Concerns have been raised about how babies with “non-accidental injuries” could be missed in busy emergency departments.
High workload, time pressure and competing demands have all been listed as “barriers to the diagnosis of non-accidental injury” in a new report by the Healthcare Safety Investigation Branch (HSIB).
The new document highlights three harrowing reports of children who had been harmed and initially sent away without safeguarding alarms being sounded.
This includes a four-week-old baby who was found to have multiple fractures and a 12-week-old who suffered a broken leg whose mother told doctors he had “caught it in the bars of his cot while rolling”, even though “an infant of this age would not have been able to roll in their cot”.
It also details the case of a six-week-old baby girl who was taken to A&E with “several marks, including a 2cm bruise on her head, a graze on her chin, and swelling and redness to her nostril”, her father explained the injuries by saying her 18-month-old brother threw a toy at her.
These highlighted some themes including: a “lack of professional curiosity” among clinicians; safeguarding or paediatric teams not being informed of the child’s A&E visit and hospital staff not being kept in the loop about the fact that the families involved had previously needed intervention from social services.
The HSIB reports states that work pressures contribute to the “challenge of diagnosing non-accidental injury”.
The authors wrote: “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, created barriers to the diagnosis of non-accidental injury.”
Some doctors told HSIB they had discharged children even though they had “low-level concerns” about non-accidental injury and they “would have made more inquiries if there had been fewer time pressures and demands”.
Matt Mansbridge, HSIB 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 emergency department.
“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 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.”
HSIB called for the Royal College of Emergency Medicine to develop new guidance to help emergency care doctors’ diagnosis and manage such cases.
It also suggested that it may be beneficial if there was an electronic system available for doctors to view any safeguarding information to assist in decision making.
Commenting on the report, NHS Providers’ director of policy and strategy, Miriam Deakin, said: “The HSIB’s findings are deeply troubling. We echo its calls for more specialist guidance and support for NHS staff who suspect that a child’s injuries are no accident.
“Emergency departments are under extreme pressure from ever-growing demand. As the HSIB highlights, an environment of heavy workloads, time pressure and demands on staff all have an impact and raise the risk that the signs of abuse could be missed.
“This is yet another symptom of severe workforce shortages right across the NHS and social care. We need an action plan from the government as soon as possible to recruit many thousands more much-needed NHS staff.
“It’s vital too that the NHS and other bodies, especially social care and the police, are joined up and can share information appropriately to protect children and young people from abuse.”
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.”