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The safety of children and their protection is everybody's business. Although bruising is the commonest presenting feature of physical abuse in children, this protocol covers all actual or suspected injuries to non-mobile children. Research has shown that children who present with a severe non- accidental injury have often been seen earlier with bruising or another injury – a sentinel injury. These injuries provide an opportunity to prevent the child suffering a more serious injury or being killed.
Any bruising (however faint or small), fractures, bleeding or other injuries such as burns should be considered as potentially an indicator of child maltreatment and should be investigated appropriately.
Children who are independently mobile which have bruising or other injuries
Infant: any child under the age of 12 months
Not independently mobile: an infant who is not pulling to stand, cruising or walking independently. It includes children with a disability who are non-mobile.
Bruising: a bruise is caused by blood being forced out of the blood vessels into the soft tissues, producing a temporary, non - blanching discolouration of skin. Bruising may be associated with the presence of other signs of injury e.g. abrasions (grazes) or erythema (red marks) but not always. This includes petechiae, which are tiny red or purple non-blanching spots, less than two millimetres in diameter and often found in clusters. Bruising associated with petechiae in the absence of a plausible explanation is highly indicative of abuse. The colour of a bruise may vary from yellow through green to brown or purple but this colour change does not allow accurate assessment of the timing of the injury.
Minor injuries may include (but are not confined to) : bleeding from the mouth and gums (including torn frenulum),nasal bleeding, abrasions (grazes), minor cuts, blisters, bruises, scratches, burns/scalds, eye injuries e.g. sub-conjunctival haemorrhages/corneal abrasions.
Any bruising (however faint or small), fractures, bleeding or other injuries such as burns should be considered as potentially an indicator of child maltreatment and should be investigated appropriately, regardless of the explanation given by carer.
Injury or bruising should be considered as a possible indicator of abuse in all non-mobile babies unless evidenced otherwise by a health professional using their clinical judgement and knowledge of safeguarding risk in the context of child development e.g. marks/bruising such as those caused by immunisations; medical interventions; traumatic delivery or birthmarks including Mongolian blue spot. When a child is seen at a health clinic; GP practice, walk in centre or minor injuries unit with bruising or minor injuries they must be referred to MASH without delay or Emergency Duty Team (EDT) if out of hours. The referrer should highlight when making the referral that this is a potential case of non- accidental injury in a non mobile infant or child. If the child already has a named social worker, they should be referred directly.
When a child is presented at the Emergency Department with bruising or other injury, MASH/EDT should be notified and the agency's child protection process followed.
Any injuries in non-mobile babies, however minor, are cause for concern.
Any child who is found to be seriously ill or injured, or in need of urgent treatment or further investigation, should be transported immediately to hospital for assessment and treatment. It is important to ensure that the child's medical needs are treated first. A referral should then be made to MASH and the agency's child protection procedures followed.
The professional who has learnt of or observed the injury should, without delay, refer the case to the MASH or the Emergency Duty Social Worker depending on the time of presentation as well as consulting with their agency Safeguarding Lead/Advisor.
The detail of what has been observed and discussed should be recorded, dated, timed and signed in the child's individual record held by the agency and should be included in the referral to Children's Social Care.
When MASH or Children's Social Care staff (for open cases) are made aware of or observe an injury/bruise then child protection process must be followed.
A decision will be made by the MASH manager (or locality Team Manager in an open case) on the appropriateness of a Strategy Meeting. The Local Authority social worker and their manager, health professionals and a police representative should, as a minimum, be involved in the strategy discussion. Other relevant professionals will depend on the nature of the individual case and time available.
A Strategy Meeting may be in the form of a telephone discussion or a face to face meeting. This should be on the same day as the concerns are raised, ideally being convened with an hour of the initial referral for acute cases. It is therefore likely that this will be in the form of a telephone discussion. Urgent action to safeguard the child may be required depending on circumstances
A medical assessment by an appropriately qualified paediatrician should almost always be arranged and should be undertaken at the earliest possible opportunity. The assessment will be carried out by a suitably experienced paediatrician who in the context of the information shared at the initial strategy meeting, will be able to give a view on the nature and possible cause of the injury(ies).
A social worker should accompany the family to all medical assessments and be available to discuss the outcome of the examination and investigation results as available.
Children's Social Care staff should ensure infants/children requiring medical assessment are accompanied by the individuals who have Parental Responsibility such that informed consent can be taken for the medical examination and any consequent investigations. If physical presence is not possible, in exceptional circumstances consent may be achieved verbally. This must be clearly documented in the agency's record.
Further investigations (including blood analysis, urine tests, radiological investigations etc.) will be carried out in accordance with national and local policy.
Where the medical assessment (history, examination and investigations) concludes the cause of the injury is accidental i.e. consistent with the explanation given or has a clear medical explanation, the paediatrician will discuss their findings with Children's Social Care. Any further interventions/support required will be considered by Children's Social Care in consultation with partner agencies. N.B. Consider that accidents may occur as a result of a failure to protect or in circumstances of inadequate supervision
If the medical assessment is inconclusive or there are concerns as to how the bruise/injury has been caused Children's Social Care in consultation with police and medical staff will consider any further investigations/support required including any emergency action required to safeguard the child or any other children as part of s47 enquiries.
When a professional has concerns about the nature and cause of an injury or bruise they should explain at an early stage why additional investigation and examination are required. The decision to refer to Children's Social Care should be explained to the parents or carers frankly and honestly. The MASH information leaflet should be given to the parents/carers.
Children's Social Work have the prime responsibility to engage with parents and other family members to ascertain the facts of the situation causing concern and to assess the capacity of the family to safeguard the child.
In most cases, parents should be able to participate fully in the enquiry and assessment process. Social workers will undertake action in line with their agency Procedures & Policy and Legislation & Guidance. They will complete assessments and meet with the parents and children alone to understand the level of risk, with contribution from professionals who already know the family. The needs and safety of the child will be paramount when determining at what point parents or carers are given information.
Particular attention should be paid to communication with parents who may have difficulty understanding the explanation, for example parents whose first language is not English or parents with learning difficulties. Translators should be used as necessary. The translator should not be a member of the family or a close member of the community.
A full explanation should be given to the family regarding the outcome of the enquiry and assessment process. Consider what support can be provided to families who may be aggrieved or upset by this process. This may include an opportunity to discuss the process with their Health Visitor, GP or a Paediatrician.
This protocol is based on the Wiltshire Safeguarding Children Board Protocol "Bruising and injuries to non- mobile children: suspected injuries or bruising in children who are not independently mobile" and has been adapted for use in Devon.
Dr Deborah Stalker, Designated Doctor for Safeguarding Children NEW Devon CCG,
Dr Eleanor Thomas, Named Doctor for Safeguarding Children Royal Devon & Exeter Hospital
Dr Rebecca Rub, Named Doctor for Safeguarding Children North Devon District Hospital on behalf of the Health Advisory Steering Group
This guideline has been approved by MASH and Devon Safeguarding Children's Board and signed off by the Eastern Locality on behalf of NEW Devon CCG.
Publication date: July 2017
Updated: December 2019