This report by the Children's Commissioner stems from the investigation of two children who were hospitalised for non-accidental injury, and then were subsequently abused while they remained in hospital. The aim of the report is to provide a set of guidelines to improve the safety of children in hospitals in New Zealand. Information for this report was gathered through interviews with the various service agencies involved in the cases, including the Department of Child, Youth and Family Services, the relevant District Health Boards, and the Police. Deficiencies in the protection of the children involved are discussed, such as breaches of procedure in supposed child abuse cases, interagency communication failures, and the blurring of professional roles. The Children's Commissioner recommends improved clarity concerning who has the responsibility for the duty of care of the child, effective interagency coordination, and that the safety of children in hospital is ensured.