Safeguarding - Initial Management of non-independently mobile infants, children and young people presenting with bruising to Leeds Teaching Hospitals (LTHT)

Publication: 22/02/2018  
Next review: 07/10/2024  
Standard Operating Procedure
CURRENT 
ID: 5404 
Approved By: LTHT Trustwide Child Protection Steering Group Nov 2017 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Safeguarding- Initial Management of non-independently mobile infants, children and young people presenting with bruising to Leeds Teaching Hospitals (LTHT)

Background:

Bruising is the commonest presenting feature of physical abuse in children. 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 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.

Unintentional non-accidental bruises in pre-mobile infants are rare, with a prevalence of <1%. (9.3.1-3; Child Protection Companion; Royal College of Paediatrics & Child Health)

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 either in the community 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.

Back to top

Procedure Method

  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, with the Paediatric Registrar or consultant on-call for the wards or a member of the safeguarding team. These discussions should not take place after the child has been discharged or left the hospital grounds.
  3. 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.”
  4. 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.
  5. To facilitate this bleep the on call paediatric registrar (Bleep 2111) or Consultant
  6. A discussion must be held with the on call Paediatric Consultant in cases where the matter on unclear, and there is uncertainty regarding the need for a safeguarding assessment. 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) that the presentation necessitates a safeguarding assessment.
  7. 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
  8. 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.
  9. 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
  10. 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
  11. The plan should be for the child to remain an inpatient in the hospital until formal haematology opinions and test results are obtained.
  12. 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 will;
    • 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 advice immediately.

Declarations of Interests

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

Back to top

Definitions

Child or Children: Anyone who has not yet reached their 18th birthday. The fact that a child has reached 16 years of age, is living independently or is in further education, is a member of the armed forces, is in hospital or in custody in the secure estate, does not change his/her status or entitlements to services or protection.

This is important because young people aged 16 and 17 years with safeguarding needs may be accessing ‘adult’ services in provider organisations, or working for the Trust as an apprentice or deemed a young person at work.

Not Independently Mobile (NIM): A child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently, this includes all children under the age of six months. Please note however that some babies can roll from a very early age and this does not constitute self-mobility. Consideration should be given to children with physical disabilities whom are also not independently mobile.

Bruising: Is the extravasation of blood in the soft tissues producing a temporary, non- blanching discolouration of the skin. This can be faint or small and with or without other skin abrasions or marks. Colouring may vary from yellow through green to brown or purple. This includes petechiae, which are red or purple non-blanching spots, less than two millimetres in diameter and often in clusters.

Medical Bruising: Bruising to very young babies may be caused by medical issues e.g. birth trauma however this is rare. In addition, some medical conditions can cause marks to the skin in very young babies that may resemble a bruise. An example of medical bruising may be ‘Congenital Dermal Melanocytosis’ (previously known as Mongolian Blue Spot).

Congenital Dermal Melanocytosis; Hyper pigmented areas usually seen at birth or in early life. They are more commonly seen in children of Asian/African descent. They are usually bluish-grey in colour, flat and round or ovoid in shape. They are typically found on the lower back/sacrum/buttocks. They are non-tender and typically take months or years to fade.

Concerns: refers to any suspicion, allegation, or other apprehension relating to the safety or wellbeing of a child or young person who may be experiencing or at risk of abuse. Individuals do not need ‘proof’ in order to raise concerns under safeguarding children procedures.

Parent: refers to the person with legal Parental Responsibility for the child. Parental responsibility continues until the child reaches 18 years of age. A child under 18 may also be a parent or carer themselves and this should be considered.

Multi-Agency procedures: the locally agreed procedures are available on the West Yorkshire Consortium Child Protection Procedures which can be accessed via: https://westyorkscb.proceduresonline.com/chapters/contents.html

Provenance

Record: 5404
Objective:

This procedure provides clear guidance on and the expected response in the event of the identification of bruising to a non-independently mobile (NIM) child.

This procedure aims to:

  • Ensure that all staff members are supported to respond in a timely manner.
  • Ensure that all staff members are fully aware of their roles and responsibilities.
  • Ensure effective communication and co-operation between Trust staff and other agencies.
  • Facilitate the necessary investigations.
  • Ensure that the parents/carers of a bruised or injured infant/child are kept fully informed of the situation and are appropriately supported.

In the event of a suspected or confirmed bruise in a non-independently mobile (NIM) child, this should be investigated further through a Child Protection Medical Examination either within the hospital or in the community. In both cases close liaison with Children’s Social Care is vital.

Clinical condition:
Target patient group: Non-mobile children attending LTHT
Target professional group(s): Secondary Care Nurses
Midwives
Secondary Care Doctors
Adapted from:

Evidence base

Children Act 2004. London, HMSO.  
Data Protection Act 1998. London, HMSO.
Health and Safety at Work Act 1974. London, HMSO
HM Government (2018) Working together to Safeguard Children
https://www.gov.uk/government/publications/working-together-to-safeguard-children--2

LSCP
https://www.leedsscp.org.uk/Practitioners/Local-protocols/Multi-agency-Protocol-for-Bruising-in-Non-independ
West Yorkshire Consortium Inter Agency Safeguarding and Child Protection Procedures
https://westyorkscb.proceduresonline.com/index.htm

Approved By

LTHT Trustwide Child Protection Steering Group Nov 2017

Document history

LHP version 3.0

Related information

Not supplied

Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.