A report into physical abuse in babies admitted to emergency departments has praised the role of nurses in spotting what other clinicians miss – but called for drastic improvements in data sharing between social services and the NHS.
The report, by the Healthcare Safety Investigation Branch (HSIB), looked into non-accidental infant injuries in NHS emergency departments (EDs).
“Nursing staff on the paediatric ward were ‘surprised’ and ‘worried’ that Amelia had been discharged”
Specifically, HSIB investigated instances when EDs missed signs that injuries on infant, defined as children under a year old, were non-accidental, and inflicted by parents or guardians.
Contained in the report were three specific cases where this happened – of a six-week-old, a 12-week-old and a four-week-old.
In the case of four-week-old Finn (not his real name), his parents took him into the ED with a bruise to his face, which was examined by a doctor who remarked that the mother and father seemed “well dressed” and behaved appropriately around the infant.
The parents’ explanation of the injury – that Finn’s head dropped while being burped and hit the father’s shoulder blade – was accepted by the doctor.
A nurse in the ED had noted a lack of affection from the father towards the baby, despite Finn’s “evident” distress, and an emergency nurse practitioner in another part of the ED came across Finn, and queried the case as potentially abusive.
This second nurse was told the doctor had decided otherwise, and Finn was discharged with no flag for abuse being placed on his file.
The infant was brought to the ED four days later with a bloody nose and mouth; his parents claimed ignorance about the injuries, with a scan revealing multiple fractures triggering a police and social services response.
In the 12-week-old’s case, identified as Jakob (not his real name), a lack of data sharing between GP surgeries and the ED led to a near-miss.
The potential for Jakob’s case being a non-accidental injury was flagged by a family nurse practitioner, when he was admitted to the ED.
The third case saw six-week-old Amelia (not her real name) admitted with bleeding from her nose and mouth and a graze.
Her father claimed it was due to her 18-month-old brother throwing a toy at her and pleaded ignorance regarding the graze.
A consultant paediatrician was satisfied the injuries were accidental and discharged her without any inquiries made to social services.
The infant was admitted to a paediatric ward 22 days later after her GP raised concerns about the baby’s wellbeing and comments from her mother about not wanting Amelia.
At the ward, nursing staff echoed the GP’s fears and noted remarks from the mother that she found Amelia “aggressive” and had not bonded with her.
A discussion took place with social services, however Amelia was discharged again.
The report reads: “Nursing staff on the paediatric ward were ‘surprised’ and ‘worried’ that Amelia had been discharged and shared their views with the trust’s safeguarding team.”
The nursing staff’s concerns triggered an investigation, which ultimately led to Amelia and her brother being taken into emergency foster care.
HSIB’s report blamed the missed cases in part on a “lack of professional curiosity” among some ED clinicians.
“This is yet another symptom of severe workforce shortages right across the NHS and social care”
It pointed to another case, where a parent had put a mystery injury on an immobile child down to rolling in their cot, which would have been impossible for the infant.
However, the report acknowledged spotting such abuse cases involved a level of scepticism toward the parents of injured children that many NHS staff felt was contrary to their training.
The HSIB further noted failings in data sharing between social services, police, the EDs and other NHS sites.
It recommended more training for ED staff at spotting non-accidental injury in infants, as well as heightened sharing of information between agencies to make sure flags – which in these cases had to be actively sought after – were immediately shown to often overstretched ED clinicians.
HSIB noted the key role nurses played in catching the abuse that doctors and other staff missed, and said: “Medical staff told the investigation that experience was one of the most important factors in identifying non-accidental injuries and that there were often junior doctors working within the ED who did not have this experience.
“The staff said that the nursing team, particularly if they had worked in the department for some time, were an important resource for identifying potential non-accidental injuries.”
Responding to the findings, 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.”
Ms Deakin said the HSIB’s report highlighted an “environment of heavy workloads” and time pressure in EDs, and that these raised the risk of abuse signs being missed.
She added: “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.”