Safeguarding - Initial Management of Non-Independently Mobile Infants, Children and Young People Presenting with Bruising to Leeds Teaching Hospitals (LTHT)

• Background
• Procedure Method (Step by Step)
• Declarations of Interests
• Definitions

Background:

Bruising is the most common injury in children who are being abused and children who are not being abused. Bruising to pre-mobile infant is rarely accidental (only 0.6-1.3% of cases) (RCPHC, 2020).

Bruising is also a widely reported “sentinel” injury in babies and younger and its recognition is vital in prevention of more severe abuse. Investigations into children who have died or suffered serious harm, when abuse or neglect is thought to be involved (Child Safeguarding Practice Reviews), indicate that bruising in mobile children is often ignored or underestimated. Child-Protection-Evidence-Chapter-Bruising_Update_final.pdf (rcpch.ac.uk)

Bruising is the commonest presenting feature of physical abuse in children. Any part of the body is vulnerable to bruising from abuse, however the head is the most common site.

Patterns of bruising suggestive of physical child abuse include:

• bruising in any children who are not independently mobile
• bruising in babies
• bruises that are away from bony prominences
• bruises to the face, back, abdomen, arms, buttocks, ears, neck and hands
• multiple or clustered bruising
• imprinting and petechiae
• symmetrical bruising

Non-Independently mobile (NIM) infants are less likely to sustain bruising and there is a direct correlation that accidental bruising becomes more likely the more mobile a child becomes.

Nationally, it is apparent from Child Safeguarding Practice Reviews (investigations into children who have died or suffered serious harm, when abuse or neglect is thought to be involved), that bruising is often ignored or underestimated. This means opportunities to protect children from abuse may not be taken.

It is for this reason that the National Institute for Health and Clinical Excellence (NICE) direct health care professionals to suspect child maltreatment in cases of bruising or petechiae in children that are not caused by a medical condition in a child who is not independently mobile. Further information can be found in the NICE guidance; Child Maltreatment: when to suspect maltreatment in under 18’s (2017) https://www.nice.org.uk/guidance/cg89

Local guidance concerning multiagency procedures for the management of bruising in non-mobile infants and children exists and is hosted by the Leeds Local Safeguarding Children Partnership (LSCP). This information can be found here: https://www.leedsscp.org.uk/Practitioners/Local-protocols/Multi-agency-Protocol-for-Bruising-in-Non-independ

Key Points include;

• It is extremely rare for a non-mobile baby to sustain accidental bruising. Therefore all such bruising should be suspected by professionals to be an indicator of physical abuse and be thoroughly investigated.
• Practitioners should be open to the possibility that a child with a disability could potentially be harmed deliberately. It should not be assumed that bruising has occurred during transfer from a hoist, bed or wheelchair etc.
• Practitioners should always seek to obtain and document what life is like for the child and document their “Voice”. This is of increased importance for non-verbal children who may not be able to communicate they are suffering abuse or harm. Therefore consideration of their body language, verbal cues and other such means of communication should be clearly documented.

A decision that the child has not suffered abuse must be a joint decision and must not be made by a single agency.
The guidance directs frontline practitioners within the acute hospital setting to have a discussion with social care. Social Care should then arrange a Paediatric Safeguarding Medical Assessment with the Paediatric Consultant On-call. This should be either in the community if required and if it is safe for the child to be discharged or as an in-patient if they require admission for medical care or as a place of safety.

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Procedure Method (Step by Step)

1. Ensure the immediate safety of the child. Police or LTHT security (49999) should be considered if parents or carers attempt to remove the child from the hospital prior to being discussed and seen by a paediatrician.
2. The case should be discussed, at the time, of the presentation and should not take place after the child has been discharged or left the hospital grounds.
3. The case should be reviewed by a health professional who has the appropriate expertise to assess the nature and presentation of the bruise, any associated injuries, and to appraise the circumstances of the presentation including the developmental stage of the child, whether there is any evidence of a medical condition that could have caused or contributed to the bruising, or a plausible explanation for the bruising.
4. It should also be remembered that an underlying condition that may make a child more susceptible to bruising such as Von-Willebrands disease, does not mean a child is not being physically abused.
5. A discussion must be held with the on call Paediatric Consultant in cases where the matter is unclear, and there is uncertainty regarding the need for a full safeguarding assessment.
6. These cases require a comprehensive history taking and a full examination to clarify concerns and obtain any evidence suggesting maltreatment or abuse. This usually takes place on the Children Assessment Treatment (CAT) unit. NICE guidance on when to suspect child maltreatment states “Do not rely solely on information from the parent or carer in an assessment.”
7. Any marks discovered at birth by midwife / obstetrician / paediatrician at birth or in early life should have been clearly recorded in both the baby’s and maternity notes so these should be checked.
8. Following this discussion, the health professional who has identified the bruising must explain to the carer and/or the child (if deemed able to be included in the discussion) if the presentation necessitates a safeguarding assessment.
9. All parents/carers should be given the leaflet “What happens when we have safeguarding concerns about your child” https://www.leedsth.nhs.uk/patients-visitors/our-hospitals/leeds-childrens-hospital/a-z-of-children-hospital-leaflets/safeguarding.
10. A multi-agency discussion must take place to consider any other information on the child and family and any known risks, and to jointly decide whether any further assessment, investigation or action is needed to support the family or protect the child. This multi-agency discussion should always include the health professional who reviewed the child.
11. Following conversations with family, child (if appropriate), and Social Care, a Child Protection Medical Examination may be carried out. Social Care must be kept up to date with relevant findings. It is very important to consider any other children or vulnerable adults who reside with the non-mobile child and if they too require safeguarding or medical examination.
12. If a Child Protection Medical Examination is required, all parents/carers should be given the leaflet “What happens when your child needs a Child Protection Medical Examination” https://www.leedsth.nhs.uk/patients-visitors/our-hospitals/leeds-childrens-hospital/a-z-of-children-hospital-leaflets/safeguarding
13. A referral should be made to Children Social Care (prior to discharge for an ongoing management plan) as per Trust Safeguarding Children Policy. http://nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=587
14. Any clinically unwell children or infants will usually be admitted. Children who can safely be discharged may have a Child Protection Medical Examination arranged by Children Social Care and undertaken in the community by Leeds Community Healthcare. This decision must only be made after discussion with a senior doctor with sufficient experience in paediatrics and safeguarding.
15. In cases where the child is no longer in the hospital (because the parent has removed the child without the child being seen), the health professional who identified the concern must;

• Contact the child and parent/carers and discuss their safeguarding concerns.
• Contact the on-call paediatrician team on the Children’s Assessment & Treatment (CAT) unit, referring the patient for safeguarding assessment & Consultant Paediatrician opinion (following discussion), with an agreed time of attendance, and a telephone number to contact the carer if the child does not attend within this time frame.
• Advise the CAT unit team of the ongoing involvement (if any) of the referring team
• If there is any uncertainty the case should be escalated and discussed with the on call Consultant Paediatrician.
• If the child does not attend within the timeframe presented by the referring team or if the family cannot be reached to ascertain their safety  the case must  be discussed with the on call Paediatric Consultant & may require an urgent referral to Children’s Social Care and/ or the Police.
• IN CASES OF DISPUTE OR UNCERTAINTY the on call Paediatric Consultant should be contacted for senior advice immediately.

Declarations of Interests

The author does not have any other interests which could affect the motivation or decision making in this SOP.

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