Management of newborn babies who have been dropped in hospital

Publication: 07/11/2019  --
Last review: 01/01/1900  
Next review: 07/11/2021  
Clinical Guideline
CURRENT 
ID: 6209 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline 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.

Management of newborn babies who have been dropped in hospital

This guideline outlines the approach to assessment and treatment of babies who have been dropped whilst in hospital. It does not cover babies admitted from home or the community with head injuries.

  1. Guideline
  2. Appendix 1 Modified Glasgow Coma Scale for Infants
  3. Appendix 2 Head injury advice sheet for parents
  4. Appendix 3 Proforma for documentation of assessment

Aims

To improve the diagnosis and management of babies <28 days of life who have been dropped by a parent, relative or healthcare professional whilst in hospital.

Objectives

Scope: This guideline advises LTHT staff on how they should respond after a baby is dropped by a parent, relative, visitor or healthcare professional, or slips from that person’s hold or lap, regardless of the surface onto which the baby falls or if there are obvious signs of injury. It should be used in conjunction with the NICE guideline: “head injury, assessment and early management” (see: https://www.nice.org.uk/guidance/cg176).

It does not cover babies who are dropped at home, in public places or while visiting hospitals, as normal processes for accessing emergency care will be followed for these cases; nor for toddlers or older children who fall, as the risks of injury and clinical considerations in these groups will be very different. The purpose is not to apportion blame, but to guide clinical management.

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Background

NHS Improvement issued a safety alert in 2019 as the National Reporting and Learning System (NRLS) identified 182 babies who had been accidentally dropped in obstetric/midwifery inpatient settings in a 12 month period. Eight babies had significant injuries (including fractured skulls and/or intracranial bleeds). A further 66 babies had been reported as being accidentally dropped on paediatric wards, and two incidents were reported in mother and baby units in mental health trusts. Almost all of these 250 incidents occurred when the baby was in the care of parents or visiting family members, rather than in the care of healthcare professionals.

Prevention:

  • Health professionals should not carry a baby in their arms when moving around ward areas. The baby should be placed in a bassinette / pram / cot / resuscitaire.
  • Wet, newborn babies should be dried and wrapped in a towel immediately, or placed in a plastic wrap according to NLS guidelines.
  • Mothers are not recommended to carry their newborn baby in their arms in hospital. Mothers identified at higher risk of falls should be offered assistance in lifting, holding or moving their baby from the cot.
  • All new mothers should be given advice on safe sleeping and how to avoid falling asleep whilst holding their baby. If a mother is excessively tired, she should be given additional advice and support.
  • Any concerns regarding parenting capacity or safety should be identified, documentated and acted upon at the earliest opportunity.

Early identification of any safeguarding concerns should be discussed with Children Social Work Services as soon as possible, to allow for assessment and planning to take place.

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Immediate stabilization and assessment

Management by first responder:

  • If the baby has altered consciousness or is unresponsive, cyanosed or not breathing: call the neonatal crash team (maternity areas) or the paediatric crash team (paediatric wards or public areas) on 2222 clearly stating your location and nature of the emergency.
  • Normally a parent will have instinctively picked up their baby, but if not, if safe to do so, move the baby to an assessment area such as the nearest resuscitaire or baby’s own cot. If there was significant trauma (fall of >1 m onto a hard surface) consider manual immobilsation of the cervical spine whilst seeking help.
  • Perform immediate neurological observations (and modified Glasgow Coma Scale if competent to do so- see appendix 1.)
  • If baby is responsive and breathing then bleep the neonatal registrar/ advanced practitioner (maternity and neonatal areas) or paediatric registrar (paediatric or public areas) for urgent assessment (if not, call crash team as above).

Management by Paediatric / Neonatal staff

  • Stabilise using ABC approach with protection of the C-spine as appropriate. 
  • Take a full history including mechanism of injury and record names of all people present at the time or who witnessed the event.
  • Explore Vitamin K status.
  • Examine the baby with particular reference to neurological examination, pupil responses and check for any signs of injury by fully examining the whole baby. Document all findings accurately on the attached proforma (see appendix 3). Document any injuries using a ‘baby-gram’ drawing, front and back. Differentiate any new/emerging injuries from birth injuries / marks (e.g. forceps marks, Mongolian blue spot or chignon)
  • If GCS <15, or baby is unwell or vomiting admit to Neonatal Unit (NNU) for observations and consider need for CT scan - (see below)
  • If GCS is 15 and baby is well, with no visible marks it may stay with the mother, if safe to do so. Prescribe paracetamol if any signs of pain. Baby should stay in hospital with appropriate neurological observations (half hourly initially, reviewed depending on mechanism of injury). If this cannot be achieved on the post natal ward consider transfer to transitional care or NNU. 

Note: The patient safety alert could not give the exact height the baby was dropped from but confirms newborns have suffered skull fractures and intracranial bleeds after being dropped from relatively low heights (e.g. from laps, arms or beds) in inpatient units.

Safeguarding

  • If there is any concern of non-accidental injury (NAI) or other safeguarding issues discuss with the responsible neonatal or paediatric consultant who should alert the children’s safeguarding team (social work emergency duty team out of hours). Keep the baby in a place of safety with appropriate supervision whilst this is assessed. 

Risk management

  • In all cases complete a datix for the incident, sent to the appropriate ward manager.
  • Where a member of staff has dropped the baby, a verbal apology should be offered immediately, followed by a letter under the Duty of Candor process.

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Investigation

Indication for urgent CT scan (within 1 hour) - ring CT as well as request on ICE. Child will need to be accompanied by a doctor and nurse with resuscitation equipment.

  • Suspicion of non-accidental injury
  • Seizure post trauma
  • GCS <15
  • Depressed skull fracture
  • Tense fontanelle
  • Basal skull fracture (Panda eyes)
  • Bruising and swelling >5cm in the area of a skull injury
  • Or more than one of
    • Loss of consciousness for >5 mins
    • Drowsiness
    • Vomiting >3 times (exclude minor normal baby possets and any pre-existing vomiting illness)
    • Dangerous mechanism of injury (severe trauma, crush injury)
  • Following CT scan admit to NNU / paediatric ward as appropriate for half hourly neuro observations
  • If CT is abnormal: discuss with neurosurgical team

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Discharge

  • The baby should have 24 hours of normal observations prior to discharge. The neurological examination should be normal.
  • Discharge should be authorized by a consultant neonatologist / paediatrician.
  • The GP and community midwife must be informed of the injury with a discharge letter. (Neonatal discharge summary / K2 summary)
  • The head injury proforma should be scanned and uploaded to PPM with the medical records.
  • A patient advice sheet (see Children’s Hospital Leaflets pages) should be given regarding safety advice after head injury and a contact number for advice.
  • Follow up in clinic only if baby required admission to NNU or other concerns.

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Appendix 1 : Modified Glasgow Coma Score for Infants

 

Infant

Score

Eye opening

Spontaneous

4

 

To speech

3

 

To pain only

2

 

No response

1

Best verbal response

Coos and babbles

5

 

Irritable cries

4

 

Cries to pain

3

 

Moans to pain

2

 

No response

1

Best motor response

Spontaneous and purposeful

6

 

Withdraws to touch

5

 

Withdraws to painful stimulus

4

 

Abnormal flexion posture to pain

3

 

Abnormal extension to pain

2

 

No response

1

If intubated the motor response is the most reliable element.

Appendix 2: Advice sheet for parent/carer after neonatal head injury

Appendix 3: Proforma for recording (scan and upload to PPM once completed)

Provenance

Record: 6209
Objective:

Scope: This guideline advises LTHT staff on how they should respond after a baby
is dropped by a parent, relative, visitor or healthcare professional, or slips from that person’s hold or lap, regardless of the surface onto which the baby falls or if there are obvious signs of injury. It should be used in conjunction with the NICE guideline: “head injury, assessment and early management” (see: https://www.nice.org.uk/guidance/cg176).

It does not cover babies who are dropped at home, in public places or while visiting hospitals, as normal processes for accessing emergency care will be followed for these cases; nor for toddlers or older children who fall, as the risks of injury and clinical considerations in these groups will be very different. The purpose is not to apportion blame, but to guide clinical management.

Clinical condition:

Head injury / Non accidental injury / dropped baby

Target patient group:
Target professional group(s): Secondary Care Nurses
Midwives
Secondary Care Doctors
Tertiary care teams
Adapted from:

Evidence base

References and Evidence levels:
C. Expert consensus and national guidance from NPSA

References:

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

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