HSIB’s latest report reinforces that specific guidance, detailed multi-agency information and improved access to specialist safeguarding support is crucial for ED clinicians that suspect a baby or young child’s injuries are non-accidental.
The report underpins an investigation that examined what influences the diagnosis of non-accidental injury in infants (children under 1 year of age) when they are seen in the emergency department (ED). Specifically, HISB looked at what support and information available to aid ED staff in such a complex and difficult situation – consultants interviewed during the national investigation said that their roles ‘required fine judgements about degrees of risk and decisions that had potentially significant consequences in relation to people’s welfare.’
Due to the subject matter, HSIB did not focus on one reference case to illustrate the issues associated with diagnosing non-accidental injuries. Instead, they analysed 10 serious incident reports (written by NHS trusts). HSIB’s report does not detail all cases from the NHS reports but for an illustration of the impact, it has summarised three cases of infant injuries that were not accidental (names all changed due to confidentiality) – Amelia (6 weeks old), Jakob (12 weeks old) and Finn (4 weeks old). By analysing the 10 NHS reports, HSIB drew out three common themes – these related to professional curiosity, safeguarding support and previous family contact with social services.
HSIB used the themes from the local NHS reports as a steer but expanded to consider what themes were emerging at a national level; often serious incident reports don’t examine the more systemic influences on care. The national investigation findings fell into three main areas; the challenge of diagnosing a non-accidental injury, information to aid diagnosis and accessing safeguarding support.
Challenge of diagnosing non-accidental injury
Within this area, HSIB examined work pressures as a key theme. ED staff and national clinical leads emphasised to the investigation that the busy environment they are working in created ‘barriers’ to a diagnosis of non-accidental injury. Specifically, they referred to the high workload, time pressure, sensitivity and potential difficulty of raising the issue, along with the competing demands and dynamic nature of the working environment.
The investigation also considered ‘professional curiosity’ and established, through interviews with ED staff, that this could include accepting what parents might say at face value, lack of knowledge of developmental milestones (for example) and being focused in on the injury without considering wider risks. Clinicians told HSIB, for example, that much of the mindset around non-accidental injuries was unfamiliar. In most other scenarios they are guided by information from parents; and in these cases, they are required to be sceptical of parents and see them as someone who may have harmed the child.
While there is guidance from the Royal College of Paediatrics and Child Health (RCPCH) and NICE on child protection and child abuse, the investigation found there is no specific guidance for ED clinicians on the identification of suspected non-accidental injuries and what to do if they suspect an infant has a non-accidental injury. ED consultants and some national stakeholders felt specific guidance and a standardised approach would be ‘helpful to lessen the decision-making burden on frontline clinicians and would be especially helpful for more junior ED staff.’
Information to aid diagnosis
HSIB looked at the information clinicians have available to support in their determination of whether an injury is accidental or not. This includes information from the adult with the infant about any previous social services involvement, the Child Protection – Information System (CP-IS), information from Social Services, a specific emergency care data, and information from GP’s.
The investigation showed that while there are several sources of information, it can be of varying levels of use, especially if it is not easily accessible or are gaps in the information – for example the CP-IS system is limited. A child may have multiple risk factors for non-accidental injury but if this does not meet the criteria to be included on the CP-IS it therefore is not included on a patient’s summary care record and may therefore remain unknown to clinicians.
In relation to the Emergency Care Data Set (the system which captures information about patients attending ED’s), the investigation found that whilst there is a field for safeguarding information and concerns to recorded, that data is of limited quality and is not utilised – the report sets out that it is – it is not currently sent to any team or body for review and action. The ECDS team told HSIB that they felt it was a missed opportunity as, with over five years of data now available, it has the potential to identify patterns and inform care in the same way as other data collected by the NHS.
Access to safeguarding support
The investigation examined the access, availability, and visibility/proximity of safeguarding support. The investigation spoke to staff who expressed that safeguarding teams provide very valuable support in what is a sensitive area, but that access and availability could be an issue. For example, the report references that many safeguarding teams are available Monday to Friday (9am – 5pm) with little or no out of hours support.
HSIB’s investigation also highlighted that many safeguarding teams worked in offices outside of treatment areas. The clinical staff and safeguarding teams the investigation team spoke to felt it would be helpful to have the safeguarding service located physically close to the ED, a view which was also echoed by feedback from national healthcare organisations during HSIB’s report consultation.
Safety conclusions
The report concludes with two safety recommendations focused on developing specific guidance for ED’s and improving the quality of emergency care safeguarding data.
- The Royal College of Emergency Medicine, working with relevant stakeholders, develops guidance to support clinicians in the diagnosis and management of non-accidental injuries.
- NHS England, working with relevant stakeholders, reviews the utility of the safeguarding data in the Emergency Care Data Set and agrees a process for assuring the quality of any data to be captured.
Matt Mansbridge, National Investigator, said: “The three case studies included in our report are a hard read – a stark reminder of the importance of recognising and diagnosing non-accidental injuries quickly in the ED. We have recognised in our report that for staff these situations are fraught with complexity and exacerbated by the extreme pressure currently felt in ED’s across the country. The clinical staff we spoke to however were open and reflective – they acknowledged that the clinician’s experience and professional curiosity in these cases is important but that there are gaps in the way they are currently supported. They want to see improvement and feel empowered to ask those more difficult questions when they are faced with the possibility that a child’s injury is not accidental.
“The evidence from our investigation echoes what staff and national leads told us – that ED 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. Our findings, observations and recommendations are aimed at supporting wider improvement within this complex area and, as we have seen in some examples, effective collaboration and sharing of information will ensure that babies and young children are safe and not put at risk of further harm.”
