................................... 16
10 FAQs ………………………………………………………………………………………………………………………………. 18
11 ANNEXTURES ................................................................................................................................. 19
11.1 ANNEX-01 (NEWBORN ID BAND)....................................................................................... 19
11.2 ANNEX-02 (BABY FOOT PRINT)......................................................................................... 19
11.3 ANNEX-03 (OBSTETRICS – NEONATOLOGY ENDORSEMENT FORM) ................... 20
11.4 ANNEX-04 (PEADTRIC PATIENT IDENTIFICATION ID BAND) ................................. 21
11.5 ANNEX-05 (CRIB CARD) ....................................................................................................... 22
11.6 ANNEX-06 (HOSPITAL STAFF ID CARD) ......................................................................... 24
11.7 ANNEX-07 (VISITATION CARD) ......................................................................................... 24
11.8 ANNEX-08 (CODE PINK COMMITTEE) ............................................................................ 25

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1 ABBREVIATIONS
AS Apgar Score
BP Blood Pressure
CBC Complete Blood Count
CCTV Closed Circuit Television
CNIC Computerized National Identification Card
CQI Continuous Quality Improvement
CS Caesarian Section
CTG Computerized Tomography
DHQ District Head Quarter
DM Diabetes Mellitus
DMS Deputy Medical Superintendent
DOB Date of Birth
ER Emergency Room
GDM Gestational Diabetes Mellitus
HC Head Circumference
HR Heart Rate
ID Band Identification Band
LMP Last Menstrual Period
MR No. Medical Record Number
NICU Neonatal Intensive Care Unit
PICU Pediatric Intensive Care Unit
PIH Pregnancy Induced Hypertension
PMDC Pakistan Medical and Dental Council
PROM Premature rupture of membranes
R.R Respiratory Rate
RBS Random Blood Sugar
SOPs Standard Operating Procedures
SVD Simple Vaginal Delivery
VD Vaginal Delivery

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2 PURPOSE
To provide guidelines for action and notification in the event of a suspected infant/child abduction.

3 DEFINITIONS
Neonate: A child less than four weeks of age

Infant: A child between the ages of one month and one year of age

Pediatric patients: Patients between the ages of 1 year and 12 years

Child Abduction: Any illegal, unlawful, or coercive taking away of child against the
consent of his/her parents and legal guardian

4 RESPONSIBILITY
It is the responsibility of all staff members to always be alert for persons in all areas who exhibit
unusual behavior and to be aware of patients who may be at risk due to family situations. Unusual
behavior can be described as: loitering at the Nursery extensively, inappropriate questions about a
baby or babies, following of nurses as babies are taken to their mothers, or asking questions about
staff procedures or security measures.

During a CODE PINK, it is the responsibility of the hospital staff to stop and question anyone
with children, bulky packages, suitcases, baby in their arms, wearing a heavy coat or jacket, or
anyone who may appear suspicious.

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5 POLICY

1. Code Pink Committee must be organized; its members and staff working in Labor room,
Nursery, NICU, PICU and the Peads Ward shall be properly oriented on their roles and
responsibilities including the things to be asked to the visitors in the area.
2. All personnel in the area are responsible to be familiar with the hospital Child Abduction
Response Plan as it applies to their area.
3. Any employee suspecting of child abduction or missing shall immediately notify admin officer,
Security guard of the unit and Security Supervisor of contracted Security Agency.
4. The telephone Operator upon receiving call for “CODE PINK” shall announce in the public
address system for the Code Pink to be activated, in which all the Code Pink Team shall
response without delay.
5. All exits shall be closed to prevent the culprit escape.
6. In service training and annual drill for “CODE PINK” shall be required for all persons even
newly hired to be included in the orientation program.
7. Follow strictly for Staff ID Card policy.
8. Follow strictly for Patient identification policy
9. There should be CCTV Control of Labor room, Gynae wards, Nursery, NICU, PICU, Pediatric
wards specially including other areas and hospital exit points.

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6 PREVENTION
1. ENSURE THE PROPER IDENTIFICATION OF THE CHILD
a) All Nursing Staff members assisting deliveries in the delivery room must apply pink
ID Band (Baby Girl) and blue ID band (Baby Boy) on right wrist with corresponding
name of the mother, gender of baby, date of birth before handing over to mother/
transferring to the newborn unit(Sample ID band attached at Annex-01).
b) Both sets of Foot print must be printed in the baby’s record to be attached in the
patient file (Template attached at Annex-02).
c) Baby Handing over to neonatal department must be documented in Obstetrics-
Neonatology Endorsement form (attached at Annex-03)
d) In-patient infant and pediatrics patients will be made to wear an identification band
(attached at Annex-04), with the father’s name and his contact number on it. On
discharge from hospital, ID band is verified and removed by the nurse.
e) When two or more patients have the same or similar last names, charts and infant
crib/bed card shall be labelled NAME ALERT and mother’s first name will be
included on the chart and crib card. (Template attached at Annex-05)
2. THE AREA AROUND THE NEONATAL INTENSIVE CARE UNIT, THE
NURSERY (IF PRESENT), AND THE AREA OF PAEDIATRIC WARDs WILL BE
CONSIDERED SECURE AREAS
a) The Hospital authorized staff to enter such areas must display Hospital Staff
Identification Card.
i. The identification card must be visibly displayed.
ii. Security must check for the presence of the identification card, as well as match
the displayed picture to the individual’s face.
iii. In case where there is a mismatch between the identification card and the face of
the personnel carrying it, both individuals are to be referred to the hospital’s
Medical Superintendent, who will initiate a case comprising of legal and/or
disciplinary action against both parties.
iv. Individuals lacking this card will not be permitted to enter into these secure areas.
b) Hospital staff with duty in these secure areas who have misplaced or forgotten their
card must inform the head Nurse and Hospital administration.
c) Children will NEVER be removed from the secure area unless discharged by the
competent authority.
i. The mothers may visit the breastfeeding area after identification for breast
feeding.
ii. A specified Nurse should be in charge of the breast feeding area.

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d) Only parents/ legal guardians are allowed to accompany the child during his/her
hospital stay.
e) Security Guards should be present regularly on the duty.
f) Visiting hours must be observed strictly.
g) No attendants are allowed to stay overnight with the patient except the parents/ legal
guardian.

3. THE CHILD’S PARENTS WILL NOMINATE NO MORE THAN TWO (2)

INDIVIDUALS AUTHORISED TO VISIT THE CHILD; AND THEY WILL BE
PROVIDED WITH A SPECIAL PATIENT ATTENDANT CARD AUTHORISING
THEM TO ENTER PEADS WARD/PICU.
a) The Parents will provide the details of the individuals authorized to visit the child.
These details will include the following:
i. Name
ii. Relationship with the child.
iii. National ID card may be deposited against the attendant card to be provided.
iv. Telephone number
b) Such individuals will be provided with patient attendant card (attached at Annex-7).
c) The individuals will only be allowed to visit during the visiting hours.

4. PATIENTS AT RISK OF BEING ABDUCTED WILL BE PLACED CLOSE TO

THE NURSES STATION IN THE LINE OF SIGHT OF THE NURSES

These patients are to be subjectively assessed, and include, but are not only limited to, the
following:

a) Custody is being disputed.

b) Infants left alone in ward for extended periods of time.
c) Domestic disputes/abuse.
d) Threats to leave against medical advice by non-custodial parent.
e) In the events where custody isn’t clear.
f) For divorced mother.

5. STAFF MUST ALWAYS BE VIGILANT AND AWARE OF; AND NOTIFY

SECURITY OF; ANY UNIDENTIFIED / UNKNOWN PERSONS
Such individuals may include the following:
a) Unnecessarily follow staff of a secured area.

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b) Asking detailed questions about the layout.

c) Impersonating a nurse or other allied health professional.

6. NEONATE/ MOTHER CONTACT

a) Assure the neonate taken from nursery is released only to mother after positive Id
check by comparing the mother ID band with neonates.
b) MR of the mother must match with neonate‘s number on the identity band before
the neonate can be released.
c) Assure that the neonate is only removed from mother’s care (ward/room) by
authorized personnel.
d) Mothers will be instructed to release the baby to authorized personnel wearing
appropriate identification. Initially it should be discussed with the patient during
the ante-natal visits and admission for delivery and post-delivery.

7. ALL NEONATES MUST BE TRANSPORTED IN HOSPITAL BASSINETS,(Baby

Cart)
a) Neonates will only be transferred to the mother via a baby cart.
b) Nobody involved in neonatal care is allowed to transport the child in any other way
(like being held in the arms), including the parents and/or authorized visitors.
c) The parents may pick up the child, but MUST NOT go out of the secure area with
the child.
d) Anyone found carrying a baby in the hallway will be questioned by the security guard
or newborn/ ward nurse where the mother is admitted.

8. PARENTS SHOULD BE ADVISED NOT TO ALLOW THEIR CHILD TO BE

TAKEN FROM THE WARD BY A WORKER UNLESS PERMITTED BY THE
CONCERNED DUTY STAFF.

9. ACCESS CONTROL:
a) Entry and exit into the post-natal ward and nursery will be constantly monitored by
electronic surveillance and by the nurse assigned to the patient.
b) All personnel and visitors will enter and exit the ward via the designated main
entrance.
c) Emergency exits will not be used by visitors except during an emergency.

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10. CODE PINK COMMITTEE MEMBERS shall compose of the following:

a) Medical Superintendent
b) Deputy Medical Superintendent on duty
c) Security Officer and contracting security agency security guards
d) Head Nurse/ Charge Nurse on duty
e) Department Head
f) Doctor on duty
g) Nursing Supervisor
(Annex 8)

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7 CHILD ABDUCTION RESPONSE PLAN

1. MISSING CHILD

a) A staff member should stay with the person who has reported the child missing or
send another employee with that person (if the family member chooses to look for
the missing child).
b) The person reporting the missing child should not be allowed to leave the premises
unaccompanied.
c) All witnesses and/or involved personnel should remain at the location until they are
released by the DMS. If the event occurs at shift change, no employees should be
allowed to leave the hospital.

2. SUSPECTED ABDUCTION / COMMUNICATION

Check desk to see if patient has been checked out, if not, call the Public Address
system to initiate Code Pink.
"Code Pink – 0/1/5" - Location – aleph/bay – laal/neela
o 0 Infant < 1 year
o 1 Child 1-5 years
o 5 Child > 5 years
o Location ward name
o aleph Culprit Known
o bay Culprit Unknown
o laal Culprit is female
o neela Culprit is male
NOTE: Contact Security via telephone exchange. Give his/her name, MR no,
location / floor (i.e., NICU, 2nd Floor, etc.)

3. DEPARTMENTAL RESPONSIBILITIES / STAFF ROLES

1. Nursing Unit
a) Recheck all wards/rooms
b) Secure the area where the abduction occurred.
i. To preserve any forensic evidence.
c) Counsel the parents.
d) Protect parent(s) from stressful contact with the media or other
interference
e) Notify Admitting Consultant

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2. Nursing Administration (Head Nurse)

a) Ask Operator to contact:
i. Nursing Director
ii. DMS on duty
iii. Hospital Medical Superintendent
iv. Hospital Security In charge
b) Hold all hospital Staff.
i. All employees should remain in department or report back to
department until cleared to go home.

3. Code pink members

They should respond immediately and execute their designated roles and
responsibilities as outlined in the child abduction response plan during the rescue.

4. All Staff
a. Secure all hospital exits.
b. Notify Single entrance and exit point for in and out. Let the family
member of missing child to accompany the security guard there for
recognition purpose.
c. The staff will question individuals
i. Inform people before asking any questions that a child is missing.
ii. If they have a child:
i. Ask the person “Is this your child?”
ii. Check the child and/or adult for hospital ID bands.
(Parents/legal guardians of inpatient children are given an
ID band to identify them with their child). Outpatients
will be identified by OPD slip issued at the time of
registration and their CNIC.
iii. Ask person to open any large bags or purses (if missing child is an
infant).
iv. If the person has a child with them that is a toddler or older, ask
the child, “Who is the person with you?”
v. If the person has a child with them that is a toddler or older, ask
the child, “What is your name?”
vi. Ask the person where they have been in the hospital.
vii. Notify security in issues of
i. Non-compliance

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ii. Changes in story over the course of discussion

iii. Suspicion of lack of truth
d. If an employee identifies the abductor, the employee should ask them
to come with them to an area with a phone and call Security.
5. Security

The security staff will mobilize and organize, with at least one individual by the
telephone to receive telephone calls from the staff, and the rest engaged in the
following:

a) Lockdown the Hospital.

i. Everyone must enter or exit through the designated single entry and
exit gate.
b) Search the facility and hospital grounds.
c) Obtain information from child's nurse, parents and others that may
have been around infant/child:
i. sex of infant/child
ii. age of infant/child
iii. name of infant/child
iv. Pictorial evidence of child
v. description of infant/child clothing
vi. Description of suspected abductor
d) Assume control of the crime scene from the nursing staff.
e) Liaise with the police
f) Take suspects into custody

6. Medical Superintendent
a) Notify Police Department
b) If necessary, respond to media; document.
c) Document this as a sentinel event, with surrounding and mitigating
circumstances described in detail, and to be brought up in the
Continuous Quality Improvement (CQI) Meetings

8 AFTER RECOVERY
1. Security will authorize a Code Clear and return access control to normal.
2. All staff will return to their work area.
3. Staff stress debriefing by Medical Superintendent, if requested.

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9 SUPPORTIVE DATA
1. Personnel Assigned to Delivery room, Newborn and Pediatric Ward will receive the
following training during their orientation period and annually thereafter
a) Infant/ Child vulnerability
b) Infant/ Child Abduction policy
c) Suspicious Activity response
d) Access control
e) Employee Identification Card
f) Visitor Identification
g) Instructions to Mothers
h) Newborn Identification Bands
i) Footprint Requirements for Newborn
j) Responding to abduction attempts
2. Delivery Room, Newborn, and Pediatric Wards will be on lookout for the following:
a) Repeat visitors to the units with extreme interest in babies and children
b) Theft of personnel identification or uniform
c) Extensive questioning, regarding the units protocol or the babies and children
d) Anyone carrying an infant instead of using a baby cart or carrying huge bags, large
packages or loosely wrapped bundles from the delivery room or newborn unit
3. Incidents will be reviewed through the sentinel event in CQIs for possible
improvements.

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Employee Suspects child has been

abducted

Call Operator
*Code Pink”

J
STAFF NURSE: SECURITY:
1. Recheck wards and rooms. 1. Lockdown Hospital
2. Secure the area. 2. Obtain information from
3. Intimate Hospital Administration Infant’s/Child’s nurse and parents
4. Notify Incharge Security 3. Search the facility.
5. Counsel the parents
6. Notify Primary Physician. OTHER STAFF:
1. Secure all exits.

NURSING ADMINISTRATION (Head Nurse):

I HOSPITAL ADMINISTRATION:
1. Intimate Nursing Director. 1. Notify Police
2. Intimate Hospital Administration. 2. Handle media Calls
3. Intimate Hospital Security 3. Stress debriefing
Supervisor.
4. Intimate DMS on duty and MS

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10 FAQs

10.1 What is code Pink?

Code Pink is when a neonate, infant or child admitted in hospital is suspected or confirmed as missing.

10.2 What is the role of Parents to prevent child abduction?

Parents should be alert to any unusual behavior/ loitering and report suspicious behavior to on duty Nurse

and Security Officer. They must be oriented to never give baby to any unknown person or unauthorized

hospital staff.

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11 ANNEXTURES
11.1 ANNEX-01 (NEWBORN ID BAND)

11.2 ANNEX-02 (BABY FOOT PRINT)

New Born Identification
Name of Mother Gender of Baby
Mother MR # Date & Time of Birth _____/______/______ ___ : ___
AM/PM
Mothers Right Index Fingerprint Infants Left Footprint Infants Right Footprint

Nurse Name (Taking Print & Hospital ID Date: ________ /____ Time
Applying ID Band) & Sign: /________ ___:___
AM/PM

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11.3 ANNEX-03 (OBSTETRICS – NEONATOLOGY ENDORSEMENT FORM)

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11.4 ANNEX-04 (PEADTRIC PATIENT ID BAND)

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11.5 ANNEX-05 (CRIB CARD)

Neonate Crib/ Bed Card

Pediatric In Patient Crib / Bed Card

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NAME ALERT in case of Patients with similar Name

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11.6 ANNEX-06 (HOSPITAL STAFF ID CARD)

11.7 ANNEX-07 (VISITATION CARD)

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11.8 ANNEX-08 (CODE PINK COMMITTEE)

A committee of following members is hereby constituted vide order No. ___________

dated _______________ to prevent and rescue infant / child abduction.
1. Medical Superintendent Chairman
2. Deputy Medical Superintendent on duty Co-Chairman
3. Security Officer and contracting security agency security guards Member
4. Head Nurse / Charge Nurse on duty Member
5. Department Head Member
6. Doctor on duty Member
7. Nursing Supervisor Member

The committee is responsible for:

a) Code Pink committee members and staff working in labor room, nursery and
PEADS ward shall be properly oriented on their roles and responsibilities.
b) The committee is responsible for in-service training and annual drill of all staff on
code pink policy.
c) Committee shall ensure the following:
i. Patient identification (Baby)
ii. Visiting hours and visiting rules must be observed strictly.
iii. Security guards on duty shall make regular rounds all over the hospital.
iv. No visitors are allowed to stay overnight with the baby except the
parents/legal guardian.
d) The committee members shall meet every three months to check the compliance of
Code Pink SOPs.
e) They must coordinate with each other for execution of Child abduction response
plan in case of suspected child abduction.
f) The convener shall take over on the operation of code pink until the law
enforcement agency arrives to be responsible for the directions of activities during
the Code Pink.
g) Incident will be registered as sentinel event and reviewed in CQI meetings for
possible improvements.

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