Staff in hospital emergency departments in England are struggling to spot when infants are being physically abused by their parents, raising the risk of further harm, an investigation has found.
Clinicians often do not know what to do if they are concerned that a child’s injuries are not accidental because there is no guidance, according to a report from the Healthcare Safety Investigation Branch (HSIB) that identifies several barriers to child safeguarding in emergency departments.
Matt Mansbridge, a national investigator, said the report drew on case studies of three children who were abused by their parents, which he said were a “hard read” and a “stark reminder” of the importance of diagnosing non-accidental injuries quickly, since these are the warning sign in nearly a third of child protection cases for infants under the age of one.
“For staff, these situations are fraught with complexity and exacerbated by the extreme pressure currently felt in emergency departments across the country,” Mansbridge said. He said the clinicians interviewed wanted to “see improvement and feel empowered” to ask difficult questions.
“The evidence from our investigation echoes what staff and national leads told us – that emergency department staff should have access to all the relevant information about the child, their history and their level of risk, and that safeguarding support needs to be consistent and timely/ Gaps in information and long waits for advice will only create further barriers to care,” he said.
The report, which is based on 10 serious incident reports written by NHS trusts, notes that it is “complex and difficult” to identify whether an infant is at risk, especially since clinicians usually draw on information from parents to establish diagnoses, but safeguarding requires them to be sceptical.
In one case study in the report, a doctor dismissed a nurse’s concerns about a child’s injury and distress because the parents were “well dressed”, had an “appropriate interaction” with their child, and were not known to social services. The child was flagged to the safeguarding team only when they returned with a further injury, and was placed into foster care.
In other case studies, the child protection information-sharing system that clinicians used did not provide them with important context – for example, a history of domestic abuse or previous social service involvement – because they did not meet the threshold for inclusion. The system also does not trigger an alert if a child has regularly visited the emergency services in different hospital trusts.
Other barriers to diagnosing non-accidental injury identified by the HSIB included high workloads and time pressures on staff; inconsistent, insufficient and slow approaches to information sharing and data storage; and challenges in swiftly escalating concerns to safeguarding teams.
To improve the situation, the HSIB recommends that the Royal College of Emergency Medicine develop guidelines for emergency services; that NHS England review whether its safeguarding data is fit for purpose; that safeguarding teams be situated in emergency departments; and that an electronic system for checking safeguarding information be made available so that clinicians can quickly check a child’s record.
An NHS spokesperson said: “It’s vital staff have the training and support they need to recognise and handle these incredibly difficult cases, and share information effectively in the best interests of the child. All safeguarding training received by emergency care staff aligns with standards set by the royal colleges.”
